Journal of the New Zealand Medical Association Vol 133 | No 1512 | 3 April 2020

New Zealand’s elimination strategy for the COVID-19 pandemic and what is required to make it Here we go again? A new pandemic of the work 21st century

Sleep habits of intermediate-aged students: roles for the students, parents and educators

A consensus statement on the use of Bullying and Admission to ICU “solely angiotensin receptor blockers and angiotensin harassment in for possible organ converting enzyme inhibitors in relation to ophthalmology: donation”—audit of current COVID-19 (corona virus disease 2019) a trainee survey New Zealand practice Publication Information published by the New Zealand Medical Association

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EDITORIALS 39 8 Admission to ICU “solely for Here we go again? A new possible organ donation”—audit of pandemic of the 21st century current New Zealand practice Geo rey Rice Stephen Streat, Annette Flanagan, Joanne Ritchie 10 New Zealand’s elimination strategy 45 for the COVID-19 pandemic and Inherited thrombophilia testing what is required to make it work in a large tertiary hospital in New Michael G Baker, Amanda Kvalsvig, Zealand: implementation of a Ayesha J Verrall, Lucy Telfar-Barnard, Choosing Wisely protocol Nick Wilson to reduce unnecessary testing and costs ARTICLES Myra Ruka, Helen Moore, 15 Denis O’Kee e Trial removal of indwelling 59 urinary catheters in stroke Sleep habits of intermediate-aged patients: a clinical audit at North students: roles for the students, Shore Hospital parents and educators Dushiyanthi Rasanathan, Xu Wang Kate Ford, Paul T Kelly, 22 Rebecca Williamson, Michael Hlavac A persuasive approach to VIEWPOINTS antimicrobial stewardship in Christchurch hospitals produced a 67 sustained decrease in intravenous Transition of the medical model clarithromycin dosing and of care at Ashburton hospital over expenditure via a switch to 10 years: the perspective of rural azithromycin orally generalists Sharon J Gardiner, Sarah CL Metcalf, Steve Withington, Sampsa Kiuru, Anja Werno, Matthew P Doogue, Scott Wilson, John Lyons, Stephen T Chambers, on behalf of Alexander Feberwee, Janine Lander the Canterbury District Health Board 76 Antimicrobial Stewardship Committee Neoliberalism: what it is, how 31 it affects health and what to do On the use of a new monocular- about it indirect ophthalmoscope for Pauline Barnett, Philip Bagshaw retinal photography in a primary care setting Aqeeda Singh, Kirsten Cheyne, Graham Wilson, Mary Jane Sime, Sheng Chiong Hong

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85 LETTERS A consensus statement on the 96 use of angiotensin receptor Educational interventions blockers and angiotensin on contraceptive methods in converting enzyme inhibitors in adolescents: face-to-face or virtual? relation to COVID-19 (corona Victor Moquillaza Alcántara, Angela Yauyo virus disease 2019) Puquio, Xiomara Marquez Lopez, Hari Talreja, Jasmine Tan, Pamela Villegas Yaranga Matt Dawes, Sharen Supershad, Kannaiyan Rabindranath, James Fisher, 99 Sajed Valappil, Veronica van der Merwe, Type A aortic dissections: Lisa Wong, Walter van der Merwe, challenges of atypical presentation Julian Paton in remote New Zealand Varun J Sharma, Minesh Prakash, CLINICAL CORRESPONDENCE Francesco Pirone, Brian Chan, Zaw Lin 88 102 Bilateral vertebral artery dissection Bullying and harassment in and cerebellar stroke: a rare ophthalmology: a trainee survey complication of massage Neeranjali S Jain, Hannah K Gill, William Birkett, Pourya Pouryahya, Hannah M Kersten, Stephanie L Watson, Alistair D McR Meyer Helen V Danesh-Meyer 93 100 YEARS AGO DRESS syndrome due to iodinated contrast medium 104 Yassar Alamri, Blake Hsu Presidential Address, 1920 By DR. H. LINDO FERGUSON

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Trial removal of indwelling urinary catheters in stroke patients: a clinical audit at North Shore Hospital Dushiyanthi Rasanathan, Xu Wang We performed an audit that identifi ed stroke patients admitted to North Shore Hospital between 26 November 2018–24 May 2019, who had a urinary catheter inserted during their time in hospital. We looked at the reasons for catheter insertion, how many days patients had catheters in before trial of removal and whether these patients developed a urinary tract infection. Conclusions from this audit include the need to consider whether the decision to insert a catheter is appropriate, and the importance of removing catheters as soon as possible to reduce risk of infection. Urinary catheters and associated infection can affect stroke patients’ hospitalisation time and recovery. A persuasive approach to antimicrobial stewardship in Christchurch hospitals produced a sustained decrease in intravenous clarithromycin dosing and expenditure via a switch to azithromycin orally Sharon J Gardiner, Sarah CL Metcalf, Anja Werno, Matthew P Doogue, Stephen T Chambers, on behalf of the Canterbury District Health Board Antimicrobial Stewardship Committee Optimising use of available antibiotic medicines (antibiotic stewardship) helps reduce anti- biotic resistance. Giving antibiotics by the oral rather than intravenous (IV) route can help avoid problems like infection caused by the IV line. We used strategies like leadership and pharmacy support, and education, to encourage our prescribers to avoid the IV route for treatment of community-acquired pneumonia where appropriate. This produced a sustained decrease in use of clarithromycin IV (by 72%) and cost savings of around $100,000 per annum. On the use of a new monocular-indirect ophthalmoscope for retinal photography in a primary care setting Aqeeda Singh, Kirsten Cheyne, Graham Wilson, Mary Jane Sime, Sheng Chiong Hong The oDocs Nun is a newly released smartphone-based ophthalmoscope, which can be used to capture images of the back of the eye. This study aimed to subjectively assess the quality of the images captured with it in order to determine the feasibility of its use in a clinical envi- ronment. Twenty-eight general practitioners (GPs) captured and uploaded 357 photographs, which were then rated by two ophthalmologists and two optometrists. Overall, it was found that the oDocs Nun is a promising tool which GPs can use in the primary care setting. Admission to ICU “solely for possible organ donation”—audit of current New Zealand practice Stephen Streat, Annette Flanagan, Joanne Ritchie There are a small number of patients (49 over a recent two-year period) with likely fatal acute illness who are admitted to ICUs in New Zealand “solely for possible organ donation”, commonly after a preliminary discussion with their family about donation. Around 40% (20/49) of these patients donated organs after their death in the ICU. These organs were trans- planted into 58 recipients, 14% of the 417 recipients of organs from deceased donors over the two-year period. Organ Donation New Zealand is supporting expansion of this practice within recommended best practice guidelines.

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Inherited thrombophilia testing in a large tertiary hospital in New Zealand: implementation of a Choosing Wisely protocol to reduce unnecessary testing and costs Myra Ruka, Helen Moore, Denis O’Kee e Inherited thrombophilia testing should only be performed in a small subset of patients who are likely to derive benefi t. Internationally and nationally, testing patterns refl ect an overuse of this test due to testing patients that do not fulfi l clinical criteria for testing. An audit on Waikato Hospital Laboratory testing patterns over a one-month period revealed only 1 of 94 tests complied with British Society of Haematology guidelines testing criteria. A multimodal choosing wisely programme was implemented into Waikato Hospital laboratory with a subse- quent reduction in test requests, tests performed and cost of testing. Sleep habits of intermediate-aged students: roles for the students, parents and educators Kate Ford, Paul T Kelly, Rebecca Williamson, Michael Hlavac In this group of students, most achieved a sleep duration within the advised Ministry of Education and Sleep Health Foundation guidelines. Students that used an electronic device before bedtime were more likely to achieve less sleep than non-device users. Further, students whose parent chose their bedtime went to sleep earlier and achieve more sleep compared to students that chose their own bedtime. Therefore, parental guidance with regard to bedtimes and reduction in device usage before sleep are two factors that may improve sleep in this group. Transition of the medical model of care at Ashburton hospital over 10 years: the perspective of rural generalists Steve Withington, Sampsa Kiuru, Scott Wilson, John Lyons, Alexander Feberwee, Janine Lander Over a 10-year period from 2008 to 2017, Ashburton Hospital’s medical staffi ng system has changed through a gradual, planned replacement of surgeons, anaesthetists and physicians by generalist rural hospital doctors who now manage all people presenting to the hospital. The transition was driven largely by problems with specialist medical staff recruitment and replacement, which is common to rural hospitals in New Zealand and elsewhere, but was made possible by a new qualifi cation in rural hospital medicine, and a group of doctors working Ashburton willing to take up this training. Following this transition, the hospital only offers a very limited range of surgical services on site, but nevertheless assesses and treats a much larger number of acute patients than before, while keeping admissions and overall medical staffi ng constant, and with only a small increase in transfers to Christchurch, similar to the population increase over the period. This represents a successful transition of medical model of care in Ashburton hospital and its challenges and lessons learned may be of benefi t to other rural hospitals in New Zealand.

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Neoliberalism: what it is, how it affects health and what to do about it Pauline Barnett, Philip Bagshaw Neoliberalism is about getting government out of providing most services, and letting private enterprise and markets take over through competition, including the creation of a ‘fake market’ for public healthcare services. It is supposed to give individuals more choice. However, it has favoured the ‘haves’ at the expense of the ‘have nots’ in levels of income and health in New Zealand. Some of the worst effects of neoliberalism have been reduced but it still remains buried in our psyche and in some of the ways our society functions. To root it out in healthcare we need bold new initiatives with greater investment of money, particularly where it is needed most, and an emphasis on equity of health for all citizens. A consensus statement on the use of angiotensin receptor blockers and angiotensin converting enzyme inhibitors in relation to COVID-19 (corona virus disease 2019) Hari Talreja, Jasmine Tan, Matt Dawes, Sharen Supershad, Kannaiyan Rabindranath, James Fisher, Sajed Valappil, Veronica van der Merwe, Lisa Wong, Walter van der Merwe, Julian Paton Some patients have been expressing concerns to doctors after the idea started circulating on social media that two common hypertension (high blood pressure) drugs could lead to more severe cases of COVID-19. However, a high-powered group of doctors and scientists in Aotearoa New Zealand have scrutinised the evidence for this theory and determined it is inconclusive and should be disregarded.

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Here we go again? A new pandemic of the 21st century Geo rey Rice

s the COVID-19 pandemic has wors- but we don’t really know as yet how this ened rapidly over the past few weeks, particular virus will behave as it passes Acomparisons have been made with through large populations. COVID-19 is the great infl uenza pandemic of 1918, with highly infectious, with high case fatality for people asking “Are we about to see a repeat the elderly. of that global disaster?” History doesn’t The 1918 A/H1N1 infl uenza pandemic actually repeat: it only appears to. Differ- saw three distinct waves across 18 months. ent circumstances will produce different The fi rst wave was quite mild, a doctor’s outcomes in different places, even from the delight: “many people sick, not many same infectious disease. dying”. But the second wave later in the Here in New Zealand we have been year was much more severe and killed better prepared than most countries for an estimated 50 million people. The third a pandemic, with a comprehensive and wave in 1919 was less severe, and did recently updated plan for infl uenza. So far not affect all countries equally. Australia the government and Ministry of Health have came through with a very low death rate, been guided by that plan, and have mounted whereas some regions in Japan suffered a measured step-by-step response, aimed losses almost as bad as in 1918. at ‘fl attening the curve’ of cases. Some of Will this COVID-19 pandemic be all over us had been asking for an earlier school in one wave, or will it recur? The 1889–94 closure, but as soon as there was clear ‘Russian’ fl u pandemic kept coming back in evidence of community spread the author- successive waves, but with declining death ities announced a Level 3 emergency and rates and a low overall mortality of only moved within 48 hours to a complete Level 4 about one million. We are in uncharted lockdown. One of the big lessons of 1918 had waters with COVID-19. Computer modelling been applied: respond quickly or it will run has been exceptionally helpful in predicting away out of control. the short-term curve, based on normal Some countries had not learned that epidemiological patterns, the reproduction lesson. The forecasts for the UK and North rate of the virus, and the effect of mitigation America are grim, because they failed to measures. We can only hope that this virus take the threat seriously enough or respond stays stable and does not start transmuting early enough. A week is a long time in into anything nastier. a pandemic, as Wellington discovered In some respects COVID-19 is already much in November 1918, when delay proved nastier than fl u for the elderly. The 1918 dangerous and resulted in a death rate virus tended to produce secondary infections nearly twice that of Christchurch. of bacterial pneumonia, and most people So far New Zealand appears to have had a fi ghting chance of recovering from mainly done the right things, and in a that, but COVID-19 seems to penetrate much reasonably timely fashion. Our leadership deeper into the lungs, causing destructive so far has been superb. But our pandemic viral pneumonia. As patients become planning was done mainly with infl uenza breathless, they lack oxygen, and need in mind, and here we are confronted by mechanical respiration in order to survive. a novel coronavirus. In the race to fi nd We have all been shocked by the scenes in a vaccine the scientifi c world is quickly hospitals in Northern Italy, where predom- fi nding out a lot more about the virus itself, inantly elderly patients have been dying

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in large numbers. In Spain old folks have In Italy and Spain people have been been left to die alone. Though India has at clapping to show their appreciation for the last moved to a lockdown, it remains to be desperate efforts of hospital staff. We must seen how that vast population will cope with work harder to ensure that things don’t get rapidly escalating infection rates, and the that bad here, but whatever happens we will possibilities for much of Africa are almost certainly owe our medical sector enormous too terrible to think about. Nick Wilson’s gratitude. ‘Elimination’ is now the goal and modelling now warns that if the present staying at home is the best way the rest of strategy fails New Zealand could be facing us can help to ‘break the chain’ and ensure a very severe outcome, with 8,000 to 14,000 that our hospital system does not collapse deaths. But China has shown that drastic under the strain. Yet that also reduces herd measures can eliminate the infection. immunity, and increases the prospect of rein- Whether this pandemic comes to be fection if elimination fails, before a vaccine called ‘the Exodus of the Elderly’ or ‘the becomes available. This may only be the start Pensioners’ Plague’ is up to some future of a prolonged crisis, in which our resilience historian to decide, but one thing is starkly and ingenuity as a nation is put to the test. clear at this point. If present measures ‘Kia kaha’. We are all in this together. fail, this could be the most severe test our Dr Rice is Emeritus Professor of History hospital system has ever had to face. Doctors at the University of Canterbury and author and nurses, ambulance paramedics and of Black November: the 1918 Infl uenza rescue helicopter staff are our front-line Pandemic in New Zealand (second edition, fi ghters, supported by an army of orderlies, 2005), Black Flu 1918: the story of New aides, carers and other staff. Retired medical Zealand’s worst public health disaster personnel are now coming forward, as in (2017) and That Terrible Time: Eye-witness the UK, to bolster the response. In 1918 Accounts of the 1918 Infl uenza Pandemic in many doctors and nurses caught the fl u, and New Zealand (2018). over 50 of them died.

Competing interests: Nil. Author information: Geoffrey Rice, Professor, University of Canterbury, Christchurch. Corresponding author: Geoffrey Rice, Professor, University of Canterbury, Christchurch. [email protected] URL: www.nzma.org.nz/journal-articles/here-we-go-again-a-new-pandemic-of-the-21st-century

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New Zealand’s elimination strategy for the COVID-19 pandemic and what is required to make it work Michael G Baker, Amanda Kvalsvig, Ayesha J Verrall, Lucy Telfar-Barnard, Nick Wilson

n this editorial we summarise the threat lot more factors than basic data, including posed by the COVID-19 pandemic, the the fact that populations take measures to Ijustifi cation for the elimination strategy protect themselves.3 Under one of the more adopted by New Zealand, and some of the likely scenarios if the country’s current actions required to maximise the chances elimination strategy fails, New Zealand of success. could expect approximately 14,400 deaths.3 What is the size and nature of the In addition, large numbers of people who are ill and hospitalised could swamp health threat? services at all levels and prevent the delivery The COVID-19 pandemic, caused by the of elective services and preventive care. SARS-CoV-2 virus, has shown a relentless ability to infect the world’s population. A poorly controlled pandemic will greatly The virus is highly infectious, with each increase health inequities. Like seasonal case typically infecting 2–3 others (a infl uenza in New Zealand, risk is partic- reproduction number [Ro] of about 2.5). ularly concentrated in older people and 4 Consequently, it has the potential to infect those with severe comorbidities. Therefore about 60% (crudely estimated as 1-1/Ro) of Māori and Pacifi c peoples could be more the world’s population during the next 1–2 vulnerable, as seen in past infl uenza 5 years as pandemic waves work their way pandemics. around the planet. What are the strategic options? There are many measures of health Pandemic planning in New Zealand, as impact, but case-fatality risk (CFR) is one of in most countries, has been dominated by the most important. A reasonable working measures to manage infl uenza pandemics. estimate is a 1% CFR for the infected popu- For good reason, given experience with the lation as a whole, with risk increasing 1918 infl uenza pandemic.6 With the rising markedly for aged 60+ years and those with threat of the COVID-19 pandemic in January, comorbidities.1 The more useful measure is New Zealand used its existing national the infection fatality ratio, which is based infl uenza pandemic plan as a basis for its on the total proportion of the population response.7 This planning is appropriately infected and can usually only be estimated based on a mitigation model, and focuses retrospectively by serological surveys. on delaying the arrival of infl uenza, and a Modellers have now cleverly calculated this range of measures to ‘fl atten the curve’ of the for China, producing an estimate of 0.66% pandemic. There is no expectation that any (0.39–1.33).2 Putting these numbers together measures can halt an infl uenza pandemic suggests this pandemic could kill 0.4% of (short of complete border closures, termed the world’s population (about 30 million ‘protective sequestration’, which has people). protected Pacifi c Islands in the past8). In New Zealand, we have used disease We are now seeing this mitigation modelling to improve on these estimates, approach being applied in countries across because modelling can take account of a Europe, North America and Australia

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where the COVID-19 pandemic is spreading By mid-March there was growing widely. A variation of this approach is the support for an elimination strategy.18 The suppression strategy, where the curve is fl at- Government introduced a four-tier response tened to the point where there are relatively system on 21 March and the country was few cases. This approach is likely to require placed on ‘level 2’ response (which involved a prolonged ‘lockdown’ response which may limitations on mass gatherings and encour- last for months until an effective vaccine aging increased physical distancing). The or antivirals are available.9 Attempts at country then escalated rapidly to ‘level 4’ the suppression approach are increasingly (widely described as a ‘lockdown’ involving replacing mitigation as the pandemic over- closing all schools, non-essential workplaces, whelms healthcare systems. social gatherings and severe travel restric- But COVID-19 is not pandemic infl uenza.10 tions) which came into force on the evening The potential to contain it has not been of 25 March 2020. A national emergency was adequately appreciated. This difference also declared, giving authorities additional is largely a function of the biology and powers to enforce control measures. epidemiology of this infection. COVID-19 This elimination strategy is a major infection has a longer incubation period departure from pandemic infl uenza miti- (median of 5–6 days) than infl uenza (1–3 gation. With the mitigation strategy, the days). This feature provides an opportunity response is increased as the pandemic for case identifi cation and isolation and progresses and more demanding interven- tracing and quarantining of contacts to tions such as school closures are introduced succeed, but probably only if done swiftly later to ‘fl atten the curve.’ Elimination and effectively.11 partly reverses the order by introducing The strongest evidence that containment, strong measures at the start in an effort to on the path to elimination, works comes from prevent introduction and local transmission the remarkable success of China in reversing of an exotic pathogen such as COVID-19. a large pandemic.12 Of particular relevance This approach has a strong focus on border to New Zealand are the examples of smaller control, which is obviously easier to apply for Asian jurisdictions, notably Hong Kong, island states. It also emphasises case isolation Singapore,13 South Korea14 and Taiwan.15 and quarantine of contacts to ‘stamp out’ chains of transmission. If these measures fail New Zealand had a brief time-window and there is evidence of community trans- to refi ne its plan before the pandemic mission, it then requires a major response arrived with the fi rst COVID-19 case on (physical distancing, travel restrictions and 28 February.16 At the time of writing, potentially mass quarantines or ‘lockdowns’) there were just over 800 identifi ed cases, to extinguish chains of transmission. almost entirely in people who had recently returned from overseas or their contacts. Benefits and risks However, there were several cases of The elimination strategy has benefi t community transmission, which was likely over mitigation: if started early it will to be more widespread than numbers indi- result in fewer cases of illness and death. cated because the initially limited diagnostic If successful it also offers a clear exit path testing capacity was focused on people with with a careful return to regular activities a travel history. with resulting social and economic benefi ts New Zealand therefore had a major for New Zealand. The elimination strategy choice. A more familiar mitigation can also support Pacifi c Island neighbours strategy or a more ambitious elimination to remain free of this virus once they relax approach. Technically, elimination is the current border controls. eradication of an infectious disease at a The elimination strategy also has risks and country or regional level, with the term these may be substantial. To make elimi- eradication reserved for global extinction nation work, New Zealand had no feasible of an organism. Disease elimination has alternative but to escalate its response to been applied to a wide range of human a national ‘lockdown’, mainly to give it and animal infectious diseases, though an time to ramp up key control measures.18 A effective vaccine is often required.17 full national ‘lockdown’ was probably also needed to ensure the population would

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swiftly transition to the physical distancing 4. Intensive physical distancing, behaviours needed to limit spread and extin- currently implemented as a lockdown guish chains of transmission. New Zealand (level 4 alert) that includes school disease control planning was not greatly and workplace closure, movement infl uenced by the SARS pandemic, which and travel restrictions, and stringent many countries in Asia experienced, and measures to reduce contact in public public awareness of concepts like quarantine spaces, with potential to relax these and isolation have probably been poor.19 measures if elimination is working; The lockdown does, however, have large 5. A well-coordinated communication social and economic costs, and is likely strategy to inform the public about to be particularly tough for those with control measures and about what the fewest resources. The Government to do if they become unwell, and to response includes a range of interventions reinforce important health promotion to support these groups, including a major messages. economic support package and restrictions Given how infectious the SARS-CoV-2 on rent increases. virus is, multiple measures will need to be What we need to do to make taken to ensure all of these control inter- elimination work ventions are working in an optimal way. Elimination is a well-recognised strategy For example, there is good evidence for the for infectious disease control, and New use of mobile phone technology to speed Zealand can draw on public health expe- up the effectiveness of contact tracing and 21 rience of eliminating a range of human and quarantine. Greater use of face masks may animal infectious diseases. In particular also be needed to reduce the risk of virus there are lessons to be learned from the transmission by people during the pre-symp- 22 measles and rubella elimination strategy,17,20 tomatic phase of their infections. albeit with the difference that we do not At the same time as the above pandemic yet have an effective vaccine for COVID-19. control measures are implemented, steps Past experience has taught us that there are need to be taken to reduce impacts of three factors that are critical to elimination the pandemic on the health system and success: 1) high-performing epidemiological healthcare workers if successfully achieving and laboratory surveillance systems; 2) an elimination is prolonged. Preparation effective and equitable public health system of hospitals is already underway with that can ensure uniformly high delivery of enhanced infection control measures and interventions to all populations, including sourcing of staff and equipment to increase marginalised groups (in this instance inter- surge capacity. In particular, health services vention is focused on diagnosis, isolation of are working actively to expand intensive cases and quarantine of contacts rather than care unit (ICU) and ventilator spaces in case vaccine); and 3) and the ability to sustain the there is a need to treat large numbers of national programme and update strategies patients with respiratory failure. to address emerging issues. The control measures will also require The essential elements of an elimination a rapid and potentially large expansion of strategy for COVID-19 are likely to include: other workforce and support systems (eg, 1. Border controls with high-quality information systems for case and contact quarantine of incoming travellers; management). 2. Rapid case detection identifi ed by The exit path will need to be based on widespread testing, followed by rapid demonstrable high-performing border case isolation, with swift contact controls and case and contact follow-up, tracing and quarantine for contacts; along with suffi cient testing and surveillance to detect a low risk of COVID-19 circulation 3. Intensive hygiene promotion (cough in the population. Under these circum- etiquette and hand washing) and stances, the ‘lockdown’ can be gradually provision of hand hygiene facilities in relaxed, potentially on a regional basis. public settings;

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What to do if the elimination strategy. Its actions in the coming weeks will strategy fails? decide if this goal can be achieved. To justify this sacrifi ce we need to put maximum effort Success with the elimination strategy is into giving this intervention the best possible far from certain in New Zealand. In the chance of success. These are uncharted meantime, the country will need to keep waters for public health. accelerating its preparations for a potential shift to the suppression or the mitigation The strategy will need to be fi ne-tuned strategy. These preparations could vastly and enhanced in multiple ways as we learn reduce the mortality burden of vulnerable more about how COVID-19 behaves in the populations (particularly older people New Zealand setting. To achieve that, we will and those with chronic conditions23). In need to make maximum use of the many particular, there could be a ‘safe haven’ science disciplines and technologies we have programme to protect such populations in available to inform and guide our response their own homes, institutions and commu- in innovative ways. The COVID-19 pandemic nities. These could be rolled out by city, has also forcefully demonstrated the need for region and nationally, based on the spread ongoing provision of effective public health of the pandemic within the country. infrastructure and resources to ensure that New Zealand is able to protect its population Conclusions during a severe public health emergency.24 New Zealand society has made a large ‘upfront’ sacrifi ce in pursuing an elimination

Competing interests: Nil. Author information: Michael Baker, Department of Public Health, University of Otago, Wellington; Amanda Kvalsvig, Department of Public Health, University of Otago, Wellington; Ayesha J Verrall, Department of Pathology and Molecular Medicine, University of Otago, Wellington; Lucy Telfar-Barnard, Department of Public Health, University of Otago, Wellington; Nick Wilson, Department of Public Health, University of Otago, Wellington. Corresponding author: Prof Michael G Baker, Department of Public Health, University of Otago, 23 Mein St, Wellington 7343. [email protected] URL: www.nzma.org.nz/journal-articles/new-zealands-elimination-strategy-for-the-covid-19- pandemic-and-what-is-required-to-make-it-work

REFERENCES: 1. Wilson N, Kvalsvig A, 2. Verity R, Okell LC, Dorigatti Health Impacts from the Telfar Barnard L, et al. I, et al. Estimates of COVID-19 Pandemic for Case-Fatality Risk Estimates the severity of corona- New Zealand if Eradica- for COVID-19 Calculated virus disease 2019: a tion Fails: Report to the by Using a Lag Time for model-based analysis. NZ Ministry of Health. Fatality. Emerg Infect Lancet Infect Dis 2020 Wellington: University of Dis 2020 doi: http://doi. 3. Wilson N, Telfar Barnard L, Otago Wellington, 2020. org/10.3201/eid2606.200320 Kvalsvig A, et al. Potential

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4. Walker TA, Waite B, 11. Hellewell J, Abbott S, 17. Centers for Disease Control Thompson MG, et al. Gimma A, et al. Feasibility Prevention. Global Disease Risk of Severe Infl uenza of controlling COVID-19 Elimination and Eradi- Among Adults With outbreaks by isolation of cation as Public Health Chronic Medical Condi- cases and contacts. The Strategies. Proceedings of a tions. J Infect Dis 2020; Lancet Global Health conference. Atlanta, Geor- 221(2):183–90. doi: 10.1093/ 2020 doi: 10.1016/S2214- gia, USA. 23–25 February infdis/jiz570 [published 109X(20)30074-7 [published 1998. MMWR supplements Online First: 2019/11/05] Online First: 2020/03/03] 1999; 48:1–208. 5. Wilson N, Barnard 12. WHO-China Joint Mission. 18. Baker MG, Wilson N. Why LT, Summers JA, et al. Report of the WHO-China New Zealand needs to Differential mortality Joint Mission on Coro- continue decisive action to rates by ethnicity in 3 navirus Disease 2019 contain coronavirus. Public infl uenza pandemics over (COVID-19). 2020;(16-24 Health Expert Blog, 2020. a century, New Zealand. February). http://www. 19. Wong JEL, Leo YS, Tan Emerg Infect Dis 2012; who.int/docs/default- CC. COVID-19 in Singa- 18(1):71–77. doi: http://doi. source/coronaviruse/ pore—Current Experience: org/10.3201/eid1801.110035 who-china-joint-mission- Critical Global Issues That 6. Rice GW. Black Flu on-covid-19-fi nal-report.pdf Require Attention and 1918: The Story of New 13. Ng Y, Li Z, Chua YX, et al. Action. Jama 2020 doi: Zealand’s Worst Public Evaluation of the Effective- 10.1001/jama.2020.2467 Health Disaster. Christ- ness of Surveillance and 20. World Health Organization. church: Canterbury Containment Measures for Guidelines on verifi cation University Press 2017. the First 100 Patients with of measles elimination and 7. Ministry of Health. COVID-19 in Singapore rubella: World Health Orga- New Zealand Infl uenza - January 2-February 29, nization. Regional Offi ce Pandemic Plan: A frame- 2020. MMWR Morb Mortal for South-East Asia, 2016. Wkly Rep 2020; 69(11):307– work for action (2nd 21. Ferretti L, Wymant C, 11. doi: 10.15585/mmwr. edn). Wellington, 2017. Kendall M, et al. Quan- mm6911e1 [published 8. McLeod MA, Baker M, tifying dynamics of Online First: 2020/03/20] Wilson N, et al. Protective SARS-CoV-2 transmission effect of maritime quar- 14. Cohen J, Kupferschmidt suggests that epidemic antine in South Pacifi c K. Countries test control and avoidance is jurisdictions, 1918–19 tactics in ‘war’against feasible through instan- infl uenza pandemic. COVID-19. Science 2020; taneous digital contact Emerg Infect Dis 2008; 367(6484):1287–88. tracing. medRxiv 2020 doi: 10.1126/ 14(3):468–70. [published 22. Servick K. Would everyone science.367.6484.1287 Online First: 2008/03/08] wearing face masks help 9. Ferguson N, Laydon D, 15. Wang CJ, Ng CY, Brook us slow the pandemic? Nedjati-Gilani G, et al. RH. Response to COVID- Science 2020 doi: 10.1126/ Impact of non-pharma- 19 in Taiwan: Big Data science.abb937 Analytics, New Technology, ceutical interventions 23. Blakely T, Baker M, Wilson and Proactive Testing. (NPIs) to reduce COVID-19 N. The maths and ethics Jama 2020 doi: 10.1001/ mortality and healthcare of minimising COVID-19 jama.2020.3151 [published demand. Imperial College deaths in NZ. Public Health Online First: 2020/03/04] 2020; (16 March):1–20. Expert Blog. Wellington: 10. Anderson RM, Heesterbeek 16. World Health Organiza- University of Otago, 2020. tion. Coronavirus disease H, Klinkenberg D, et al. 24. Baker M, Wilson N, Delany 2019 (COVID-19) Situation How will country-based L, et al. A preventable Report – 39. 2020;(28 mitigation measures measles epidemic: Lessons February). http://www.who. infl uence the course of the for reforming public int/docs/default-source/ COVID-19 epidemic? Lancet health in NZ. Public coronaviruse/situa- 2020 doi: 10.1016/S0140- Health Expert Blog 2020 6736(20)30567-5 tion-reports/20200228-si- trep-39-covid-19. pdf?sfvrsn=5bbf3e7d_4

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Trial removal of indwelling urinary catheters in stroke patients: a clinical audit at North Shore Hospital Dushiyanthi Rasanathan, Xu Wang

ABSTRACT BACKGROUND: This is a baseline clinical audit looking at indwelling urinary catheter (IDC) use and trial removal of catheter (TROC) in stroke patients. We collected data on stroke patients admitted to North Shore Hospital between 26 November 2018–24 May 2019, who underwent insertion of an IDC as an inpatient. A minority of patients had TROC within the recommended guideline period. A high incidence of urinary tract infection (UTI) was found in this patient population. Insu icient documentation and inappropriate indications for IDC insertion were features noted during this audit. Daily electronic reminders and prompting by all members of the rehabilitation team concerning TROC are important to reduce catheter days and reduce UTI rates. AIMS: To identify if the trial removal of indwelling urinary catheters (TROC) in stroke patients complies with the 2016 American Heart Association/American Stroke Association (AHA/ASA) AHSA guidelines, and to identify any precipitating factors that prevent compliance with the guidelines. METHODS: We performed a clinical baseline audit that identified patients who were admitted to the acute stroke ward at North Shore Hospital with a diagnosis of stroke from 26 November 2018–24 May 2019 and had an indwelling urinary catheter (IDC) inserted during their admission. The audit consisted of both retrospective and prospective components. Data was collected on patient demographics, the documented indication for IDC insertion, total number of catheter days, the incidence of UTIs and the outcomes a er catheter removal. RESULTS: A total of 49 patients were included. 4.1% of patients had catheters removed within 24 hours (95% confidence interval: 0.011–0.137). The average number of catheter days before removal of IDC was approximately five days. 24.5% of our patient sample went on to develop a urinary tract infection. CONCLUSIONS: Insu icient documentation and inappropriate indications for IDC insertion were features noted during this audit. Daily electronic reminders and prompting concerning TROC are important to reduce catheter days and reduce infection rates. Indwelling catheters and associated infections impact the length of hospitalisation, mortality and morbidity of stroke patients.

ndwelling urinary catheters (IDCs) are Shore Hospital, Auckland, New Zealand. commonly used in stroke patients; yet To distinguish IDCs from the various other Ithey also present unique challenges for types of urinary catheters, an IDC is defi ned this population. It is vital that IDCs are used as a draining tube inserted into the urinary only when necessary and removed when bladder through the urethra. It is connected appropriate to prevent the development of to a closed collection system. Alternative complications. As such, we wanted to inves- forms of urinary catheters include intermit- tigate whether IDCs were removed within a tent catheterisation, external catheters and stated guideline period for stroke patients suprapubic catheters.1 An IDC is the most admitted to the acute stroke ward at North common form of urinary catheterisation.1

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The indications for appropriate urinary from the hands and equipment of health catheterisation include acute urinary professionals. Endogenous contamination retention, bladder outlet obstruction and to can occur from nearby internal colonisation improve comfort during end of life cares.1 of bacteria in a patient.7 The duration of Inappropriate indications for IDC insertion catheterisation is the most important risk include urinary incontinence, monitoring factor for the development of infection.5 In of urine output without a critical need and the general medical population, the risk of using catheters to obtain urine samples for UTI is 3–10% per day of catheterisation.7 The diagnostic testing, despite a patient being longer an IDC is in place, the greater the like- able to voluntarily void.1 Priority recom- lihood of bacteria and UTI.6 mendations for appropriate IDC use include A UTI can result in further medical compli- inserting catheters only for appropriate cations for patients who have had a stroke. indications and to leave them in place Stroke patients are particularly prone 2 only as long as needed. It is estimated that to developing UTIs due to immunosup- approximately one quarter of catheterisa- pression, bladder dysfunction and increased 3 tions are unnecessary. use of urinary catheters.3 Studies suggest Stroke patients have a number of risk that ischaemia in the brain may lead to a factors that predispose them to acute systemic immunodepression that predis- urinary retention and thereby requiring poses patients to infection.2 A UTI can cause urinary catheterisation. Urinary retention, electrolyte disturbances, hypoxia and fevers. urgency, frequency and incontinence occur These can have a detrimental effect upon in approximately 29–58% of patients after the vitality of neurons within the ischaemic stroke.2 Bladder dysfunction following a penumbra; the area of reversible injured stroke is classically due to interference in brain tissue around the ischaemic core, thus the central nervous system control and the delaying the recovery of the brain. Fever coordination of voiding refl exes. Psycho- can alter the blood-brain barrier permea- logical mechanisms can also contribute to bility, increase cerebral metabolic demands these problems. The potential loss of privacy and promote acidosis, as well as the release with bladder functioning after a stroke can of excitatory amino acids.5 Fever and the interfere with normal bladder patterns and systemic infl ammatory response associated subsequently lead to urinary retention, as with UTIs can thus impair stroke recovery. psychological factors may prevent easy evac- A population-based study found that the uation.2 Speech dysfunction and alterations length of inpatient stay was extended by an in mental status also impair the ability to average of 41% in patients with ischaemic communicate a voiding problem, which can stroke who developed a UTI.2 Infection also induce urinary retention.4 The impact is also a risk factor for delirium, which on continence and dignity that a stroke can worsens neurological state and adversely cause is an important focus for all members affects the length of admission and mortality of the stroke rehabilitation team.3 in stroke patients.7 Urinary tract infections (UTIs) are the UTI in a stroke patient can impair the most common form of hospital-acquired process of rehabilitation.6 UTI and catheter infection and are estimated to account for use can prolong the period of immobility more than 30% of all infections in hospitals.1 for patients as systemic illness, intra- An estimated 80% of UTIs in hospitals are venous antibiotics and urinary catheters attributable to an IDC.5 A UTI is the most make it more diffi cult to begin intensive important adverse outcome of urinary physical therapy.2 UTIs are related to unde- catheter use. Bacteraemia and sepsis can sirable outcomes, including deterioration develop in a small proportion of infected in neurological state, increased length of patients.6 As early as the fi rst day after hospitalisation and long-term disability.5 catheterisation, a biofi lm develops on both Infections and other adverse effects asso- extraluminal and intraluminal surfaces of ciated with IDCs therefore lead to increases the catheter, increasing the capability of in patient discomfort, morbidity, mortality micro-organisms to adhere to the surfaces and amplifi es the economic burden of care.7 and promoting colonisation. This is an Thus it is vital that IDCs are only used when important factor in the pathogenesis of many necessary, and that they are removed as catheter-associated UTIs (CAUTIs).2 CAUTIs soon as possible. may be caused by exogenous contamination

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26 November 2018–24 February 2019. Aim and objectives The nursing handover software program The aim of this audit is to identify if the ‘Trendcare’ was used to identify patients practice of trial removal of indwelling during this period who were admitted to the urinary catheter (TROC) complies with the ward with a stroke and had an IDC inserted 2016 American Heart Association/American during their admission. The prospective Stroke Association (AHA/ASA) AHSA guide- aspect of the audit was conducted from 25 lines, and to identify any precipitating February–24 May 2019. This aspect of the factors that prevent compliance with the audit identifi ed all new patients admitted guidelines. with a stroke and followed up patients Criteria and standards who had an IDC inserted. Patients who had symptoms of UTI and had a mid-stream Criterion Standard Class Evidence urine sample indicative of infection were base considered to have developed a UTI. Removal of the 100% Class I (Bene- Level B Data was collected from clinical notes, urinary catheter fit>>>risk) within 24 hours Procedure/ Trendcare and discharge summaries and of insertion, a er treatment entered into a Microsoft Excel spreadsheet. admission for SHOULD be The data collected included: acute stroke is performed • patient demographics recommended. • the nature of stroke

This audit used the 2016 American Heart • date and documented indication of Association/American Stroke Association catheter insertion (AHA/ASA) Guidelines for Adult Stroke • number of catheter days (the number Rehabilitation and Recovery, which states of days the patient had a catheter that TROC should be attempted within 24 in-situ) hours after insertion.8 The NICE accredited • whether patients went on to develop ‘National Clinical Guidelines for Stroke’ a UTI published in 2016 were also consulted, • outcomes of catheter removal which recommended that people with stroke should not have an IDC inserted unless indi- • patient discharge destination cated to relieve urinary retention or when Minor statistical analysis was also fl uid balance is critical.7 conducted using a spreadsheet and asso- ciated statistical functions. A 95% confi dence Methodology interval for the average number of catheter This is a baseline audit that identifi ed days for our patient sample was estimated patients admitted to the acute stroke ward using a t-test based method. at North Shore Hospital with a radio- logical or clinical diagnosis of stroke from 26 November 2018–24 May 2019. The Results audit consisted of both retrospective and A total of 49 patients had an IDC inserted prospective components. The retrospective during their admission for stroke during the component covered the period between six-month audit period (n=49).

Table 1: Documented indications for IDC insertion for stroke patients during the audit period.

Documented indication for catheterisation N/49 (%)

Urinary retention 24 (49.0)

Monitoring for acutely unwell/unstable patient 5 (10.2)

Incontinence 4 (8.2)

Comfort cares 3 (6.1)

Immobility 2 (4.1)

Urgency 1 (2.0)

Not documented/unknown cause 10 (20.4)

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Catheter removal within 24 hours empty their bladder increases their overall happened in only 2 of 49, 4.1% (95% CI number of catheter days, as catheters need 1.1–13.7) of patients. The average number to be re-inserted and monitored.11 of catheter days for our patient sample A key feature noted during this audit was before TROC was approximately fi ve days. the issue of insuffi cient documentation of The mean time to catheter removal was 5 the indications for IDC insertion. Waitemata (5.1) days, with a standard deviation of 4.4. DHB uses specifi cally designed IDC insertion The 95% confi dence interval for the average stickers for health professionals to complete number of catheter days before TROC is in clinical notes. 20.4% of the patients’ notes between 3.5–6.7 days. Because this confi - in this audit did not have any documented dence interval does not include the number indication for IDC. Several also stated an 1, indicative of 24 hours, the analysis is inappropriate reason for catheterisation, signifi cant in showing that we are not including urinary incontinence, agitation TROCing patients according to the AHA/ASA and patient discomfort. This appears to be a guidelines recommendation of 24 hours. universal issue as the literature commonly UTI developed in 12/49 (24.5%) of patients. notes inappropriate documentation of the 29.0% of patients who were TROCd (9/31 indications for an IDC and the use of limited patients) were considered to have a failed clinical reasoning to determine if an IDC is TROC and underwent reinsertion of an IDC. required for a patient.11 Understandably, 32.7% of patients who had an IDC inserted there are circumstances where IDCs are went on to their discharge destination used for patient comfort and nursing conve- with their IDC in situ. This encompassed 16 nience. These include IDC insertion for patients out of the 49 patients who had an terminally ill patients which can ease the IDC inserted. Discharge destinations were inconvenience, pain and hygiene diffi culties most commonly rehabilitation wards or a related to uncontrolled voiding. A competing private hospital. pressure also exists on nurses to mitigate the development of hospital-acquired pressure Discussion ulcers. This can lead to the perception that urinary catheters reduce the risk of skin This audit generated a number of note- breakdown, despite IDCs rarely being appro- worthy conclusions. The most critical of priate for patients with incontinence and which highlighted that our average period sacral wounds.12 Completion of these IDC of catheter days before TROC on the stroke stickers in the clinical notes can however, ward does not meet the recommended encourage appropriate clinical reasoning period of 24 hours, as per the AHA/ASA for the appropriateness of IDC insertion. guidelines. A minor portion of our patients They can also serve to remind the multidisci- with IDC had TROC within 24 hours (4.1%). plinary team to question when a catheter is Of the patients who had an IDC inserted no longer indicated and consider removal. during their time as an inpatient, 24.5% went on to develop UTIs. Concerningly, 29% Another notable factor that contributed of patients had failed TROCs. This raises to the increase in catheter days for our a number of questions regarding exactly patients was the practice of TROC on the when it is appropriate to TROC a patient. wards between 6–7am. There were several instances where a TROC was requested on Waitemata District Health Board’s guide- the previous day, with no subsequent TROC lines concerning catheter management occurring the next day. The TROC would denote how a patient’s risk factors for an then be completed the following day as the unsuccessful TROC include diffi culty voiding time period for TROC had passed. There prior to ICD insertion, chronic retention, were also numerous patients for whom a diabetes mellitus, Parkinson’s disease and TROC was decided during the morning ward diffi culty with catheter insertion.10 Situa- round, around 0830 for example, who were tional risk factors for unsuccessful TROC only TROCd the following day at 0600. This include having unrelieved pain, having had rendered the patients with another catheter anticholinergic drugs such as Oxybutynin day and thus with a proportional increase in in the last 10 hours, recent surgery, consti- risk of infection. Coleman Gross’ study did pation and ongoing haematuria with clots. not show a difference in voiding based on Removing an IDC for a patient who cannot

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whether the catheter was removed at 7am deemed ready for purely oral fl uids and or at 10pm in their sample of stroke reha- medications, the only way to determine if bilitation patients.10 Aiming for the removal a patient can empty their bladder success- of IDC between midnight and midday is fully after using an IDC is to remove the preferable as it entails time for adequate catheter itself.11 Furthermore, the presence assessment during the day and the avail- of a urinary catheter is not always docu- ability of trained staff to re-catheterise if mented in clinical notes. This audit used needed. The TROC period of 0600–0700 often the nursing handover software ‘Trendcare’ results in another catheter day for patients, because it was the only clinical software when it may have been possible to TROC that specifi cally mentions which patients them later in the morning, while there is on the ward had IDCs. This software is not still time to monitor patients with suffi cient used by members of the medical team. numbers of staff. This highlights the limited involvement As UTIs are such a signifi cant cause that the medical teams can have with the of healthcare infection, other measures management of IDCs. to reduce infection, aside from limiting To reduce the number of catheter days catheter use and removing catheters as soon for patients, Meddings et al describes as possible, should be briefl y considered. the lifecycle of the urinary catheter and Intervention strategies that have been previ- the four steps or checkpoints in order to ously described in the literature include remove a catheter. Firstly, the physician prophylactic antibiotics, anti-septic impreg- must recognise that their patient has an IDC. nated catheters and quality improvement Secondly, the physician identifi es that the interventions to reduce inappropriate cath- IDC is no longer needed or indicated. Thirdly eterisation.2 Stat dose peri-catheterisation the clinician documents or instructs the need antibiotic prophylaxis is generally only to TROC. Finally, the TROC occurs.12 These indicated in high-risk patients, including four steps all take time, potentially rendering those with recent artifi cial joint replace- a patient with an increasing number of ments, mechanical heart valves, previous catheter days. These four steps also provide infective endocarditis, recurrent UTIs, points of intervention to fast-track this immunosuppressed patients and patients process. The removal of urinary catheters who have needed recurrent attempts to should be assessed on a daily basis.10 insert the catheter. Low-quality evidence The literature highlights the importance has suggested little to no benefi t in antimi- of ongoing reminders, both electronically crobial prophylaxis for patients undergoing and by nursing and MDT staff to the medical 1 urinary catheterisation. A recent liter- team with regards to the appropriate time ature review showed many of the studies for TROC. Interventions trialled previously addressing strategies to prevent CAUTI were include stop orders directed at physicians, not of suffi cient quality to allow conclusions requiring an order to be renewed or discon- 1 to be formed regarding these interventions. tinued on the basis of review at regular The literature is consistent in that limiting intervals.12 A notifi cation on our Clinical catheter use and minimising the duration Portal system, for example on the ‘Inpatient of catheterisation are the primary strategies Snapshot’ page which is reviewed at least 5 for CAUTI prevention. daily by the medical team, stating that the The most signifi cant feature noted during patient has an IDC could be an effective this audit and also refl ected in the liter- reminder to TROC when appropriate. Parry ature is the importance of the medical team et al staged an intervention at Stamford being aware of IDCs in their patients. Within Hospital, Connecticut whereby nurses led the rotating members of a medical team, the prompting and auditing for TROC, with physicians may not even recognise which use of a nurse-directed urinary catheter patients have IDCs.14 Catheters are often removal protocol. This was an extremely used and managed inappropriately, and successful intervention which saw a doctors are often unaware that urinary cath- 50% reduction in catheter use and a 70% eterisation has been excessively prolonged reduction in CAUTIs throughout the hospital. in patients until a catheter-related compli- It highlighted the importance of a multi- cation occurs.9 Unlike an intravenous disciplinary approach to the management luer which is removed when a patient is of IDCs. The intervention caused a culture

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change for the facility, enhancing teamwork and ownership among disciplines involved Conclusion and in the care of patients with IDCs.15 recommendations The limitations of this audit include the • 4.1% of the sample had their IDCs small sample size of the audit, limiting the removed within the recommended propensity for greater statistical analysis 24 hours. The analysis is signifi cant due to the potential for signifi cant random in showing that we are not removing error. A longer audit period would enable catheters in patients according to the the inclusion of more patients, increasing AHA/ASA guidelines recommendation the possibilities for more extensive statis- of 24 hours. tical analysis. There was also limited • The average number of catheter days information on the patients’ follow up for our patient sample before removal urinary patterns, including whether of IDC was approximately fi ve days. patients required another IDC at their • 24.5% of our patient sample went on discharge destination. Furthermore, the to develop a urinary tract infection. patients who were discharged with a This is concerning for the adverse catheter in situ were not followed up in impact that infections have upon terms of TROC and UTI outcomes. The the rehabilitation process of stroke measurement of catheter days in the retro- patients. spective component of our audit was also dependent on the accuracy of nursing docu- • Consider if a patient has an appro- mentation in the Trendcare program. priate clinical indication for urinary catheterisation and document this, The main goals in the acute stroke unit before inserting an IDC. include commencing early rehabilitation, as well as the prevention, diagnosis and • Daily electronic reminders and management of stroke complications.3 prompting by all members of reha- There is limited high-quality data on the bilitation team concerning TROC are frequency, type, duration and indications important to reduce catheter days and for urinary catheter use in stroke patients. reduce infection rates. This is attributable to poor clinical docu- • Limited literature exists concerning mentation and because the topic has IDC removal in stroke patients. previously received little focus. Preventing There is signifi cant scope for further UTI after stroke can reduce length of hospi- research. 2 talisation and decrease the cost of care. • Recommendations for re-audit include The simple measures of eliminating the use having a longer time-period to capture and duration of unnecessary IDCs have the a greater sample size. A re-audit in potential to decrease the incidence of UTI, one year’s time is recommended to reduce the time to mobilisation, improve examine the rates of TROC within the patient comfort and ultimately result in guidelines, the rates of UTI and the improved outcomes for our stroke patients. rates of failed TROC in comparison to this baseline audit.

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Competing interests: Nil. Author information: Dushiyanthi Rasanathan, House Surgeon, Department of General Medicine, Waitemata District Health Board, Auckland; Xu Wang, General Medicine and Stroke Physician, Department of General Medicine, Waitemata District Health Board, Auckland. Corresponding author: Dr Dushiyanthi Rasanathan, House Surgeon, Department of General Medicine, Waitemata District Health Board, Shakespeare Road, Auckland. [email protected] URL: www.nzma.org.nz/journal-articles/trial-removal-of-indwelling-urinary-catheters-in-stroke- patients-a-clinical-audit-at-north-shore-hospital

REFERENCES: 1. Healthcare Infection 6. Gross JC, Hardin-Fanning F, Acute Stroke: Incidence Control Practices Advisory Kain M, et al. Effect of time and Risk Factors. PM R. Committee. Guideline for of day for urinary catheter 2018 Feb; 10(2):160–167. Prevention of Catheter removal on voiding behav- 12. Meddings J, Rogers MA, Associated Urinary Tract iors in stroke patients. Urol Krein SL, et al. Reducing Infections. Atlanta (GA): Nurs. 2007 Jun; 27(3):231–5. unnecessary urinary Centers for Disease Control 7. Crouzet J, Bertrand X, catheter use and other and Prevention; 2019. Venier AG, et al. Control strategies to prevent 2. Poisson SN, Johnston SC, of the duration of catheter associated urinary Josephson SA. Urinary tract urinary catheterization: tract infection: an integra- infections complicating impact on catheter tive review. BMJ Qual Saf. stroke: mechanisms, associated urinary tract 2014 Apr; 23(4):277–89. consequences, and possible infection. J Hosp Infect. 13. Waitemata District Health solutions. Stroke. 2010 2007 Nov; 67(3):253–7. Board. Best Care Bundle Apr 1; 41(4):e180–4. 8. Intercollegiate Stroke Urinary Retention. 3. Ntaios G, Papavasileiou V, Working Party. National Auckland (NZ): Waitemata Michel P, et al. Predicting clinical guideline for District Health Board; 2018. functional outcome and stroke. London: Royal 14. Tyson AF, Campbell symptomatic intracranial College of Physicians; EF, Spangler LR, et al. hemorrhage in patients 2016. Report No.: 5. Implementation of a with acute ischemic 9. Winstein CJ, Stein J, Arena Nurse-Driven Protocol stroke: a glimpse into the R, et al. Guidelines for Adult for Catheter Removal crystal ball?. Stroke. 2015 Stroke Rehabilitation and to Decrease Catheter Mar; 46(3):899–908. Recovery: A Guideline for Associated Urinary Tract 4. Son SB, Chung SY, Kang S, Healthcare Professionals Infection Rate in a Yoon JS. Relation of urinary From the American Heart Surgical Trauma ICU. J retention and functional Association/American Intensive Care Med. 2018 recovery in stroke patients Stroke Association. Stroke. Jan 1:885066618781304. during rehabilitation 2016 Jun; 47(6):e98–e169. 15. Parry MF, Grant B, Sestovic program. Ann Rehabil Med. 10. Waitemata District Health M. Successful reduction 2017 Apr; 41(2):204–210. Board. Urethral Catheter in catheter associated 5. Lo E, Nicolle LE, Coffi n Management-Urology. urinary tract infections: SE, et al. Strategies Auckland (NZ): Waitemata focus on nurse-directed to prevent catheter District Health Board; 2016. catheter removal. Am associated urinary tract 11. Frost FS, Fan Y, Harrison J Infect Control. 2013 infections in acute care A, et al. Failed Removal Dec; 41(12):1178–81. hospitals. Infect Control of Indwelling Urinary Hosp Epidemiol. 2014 Catheters in Patients With Sep; 35 Suppl 2:S32–47.

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A persuasive approach to antimicrobial stewardship in Christchurch hospitals produced a sustained decrease in intravenous clarithromycin dosing and expenditure via a switch to azithromycin orally Sharon J Gardiner, Sarah CL Metcalf, Anja Werno, Matthew P Doogue, Stephen T Chambers, on behalf of the Canterbury District Health Board Antimicrobial Stewardship Committee

ABSTRACT AIMS: To assess a persuasive multimodel approach to decreasing unnecessary intravenous (IV) clarithromycin use for community-acquired pneumonia (CAP) in Canterbury District Health Board (CDHB) hospitals. METHODS: In December 2013, CDHB guidelines for empiric treatment of CAP changed to prioritise oral azithromycin over IV clarithromycin. The multimodel approach we used to implement this change included obtaining stakeholder agreement, improved guidelines access, education and pharmacist support. The impact of the intervention was evaluated by comparing macrolide usage and expenditure for the four years pre- and post-intervention. RESULTS: Mean annual clarithromycin IV use decreased by 72% from 6.4 to 1.8 defined daily doses (DDDs) per 1,000 occupied bed days (OBDs) post-intervention, while oral azithromycin increased by 833% (4.2 to 39.2 DDDs per 1,000 OBDs). Concurrently, oral clarithromycin use decreased by 91% (32.9 to 2.9 DDDs per 1,000 OBDs), and roxithromycin by 71% (17.0 to 5.0 DDDs per 1,000 OBDs). Mean annual total macrolide use decreased by 21% (68.2 to 53.9 DDDs per 1,000 OBDs), while expenditure decreased by 69% mainly through avoided IV administration. CONCLUSIONS: A persuasive multimodel approach to support adoption of CAP guidelines produced a sustained decrease in IV clarithromycin use, which may have clinical benefits such as reduced occurrence of catheter-related complications.

aximising the use of oral rather IV line-related infections, increased patient than intravenous (IV) antimicro- mobility, reduced nursing time and earlier Mbial agents is one of the safest and discharge from hospital.1 Our unpublished most cost-effective interventions available in internal audit (2011) of community-acquired antimicrobial stewardship (AMS), provided pneumonia (CAP) management showed that that an effective concentration reaches the many clinically stable patients unnecessarily site of infection with oral dosing. Advan- received a macrolide via the IV route. Possi- tages of the oral route include avoidance of ble reasons for this include delays in clinical

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reassessment of patient progress, lack of Management Agency (‘PHARMAC’) funding clinical confi dence in oral formulations, fear azithromycin in the community (fi ve days’ about patient complaints and medical team maximum per prescription for any indi- dynamics.2,3 Local prescribers were partic- cation) in December 2012 (improving ularly concerned that the oral regimen for accessibility and reducing cost), as well as CAP should be highly effective for treating in hospital. Clarithromycin IV was retained Legionnaires’ disease because of the high in the guideline for patients with severe rates of Legionella longbeachae infection in disease and those unable to take medicines the region.4,5 orally (Table 1). The committee gave the task In 2013 our AMS committee recom- of leading this change to a newly appointed mended that the Canterbury District Health AMS pharmacist. Key stakeholders including Board (CDHB) hospital guidelines for senior respiratory, general medicine and management of CAP include oral azithro- emergency medicine physicians agreed to mycin (rather than oral roxithromycin or the changes prior to release of the guidelines ‘defaulting’ to IV clarithromycin) when an in December 2013. Here, we describe the agent active against Legionella spp., was collection of persuasive strategies used to indicated. The ability to prescribe azithro- facilitate adoption of the new CAP guidelines mycin for inpatient management of CAP in our hospitals, together with an evaluation had been facilitated by the Pharmaceutical of the impact of this initiative on macrolide usage and expenditure.

Table 1: Empirical antimicrobial guideline for community-acquired pneumonia (CAP) in Canterbury District Health Board (CDHB) hospitals (2013), with key changes from the previous version identifi ed.

CAP severity New guideline (published December 2013) Key changes from previous version Mild amoxicillin PO 500mg three times daily azithromycin replaced roxithromy- (CURB-65 0-1) or cin azithromycin PO 500mg once dailya

Moderate amoxicillin IV 1g every 8 hours oral azithromycin or doxycycline (CURB-65 2) Add, if risk factors for Legionella spp., replaced IV clarithromycin azithromycin PO 500mg once dailya or doxycycline PO 200mg once daily

Severe amoxicillin+clavulanate IV 1.2g every 8 hours new recommendation to give only (CURB-65 3-4) and either one or two clarithromycin IV doses clarithromycin IV 500mg every 12 hours before changing to oral azithromycin or azithromycin PO 500mg once daily

Extremely ce riaxone IV 2g every 12 hours severeb and (CURB-65 5) gentamicin IV every 24 hours and clarithromycin IV 500mg every 12 hours

CURB-65 pneumonia severity score, which predicts mortality based on assignment of points for Confusion, Urea concentration, Respiratory rate, Blood pressure and age (65 years or older).20 IV, intravenous; PO, per os. a. Acceptable alternative azithromycin regimen for mild to moderate CAP was 500mg initially then 250mg once each day for four days (both regimens comprised 1,500mg per course). b. CDHB guidelines for immunocompetent patients with severe CAP treated in the intensive care unit di er and comprised ciprofloxacin IV plus amoxicillin+clavulanic IV.

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brief (10 minute) teaching sessions Methods to staff in key clinical areas, such as Setting the general medical wards and the CDHB provides government-funded emergency department. The presen- healthcare services for a population tations outlined the guideline changes of ~570,000 people in Canterbury, New as well as the relative advantages and Zealand.6 The Christchurch Hospital disadvantages of IV clarithromycin campus, which is the largest CDHB facility versus oral azithromycin including at ~800 beds,7 offers a full range of inpatient consideration of IV catheter-related and outpatient services, and receives more complications, drug interactions, than 95% of acute admissions for CDHB. dosing regimen and cost. An infec- The CDHB hospital AMS committee has tious diseases physician participated multidisciplinary (pharmacists, junior in the education sessions when the and senior doctors, nurses and laboratory audience included senior medical scientists) membership from services that doctors. Written information to include Infectious Diseases, Pharmacy, support key messages comprised Clinical Microbiology and Clinical Phar- bulletins (single-sided A4 documents) macology. One of its core functions is to disseminated electronically to clinical produce hospital guidelines for management staff at baseline (December 2013) of common infections. The committee and at four months into the initiative primarily uses persuasive rather than (April 2014) highlighting the initial restrictive approaches to infl uence antimi- progress made, along with a poster crobial prescribing. Persuasive measures placed in clinical areas. include local consensus building processes 3. Access to macrolides: Clarithromycin and discussion with opinion leaders during IV vials were removed from most guideline development as well as multi- wards except from locations such modal clinician education and verbal as the emergency department that reminders from pharmacists.8 There were need rapid access for acutely unwell some restrictive interventions in place prior patients. The intent was to have to the intervention. These were selective most requests for clarithromycin IV laboratory reporting of susceptibilities to screened against the guidelines by the respiratory pathogens,8 with some external pharmacy department for appropri- antimicrobial restrictions applied by ateness prior to supply. Prescriptions PHARMAC9. For example, levofl oxacin is that appeared inconsistent with not publicly funded at all in New Zealand the guidelines would be discussed while moxifl oxacin is only funded for with the prescribing medical team, specifi c subsets of patients with CAP such but clarithromycin IV could still be as those with multiresistant Streptococcus dispensed even if the intended use pneumoniae. was not compliant with guidelines. Multimodel approach to facilitate Access to azithromycin 250mg tablets was assisted by adding it to clinical guidelines adoption areas as a ‘stock’ item. 1. Guideline access: Access to CDHB anti- microbial guidelines was improved 4. Ongoing support by healthcare via a new easily searchable elec- providers: The specialist AMS phar- tronic format that replaced the macist led this initiative, supported existing Portable Document Format by infectious diseases physician (PDF) and was accessible on mobile champions who also worked in devices (tablets and phones) as well general medicine, likely assisting as computers.10 Hardcopies (book with changing practice. Additionally, and poster) of the guideline were also pharmacy staff in clinical areas and available in clinical areas. the dispensary actively supported this initiative by engaging with 2. Education: Verbal education sessions prescribers when clarithromycin IV for medical, nursing and pharmacy use appeared inconsistent with the staff were conducted by the AMS guidelines, and by promoting an early pharmacist. These comprised ~20 switch to oral azithromycin.

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Macrolide usage and expenditure (2014–2017) the guideline change. Data Data on adult inpatient macrolide usage for adult inpatients were included. Paedi- and expenditure at the four main CDHB atric and psychiatric inpatients, and all hospitals—Christchurch, Christchurch outpatient areas were excluded. All dosage Women’s, Burwood and the Princess formulations (IV, and solids and liquids for Margaret—were extracted from hospital oral administration) of macrolides used at pharmacy dispensing software (ePharmacy, CDHB hospitals were included (Table 2). v1.7, DXC Technology, VA, US) into Microsoft Usage was expressed as defi ned daily doses Excel™. The time periods evaluated were (DDDs) per 1,000 occupied bed days (OBDs) the four years before (2010–2013) and after for the individual macrolides, and for all macrolides combined.11

Table 2: Mean annual macrolide usage and expenditure for adult inpatients in Canterbury District Health Board (CDHB) hospitals for the four years before (2010–2013) and after (2014–2017) the changes in empiric antimicrobial guidelines for community-acquired pneumonia (CAP). Oral formulations (tablets and suspension) for each macrolide are com- bined, as relevant.

Formulations in use at CDHB DDDs per 1,000 OBDs Expenditure hospitals (mean usage per year) (unadjusted mean cost in $NZ per year) Form Strength (cost per unit*) 2010–2013 2014–2017 % Change 2010–2013 2014–2017 % Change

Azithromycin Tab 250mg ($0.30–$0.35) 500mg ($0.53–$3.12)a 4.2 39.2 ↑ 833% $1,035 $4,133 ↑ 300% Susp 200mg/5mL ($6.60–$12.50)b

Clarithromycin Vial 500mg ($12.04–$30.00)c 6.4 1.8 ↓ 72% $106,734 $23,967 ↓ 78%

Tablet 250mg ($0.28–$0.58)d 500mg ($0.74–$1.75)e 32.9 2.9 ↓ 91% $12,018 $710 ↓ 94% Susp 125mg/5mL ($23.12) 250mg/5mL ($23.12)

Erythromycin** Vial 1g ($10.99–$16.00)f 2.5 2.5 ↔ $8,243 $10,559 ↑ 28%

Tablet 250mg ($0.23) 400mg ($0.18) 500mg ($0.47) 5.1 2.6 ↓ 49% $1,438 $748 ↓ 48% Susp 200mg/5mL ($4.57–$5.18) 400mg/5mL ($6.04–$6.99)

Roxithromycin Tablet 150mg ($0.15–$0.19) 17.0 5.0 ↓ 71% $1,706 $409 ↓ 76% 300mg ($0.29–$0.35)

Total 68.2 53.9 ↓ 21% $131,175 $40,526 ↓ 69%

DDD, defined daily doses; OBDs, occupied bed days; Susp, suspension; $NZ, New Zealand dollars. *Prices were CDHB hospital pharmacy acquisition costs (unpublished) per unit [tablet, vial or bottle (liquid)] until March 2013 when Pharmaceutical Management Agency (PHARMAC) subsidy prices were used.9 Dates for a price change greater than 20% were as follows: a: decrease from $3.12 to $0.63 February 2013, and to $0.53 July 2015; b: increase from $6.60 to $12.50 per 15mL August 2015; c: decrease from $30.00 to $20.40 July 2015, and to $12.04 December 2017; d: decrease from $0.58 to $0.28 June 2014; e: decrease from $1.75 to $0.82 February 2012, and to $0.74 July 2014; f: increase from $10.99 to $16.00 March 2013. **Erythromycin salts were lactobionate (IV), stearate (250mg, 500mg) and ethylsuccinate (400mg, 200mg/5mL, 400mg/5mL).

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Expenditure was determined in New offset by a substantial increase in use of Zealand dollars ($NZ) using the pharmacy azithromycin (by 833%). The mean number purchasing price per unit until 1 March of IV clarithromycin doses used (not stan- 2013, after which PHARMAC subsidy prices dardised against OBDs) annually was 3,601 were used.9 Costs of consumables for IV pre-initiative and 985 post-initiative. This administration were set as $NZ8.49 per equated to approximately 2,617 avoided dose for a giving set (Alaris secondary set, IV clarithromycin doses each year. There CareFusion, Switzerland), plus two sodium was no change in the mean annual usage chloride 0.9% infusion bags for the dose of erythromycin IV, which is the other IV (250mL) and for the post-dose fl ush (100mL). macrolide in use at CDHB hospitals. Other direct costs such as those of water for Mean annual expenditure for the four injection, syringes and needles for recon- years pre- and post-initiative are shown stitution, and indirect costs such as nursing in Figure 2 and Table 2. Overall, mean time were not included. expenditure on macrolides decreased by 69% ($NZ90,649) from $NZ131,175 per Results annum before the initiative to $NZ40,526 Macrolide usage and expenditure per annum after the initiative. Most of this resulted from savings attached to Mean annual macrolide usage for the four avoided use of clarithromycin IV and orally years before and after commencement of ($NZ82,767 and $NZ11,308 saved annually, this initiative are shown in Figure 1 and respectively), and was offset by a small Table 2. Overall mean annual macrolide increase in costs associated with azithro- use, as DDDs per 1,000 OBDs, decreased by mycin orally ($NZ3,098). The annual savings 21% post-initiative due to reductions in use ($NZ82,767) from avoided use of clarithro- of clarithromycin IV (by 72%), along with mycin IV were greater ($NZ104,000) if giving decreases in use of oral clarithromycin (by sets and infusion bags are also considered 91%), erythromycin (by 49%) and roxithro- (data not shown). mycin (by 71%). These reductions were

Figure 1: Macrolide usage per quarter in adult inpatients at four CDHB hospitals (2010–2017). Data presented as individual (combined oral formulations, and IV vials) and total macrolides, as defi ned daily doses (DDDs) per 1,000 occupied bed days (OBDs). Erythromycin not shown.

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Figure 2: Macrolide expenditure per quarter in adult inpatients at four CDHB hospitals (2010–2017). Data presented as individual (com- bined oral formulations, and IV vials) and total macrolides, in New Zealand dollars. Erythromycin not shown.

While not directly involved in the Discussion macrolide initiative, our guideline changes This initiative demonstrates that a for CURB-2 pneumonia also included collection of persuasive measures can doxycycline as an alternative to oral produce immediate and sustained changes azithromycin when cover against Legio- in antimicrobial prescribing practice with nella spp., was required. Doxycycline substantial cost savings. In this case, a usage (reported briefl y for completeness) multipronged campaign focusing on oral increased from around 16–17 per 1,000 azithromycin as the preferred macrolide for OBDs pre-initiative to around 20–23 DDDs CAP resulted in a ~70% decrease in use of per 1,000 OBDs post-intiative. However, both clarithromycin IV and roxithromycin we recently changed our CAP guidelines PO. With the mass shifts away from use to cease recommending doxycycline for of other macrolides at CDHB use of azith- Legionella spp., as local research suggested romycin increased by ~800% because of it may be ineffective.13 the low starting point. The large decrease The readily quantifi able benefi ts of our (~90%) in use of oral cla rithromycin was initiative were mainly through avoided likely because it had been used as the logical IV doses (~2,600 annually). The direct cost follow-on to clarithromycin IV. savings (drug plus some consumables) This initiative had strong support from of ~$NZ90,000 point to the ability of AMS medical staff who were confi dent in the programmes to generate fi nancial savings, effi cacy of azithromycin in Legionnaires’ potentially covering any investment disease.12 Routine polymerase chain reaction in resourcing.14 The clinical benefi ts of testing of lower respiratory specimens for appropriate avoided IV antimicrobial Legionella spp., commenced in 2010, which administration include reduced complica- was prior to our initiative.5 tions from IV access, shorter hospital length

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of stay and a lower need for outpatient usage were extracted from CDHB hospital parenteral antimicrobial therapy.1 A further pharmacy dispensing software, which benefi t of the shift away from clarithro- is a composite of dispensings to indi- mycin (IV and PO) is that azithromycin does vidual patients and to clinical areas. The not inhibit drug metabolism by cytochrome assumption that dispensings to clinical P450 3A appreciably, and thus carries a areas (eg, wards) match patient usage is much lower potential for adverse drug inter- often applied in hospital settings,17 but is actions.15 We have not made any estimate of clearly several steps away from adminis- the administration, health or cost benefi ts trations to patients. Second, we assumed of this initiative, other than those related that CAP was the dominant indication for directly to drug expenditure. However, it macrolide use in hospitalised patients at is probable that these extend beyond those CDHB. This seems likely from the bulk presented here. shifts in macrolide usage associated with We cannot determine the relevant our initiative, but some other infective weightings of the various components of (eg, atypical mycobacterial infections) and our multimodel initiative (specialist AMS non-infective (eg, prokinetic and anti-in- pharmacist, physician champions, stake- fl ammatory effects) indications will also holder support, multifaceted and repeated be in play. Third, an external restrictive education strategies, and ongoing pharmacy element for access to clarithromycin IV involvement) in terms of their contri- was applied on 1 July 2013, with PHARMAC bution to its overall success. However, restricting clarithromycin IV to second-line 18 it was largely a ‘front-loaded’ approach treatment of CAP until 1 June 2015. While that was completed within six months. these restrictions added a useful ‘argument’ One factor that we believe was integral to to drive a change in prescribing, the shift its success was obtaining the support of in macrolide prescribing coincided with senior clinicians from relevant specialties our initiative rather than with initiation prior to implementation, and ensuring that of the restrictions. Finally, this and other 19 there were multiple opportunities (verbal persuasive initiatives at CDHB may have education sessions plus memos, bulletins, been successful, in part, because of a long posters) for senior clinicians not involved history of prioritising a collegial approach in the initial guideline development to over removing the prescriber’s autonomy become aware of the changes. This recog- with enforced antimicrobial restrictions. nises the role of ‘prescribing etiquette’ On this basis, it should be noted that while (related to medical hierarchy) in antimi- restrictive interventions may produce a crobial prescribing behaviours within swifter change in antimicrobial prescribing, clinical teams, and the ability of healthcare both persuasive and restrictive approaches 8 leaders to infl uence the success of a quality produce a comparable effect at 12 months. improvement initiative.3 The improved In conclusion, we demonstrated that a effi cacy of azithromycin compared with multipronged initiative designed to improve other macrolides has been affi rmed since adoption of antimicrobial guidelines can then which may contribute to the sustained produce a substantial and sustained change acceptance of the regimen.16 in prescribing. In particular, we did not use The limitations of this work relate formal behaviour change techniques such primarily to the rather blunt mechanism as audit and feedback to individual teams or for assessing macrolide usage and patient prescribers. Rather, the aim was to create an outcomes. First, our data on macrolide enabling environment with which to change clinical practice.

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Competing interests: Dr Werno reports that she is a Member of the Anti-Infective subcommittee, Pharmacology and Therapeutics Advisory Committee (PTAC), PHARMAC (www.pharmac.health.nz). Acknowledgements: We thank Margaret Simpson (Pharmacy Services) and Andrew Villazon (Decision Support) of Canterbury District Health Board for their help with data extraction. We are also indebted to the Pharmacy Services at Canterbury District Health Board—their ongoing support is essential for the success of our AMS initiatives. Author information: Sharon J Gardiner, Antimicrobial Stewardship Pharmacist, Departments of Infectious Diseases, Clinical Pharmacology and Pharmacy, Christchurch Hospital, Canterbury District Health Board, Christchurch; Sarah CL Metcalf, Infectious Diseases Physician, Department of Infectious Diseases, Christchurch Hospital, Canterbury District Health Board, Christchurch; Anja Werno, Medical Microbiologist, Department of Microbiology, Canterbury Health Laboratories, Canterbury District Health Board, Christchurch; Matthew P Doogue, Clinical Pharmacologist, Department of Medicine, University of Otago, Christchurch; Stephen T Chambers, Infectious Diseases Physician, Department of Pathology, University of Otago, Christchurch. On behalf of the Canterbury District Health Board Antimicrobial Stewardship Committee. Corresponding author: Dr Sharon J Gardiner, Department of Infectious Diseases, Christchurch Hospital, PO Box 4710, Christchurch. [email protected] URL: www.nzma.org.nz/journal-articles/a-persuasive-approach-to-antimicrobial-stewardship- in-christchurch-hospitals-produced-a-sustained-decrease-in-intravenous-clarithromycin- dosing-and-expenditure-via-a-switch-to-azithromycin-orally

REFERENCES: 1. Barlam TF, Cosgrove SE, 4. Priest PC, Slow S, Chambers 7. Ministry of Health. Abbo LM, et al. Imple- ST, et al. The burden of Christchurch Hospital. menting an antibiotic Legionnaires’ disease in Wellington: New Zealand; stewardship program: New Zealand (LegiNZ): 2019. Available from: http:// guidelines by the Infec- a national surveillance www.health.govt.nz/your- tious Diseases Society of study. Lancet Infect health/certifi ed-providers/ America and the Society for Dis 2019; 19:770–7. public-hospital/christ- Healthcare Epidemiology 5. Murdoch DR, Podmore church-hospital Accessed of America. Clin Infect RG, Anderson TP, et al. 27 September 2019. Dis 2016; 62:e51–e77. Impact of routine system- 8. Davey P, Marwick CA, Scott 2. Broom J, Broom A, Adams atic polymerase chain CL, et al. Interventions K, Plage S. What prevents reaction testing on case to improve antibiotic the intravenous to oral fi nding for Legionnaire’s prescribing practices antibiotic switch? A disease: a pre-post compar- for hospital inpatients. qualitative study of hospital ison study. Clin Infect Cochrane Database Syst doctors’ accounts of what Dis 2013; 57:1275–81. Rev 2017; 2:CD003543. infl uences their clinical 6. Ministry of Health. doi: 10.1002/ 14651858. practice. J Antimicrob Canterbury DHB. Welling- CD003543.pub4. Chemother 2016; 71:2295–9. ton: New Zealand; 2019. 9. Pharmaceutical 3. Charani E, Castro-San- Available from: http://www. Management Agency chez E, Sevadalis N, et health.govt.nz/new-zea- (PHARMAC). Section al. Understanding the land-health-system/ H – Hospital Pharmaceu- determinants of antimi- my-dhb/canterbury-dhb ticals. Wellington: New crobial prescribing within (updated 25 February Zealand; 2019. Available hospitals: the role of 2019). Accessed 27 at: http://www.pharmac. “prescribing etiquette”. Clin September 2019. govt.nz/tools-resources/ Infect Dis 2013; 57:188–96. pharmaceutical-schedule/

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section-h/ Accessed 28 Legionella longbeachae to support antimicrobial September 2019. isolates. J Antimicrob stewardship in acute care 10. Canterbury District Health Chemother 2018; 73:1102–4. hospitals: a retrospective Board. The Pink Book. 14. Schuts EC, Hulscher observational study. Christchurch: New Zealand; MEJL, Mouton JW, et Eur J Clin Micro Infect 2019. Available from: al. Current evidence on Dis 2019; 38:347–55. http://www.pinkbook. hospital antimicrobial 18. Pharmaceutical Manage- org.nz/index.htm?toc. stewardship objectives: ment Agency (PHARMAC). htm?90640.htm Accessed a systematic review and Section H – Hospital 01 October 2019. meta-analysis. Lancet Pharmaceuticals. Update 11. WHO Collaborating Infect Dis 2016; 16:847–56. effective 1 June 2015. Centre for Drug Statistics 15. Westphal JF. Macrolide – Wellington: New Zealand; Methodology. Defi ned induced clinically relevant 2019. Available at: http:// daily doses. Defi nition and drug interactions with cyto- www.pharmac.govt. general considerations. chrome P-450A (CYP) 3A4: nz/2015/05/18/HMLUp- Geneva: Switzerland; 2018. an update focused on clar- datePubl.pdf Accessed Available from: http://www. ithromycin, azithromycin 01 October 2019. whocc.no/ddd/defi nition_ and dirithromycin. Br J Clin 19. Gardiner SJ, Metcalf SCL, and_general_considera/ Pharm 2000; 50:285–95. Chin PKL, et al. Metro- Accessed 01 October 2019. 16. Garcia-Vidal C, Sanchez-Ro- nidazole stewardship 12. Plouffe JF, Breiman driguez I, Simonetti AF, initiative at Christchurch RF, Fields BS, et al. et al. Levofl oxacin versus hospitals: achievable with Azithromycin in the azithromycin for treating immediate benefi ts. NZ treatment of Legionella legionella pneumonia: Med J 2018; 131:53–8. pneumonia requiring a propensity score anal- 20. Lim WS, van der Eerden hospitalization. Clin Infect ysis. Clin Microbiol MM, Laing R, et al. Defi ning Dis 2003; 37:1475–80. Infect. 2017; 23:653–8. community acquired 13. Isenman H, Anderson T, 17. Kallen MC, Natsch S, pneumonia severity on Chambers ST, Podmore RG, Opmeer BC, et al. How presentation to hospital: Murdoch DR. Antimicrobial to measure quantitative an international derivation susceptibilities of clinical antibiotic use in order and validation study. Thorax 2003; 58:377–82.

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On the use of a new monocular-indirect ophthalmoscope for retinal photography in a primary care setting Aqeeda Singh, Kirsten Cheyne, Graham Wilson, Mary Jane Sime, Sheng Chiong Hong

ABSTRACT AIM: There is consensus among general practitioners regarding the di iculty of direct ophthalmoscopy. Hence, there is increasing interest in smartphone-based ophthalmoscopes; the New Zealand-made oDocs Nun ophthalmoscope is one such device, released in November 2018. This study aims to subjectively assess the quality of the images captured with it in order to determine the feasibility of its use in a primary care setting. METHOD: Twenty-eight general practitioners (GPs) from di erent practices throughout New Zealand agreed to participate in this prospective observational study and were sent an oDocs Nun ophthalmoscope. Using the device, clinicians took retinal photographs of patients who presented with visual complaints and uploaded one image per eye onto a database. Three hundred and fi y-seven photographs were collated and rated by four professionals (two ophthalmologists and two optometrists) on the basis of image quality and the anatomical features visible. RESULTS: On a Likert scale from 1 (poor quality) to 4 (very good quality), the median and mode values for each professional’s rating of all photographs were both 2. On average, 94.5% of the photographs were deemed to have visible optic discs and 50.0% to have visible maculae adequate for detecting an abnormality. Pairwise comparison showed 93.7% agreement among the four professionals for optic disc visibility, and 74.2% agreement for macula visibility. CONCLUSION: The oDocs Nun is a promising tool which GPs could use to circumvent the challenges associated with direct ophthalmoscopy. With appropriate training to ensure proficiency, it may have a valuable role in telemedicine and tele-referral.

n 1851, Professor von Helmholtz rev- (HEINE Optotechnik, Herrsching, Germany) olutionised the ophthalmoscope, an are based on the above optical principle. instrument which is an indispensable It is widely agreed among primary care I 1,2 tool for examination of the human retina. clinicians that the modern direct ophthal- It is a small-scale Galilean telescope, where moscope is diffi cult to use and requires a the patient’s refractive media, namely the certain level of profi ciency.5,6 Direct ophthal- cornea and the lens, act as the objective lens moscopy is an old technique with multiple and the pin hole acts as the eye piece; the inadequacies, which are contributing to its result is a magnifi ed image of the retina but demise, such as its limited fi eld of view, ex- with a signifi cantly reduced fi eld of view.3,4 treme proximity to the patient, and the steep The modern direct ophthalmoscope, such as learning curve required to use it accurately. those manufactured by Welch Allyn (Hill- These factors have made the direct ophthal- Rom Services Inc, Alabama, US) and Heine moscope a poorly designed instrument for

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mass-uses; for example, emergency ocular The rationale of this study is to subjec- telemedicine or the diabetic retinopathy tively determine the quality of retinal screening programme.5,7,8 photographs acquired with the oDocs nun To address the aforementioned chal- ophthalmoscope in a primary care setting lenges of using the direct ophthalmoscope, by general practitioners (GPs), and see if Welch Allyn launched the PanOptic ophthal- anatomical regions of the human retina are moscope in the early 2000s. The product identifi able in those photographs. It aims is generally well received by the clinical to assess if the oDocs Nun is a feasible tool community; the device offers a wider fi eld to capture retinal images in a real-world of view and allows a smartphone adapter to clinical setting where patients present with be attached to acquire retinal photographs.9 ophthalmic problems, with implications for However, the maximum fi eld of view in telemedicine and tele-referral. dilated eyes is only 25° and is deemed to be inadequate for detecting some retinal Methods diseases, such as diabetic retinopathy, age-re- This was a prospective and observational lated macular degeneration, retinopathy of study designed to subjectively assess the prematurity, and peripheral retinal tear or quality of the retinal photographs acquired 10–12 detachment. The company also launched through the oDocs nun ophthalmoscope an iPhone (Apple Inc, California, US) adapter in a primary care setting. The study was called iExaminer that would allow clinicians approved by the University of Otago Human to acquire images of the retina. Since then, Ethics Committee. Māori consultation was there have been at least three known regula- carried out with Ngāi Tahu and Ngati Porou. tory-approved smartphone ophthalmoscopes launched by different companies. Peek Participants and study members A research participation invitation was Retina (Peek Vision Inc, UK) and D-Eye sent to 52 general practices throughout (D-Eye Care, Italy) are smartphone ophthal- New Zealand. A total of 28 general practi- moscopes based on the same principles of tioners agreed to participate in the study. direct ophthalmoscopes. These devices are At the time of the study, the physicians also limited by their narrow fi eld of view were all practising and registered with ranging from 10° to 20° fi eld of view.13 Volk the Royal New Zealand College of General (Volk Inc, US) released a smartphone-based Practitioners. ophthalmoscope (Volk iNview) with a larger fi eld of view (45°); however, there is limited Study members were recruited from clinical evidence of its quality and actual patients who presented to the primary care performance.14,15 Furthermore, the device is practices with visual complaints. Patients designed to fi t only the older generations of who fulfi lled the study criteria were given iPhone devices. the opportunity to participate in this study. The study criteria are listed in Table 1. A new ophthalmoscope, based on the principle of indirect monocular ophthalmo- Clinical protocol scopy, has been released by oDocs Eye Care The participating clinicians received (oDocs Eye Care Limited, New Zealand).16 standard training protocol, which included The company claims that the device is reading the user manual of the device, capable of acquiring high-quality retinal watching a two-minute training video, photographs with a fi eld of view of up to 40° and practices on fake eyes. The clinicians in eyes with a 6mm pupil and above, or 15° were allowed to practise the skill once they in non-mydriatic pupils as small as 2mm. felt confi dent and competent in using the Unlike the other smartphone ophthalmo- ophthalmoscope. scopes, the oDocs nun ophthalmoscope’s Patients who were accepted into the study phone adapter is compatible with a wider had the symptomatic eye dilated with tropi- range of smartphones including those from camide 1%. The clinician instilled one drop Android (Alphabet Inc, US) and Apple. The of tropicamide 1% into the patient’s eye. device can be used in conjunction with a The patients were then asked to wait in the smartphone for retinal image and video waiting room for at least 20 minutes. The acquisition for clinical photo-documentation clinician then used the video function of the and telemedicine. phone to acquire a live video of the retina

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Table 1: Inclusion and exclusion criteria for study participants.

Inclusion criteria Exclusion criteria 1.1 Patient with visual symptoms as below: 2.1 Patient with media opacities such as clinically Visual disturbances (blurry vision, loss of significant cataract, corneal ulcers or scars. vision or visual field) Other symptoms: Photopsia, floaters, aniseikonia, distortion Ocular pain

1.2 Patients aged between 18 and 85 years old. 2.2 Patient incapable of giving informed consent.

1.3 Patients with clinical indications for 2.3 Patient with contraindications for pharmacological dilated retinal examination pharmacological dilation. These include known (as per criteria 1.1). history of narrow angle, angle closure glaucoma, and adverse drug reaction to tropicamide.

1.4 Patients capable of following orders for 2.4 Patient physically or mentally incapable of verbal commands such as direction of gaze. following commands. These include patients with photophobia and blepharospasm. from which still photographs were extracted Rating of the photographs for analysis. Four experienced ophthalmic profes- The clinician chose only one still image sionals (two general ophthalmologists per eye to upload. The image selected was and two optometrists) were involved with requested to be of the highest image quality, rating each of the photographs collected, showing the widest fi eld of view, and which were presented in the form of a including the posterior pole of the human questionnaire. Two factors were rated for retina covering both the optic disc and the each photograph in the questionnaire: macula. photograph quality and the presence of Smartphones and depository of the anatomical features, namely the optic disc and macula. All professionals were photographs blinded from each other’s responses. The The smartphones used in the study were photographs were presented to the profes- either iPhone 7 or iPhone 8. The photo- sionals on a digital computer screen with a graphs were stored on password-protected minimum resolution of 1080 pixels by 720 smartphones and transferred to a pass- pixels. word-protected hard drive at the conclusion of the study. The four professionals fi rst rated the quality of each photograph using a Likert Data protection and storage scale ranging from 1 to 4. The score transla- Transfer of data between the GPs and tions were: researchers was done with encrypted 1. Poor quality and unacceptable technology. Clinicians uploaded the selected photographs onto Microsoft 2. Average quality and acceptable Azure (Microsoft Corp, US), an end-to-end 3. Good quality encryption storage platform. Microsoft 4. Very good quality Azure supports HIPAA compliance, which The terms ‘acceptable’ and ‘unacceptable’ can be regarded as equivalent to the New referred to the adequacy of the quality of Zealand HIPC requirement.17,18 the images to detect an abnormality. Photographs used were anonymised. The four professionals then rated if the Information such as name, date of birth, anatomical features of the retina, namely gender and age were collected for epidemi- the optic disc and macula, were visible in ological purposes but will not be linked or each image and adequate for detecting an made publicly available. Protocols for data abnormality, with binary responses of ‘yes’ management and collection were compliant or ‘no’. to the Health Information Privacy Code 1994.

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Statistical analysis Photograph quality: the quality of The end results were collated on a spread- most photographs was rated as at least sheet and Microsoft Excel (Microsoft Corp., average and acceptable by the ophthalmic Albuquerque, NM, US) was used for statis- professionals. tical analysis. Statistical measures such as On a Likert scale from 1 (poor quality and median and mode were calculated for image unacceptable) to 4 (very good quality), the quality, and percentages were calculated for median and mode values for each profes- identifi able anatomical features. For both sional’s rating of all photographs were either factors, inter-professional agreement was 2 or 3. The detailed medians and modes calculated as a percentage. This was done are given in Table 2. Across the four profes- using pairwise comparisons, which involved sionals, on average, 7.1% of the images were taking the number of times a professional rated as 1, 46.3% were rated as 2, 37.9% was in agreement with another profes- were rated as 3 and 8.7% were rated as 4. sional over the total number of pairwise Pairwise comparison showed that there was comparisons. 44.6% agreement between all four profes- sionals regarding these ratings.

Results Table 2: Median and mode values for each Patient demographics professional’s rating of all photographs for A total of 339 participants were recruited photograph quality. during the study period. Eighteen patients had bilateral retinal photographs and the Median Mode rest of the participants had only one eye Professional 1 3 3 examined with the oDocs Nun ophthalmo- scope. A total of 357 retinal photographs Professional 2 2 2 were acquired with the device. The mean Professional 3 2 2 age of the participants was 68.2 years old and the median age was 71 years old. One Professional 4 2 2 hundred and ninety-four (57.2%) of the Overall 2 2 participants were female and 145 (42.8%) were male.

Figure 1: Graph depicting the individual percentages of each professional for the proportion of photo- graphs having a visible optic disc adequate for detecting an abnormality.

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Figure 2: Graph depicting the individual percentages of each professional for the proportion of photographs having a visible macula adequate for detecting an abnormality.

Optic disc: all professionals agreed that being rated as 4 (very good quality), there the majority of the photographs had a was suffi cient agreement among all four visible optic disc adequate for detecting ophthalmic professionals that the quality of an abnormality. most of the retinal photographs taken by GPs Professionals’ ratings of the percentage using the oDocs Nun was acceptable. This of photographs in which there was a visible was supported by the high inter-professional optic disc adequate for detecting an abnor- agreement that the majority of the photo- mality ranged from 89.9% to 97.2%, with the graphs had an image of the optic disc that average being 94.5% (see Figure 1). Pairwise was suffi cient to detect any abnormalities. comparison showed an inter-professional However, there was also agreement among agreement of 74.2%. Out of the 357 images, the four professionals that only half of the there were only three images that all four photographs had an adequate image of the professionals agreed did not adequately macula to detect an abnormality. Although show the optic disc. there is rising popularity of indirect ophthal- moscopes, GPs are still more accustomed to Macula: on average, at least half of using the direct ophthalmoscope despite its the photographs were deemed to have a various drawbacks. 19,20 As a result, there is visible macula adequate for detecting an need for a longer training time before the abnormality. user becomes profi cient at utilising unfa- Professionals’ ratings of the percentage miliar equipment such as the oDocs Nun. of photographs in which there was a visible Nevertheless, the success of the oDocs Nun macula adequate for detecting an abnor- in capturing many images that professionals mality ranged from 44.0% to 67.2%, with the rated as being of acceptable quality for average being 50.0% (see Figure 2). Pairwise identifying an abnormality indicates the comparison showed an inter-professional potential of this instrument to be used as an agreement of 74.2%. ophthalmoscope in the primary care setting. As previously mentioned, the oDocs Nun Discussion is a new device based on the principle This study has successfully demonstrated of indirect monocular ophthalmoscopy; that the oDocs Nun is a promising tool compared to the direct ophthalmoscope, it which could be used to circumvent the has a wider angle of view (40°),21 as well as challenges associated with direct ophthal- potential greater ease and comfort of use moscopy. Despite only 8.7% of photographs due to having reduced patient proximity.8

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Moreover, compared to other smartphone only 15.8% of the responses were either 1 retinal imaging devices mentioned earlier or 4. This indicates that only two options which are simple direct ophthalmoscopes, for image quality (acceptable vs unac- the oDocs Nun has a wider fi eld of view, ceptable for detection of an abnormality) and has coaxial illumination.24 Beyond may have been needed in the question- this, the oDocs Nun could potentially have naire, which could have signifi cantly a signifi cant role in the fi eld of telemed- increased the inter-professional agreement. icine. Telemedicine refers to the practice Secondly, there were no measures taken of remote medicine through technological to determine intra-professional reliability; means, which includes remote consultation, for future research, it would be advanta- treatment, surgery and monitoring.22,23 geous to randomly select some images to Teleophthalmology is a branch of telemed- be reassessed by the same professional. icine which involves delivering eye care Moreover, the GPs may have needed more through either a store-and-forward method extensive training or longer time to become or real-time communication.24 There is accustomed to using the oDocs Nun before robust evidence to support that teleoph- uploading an image; greater practice with thalmology is suitable for things such as the device for all GPs may have increased screening for diabetic retinopathy.25,26 In the number of photographs with an this, teleophthalmology essentially involves adequate image of the macula. a trained individual, such as a GP, using This study has indicated that the oDocs a device which can produce adequate Nun is a suitable device that GPs can use in photographs of the retina that can be the primary care setting, which sidesteps sent to ophthalmologists for further eval- the challenges associated with the direct uation; the oDocs Nun could therefore ophthalmoscope. Previous studies have also potentially become an integral part of indicated the preference for indirect ophthal- teleophthalmology and emergency teleoph- moscopes by health practitioners;21,30–32 27 thalmology. Ethical issues revolving around utilisation of devices such as the oDocs patient security and privacy are no longer Nun could improve the implementation of hindrances as there are multiple platforms complete eye examinations by GPs. Although now built with legal compliance; there is also mydriasis was used in this study, the oDocs global progress towards creating paperless Nun is suitable for non-mydriatic pupils, 28,29 automated digital workfl ows in hospitals. hence saves time during consultations. The Fundamentally, the advancement of the fi eld oDocs Nun also may have a role in screening of teleophthalmology with novel devices such programmes because of its ease of use as the oDocs Nun enables many advantages: and potential application of telemedicine. short examination time, electronic medical Moreover, it is a device which could also be photographs, the ability of non-ophthalmol- used to teach ophthalmological techniques to ogists to screen for diseases, and a decreased medical students because of its ease of use. need for further resources, especially in rural In conclusion, it was found that the or deprived areas, for example.26,27 oDocs Nun is a new and promising indirect There are various limitations of this study ophthalmoscope. Overall, most photo- as well as areas which may be improved graphs were rated by professionals to be of for future research. Firstly, the ques- acceptable quality; 94.5% of photographs tionnaire for the four professionals used were deemed to a visible optic disc and subjective terms in the questions, which 50.0% had visible maculae which were were dependent on the interpretation of adequate for detecting an abnormality. the professionals. This may have intro- As compared with other similar devices, duced systematic errors if the defi nitions the oDocs Nun offers a wider fi eld of view, of the terms were different for each profes- co-axial illumination and image acquisition sional. Regarding image quality, although capabilities when used in conjunction with a all professionals rated the majority of smartphone. The device has potential roles the photographs as above average and in telemedicine, screening programmes, acceptable, there was low inter-profes- and student learning, and it may success- sional agreement of only 44.6%. This may fully reduce the obstacles GPs face in have been due to there being four points ophthalmic consultations related to the on the Likert scale; as mentioned above, direct ophthalmoscope.

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Competing interests: Dr Sime and Dr Hong report non-fi nancial support from oDocs Eye Care Ltd outside the submitted work. In addition, Dr Hong has a patent Co-axial illumination issued. Acknowledgements: The authors would like to thank Dr Kelechi Ogbuehi and Vishal Narkhede for their contribution to this study. Author information: Aqeeda Singh, Student, Dunedin School of Medicine, University of Otago, Dunedin; Kirsten Cheyne; Research Assistant, Ophthalmology Department, University of Otago, Dunedin; Graham Wilson, Gisborne Hospital, Tairawhiti District Health Board, Gisborne; Mary Jane Sime, Dunedin Hospital, Southern District Health Board, Dunedin; Sheng Chiong Hong, Christchurch Hospital, Canterbury District Health Board, Christchurch. Corresponding author: Aqeeda Singh, Dunedin School of Medicine, University of Otago, 6/543 George Street, Dunedin 9016. [email protected] URL: www.nzma.org.nz/journal-articles/on-the-use-of-a-new-monocular-indirect- ophthalmoscope-for-retinal-photography-in-a-primary-care-setting

REFERENCES: 1. Keeler R, Burrows C, Singh 7. Gill JM, Cole DM, Lebowitz 12. Brazionis L, Ryan C, Yao AD. The 150th anniver- HM, Diamond JJ. Accuracy JJ, Bursell S-E, Jenkins sary of the binocular of screening for diabetic A. Comparison of two indirect ophthalmoscope: retinopathy by family ultra-portable, low-cost, 1861–2011. British Jour- physicians. Ann Fam digital non-mydriatic nal of Ophthalmology Med 2004; 2:218–20. retinal cameras for ocular 2011; 95:306–7. 8. Petrushkin H, Barsam A, health screening and 2. Medow NB, Albert DM. Mavrakakis M, Parfi tt A, retinal calibre measure- Ophthalmoscope quickly Jaye P. Optic disc assess- ment in adults with or changed view of the ment in the emergency without diabetes. Austra- eye. Ophthalmology department: a compar- lian Diabetes Society and Times; Monmouth Junc- ative study between the Australian Diabetes tion 1999; 24:9–11. the PanOptic and direct Educators Association Annual Scientifi c Meet- 3. Wilkinson ME. Essen- ophthalmoscopes. Emerg ing 2015. Adelaide, tial Optics Review for Med J 2012; 29:1007–8. South Australia 2015. the Boards. United 9. DeMeis R. Ophthalmoscope States: Medrounds widens retinal view. 13. Bastawrous A, Giardini Publication; 2006. Design News; Manhas- ME, Bolster NM, et al. Clinical Validation of a 4. Hughes HA, Everitt PF. sett 2002; 57:2. Smartphone-Based Adapter On the fi eld of view of 10. Allyn W. PanOptic™ for Optic Disc Imaging in a Galilean telescope. Ophthalmoscope and Kenya. JAMA Ophthal- Transactions of the iExaminer™ System. mol 2016; 134:151–8. Optical Society 1920;22. Skaneateles Falls, NY 13153 14. Felgueiras So, Costa Jo, 5. Mackay DD, Garza PS, USA: Welch Allyn; 2016. alves JoG, Soares F. Mobile- Bruce BB, Newman NJ, 11. Tan A, Mallika P, Aziz based Risk Assessment of Biousse V. The demise S, Asokumaran T, Diabetic Retinopathy using of direct ophthalmos- Intan G, Faridah H. a Smartphone and Adapted copy: A modern clinical Comparison between the Ophtalmoscope. 11th challenge. Neurol Clin panoptic ophthalmoscope International Conference Pract 2015; 5:150–7. and the conventional direct on Health Informatics. ophthalmoscope in the 6. Yusuf IH, Salmon JF, Porto, Portugal 2018. Patel CK. Direct ophthal- detection of sight threaten- 15. Bandello F, Zarbin MA, moscopy should be ing diabetic retinopathy: Lattanzio R, Zucchiatti I. taught to undergraduate the kuching diabetic eye Management of Diabetic medical students-yes. Eye study. Malays Fam Physi- Retinopathy Karger; 2017. (Lond) 2015; 29:987–9. cian 2010; 5:83–90.

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16. oDocs nun - The next 22. Zhao L, Ma Y, Yang G, 27. Sreelatha OK, Ramesh generation ophthalmo- Meng Q. Research on SV. Teleophthalmology: scope. oDocs Eye Care, development and appli- improving patient 2018. 2019, at http://www. cation of Tele-medicine. outcomes? Clin Ophthal- odocs-tech.com/odocs-nun/ International Conference mol 2016; 10:285–95. 17. Is Azure HIPAA Compli- on Computer and Commu- 28. Hale TM, Kvedar JC. Priva- ant? HIPAA Journal, nication Technologies in cy and Security Concerns 2018. 2019, at http:// Agriculture Engineering in Telehealth. AMA Journal www.hipaajournal.com/ 2010 June 2010. p. 347–50. of Ethics 2014; 16:981–5. azure-hipaa-compliant/ 23. Simon P. Telemedicine. 29. Digital health. New Zealand 18. Yogarajan V, Mayo M, In: André A, ed. Digi- Government, 2019. at Pfahringer B. Privacy tal Medicine. Cham: http://www.health.govt.nz/ protection for health Springer International our-work/digital-health) Publishing; 2019:9–27. information research in 30. McComiskie JE, Greer RM, New Zealand district health 24. Bahaadinbeigy K, Yogesan Gole GA. Panoptic versus boards. The New Zealand K. A Literature Review conventional ophthalmo- Medical Journal 2018; 131. of Teleophthalmology scope. Clin Exp Ophthalmol 19. Chiong HS. Ophthal- Projects from Around 2004; 32:238–42. the Globe. In: Yogesan K, moscopy through the 31. Lowe J, Cleland CR, Goldschmidt L, Cuadros ages. NZ Optics 2018 Mgaya E, et al. The J, eds. Digital Teleretinal December 2018:14–20. Arclight Ophthalmoscope: Screening: Springer-Verlag 20. Harle DE, Davies K, Shah A Reliable Low-Cost Berlin Heidelberg; 2012. R, et al. Technical Note: Alternative to the A comparison of a novel 25. Shackelford J. The effective- Standard Direct Ophthal- direct ophthalmoscope, the ness of diabetic retinopathy moscope. J Ophthalmol Optyse, to conventional screening by primary care 2015; 2015:743263. providers: A systematic direct ophthalmoscopes. 32. Wu AR, Fouzdar-Jain S, Suh review of literature. Wich- Ophthalmic Physiol DW. Comparison Study of ita, United States Wichita Opt 2007; 27:100–5. Funduscopic Examination State University; 2006. 21. Day LM, Wang SX, Huang Using a Smartphone-Based CJ. Nonmydriatic Fundo- 26. Cummings DM, Morrissey Digital Ophthalmoscope scopic Imaging Using S, Barondes MJ, Rogers L, and the Direct Ophthalmo- the Pan Optic iExaminer Gustke S. Screening for scope. J Pediatr Ophthalmol System in the Pediatric diabetic retinopathy in Strabismus 2018; 55:201–6. Emergency Department. rural areas: the potential Acad Emerg Med of telemedicine. J Rural 2017; 24:587–94. Health 2001; 17:25–31.

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Admission to ICU “solely for possible organ donation”—audit of current New Zealand practice Stephen Streat, Annette Flanagan, Joanne Ritchie

ABSTRACT AIM: Admission of patients with likely fatal illness to ICU “solely for possible organ donation” has been a long-standing practice in New Zealand. This is advocated as a means of increasing the availability of organs for transplant. We sought to determine the extent and characteristics of current clinical practice. METHOD: We identified patients admitted “solely for possible organ donation” from a total of 2,686 patients who died in the 24 public hospital ICUs in New Zealand between 1 July 2017 and 30 June 2019. We determined their characteristics, resource utilisation and organ and tissue donation outcomes. RESULTS: There were 49 patients (F26, M23; age range 9 days to 79 years, median 57 years, European 36, Māori 11, Pacific 1, Asian 1). On 26 occasions (57%) ICU admission was preceded by a “preliminary family discussion about donation”. Eighteen of the 24 ICUs admitted at least one patient (range 1 to 13, median 2) over the two-year period. All 49 patients had evidence of catastrophic brain damage at the time of ICU admission; they used a total of 60 ICU days, including 15.5 days for one patient who was actively treated a er spontaneous improvement. Death occurred between 5 minutes and 15 days, median 18.7 hours a er ICU admission; all but one death occurred by 82 hours. Distribution of ICU stay was similar for the 20 patients who donated and for those 29 who did not. Brain death developed in 22 patients, 20 of whom donated 63 organs, 15% of the total 430 organs donated by all deceased donors over the period. Organs from 20 donors were transplanted into 58 recipients, 14% of the total 417 recipients of deceased-donor organs over the period. Nine of the 49 patients also donated tissues for transplantation. CONCLUSION: There are already a small number of patients being admitted to ICUs in New Zealand “solely for possible organ donation”, the majority following prior family discussion of donation. These patients occupy a small number of ICU bed-days and contribute ~15% of the deceased donation activity. Organ Donation New Zealand has developed and recently promulgated recommended best practice guidelines for clinicians in the ICU and emergency departments and is supporting expansion of the practice within the scope of these guidelines.

he practice of admitting patients with to provide for the needs of other critically likely fatal acute illness to ICU “solely ill patients. In 2014 Organ Donation New Tfor possible organ donation” is in- Zealand (ODNZ), in collaboration with creasingly being advocated for as a potential clinicians in intensive care medicine and source of additional organs for transplan- emergency medicine, began developing best tation. This practice has a comparatively practice clinical guidelines on this practice. favourable cost-utility when compared to In 2017 ODNZ began prospectively collect- ICU admission for other indications.1 Some ing additional data about the practice as intensive care clinicians have expressed part of our confi dential national registry of concerns about the boundaries of moral deaths in public hospital ICUs. In June 2019 rectitude of this practice, its impact on the our best practice guidelines2 were released families of dying patients and the effect to clinicians. More recently the Australian that it might have on the ability of the ICU and New Zealand Intensive Care Society

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(ANZICS) recommended that “intensivists, the current extent and nature of the in collaboration with donation staff, should clinical practice of admitting critically ill develop local pathways so that patients with patients to ICU “solely for possible organ potential for organ donation who are near donation”. Data of interest were analysed the end of life in other hospital departments within an Excel® spreadsheet which or remote centres are referred to an inten- included demographics, clinical details, sive care unit for exploration of the possi- whether a preliminary family discussion bility of organ donation.”3 The ODNZ best about donation had taken place before ICU practice guidelines are consistent with this admission, the ICU length of stay, organ (and recommendation. tissue) donation outcomes, and the organs We sought to determine the existing extent and tissues actually transplanted. The extent of the practice in New Zealand including of donation from these actual donors was the incidence, patient circumstances, use of reported in the context of donation from all ICU resource, organ (and tissue) donation other deceased donors over the same time outcomes and the extent to which these period. Estimates of the costs and benefi ts of donation outcomes contributed to transplan- the practice of admission “solely for possible tation. We used these data along with other organ donation” were made from these data reported sources1,4 to make estimates of the and other reported sources. Simple para- costs and benefi ts of the practice and place metric statistics were used as appropriate. these in a broader context. Results Method There were a total 2,686 deaths in the ODNZ has maintained a confi dential 24 public hospital ICUs over the two-year voluntary registry of all deaths in the 24 study period (1 July 2017 to 30 June 2019), New Zealand public hospital ICUs since including 49 deaths of patients who had 2008. The registry is used by ODNZ as part been admitted to ICU “solely for possible of a comprehensive quality improvement organ donation”. On 26/49 occasions (57%) programme to ensure that opportunities for the ICU admission occurred after a “prelim- deceased organ (and tissue) donation are inary family discussion about donation”. recognised and appropriately supported. Table 1 shows demographic and clinical The registry is hosted by a private provider details of the 49 patients, and Table 2 shows and includes detailed clinical information the cause of death for those who did [n=22] relevant to possible organ donation. Data and did not [n=27] become brain dead. are entered online, soon after a patient’s Table 1: Gender, age and ethnicity of 49 patients death by authorised nurses with individual admitted to ICU “solely for possible organ passwords in every ICU (‘ICU Donation Link donation”. Nurses’). Each patient is assigned a unique identifi er by the data hosting company for Gender 26 F, 23 M the purposes of communication between the ICUs and ODNZ. Data are anonymised, Age Range 9 days to 79 years, median encrypted, securely maintained and made 57 years available to ODNZ. Two additional data Ethnicity European 36, Māori 11, Pacific 1, elements have been collected since July Asian 1 2017: “Was the patient admitted to ICU solely for possible organ donation?” and “Did a preliminary family discussion about Sixteen of the 24 ICUs had admitted at donation take place before ICU admission?” least one patient (range 1 to 13, median 2). ODNZ maintains a separate confi dential Prior “preliminary family discussion about registry of all deceased organ donors since donation” was no more common in the 1993. This includes which organs from each three ICUs who admitted six or more such donor were actually transplanted. patients than in the other 13 ICUs (15/27 vs 11/22, Fishers exact test value = 0.9, NS). This study was a two-year (1 July 2017 to The 49 patients used a total of 60 ICU days, 30 June 2019) retrospective audit of these including 15.5 days for one patient who two registries, which sought to establish was actively treated after spontaneous

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Table 2: Cause of death in 49 patients admitted to ICU “solely for possible organ donation”.

Brain dead [n=22] Not brain dead [n=27] Total [n=49] Intracerebral haemorrhage 5 10 15

Subarachnoid haemorrhage 6 8 14

Traumatic brain injury 6 5 11

Hypoxic-ischaemic encephalopathy 0 3 3

Spontaneous subdural haemorrhage 2 1 3

Cerebral infarct 2 0 2

Brain tumour 1 0 1 improvement before deteriorating due to late re-bleeding from a cerebral artery Discussion aneurysm. Death occurred between fi ve This is the fi rst study to accurately minutes and 15 days, median 18.7 hours quantify the existing practice in New after ICU admission; all but one death Zealand of admitting patients to the ICU occurred by 82 hours. Distribution of ICU “solely for possible organ donation”. The stay was similar for the 20 patients who practice is established in New Zealand, with donated and for those 29 who did not. Brain two thirds of the ICUs having admitted at death was determined to have developed least one patient solely for possible organ in 22 patients, 20 of whom donated organs. donation over the two years of the study. Table 3 shows the organs donated and There is considerable variability between transplanted from these donors, along with ICUs in the frequency with which this organs transplanted from all other deceased occurs. This is likely to refl ect both hospital donors over the same two years. size and services, and also aspects of both ICU and ED culture and communication These 20 donors (15% of the 136 total around patients at the end of life. There is deceased donors over the period) donated also variability in the frequency in which 63 organs, 15% of the total 430 organs ICU admission is preceded by a preliminary donated by deceased-donors. The 63 organs discussion of organ donation, although such were transplanted into 58 recipients, 14% of discussion did occur on 57% of occasions. the 417 recipients of organs from deceased- donors. Nine patients, including four who Admission policies in New Zealand donated organs, also donated tissues (eight ICUs, in line with worldwide consensus donated eyes and two donated heart valves). recommendations,5 prioritise admission

Table 3: Organs donated and transplanted from donors admitted solely for possible organ donation, and from all other deceased donors, together with the number of corresponding transplanted recipi- ents* over two years 1 July 2017 to 30 June 2019.

“Admitted for possible organ donation” All other donors Total (DBD, n=20) (DBD 101, DCD 15) Hearts 8 33 41

Lungs 7 48 (DCD 4) 55

Livers 16 79 (DCD 1) 95

Kidneys 31 199 (DCD 25) 230

Pancreas 1 8 9

Organs 63 367 430

Recipients* 58 359 417

*Note: Some recipients received multiple organ transplants.

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to patients who are most likely to derive ICU stay of all 49 patients would be $330,000 benefi t from that admission. These patients ($6,735 per admitted patient) or $244,750 have a potentially reversible acute illness for 48 patients ($5,099 per patient) if the which is too severe to be managed in a actively treated patient is excluded. Attrib- ward setting, and not so severe that death uting these costs to the 58 recipients of is extremely likely irrespective of ICU donated organs would result in an addi- admission. In that context however, there tional cost per recipient of $5,690 [all 49 ICU are some situations where end-of-life care admissions] or $4,220 [48 ICU admissions is probably best provided in an ICU setting not actively treated]. This is approximately (eg, lethal-extent burn injury). Sometimes 2.5% of the cost of an (adult) liver trans- space, time, privacy and personnel may not plant or 6% of the cost of a renal transplant be available to provide for the end-of-life (Professor Stephen Munn, personal commu- care needs of a ventilated patient or their nication). ICU admission solely for possible family in the emergency department and organ donation does not currently result ICU may have the necessary capabilities. in any additional reimbursement to ICUs These issues are complex and vary between and can be seen as of lesser priority than hospitals, refl ecting locally available admission of a critically ill patient for active hospital resources and the services that the treatment. This view is particularly held if ICU provides to each hospital. A combined ICUs resources, including staff with specifi c Australian and New Zealand report6 from a expertise in organ donation are limited or large but incomplete set of ICUs found that unavailable. The contribution of this ICU 3,700 (0.4% of the total 1,024,203 patients admission practice to national transplan- admitted to the 177 ICUs over a 10-year tation activity is already signifi cant (~15%), period between 1 January 2007 and 31 similar to what was found in seven hospitals December 2016) were admitted for “palli- in the Netherlands in 2013–2014 where ative care of a dying patient” and that these 8/72 (11%) of donors had been admitted 3,700 patients had a mortality of 86.6%. We to ICU solely for possible donation.7 Very have tried to exclude patients admitted to recently these researchers have shown a ICUs for these reasons from this report, by decrease in such potential donors not being restricting inclusion to patients “admitted referred from the ED following implemen- to ICU solely for possible organ donation”, tation of a protocol to support the practice.8 implying that they would not have been In that report of 55 patients admitted to admitted for any other reason. ICU solely for possible organ donation It is possible that there might have been (clinically similar to the 49 patients in this other patients who were also “admitted report), there were 20 actual donors (26% solely for possible organ donation” who did of the 69 total donors in the participating not die in the ICU (and therefore would not hospitals). In a nested-cohort report within 6 appear in the ODNZ registry of ICU deaths). the Australasian study of 177 ICUs, 116 of These are likely to be very few, although the 1,115 (10.4%) patients admitted “for there was one patient in this study who did potential organ donation” over a 10-year improve and receive active treatment for period were from a single large Australian 15 days before dying of a late complication. tertiary centre. In that centre, donation The Australasian report6 found that 1,115 was discussed with families before ICU (0.1% of the total ICU admissions) were admission on 59/116 occasions (51%), brain admitted for “potential organ donation” and death was determined in 75 patients (65%) that these 1,115 patients had a mortality and there were 61 donors (63%), broadly of 95.9%. Donation outcomes were not similar to the national New Zealand fi ndings reported for this cohort. in this study. All except one of the 49 patients in this The mean number of organs transplanted study died in the ICU within a few days; per donor in this study was 3.15, similar 22/49 (45%) of them became brain dead; to the 3.33 organs per donor transplanted with a similar time to death as those 29 from the other 101 DBD donors over the who did not become brain dead. Assuming two-year period. There were no DCD donors a representative cost of an ICU day in New from among the patients admitted solely for Zealand at $NZD5,500,4 the total cost of the possible organ donation; there were 15 DCD

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donors over the period from whom a mean example, care in a stroke unit rather than a of 2.0 organs per donor were transplanted. general ward setting costs $7,960/QALY,9,10 The extent of benefi t attributable to organ water fl uoridation between $12,821 and 11 transplantation, as measured by Quality $20,000/QALY, population-based screening Adjusted Life Years (QALYs) has been for abdominal aortic aneurysms $15,300/ 9,12 calculated from transplant recipient data QALY and stockpiling of antivirals in published between 2002 and 2014.1 Derived anticipation of a future infl uenza epidemic 9,13 QALYS were 8.9 for liver, 8.8 for heart, 2.8 $33,200/QALY. for lungs, 2.6 for kidney and 2.1 for pancreas Guidelines for best practice in New transplantation. These values will be conser- Zealand2 have been developed by ODNZ by a vative, as long-term survival for transplant process of wide consultation among clini- recipients is generally continuing to cians in ICUs and emergency departments improve. Applying these values of QALYs to with principle-based consensus. They are in the organs donated by the 20 DBD donors in accord with the relevant position statement this report results in a total of 313.5 QALYs of the Australian and New Zealand Intensive from 63 organs. Assuming that the QALY Care Society.3 ODNZ recommends that if effects of multiple organ transplants would the only reason for ICU admission is “solely not be strictly additive, we have conserva- for possible organ donation” and would tively reduced the number of QALYs to 58/63 otherwise not take place, such admission of its value, ie, to 308.4 QALYs or 15.4 QALYs should be preceded by an explicit discussion per DBD donor. The theoretical analysis by of the reasons for it with the family, if that is Nunnink1 estimated the maximum number possible. of QALYs at 30.6 “when all possible organs were medically suitable for transplantation” Summary and (heart, lungs, liver, kidneys and pancreas), implying fi ve or more transplant recipients conclusion per DBD donor, compared with the actual This study provides a national ‘baseline value of 2.9 recipients per donor that we measure’ of admission to ICU solely for found in this report. possible organ donation. This practice An estimate of cost per QALY, (where cost currently contributes ~15% to transplan- is based only on ICU length of stay for the 49 tation activity. ODNZ now has an ongoing patients admitted to ICU solely for possible program to encourage expansion of this organ donation), is therefore not more than practice, within the bounds of what is $1,070. Such a value represents very high considered best practice and is acceptable to cost-utility for a healthcare intervention. For families and clinicians.

Competing interests: Nil. Acknowledgements: We thank the staff of the emergency departments and intensive care units who looked after the patients and their families in this report, the ICU Donation Link Nurses who provide data to the ODNZ ICU registry, ODNZ staff who maintain the ODNZ database, and Drs Stephen Munn and Jonathan Casement for helpful discussion. Author information: Stephen Streat, Intensivist and Clinical Director, Organ Donation New Zealand, Auckland; Annette Flanagan, Donor Coordinator, Organ Donation New Zealand, Auckland; Joanne Ritchie, Intensivist, Organ Donation New Zealand, Auckland. Corresponding author: Stephen Streat, Organ Donation New Zealand, PO Box 99-431, Newmarket, Auckland 1149. [email protected] URL: www.nzma.org.nz/journal-articles/admission-to-icu-solely-for-possible-organ-donation- audit-of-current-new-zealand-practice

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REFERENCES: 1. Nunnink L, Cook DA. 5. Blanch L, Abillama FF, ness results be combined Palliative ICU beds for Amin P, et al; Council of the into a coherent league potential organ donors: an World Federation of Societ- table? Case study from one effective use of resources ies of Intensive and Critical high-income country. Popul based on quality-adjusted Care Medicine. Triage deci- Health Metr. 2019; 17:10. life-years gained. Crit Care sions for ICU admission: 10. Te Ao BJ, Brown PM, Resusc. 2016; 18:37–42. Report from the Task Force Feigin VL, Anderson CS. 2. Organ Donation New of the World Federation of Are stroke units cost Zealand. Organ and Tissue Societies of Intensive and effective? Evidence from Donation Guidelines for Critical Care Medicine. J a New Zealand stroke New Zealand Emergency Crit Care. 2016; 36:301–5. incidence and popula- Departments. Smartphone 6. Melville A, Kolt G, Ander- tion-based study. Int J App. 2019. Available son D, Mitropoulos J, Stroke. 2012; 7:623–30. to health professionals Pilcher D. Admission to 11. Moore D, Poynton M, via http://www.donor. Intensive Care for Palliative Broadbent JM, Thomson co.nz/contact-us/ Care or Potential Organ WM. The costs and 3. Australian and New Donation: Demographics, benefi ts of water fl uori- Zealand Intensive Care Circumstances, Outcomes, dation in NZ. BMC Oral Society (2019) The state- and Resource Use. Crit Care Health. 2017; 17:134. Med. 2017; 45:e1050–e1059. ment on death and organ 12. Nair N, Kvizhinadze donation (Edition 4). 7. Witjes M, Kotsopoulos G, Jones GT, et al. Melbourne: ANZICS. A, Herold IHF, et al. The Health gains, costs and Available at: http://www. Infl uence of End-of-Life cost-effectiveness of a anzics.com.au/wp-con- Care on Organ Donor population-based screening tent/uploads/2019/12/ Potential. Am J Trans- programme for abdominal ANZICS-Statement-on- plant. 2017; 17:1922–7. aortic aneurysms. Br J Death-and-Organ-Do- 8. Witjes M, Kotsopoulos Surg. 2019; 106:1043–54. nation-Edition-4.pdf AMM, Otterspoor L, et al. 13. Carrasco LR, Lee VJ, Chen 4. Gullery C. Response to The Implementation of a MI, et al. Strategies for anti- OIA request re: cost of Multidisciplinary Approach viral stockpiling for future ICU. Canterbury District for Potential Organ Donors infl uenza pandemics: a Health Board. May 2019; in the Emergency Depart- global epidemic-economic Available at: https://www. ment. Transplantation. perspective. J R Soc cdhb.health.nz/wp-content/ 2019; 103:2359–65. Interface. 2011; 8:1307–13. uploads/93568aa4-cdhb- 9. Wilson N, Davies A, Brewer 10089-daily-bed- N, et al. Can cost-effective- cost-icu-cicu.pdf

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Inherited thrombophilia testing in a large tertiary hospital in New Zealand: implementation of a Choosing Wisely protocol to reduce unnecessary testing and costs Myra Ruka, Helen Moore, Denis O’Kee e

ABSTRACT AIM: To evaluate the practice of inherited thrombophilia testing at Waikato Hospital Laboratory, benchmarked against the British Society of Haematology (BSH) guidelines with the plan to reduce unnecessary testing. METHODS: We retrospectively reviewed data on all inherited thrombophilia tests performed in the Waikato Hospital Laboratory during August 2015. We then established a local Choosing Wisely guideline for testing. A clinical and laboratory programme was developed to facilitate the implementation of this guideline. Ordering practices were re-evaluated six months a er the implementation of the Choosing Wisely programme. RESULTS: Of the 94 requests received in August 2015, only one complied with BSH guidelines. Most abnormal results did not change the clinical management of patients. In the first six months following the implementation of our intervention, there was a significant reduction of tests performed with an estimated savings of $118,000. CONCLUSIONS: The majority of inherited thrombophilia tests performed in our laboratory did not comply with BSH guidelines. A multimodal inherited thrombophilia Choosing Wisely programme was successful in reducing unnecessary testing. A laboratory protocol that required screening of every inherited thrombophilia request by a haematologist was necessary for the success of this programme.

enous thromboembolism (VTE) rep- screening panel at Waikato Hospital Labo- resents a signifi cant cause of morbid- ratory in Hamilton, New Zealand. However, Vity and mortality in New Zealand.1 testing for an inherited thrombophilia is Inherited thrombophilia is associated with controversial. an increased risk of VTE. The most common There is little evidence demonstrating inherited thrombophilias include defi cien- the clinical utility of inherited thrombo- cies in naturally occurring anticoagulants philia testing in the majority of patients such as antithrombin (AT), protein C (PC) with a VTE.5–7 Testing does not reduce and protein S (PS) as well as gene polymor- the recurrence of venous thrombosis.8–10 phisms for factor V Leiden (FVL) and pro- Also, if testing is performed in unselected 2–4 thrombin gene, G20210A (PGM). These are patients at the incorrect time, you run all included in the inherited thrombophilia the risk of attaining false-positive results.

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Some inherited thrombophilia assays are This study aimed to assess inherited affected by medications, acute thrombosis, thrombophilia testing practice at Waikato pregnancy and liver failure. False-positive Hospital Laboratory and benchmark this results can lead to overtreatment, complica- against BSH guidelines. We aimed to reduce tions from unnecessary treatment and the indiscriminate testing in our laboratory social, psychological and fi nancial costs that by implementing a multimodal inherited arise from being labelled with an incorrect thrombophilia Choosing Wisely programme diagnosis. Testing patterns both interna- for hospital and community clinicians. tionally and nationally are renowned for Requesting and testing patterns were being indiscriminate and refl ect a lack of reassessed after implementation of the awareness of the futility of testing and the programme. risk of harm arising from testing in unse- lected patients.8,11–14 Methodology Many guidelines have been published Study design and data sources to reduce unselective testing. The British We retrospectively reviewed all inherited Society for Haematology (formerly British thrombophilia tests performed at Waikato Committee for the Society of Haema- Hospital Laboratory during August 2015. tology BCSH) has produced the most We assessed an electronic version of the comprehensive restrictive guidelines that original request form to identify clinical recommend testing in a few selected cases details provided, such as indications for and only when the results will change testing and requestor details. We then clinical management.7 Other guidelines extracted data such as patient age, gender, include the American Society of Haema- inherited thrombophilia tests requested and tology (ASH) Choosing Wisely,15 American results of tests from the electronic medical College of Chest Physicians,16 NICE guide- records. If clinical details were lacking lines17 and National Laboratory guidelines in on the request form, clinical notes were New Zealand.18 reviewed, or the requestor was contacted to The National Laboratory guidelines assess indication and eligibility for testing. for inherited thrombophilia testing was When possible, a written note review was employed at Waikato Hospital prior to performed to gather further clinical data. this study. An automatic laboratory refl ex Microsoft Excel 2008 was utilised to record was implemented in 2005 that prevented and collate data. repeat molecular testing for FVL and PGM. All other inherited thrombophilia Assessing the appropriateness of screening tests, both initial and repeat requests requests were performed without a formal The BSH inherited thrombophilia testing review of clinical indications for testing and guideline was the standard against which compliance with the laboratory guideline. this audit was undertaken (Table 1).7 Waikato Hospital Laboratory serves a The clinical utility of an abnormal result large geographic catchment area with a was defi ned as an abnormal result that population of approximately 765,500 people. changed clinical management, such as The Hospital haemostasis laboratory draws duration of anticoagulation or thrombopro- requests from the hospital and community phylaxis. Costs associated with unnecessary laboratories in Hamilton, Thames, Coro- inherited thrombophilia testing were calcu- mandel, Tauranga, Rotorua, Tokoroa, Te lated based on the cost of all tests performed Kuiti, Taumarunui and Taupo. Approxi- that did not meet BSH criteria for testing in mately 1,200 inherited thrombophilia tests one month. The cost of a screening panel for were being performed annually. In 2015– inherited thrombophilia testing at Waikato 2016, a Choosing Wisely programme for hospital laboratory is $247. laboratory testing was developed at Waikato A multimodal intervention was designed Hospital. Inherited thrombophilia testing and implemented to reduce inappropriate is on the ‘Choosing Wisely’ list endorsed testing. The intervention included estab- by many speciality societies, including the lishing a local inherited thrombophilia American Society for Haematology.15 Choosing Wisely guideline in collaboration

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Table 1: BSH criteria for inherited thrombophilia testing.

Testing Indicated in the following Testing MAY be indicated in the following clinical contexts: clinical contexts: (level of evidence) (level of evidence)

Neonates and children with purpura Case finding of asymptomatic relatives with high-risk fulminans should be tested for protein thrombophilia, such as antithrombin, protein C or protein S C and protein S deficiency (1B). in thrombosis-prone families (1B).

Patients with skin necrosis in Asymptomatic pregnant women with a strong first-degree association with Vit K antagonists family history of unprovoked VTE or VTE provoked by should be tested for protein S and pregnancy or combined oral contraception exposure or a protein C deficiency (2B) minor risk factor (2C). (indication for testing would increase if the first-degree relative had a known thrombophilia)

Patients with VTE and <40yrs old and must have a history of thrombosis- prone family members (>2) (C).

with the Waikato Hospital Laboratory and Communication with key stakeholders Waikato Hospital Departments of Haema- in the hospital was vital for organisational tology, General Medicine, Obstetrics and and clinician buy-in for the new testing Neurology. The BSH, National Laboratory protocol. The fi ndings from the fi rst phase Test Referral and RCOG Green-top guide- of our study were presented at the Waikato lines7,18,19 along with the guiding principles Hospital medical presentations and grand of ‘Choosing Wisely’ and outcomes from round. The new guidelines were then meetings with the above stakeholders infl u- disseminated to all general practitioners in enced the fi nal guideline design (Tables 2 our region, informing them of the need for and 3). Testing for patients with obstetric testing in selective patients and the imple- indications continued as there were large mentation for the new testing protocol in randomised control trials underway. July 2016 (See supplementary article).

Table 2: Waikato Hematology Laboratory criteria for inherited thrombophilia testing, 2016.

• Idiopathic venous thromboembolism in young patients (<45 years).

• Warfarin-induced skin necrosis (patients should be tested for protein C deficiency and protein S deficiency one month a er stopping vitamin K antagonist therapy if this can safely be discontinued).

• Children presenting with purpura fulminans (test for protein C and protein S deficiency).

• Siblings of patients with homozygous FVL, homozygous PT20210A or compound heterozygotes for these mutations.

• Thrombosis in unusual sites (eg, cerebral, mesenteric, portal). Cryptogenic stroke in the young (<50yrs) will be performed a er exclusion of other causes.

• Recurrent miscarriage, IUGR, IUD.

In all other situations, testing should only be undertaken a er consultation with a haematologist or as part of a clinical trial.

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Table 3: Waikato Haematology Laboratory Guidelines for inherited thrombophilia testing, 2016.

• Request forms MUST provide clinical details of which criteria for testing the patient meets, or the sample will not be tested. The sample will be held for 14 days and will be tested if the requesting clinician subsequently provides appropriate clinical details.

• In the absence of meeting one of the testing criteria and testing is still thought to be appropriate, the requestor must discuss with a clinical haematologist and requestor name clearly identified on the request form along with clinical details.

• Where low levels of antithrombin III, protein C or S are found, a repeat sample will be requested to confirm the abnormal finding.

• Patients will only be tested for FVL and prothrombin gene mutation once in their lifetime. Context and timing of tests : Wherever possible, thrombophilia testing should be avoided in the following settings as one or more of the laboratory tests may give false-positive results: • In people taking hormone replacement therapy (oestrogen) • Acute thrombosis • During warfarin therapy or other vitamin K antagonists, DOAC or heparin therapy • During pregnancy and for eight weeks post-partum

A laboratory programme using the existing laboratory information service Results (LIS) was set up specifi cally for inherited A total of 94 inherited thrombophilia thrombophilia testing. The capacity to add requests were performed in August 2015. on tests for an acquired thrombophilia or Most requests were for female patients to complete a thrombophilia screen was (75%, n=70). The median age was 38 years embedded into this program. From 4 July for females and 52 years for males. A 2016, all thrombophilia requests were signifi cant number of request forms lacked reviewed by a haematologist working in the clinical information or indication for testing laboratory. Any request that did not fulfi l (21%, n=20). criteria for testing and requests lacking There was only one inherited throm- necessary clinical details were declined. bophilia request that complied with BSH The capacity to ask the requestor for more guidelines. This patient was young (<45 clinical information and communicate the years) had a VTE and a sibling with a history reasons for declining a test was embedded of VTE during pregnancy and known to be in the LIS program. The requestor of a test compound heterozygote FVL/Prothrombin that was declined was sent an electronic gene mutation. link to the new Waikato Hospital Laboratory There was an equal distribution of inherited thrombophilia Choosing Wisely requests for inherited thrombophilia tests guidelines along with contact details for generated from hospital and community the laboratory haematologist if a further clinicians 46% and 48% respectively. discussion was required. Declined samples Within the hospital, the obstetric and were held for 14 days. general medical departments generated the A re-audit of inherited thrombophilia majority of requests (Figure 1). Personal and testing patterns was performed six months Family history of VTE and obstetric compli- after implementation of the Choosing Wisely cations comprised the majority of indications programme from July 2016–December 2016. for testing (Figure 2). There were a few requests for patients with bleeding issues.

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Figure 1: Inherited thrombophilia requests by hospital department.

Clinical utility of abnormal results low protein S levels tested at the time A total of 21 patients had abnormal of pregnancy loss with no repeat level results. Of these, 76% (n=16) results would performed eight weeks post event. The not have changed clinical management third patient was tested for a presumed (Table 4). pulmonary embolus (PE). No PE was iden- tifi ed on CTPA, there was no personal or The clinical utility of test results was family history of thrombophilia, but the uncertain in 3 of 21 patients with abnormal patient had a low AT III level. results. These included two patients with

Figure 2: Indications for testing identifi ed on 74/94 laboratory request forms, 16/94 had no indication for testing on the request form but were identifi ed following clinical note review or discussion with the requestor. “Bleeding and others” include easy bruising, epistaxis and menorrhagia.

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Table 4: Abnormal results would not change clinical management.

Inappropriate testing Five patients tested at the time of pregnancy loss resulting in a decreased PS level. (A) All five were normal on repeat testing eight weeks later. One patient tested for DVT during pregnancy resulting in low PS and AT levels. (A) Repeat testing eight weeks post-partum showed normal PS and AT levels. One low protein S and protein C while on warfarin therapy. (A) Three heterozygous for FVL tested before commencing the combined oral contraceptive pill (COCP). All would require alternative contraception regardless of results due to a strong family history of VTE. (B) Four patients >60 yrs. Tested for unprovoked VTE, found to be heterozygous for FVL. No personal or family history of thrombophilia. (B) Two patients with an established diagnosis of prot S deficiency were retested. (C)

Inappropriate timing of tests (A), inappropriate indication for testing (B), repeated test despite having an established diagnosis (C).

Two patients had abnormal results that Six months after the implementation of would have changed clinical management. the new guidelines, the overall number One patient with compound heterozygosity of requests for testing had decreased, and FVL/prothrombin gene mutation and a the number of requested tests that were family history of thrombophilia. The other performed reduced signifi cantly (Figure patient was tested for a recurrent miscar- 3). Overall, 376 requests were received, of riage and found to be heterozygous for FVL which 138 fulfi lled criteria for testing. Only mutation with a true protein S defi ciency. 312 of the 376 requests had adequate clinical Both complied with criteria for testing information provided on the initial request. where clinical management would or may Sixty-four requestors were asked for addi- be infl uenced by the result. tional clinical information. The cost for unnecessary inherited throm- The majority of requests performed were bophilia tests for the month of August 2015 for obstetric complications, 66% (n=91). DVT was $23,282. A total of 1,233 tests were and VTE in those <45 yrs old comprised 20% performed in the 12-month period from of requests (n=28). Cryptogenic stroke in Sept 2014–Aug 2015. The estimated cost of the young patient made up 8% of requests unnecessary tests in that 12-month period is (n=11). Test results are detailed in Table 5. around $300,000.

Figure 3: AT III testing volumes at Waikato Hospital—used as a marker for inherited thrombophilia screening volumes.

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Table 5: Test results by indication.

Obstetric complications n (%) Normal 91 (53) Low protein S (tested at the time of pregnancy loss) 33 (36) Heterozygous FVL 5 (6)

DVT/PE, <45 yrs old with a family history of VTE Normal 18 (64) Heterozygous FVL 5 (19) Low AT 2 (7) Low PC 2 (7) Heterozygous prothrombin gene mutation 1 (3)

Neurology- cryptogenic stroke Normal 10 (91) Low PC 1 (9)

Others Normal 8 (100)

The total cost of inherited thrombophilia women taking the COCP demonstrated a testing in selected patients for the fi rst six similar prevalence of an inherited thrombo- months since programme implementation philia among those with and those without was $34,914, with an estimated savings of a family history of VTE.21 This may result in $120,000. a change in testing practice in future, but further validation studies are required. The Discussion role of testing prenatally in asymptomatic women with a family history for inherited The BSH provides comprehensive guide- thrombophilia is on the BSH criteria for lines for selective inherited thrombophilia testing where results may change clinical testing. Our laboratory fell well below the management.7 The Royal Australian and recommended guidelines for testing with New Zealand College of Obstetricians follow only 1 of 94 requests complying with the the RCOG UK green top guidelines which BSH criteria for testing. This pattern of recommend testing in this context.19 The inappropriate ordering practice is seen RCOG guidelines for recurrent miscarriage elsewhere in New Zealand8 and interna- also recommend testing in women with tionally.2,10,20 A retrospective study in a large second-trimester miscarriage. After consul- tertiary haemostasis referral laboratory, tation with the obstetric department at Westmead NSW, Australia found that less Waikato Hospital, the decision was made to than 20% of requests for inherited thrombo- test in asymptomatic women with a family philia were appropriate for testing.20 history for thrombophilia and obstetric In our study, the majority of test requests complications such as recurrent miscar- were for female patients (75%, n=70) with riage, second-trimester fetal loss, IUGR and a median age of 38 years, refl ecting the IUD. For obstetric complications, a strong perceived value of testing in the context of recommendation was made to test at least obstetric complications and testing to inform 6–8 weeks post-event to remove the ambi- suitability for the COCP. To date, guidelines guity of interpreting abnormal protein recommend against inherited thrombo- S levels. A local database of all obstetric philia testing to guide decisions around requests performed since the implemen- commencing the COCP. A family history of tation of the programme has been created thrombophilia in the context of oestrogen with the plan to evaluate the clinical utility exposure is a reliable criterion for avoiding of testing for those patients. the COCP. However, a recent large study of

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An important and reassuring fi nding in requesting behaviour. The decision to from this study was that no clinically have all requests screened by a haematol- signifi cant abnormal results were missed ogist was a necessary measure to support when applying the BSH criteria to the a change in behaviour. This process of cohort. Overall there were 21 patients with screening is time-consuming and requires abnormal results. Two of 21 patients had ongoing dedication and commitment from clinically signifi cant abnormal results, one the haematologists working in the labo- patient who fulfi lled criteria for testing and ratory. There was a signifi cant reduction in another who fulfi lled BSH criteria where testing overall within the fi rst six months of testing may be indicated. The majority of protocol implementation with 376 requests abnormal results (76%, n=16) would not overall. This suggests clinicians were more have changed clinical management. A signif- mindful of appropriate test ordering prac- icant number of false-positive results were tices. However, the majority of requests due to the inappropriate timing of tests. received did not meet the criteria for testing Interpretation of tests performed during (63% n=238) and refl ected the need for pregnancy loss, the acute phase of a VTE or ongoing clinical education around appro- while on warfarin therapy is problematic, priate ordering practices. even more so if the clinician reviewing the In future, electronic laboratory requesting patient’s results does not have expertise would circumvent the issue of insuffi cient in haemostasis and thrombosis. These clinical details provided on request forms fi ndings highlighted the need to emphasise and the labour-intensive screening of all the appropriate timing of testing when requests by a laboratory haematologist. 11 designing our local protocol. Algorithms and embedded decision-making The Waikato Hospital Laboratory tools, indicating criteria for testing and inherited thrombophilia Choosing Wisely appropriate timing of testing would help guidelines were developed in collaboration clinician decision making at the time of with various departments in the hospital. ordering the test. There is a paucity of large randomised Thrombophilia testing is expensive. controlled trials to guide testing decisions Studies repeatedly demonstrate the in many circumstances. The collaboration unnecessary fi nancial costs associated provided an opportunity to discuss clinical with indiscriminate testing.22 The esti- areas where the utility of testing is uncertain mated annual cost for unnecessary testing and arrive at a consensus for testing. The at Waikato Hospital Laboratory was BSH, National Laboratory Test Referral $306,208.65. This estimate does not account and RCOG Green-top guidelines, along with for the costs associated with retesting the guiding principles of ‘Choosing Wisely’ abnormal results, carrying an incorrect diag- infl uenced the fi nal guideline design. We nosis such as long-term anticoagulation and developed a guideline that was selective, cost of complications arising from bleeding restrictive and reduced harm but allowed and overtreatment. for testing in situations where there is no clear evidence for or against testing. Limitations of this study There are some limitations to this study. Implementation of the guidelines The small sample size and duration period required a multimodal approach covering of assessing inherited thrombophilia testing the organisational, clinical and laboratory in the fi rst and second phase of the study are arms of testing. When implementing the signifi cant limitations. In recognition of this, laboratory arm for this inherited thrombo- the study data was supplemented by looking philia programme, we had underestimated at trends of AT testing over 12 months to the ongoing need for fi ne tuning the LIS ensure the testing behaviour in August 2015 programme so that it was fi t for purpose. was typical for the 12 months prior. Optimising the capacity to individualise test approval and feedback to requestors took A retrospective design means that six months. collection of data relying solely on adequate documentation introduces information bias. The results from our initial audit showed Compliance of inherited thrombophilia that education and wide dissemination of requests with BSH may have been under- guidelines alone do not ensure a change represented due to this bias rather than a

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true fi nding. There is also a potential for inherited thrombophilia programme based investigator error and bias when collecting on our laboratory model of selective testing. the data from electronic records and written clinical notes. Conclusion The strengths of this study included the Our retrospective study demonstrated assessment of consecutive thrombophilia indiscriminate patterns of inherited throm- requests and clinical note review to gain bophilia testing in the Waikato region. detailed clinical information and outcomes. There was a reduction in requests and costs In addition, the collaborative design of following the implementation of multimodal the new guideline and multimodal imple- Choosing Wisely programme. The critical mentation programme facilitated clinician success factor for the implementation of buy-in and early adoption of the Choosing this programme was having all requests Wisely programme. The benefi ts of imple- reviewed by a laboratory haematologist menting this laboratory programme have and restricting access to testing. Although been far-reaching beyond our laboratory. time-consuming, this was a necessary Subsequent to presenting the fi ndings of measure to support appropriate testing this study at the 2017 New Zealand branch in our laboratory. We expect in future; meeting of the HSANZ (Haematology Society inherited thrombophilia testing will be more of Australia and New Zealand) another selective and performed only on patients reference haematology laboratory in New who are likely to derive benefi t from testing. Zealand has decided to implement an

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Appendix

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Competing interests: Nil. Author information: Myra Ruka, Haematology Department and Haematology Laboratory, Waikato Hospital, Hamilton; Helen Moore, Haematology Department and Haematology Laboratory, Waikato Hospital, Hamilton; Haematology, Pathlab Angelsea, Hamilton; Denis O’Keeffe, Haematology Department and Haematology Laboratory, Waikato Hospital, Hamilton; Haematology Department, University Hospital Limerick, Ireland. Corresponding author: Dr Helen Moore, Waikato District Health Board, Pembroke Street, Hamilton 3240. [email protected] URL: www.nzma.org.nz/journal-articles/inherited-thrombophilia-testing-practice-in-a-large- tertiary-hospital-in-new-zealand-implementation-of-a-choosing-wisely-protocol-to-reduce- unnecessary-testing-and-costs

REFERENCES: 1. Haematology Depart- defects in 2479 relatives. J Thromb Haemost. ment, Counties Manukau Blood. 2009; 113:5314–5322. 2007; 5:1979–1981. District Health Board. 5. Middeldorp S, van 10. Lyons S, Galloway MJ, Retrospective evaluation Hylckama Vlieg A. Does Osgerby J, Hanley J. An of hospital-acquired thrombophilia testing help audit of thrombophilia VTE rates at CMDHB. in the clinical management screens: results from (Unpublished report). of patients? Br J Haematol. The National Pathology 2008, National Policy 2008; 143:321–335. Alliance benchmarking Framework: VTE preven- 6. Middeldorp S. Evidence- review. J Clin Pathol. 2006; tion in Adult Hospitalised based approach to 59:156–159. patients in NZ, June 2012. thrombophilia testing, J 11. Favalaro E, Mc Donald 2. De Stefano V, Rossi E, Thromb Thrombolysis. D, Lippi G. Laboratory Paciaroni K, Leone G. 2011; 31:275–281. investigation of thrombo- Screening for inherited 7. Baglin T, Gray E, Greaves philia: The Good, the Bad, thrombophilia: indications M, et al. British Committee and the Ugly. Pathology. and therapeutic implica- for Standards in Haema- 2009; 1:695–710. tions. Haematologica. 2002 tology. Clinical guidelines 12. Coppens M, Reijnders JH, Oct; 87(10):1095–108. for testing for heritable Middeldorp S, et al. Testing 3. Vossen CY, Conard J, thrombophilia. Br J Haema- for inherited thrombophilia Fontcuberta J, et al. tol. 2010; 149:209–220. does not reduce recurrence Familial thrombophilia 8. Bradbeer P, Teague of venous thrombosis. and life-time risk of venous L, Cole N. Testing for J Thromb Haemost. thrombosis. Journal of heritable thrombophilia 2008; 6:1474– 1477. Thrombosis and Haemo- in children at Starship 13. Christiansen SC, Canne- stasis. 2004; 2:1526–1532. Children’s Hospital: An gieter SC, Koster T, et 4. Lijfering WM, Brouwer JL, audit of requests between al. Thrombophilia, Veeger NJ, et al. Selective 2004 and 2009. Journal clinical factors, and testing for thrombophilia in of Paediatrics and Child recurrent venous throm- patients with fi rst venous Health. 2012; 921–925. botic events. JAMA. 2005; thrombosis: results from a 9. Coppens M, van Mourik 293(19):2352–2361. retrospective family cohort JA, Eckmann CM, et al. 14. Middeldorp S, van study on absolute throm- Current practice of testing Hylckama Vlieg A. Does botic risk for currently for hereditary thrombo- thrombophilia testing help known thrombophilic philia in The Netherlands. in the clinical management

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of patients? Br J Haematol. thrombophilia testing. 20. Suchon P, Al Frouh F, 2008; 143:321–335. Clinical guideline 144. Henneuse A, et al. Risk 15. Masterson M, Levitt M, London: National Institute factors for venous throm- Greenberg P, et al. Choosing for Health and Clinical boembolism in women Wisely in Thrombophilia: Excellence, 2012. under combined oral Hematologist Required. 18. Online www.dhbshared- contraceptive: The PILl Blood. 2016; 128(22):4994. services.health.nz/ Genetic RIsk Monitoring (PILGRIM) Study. Thromb 16. Kearon C, Akl EA, Comerota Site/Laboratory/ Haemost. 2016; 115:135–42. AJ, et al. American College Laboratory-Schedule-Re- of Chest Physicians. view-Project19) Royal 21. Wu O, Robertson L, Antithrombotic therapy for College of Obstetricians Twaddle S, et al. Screen- VTE disease: Antithrombot- and Gynaecologists. ing for thrombophilia ic therapy and prevention Thromboembolic Disease in in high-risk situations: of thrombosis, 9th ed: Pregnancy and the Puerpe- systematic review and American College of Chest rium: Acute Management. cost-effectiveness anal- Physicians Evidence Based Green-top Guideline No. ysis. The Thrombosis: Clinical Practice Guide- 37b. London: RCOG; 2015. Risk and Economic lines. Chest. 2012; 141. 19. Favalaro E, Mohammed S, Assessment of Thrombo- philia Screening (TREATS) 17. NICE. Venous throm- Pati N, et al. A clinical audit study. Health Technol boembolic diseases: of congenital thrombo- Assess.2006; 10:1–110. the management of philia investigation in venous thromboembolic tertiary practice. Pathology. diseases and the role of 2011; 43(3):266–272.

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Sleep habits of intermediate-aged students: roles for the students, parents and educators Kate Ford, Paul T Kelly, Rebecca Williamson, Michael Hlavac

ABSTRACT AIM: Obtain an overview of the current sleep habits and sleep hygiene practices in a group of intermediate- aged students, and establish whether these students achieve adequate sleep according to the New Zealand education and health guidelines. METHODS: A standardised sleep health questionnaire and seven-day sleep diary were completed by 163 participants (aged 11–13; 62% female) from a cross-section of five Christchurch schools. RESULTS: In this group, 71% of students reported 9–11 hours of sleep per night (averaged over seven days). Total sleep time was independent of gender and the day of the week. Bedtimes and wake-times were earlier from Monday–Thursday compared to the weekend (p<0.0001). Fi y-nine percent of students used a device in the hour before bed. Pre-bedtime device users were more likely to achieve less sleep than non-device users (p<0.001). The majority of students (66%) did not choose their bedtime. CONCLUSIONS: In this group of students, the majority achieved a sleep duration within the advised Ministry of Education and Sleep Health Foundation guidelines, despite non-recommended sleep hygiene practices in the pre-bed routine. Parental guidance, with respect to bed times and reduction in device usage before sleep are two factors that could be employed to improve sleep in this group.

he foundations for health include There is a perception that school-aged proper nutrition, regular exercise and children are at the greatest risk of disrupted Tgood sleep quality.1 Sleep quality is sleep.5 Poor sleep hygiene practices often overlooked as a contributory factor including irregular sleep schedules, variable to poor health. Disrupted and inadequate bedtime routines, the use of electronic sleep is considered by some to be a modern devices and social media engagement societal problem which has arisen from pre-bedtime, are associated with sleep urbanisation, increased access to technology, problems in children.6 This could also be a creation of social media and an engaging refl ection of discrepancies between parental 24/7 lifestyle.2 From a public health perspec- enforcement of bedtimes on weeknights tive, the cost of inadequate sleep is wide- compared to the weekend.7 In children, spread from greater risk of motor vehicle inadequate sleep has been associated with accidents to mental illness.3 In Australia, poor immune functioning, greater risk of inadequate sleep is highly prevalent with obesity, disrupted memory consolidation, an estimated economic cost of $66.3 billion impairment of academic performance and (AUD) per year.4 Accordingly, the Australian risk of mood disorders.8–11 Both the Sleep Sleep Health Foundation are advocating the Health Foundation and the National Sleep importance of good sleep hygiene practices Foundation’s multidisciplinary expert panel and implementing preventative measures to recommended a sleep duration of 9–11 promote sleep health. hours for school-aged children between the

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ages of 6–13 years.12,13 Subsequently, the consisted of students in year 7 and 8 (aged New Zealand Ministry of Education released 11–13 years). The Christchurch schools were guidelines advocating for “quality unin- inclusive of two state schools, two Catholic terrupted sleep of 9–11 hours per night for schools and a kura kaupapa, with decile those aged 5–13 years, with consistent bed ratings ranging from 3–10. and wake-up times” and “no more than two Data collection hours per day of recreational screen time”.14 More than 20 Christchurch schools were To the authors’ knowledge, there is no invited to participate. Given the busy time structured education pertaining to sleep of the school year, only fi ve schools agreed health mandated in the New Zealand to participate and were included in the curriculum. Thus, there is a possible health study. From the collective sample of 328 education gap, and a loss of education recruited students, consent forms were opportunity in this group of students. There returned by 163 participants, an overall is evidence of increasing use of social media 50% response rate. between the ages of 11–13 years, which Education seminars were given at each may have a downstream effect of increased school just prior to the data collection. These susceptibility to poor sleep.15 Previous seminars consisted of a demonstration of the research has examined the sleep duration correct way to complete the seven-day sleep of seven year-old New Zealand children and diary and standardised sleep health ques- the sleep hygiene practices in 15–17 year-old tionnaire, and a brief presentation outlining New Zealand adolescents.16,17 However, there the importance of good-quality sleep and is limited data on the bedtime routines and sleep hygiene practices. A time frame of sleep practices of New Zealand interme- seven consecutive days was arranged with diate-aged students. The purpose of this each teacher for the sleep diaries to be study is to obtain an overview of the current completed with oversight in their classroom sleep habits and sleep hygiene practices and consistency across students within and in a group of intermediate-aged students between schools. The teachers were also during a normal term week and weekend. given an educators survey to complete; Furthermore, we want to establish whether however, the low response rate produced this student cohort achieve the Ministry of an insuffi cient sample size to present these Education guidelines pertaining to sleep fi ndings. After the week allocated for the health. The authors wished to ascertain study, the student questionnaires and sleep whether or not inadequate sleep was diaries, teacher surveys and consent forms common in this cohort. were collected from the school. Method Research measures Demographic information Study design Age, educational year, gender and Cross-sectional, observational study of ethnicity were taken from the student ques- the sleep practices and knowledge of sleep tionnaires. Ethnicity data was recorded health in a sample of intermediate-aged according to the New Zealand Ministry students. of Health Level l Ethnic Group code Setting descriptions. Participants were recruited from interme- diate classes in Christchurch, New Zealand The sleep health questionnaire in November 2018. Intermediate classes Table 1 summarises the study questions.

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Table 1: Study questions and sleep diary.

Once answered questions Answer When I am at school, I fall asleep Yes/No

At school, there are times when a realise that I have fallen asleep Yes/No

Do you have a bedroom of your own? Yes/No

Are you allowed to decide for yourself what time you go to bed? Yes/No

Would you prefer to go to bed at another hour? Yes/No

Check the activities in the hour before bedtime (answered daily) Homework Read Eating Soda Device Sport TV Gaming Talk Music

Standardised seven-day sleep diary with 30 minute graduations. Subjects shaded the total times that they were asleep for each day of the week.

Daily questions on how the subjects slept Did you have trouble falling asleep? Yes/No

Did you wake during the night? Yes/No

What woke you during the night?

Did you feel sleepy in the morning? Yes/No

Statistical analysis Results A Friedman test was used to assess differ- ences between the days of the week, for From a total of 328 recruited students, sleep onset time, sleep offset time and total 163 (50%) completed and returned the sleep time. The Wilcoxon test was used to consent form, sleep health questionnaire compare the sleep onset time and sleep offset and seven-day sleep diary. Participants were time between two paired days of the week. aged 11–13 years (mean=12, SD= 0.1) with As there was a non-signifi cant difference 37% male and 62% female. Age information between Monday to Thursday and Friday was missing for one child (1%) and gender to Sunday, the authors used these groups to was missing for one other (1%). The sample defi ne weekdays and the weekend. This test was 81% European, 10% Māori, 7% Asian, was also used to compare the sleep onset 1% Pacifi c peoples and 1% Middle Eastern/ time, sleep offset time and total sleep time Latin American/African. on weekdays (defi ned as Monday–Thursday) When averaged over the week, in the versus weekend days (defi ned as Friday– hour before bedtime (Figure 1) the majority Sunday). The Mann-Whitney test was used of students (59±2%) used a device, and to a to compare boys and girls for sleep onset lesser degree watched TV (48±2%), ate food time, sleep offset time and total sleep time, (47±5%) and/or read a book (41±6%). Despite and sleep length differences between device this fi nding, only a relatively small number users versus non-device users. This test was reported trouble falling asleep (25±7%) and also used to compare the sleep onset time, waking during the night (20±7%). However, sleep offset time and total sleep time between the majority reported feeling sleepy in the children that chose their bedtime versus morning (53±9%). When asked as a one-off children whose parents chose their bedtime. question, only 3% of the students reported Fisher’s exact test was used to determine falling asleep at school. the effect of pre-bedtime device use on short There was a statistically signifi cant sleepers (<9 hours) versus normal sleepers difference (p<0.0001) between sleep onset (>9 hours). Fisher’s exact test was also used time and sleep offset time on weekdays to look at the effect of short and normal (Monday–Thursday) compared to the sleep versus feeling sleepy in the morning. weekend (Friday-Sunday) (see Figure 2).

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Figure 1: Activities one hour before bedtime; daily average over the week (mean ± SD).

Figure 2: Sleep diary (sleep onset and sleep offset in 24-hour time on the y axis).

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Figure 3: Total sleep time (TST). Shaded area is the Ministry of Education guidelines.

Between boys and girls, there was a statis- television before bed had no signifi cant tically signifi cant difference (p<0.05) for effect on sleep length (p=0.834). sleep offset time and a non-signifi cant Almost all of the students (96%) reported difference (p=0.0871) for sleep onset time. that they do not fall asleep at school. The The average sleep onset time was earlier majority of students (85%) have a bedroom on weekdays (21:48±62 minutes) than the of their own. Most students (66%) do not weekend (22:12±78 minutes). The average determine their own bedtime and approx- sleep offset time was earlier on weekdays imately 50% would prefer to go to bed at (06:54±37 minutes) than the weekend another hour. (07:18±53 minutes). For children with parent-implemented bedtimes, the average sleep onset time was earlier compared to Discussion children that chose their bedtime (21:48±59 The aim of this study was to obtain an minutes versus 22:15±50 minutes: p<0.001). overview of the current sleep habits and Children with parent-implemented bedtimes sleep hygiene practices in a group of inter- were also more likely to have a longer sleep mediate-aged students, and establish (9.6±1 hour versus 9.2±0.87 hours: p<0.05). whether these students achieve adequate Total sleep time was independent of gender sleep according to the New Zealand (p=0.503) and the day of the week (p=0.56), education and health guidelines. In this with an average daily sleep time of 9.4±1.3 group of students, adequate sleep was hours and 71.6% meeting the recommended achieved by most, despite a large proportion guidelines (see Figure 3). On each weekend of the cohort using a device or watching night, one student reported achieving zero television in the hour before bedtime. hours of sleep and this student was different Importantly, students that used a device each time. before bed were more likely to achieve less sleep and feel sleepier compared to those Participants that used a device before that did not. Of interest is that sleep onset bed were more likely to have a shorter time and sleep offset time was earlier during sleep (9.2±1.3 hours versus 9.8±1.3 hours: weekdays than the weekend; however, total p<0.001). Pre-bed device users were also sleep time was independent of the day of the more likely to report that they felt sleepy the week. Most students reported that they did following morning (p<0.01). However, this not choose their own bedtime. effect was isolated to device use, as watching

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It is noteworthy that a signifi cant number Accordingly, we propose a set of recommen- of intermediate-aged students achieved sleep dations for students, parents and educators. within the Ministry of Education, the Sleep Firstly, all school-aged children should Health Foundation and the National Sleep receive sleep health education within the Foundation guidelines of 9–11 hours per New Zealand curriculum. At present, the night. Specifi cally, between 70–77% of the Ministry of Education guidelines advocate students achieved these recommended guide- for a consistent sleep schedule and good lines each night, over the seven-day period. quality sleep. However, there are no further Consistent with previous research in seven guidelines for sleep health or sleep hygiene year-old New Zealand children, the average practices. Intermediate-aged students’ lack total sleep time was within the guidelines of instruction of good sleep-hygiene prac- of 9–11 hours, for those aged 5–13 years.14,16 tices is a missed educational opportunity in However, approximately one in four students the New Zealand curriculum. Therefore, the did not achieve sleep within these recom- educational guidelines should be updated mended guidelines. In addition, reduced to incorporate instruction of good sleep sleep was most prominent in the weekend hygiene, knowledge of sleep health and with around 6% of the students achieving completion of a sleep diary to encourage less than seven hours of sleep, including self-awareness of their sleeping habits. a small number of students reporting not Of note, most students did not choose their sleeping at all. Therefore, while the average own bedtime, with half preferring to go to across the week of 72% of students reporting bed at a different hour. The students that adequate sleep is reassuring, it is far from the chose their own bedtime went to bed almost goal of every child achieving sleep within the half an hour later and had a shorter sleep recommended guidelines. duration than students whose parents chose Previous researchers have established that their bedtime. Therefore, adequate sleep the use of electronic devices pre-bedtime was achieved in this group due to parental has a negative impact on sleep in adoles- enforcement of bedtimes. As such, the afore- cence.18,19 Accordingly, sleep hygiene mentioned gap in sleep health education practices recommended by the Sleep Health may not affect many students until there Foundation include avoiding electronic is a decline in parental involvement and devices before bedtime.20 Moreover, device an increase in independence during late use before bed has been associated with adolescence. Based on this premise, parents obesity, reduced levels of physical activity were a mediating factor as they provided and a poor diet.21 Recently, a relationship guidance for bedtimes which ensured that has been found between device use within most students achieved adequate sleep. one hour of bedtime and inadequate sleep Therefore, we recommend that parents duration and a lower health-related quality initially implement bedtimes for this of life.22 Consistent with previous research age group and then teach and monitor in 15–17 year-old New Zealand adolescents, their children as they take increasingly the results in the present study support a more responsibility during adolescence. reduced sleep duration on the nights where Previous research reported that parent devices were used in the hour before bed.17 knowledge about good sleep habits was Hence, bedtime device use has implications poor, therefore, children’s sleep may also for physical and mental health, in addition benefi t by providing parents with sleep to the consequences associated with poor health education.24 Due to the impact of sleep. This suggests the need for parental pre-bedtime device use, we also recommend guidance and moderation of the use and that parents monitor the use of electronic availability of electronic devices before bed. devices before bed, where possible. The present fi ndings confi rm that there Teachers may be in a better position is a need for sleep health education in to assume the responsibility of teaching New Zealand schools. Educating children children about sleep, through mandated on the importance of sleep health will sleep health education. Of the four teachers promote the notion of prioritising time that returned surveys, most were unaware for good-quality sleep and prevent sleep of the current Ministry of Education guide- problems linked to poor sleep hygiene.23 lines pertaining to sleep health and did not

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teach their students sleep hygiene prac- the study population was local to Christ- tices. Therefore, we recommend providing church, New Zealand, there was an uneven teachers with their own education regarding distribution of boys and girls, and 135 of the sleep health and sleep hygiene practices. 163 students (83%) were from a decile 9 or This is crucial to inform and guide their 10 school. Therefore, these fi ndings may not teaching of the Ministry of Education guide- generalise to the New Zealand population. lines to their students. Further limitations were a relatively small While the present study was the fi rst to number of students (n=163), a 50% response our knowledge examining sleep duration rate from the 328 recruited participants and and sleep hygiene in a local group of inter- a short sampling time frame of seven days. mediate-aged students, it was not without In conclusion, sleep health education limitations. The main limitation of our study should be prioritised in the New Zealand is the reliance on self-report by the students, curriculum in order for adequate sleep to which may lead to an overestimation of be achieved by every student. Providing total sleep onset time and an underesti- this education prior to the teenage years mation of night wakings.25 However, this may help students to achieve good-quality method of reporting provided the students sleep as they become more independent. with awareness of their own sleeping Alongside education, there is a need for patterns and the ability to self-monitor consistent information pertaining to sleep their own sleep health. Future research health that can be resourced by children, could examine whether similar fi ndings parents and teachers. While parents are replicated using an objective measure provided guidance with regard to bedtimes, accessible outside of a clinical setting, for it is recommended that they moderate the example, an activity tracker. Also, while use and availability of devices before bed. the intention of the education session was Education of sleep health and sleep hygiene training focused on how to complete the practices from childhood is the key to sleep diaries and questionnaires, there was preventing lifelong consequences associated a small component of sleep health education with poor-quality sleep. to improve the data accuracy. In addition,

Competing interests: Nil. Author information: Kate Ford, Student, School of Medicine, University of Otago, Christchurch; Paul T Kelly, Sleep Unit Team Leader, Department of Respiratory Medicine, CDHB, Christchurch; Rebecca Williamson, Sleep Physiologist, Department of Respiratory Medicine, CDHB, Christchurch; Michael Hlavac, Respiratory and Sleep Physician, School of Medicine, University of Otago, Christchurch; Department of Respiratory Medicine, CDHB, Christchurch. Corresponding author: Kate Ford, Student, School of Medicine, University of Otago, Christchurch. [email protected] URL: www.nzma.org.nz/journal-articles/sleep-habits-of-intermediate-aged-students-roles-for-the- students-parents-and-educators

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REFERENCES: 1. Matricciani L, Bin YS, J Am Acad Child Adolesc 18. Hysing M, Pallesen S, Lallukka T, et al. Past, Psychiatry. 2003; 42:85–92. Stormark KM, et al. Sleep present, and future: 10. Blunden S, Hoban TF, and use of electronic trends in sleep duration Chervin RD. Sleepiness devices in adolescence: and implications for in children. Sleep Med results from a large public health. Sleep Clin. 2006; 1:105–118. population-based study. health. 2017; 3:317–323. BMJ open. 2015; 5:e006748. 11. Sekine M, Chandola T, 2. Leger D. Working Martikainen P. Work and 19. Gamble AL, D’Rozario AL, with poor sleep. Sleep. family characteristics as Bartlett DJ, et al. Adoles- 2014; 37:1401–1403. determinants of socioeco- cent sleep patterns and 3. Parliament of Australia. nomic and sex inequalities night-time technology use: Submission to the Inquiry in sleep: The Japanese results of the Australian into Sleep Health Aware- Civil Servants Study. Sleep. Broadcasting Corporation’s ness in Australia. Available 2006; 29:206–216. Big Sleep Survey. PloS one. 2014; 9:e111700. from http://www.aph. 12. Sleep Health Foundation. gov.au/DocumentStore. How much sleep do 20. Sleep Health Founda- ashx?id=9ec7f8fb-1acf you really need? Avail- tion. Ten tips for a good -4fc7-9759-0dba9954b able from http://www. night’s sleep. Available e3d&subId=661384 sleephealthfoundation. from http://www. 4. Sleep Health Foundation. org.au/how-much-sleep- sleephealthfoundation. Asleep on the job: Costs do-you-really-need.html org.au/tips-for-a-good- night-s-sleep.html of inadequate sleep in 13. Hirshkowitz M, Whiton K, Australia. Available from Albert SM, et al. National 21. Chahal H, Fung C, Kuhle http://www.sleephealth- Sleep Foundation’s sleep S, Veugelers PJ. Availabil- foundation.org.au/ time duration recommen- ity and night�time use of index.php?option=com_ dations: methodology and electronic entertainment content&view=arti- results summary. Sleep and communication cle&id=867&Itemid=1125 health. 2015; 1:40–43. devices are associated with short sleep duration and 5. Matricciani LA, Olds 14. Ministry of Education. obesity among Canadi- TS, Blunden S, et al. Updated physical guide- an children. Pediatric Never enough sleep: a lines have been released obesity. 2013; 8:42–51. brief history of sleep for children and young recommendations for people aged 5 to 17. 2017. 22. Mireku MO, Barker MM, children. Pediatrics. Available from http://www. Mutz J, et al. Night-time 2012; 129:548–556. education.govt.nz/news/ screen-based media device 6. Cain N, Gradisar M. updated-physical-guide- use and adolescents’ sleep Electronic media use lines-have-been-released- and health-related quality and sleep in school-aged for-children-and-young- of life. Environment inter- children and adolescents: people-aged-5-to-17/ national. 2019; 124: 66–78. A review. Sleep medicine. 15. Ofcom. Children and 23. Matricciani L, Bin YS, 2010; 11:735–742. parents: media use and Lallukka T, et al. Rethinking 7. Uebergang LK, Arnup attitudes report. 2013. the sleep-health link. Sleep SJ, Hiscock H, et al. Available from http:// Health. 2018; 4:339–348. Sleep problems in the stakeholders.ofcom.org.uk/ 24. McDowall PS, Galland fi rst year of elementary binaries/research/media-lit- BC, Campbell AJ, Elder school: The role of sleep eracy/oct2012/main.pdf DE. Parent knowledge of hygiene, gender and 16. Nixon GM, Thompson children’s sleep: A system- socioeconomic status. Sleep JM, Han DY, et al. Short atic review. Sleep medicine health. 2017; 3:142–147. sleep duration in middle reviews. 2017; 31:39–47. 8. Matricciani L, Olds T, childhood: risk factors 25. Tremaine RB, Dorrian Petkov J. In search of lost and consequences. J, Blunden S. Subjective sleep: secular trends in the Sleep. 2008; 31:71–78. and objective sleep in sleep time of school-aged 17. Galland BC, Gray AR, Penno children and adolescents: children and adolescents. J, et al. Gender differences Measurement, age, and Sleep medicine reviews. in sleep hygiene practices gender differences. Sleep 2012; 16:203–211. and sleep quality in New and Biological Rhythms. 9. Steenari MR, Vuontela V, Zealand adolescents aged 2010; 8:229–238. Paavonen EJ, et al. Working 15 to 17 years. Sleep memory and sleep in 6- to Health. 2017; 3:77–83. 13-year-old school children.

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Transition of the medical model of care at Ashburton hospital over 10 years: the perspective of rural generalists Steve Withington, Sampsa Kiuru, Scott Wilson, John Lyons, Alexander Feberwee, Janine Lander

ABSTRACT Rural hospitals in New Zealand face di icult workforce challenges to maintain services and quality outcomes. Ashburton Hospital has undergone a 10-year transition from a secondary specialist to a rural generalist medical model of care. Current senior medical sta (rural hospital medicine fellows) here explore their experience of the process and outcomes of this transition. Key drivers for change included commitment and support from management, senior medical sta and the local community, the new rural hospital medicine qualification and a core group of doctors willing to train in it. Challenges included the need to adapt rapidly to even a single doctor’s departure, initial lack of credibility of the new qualification, and choice between a single or two-tier system of medical rostering. While acute and elective surgical services were lost, acute medical and rehabilitation services were maintained or increased. Presentations to the acute assessment unit, including high acuity cases, have more than doubled over the period described. Workforce stability has been enhanced and commitment to training contributes to future workforce sustainability. Long-term shared strategic commitment to transition was a key factor in successfully traversing challenges faced. Rural and provincial communities should consider rural generalism as a medical model to sustain and further develop their local hospital services.

he World Health Organization (WHO) to be ineffi cient and expensive.6 Unsurpris- has identifi ed lack of rural health ingly, rural communities resisted changes workforce as a major barrier to to their healthcare services. Closure of the T 1 universal and equitable health coverage. sole rural community hospital has been Rural hospitals throughout New Zealand shown to be associated with increased local and internationally face diffi cult challenges unemployment and reduction in per capita related to workforce retention and recruit- income,7 decreased access to healthcare for ment.2–5 Moreover, there has been a tenden- the population8 and increased travel time to cy within health services to focus on special- health services.9 ised, urban-based services in terms of policy, In response to health service centrali- funding, reporting expectations and service sation, serious workforce shortages and planning. Internationally, rural hospital via- high use of locums without formal qualifi - bility has been under threat from declining cations or vocational training, the Medical 6 rural population and economic activity, and Council of New Zealand (MCNZ) recognised a reduction of rural health infrastructure a new rural scope of practice in 2008. The 4 and centralisation of services. When public Division of Rural Hospital Medicine (DRHM) hospitals were corporatised as Crown Health was created within the Royal New Zealand Enterprises, many New Zealand rural hos- College of General Practitioners (RNZCGP).2 pitals were closed as they were considered Since rural hospital medicine (RHM) was

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recognised as a specialist vocation, New FTE). Four general physicians looked after Zealand rural hospital workforce levels acute medical and rehabilitation admissions, have improved.10 ‘Rural generalism’ is and ran outpatient clinics. An experi- often represented as a broad extension enced and relatively stable medical offi cers of community medical practice in remote on special scale (MOSS) workforce had rural areas to include, for example, some replaced all resident medical offi cer (RMO) aspects of traditionally ‘specialist’ hospital positions, and a two-tier roster was main- practice, in keeping with the Cairns Decla- tained, with admissions under the surgeon ration.11 Nevertheless, as Atmore notes, or physician on-call. Limited paediatric the term ‘generalism’ is not necessarily cover was provided and all but the mildest ‘settings-bound’, neither confi ned to medical of paediatric cases requiring admission professionals, nor to general practitioners were transferred to Christchurch. Maternity (GPs) alone.5,12 For the purposes of this services were midwife-led, focused on paper, the focus will be on rural hospital primary birthing of uncomplicated preg- practice, where broad medical responsibility nancies, with occasional urgent Caesarean for all patients presenting to a rural hospital section operations performed by one is regarded as a subset of a broader concept hospital surgeon. Subspecialty outpatient of rural generalism. clinics operated with the support of Christ- Ashburton Hospital is the sole community church visiting specialists. hospital providing care for the whole rural Medical model in 2017 Ashburton District. Its tertiary referral By 2017, the SMO workforce had evolved centre is Christchurch Public Hospital, 88km to eight part- or full-time vocationally North by road. Over the 10 years from 2008 registered RHM fellows, with six FTE in to 2017 Ashburton Hospital changed its total, working a 1:5 acute roster, taking all medical model of care from a secondary medical, non-operative surgical and paedi- specialist to a rural generalist model, with atric admissions during that period. The a senior medical workforce populated second tier of the roster was made up of solely by RHM fellows. The authors all have a team of eight RMOs, ranging from PGY2 current Ashburton Hospital appointments house offi cers completing their three-month and are RHM fellows, who had partici- ‘community rotation’ in Ashburton, to RHM pated in the transition, working before, trainees and other general registrars at post- during and after the changes in a variety of graduate year (PGY) 3–5 level. After-hours roles, including as clinical directors. They one RMO on duty and one RHM SMO on call collectively documented differences in the covered the hospital and acute assessment medical model of care before and after tran- unit (AAU), and an RMO night shift was sition, based on their experiences, records in place. Three inpatient teams consisting and communications with other stake- of two to three RHM SMOs, one registrar holders, and here present their viewpoint and one other RMO provided continuity of on milestones in transition of the model of care from admission to discharge. No acute care, drivers for change, challenges faced or elective surgery was conducted, but in the process and lessons learned. Changes elective endoscopy services were main- in hospital indices of capacity and outcome tained. Maternity services continued to be were obtained from hospital documents and midwife-led and focused on uncomplicated DHB databases to compare the situation pre- deliveries, with no on-site acute Caesarean and post-transition. section service available. Maternal and Medical model in 2008 neonatal resuscitation support was provided In 2008 the specialist medical model had by the rural generalist team. Outpatient included an acute and elective general specialist surgical services were unchanged. surgical roster led by three general surgeons A timeline showing milestones in transition and supported by four anaesthetists (three is shown in Table 1.

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Table 1: Milestones in changes in medical staffi ng and model of care.

2008 Surgeons - three FTE; Physicians - four FTE, Anaesthetists - three FTE; MOSSs - five FTE. Rural hospital medicine recognised by MCNZ as a separate vocational scope. Three MOSSs and one SMO commit to further training in order to meet criteria for RHM vocational regis- tration and DRHM fellowship.

2008–9 One surgeon retired, replaced by surgeon on joint appointment with Christchurch.

2010–11 Decision made to cease acute surgery over time, and maintain an elective surgical service only. Departure of two physicians, and intermittent locum cover. Strategic conversations held about replacement with specialists or generalists.

2011–12 Elective surgery ceased as operating theatres deemed unsafe in the wake of the Feb 2011 earthquake and changes to building code. Retirement of one anaesthetist and subsequent loss of anaesthetic service. Continuation of endoscopy and outpatient surgical clinics. In- patient medical cover shared between physicians and MOSSs. Hybrid generalist roster with 1:5 call. Three MOSSs receive RHM fellowship.

2012–14 Two more RHM fellows appointed to replace departing physicians. Two-tier system with MOSSs and SMOs. Discussion regarding single vs two tier service. RHM fellows - 5.3 FTE; MOSSs & RHM trainees - seven FTE. Five MOSSs on RHM training scheme.

2015 Proposal to disestablish MOSS grade and replace with RMOs on MECA-compliant roster. Shi in focus from service delivery to clinical training and education.

2016–17 New model of care fully sta ed and functioning: RHM SMOs - six FTE; RMOs - eight FTE.

Drivers for change surgical services. Replacement of general Key local drivers for the medical model physicians also proved diffi cult, and provi- change are listed in Table 2, both ‘negative’ sions in the RMO’s 2002 Multi-Employer drivers which essentially forced change Collective Agreement (MECA), had earlier (1–5), and ‘positive’ drivers which facilitated discontinued regular, guaranteed RMO a change in the direction of rural generalism support from Christchurch. In response to (6–9). The age of the workforce was a partic- staff shortages, Medical Offi cers of Special ularly pressing issue in surgery where all Scale (MOSSs) were employed on contract or three surgeons were near retirement, and as locums to cover positions previously held the retirement of one made sustaining acute by both specialist SMOs as well as RMOs. In surgical services diffi cult. A replacement the transitional situation of Ashburton, some was found, however pending retirements MOSSs were employed in positions super- for the two others, the requirement for vising other MOSSs. general surgical skills, and the narrowing Positive drivers for change included scope of operations, made both acute and the opportunity presented by the new elective surgery less viable and the former pathway to Fellowship in RHM, and the was intentionally phased out. Anaesthetics interest shown by several medical offi cers to was similarly vulnerable following the undergo this training. This was augmented resignation of one SMO upon whom creden- by strategic commitment of the hospital tialing support depended. The February management towards a generalist medical 2011 Canterbury earthquake compounded model, and support of existing specialist recruitment challenges as changes in the SMOs for the training. Another key positive building code led to the existing operating factor was a very engaged local community, theatres being permanently closed for struc- with strong philanthropic organisations, tural reasons. There was also uncertainty who helped fund new developments, of timelines for rebuilding and ongoing including extensive rebuilding required consultation around the scope of future post-earthquake.

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Table 2: Drivers for medical model change.

1. Aging/retiring SMO* workforce 2. Di iculty recruiting replacement general surgeons, physicians, anaesthetists 3. Dependence on individual specialists for credentialing leading to vulnerability on retirement/ resignation 4. Di iculty recruiting RMOs** and increasing reliance on locum sta at MOSS*** level 5. 2011 Canterbury earthquake(s) with consequent closure of operating theatres 6. Opportunity of RHM training & qualification providing a pathway for new generalist SMOs 7. Strong community support to maintain a strong, sustainable hospital service 8. Willingness of existing specialist SMOs to support transition 9. Management support for transition

*SMOs or Senior Medical O icers operate unsupervised in hospital settings. They are usually vocationally registered with the MCNZ, but they may have only general registration, particularly in some rural hospitals. **RMOs or Resident Medical O icers work under supervision in hospitals, have general registration, and many commence formal training in a vocational specialty. ***MOSSs or Medical O icers on Special Scale are not uncommonly employed and/or remunerated as SMOs in New Zealand rural hospitals, working fully or largely independently. They are usually generally registered and not in a vocational training programme.

Challenges of transition and experience in emergency procedures, Key challenges arising during the tran- for example fracture manipulations under sition are outlined in Table 3. A cascade procedural sedation. The operating theatre in workforce issues, where a single loss of has been rebuilt with community support, personnel affected the sustainable staffi ng which will facilitate elective surgery to and therefore viability of an entire service, return in future, alongside its current was experienced on more than one occasion. utilisation for endoscopic and minor gynae- These changes were often unexpected cological procedures. and necessitated rapid changes in service Hybrid rostering, where some on call delivery, sometimes without a signifi cant shifts were covered by generalists and some transition period. The qualifi cation in RHM by physicians who needed support from was new and largely unproven in the early generalist colleagues to cover for certain stages of transition, which led to questions emergency situations (including paediatrics of credibility among some health profes- and trauma), led to a temporary increase in sionals and uncertainty of future senior cost, both fi nancial and in terms of rostering employment opportunities for trainees. demands. A particular issue of controversy Some stakeholders within and outside was whether to maintain the RHM SMO/RMO the hospital saw the move to generalism two-tier structure and focus on training, or to as a signifi cant reduction in standards of adopt a single-tier RHM system which moves care, with the loss of services such as acute focus towards service delivery. Alongside the surgery and emergency Caesarean sections medical staffi ng challenges, the departure of creating considerable unease. In response, key managers at critical junctures made it focused training on anticipated clinical diffi cult to sustain commitment to the future needs was undertaken, which has resulted vision of the service. in the development of considerable skill

Table 3: Challenges identifi ed.

1. Cascade of workforce issues, with one sta member departure a ecting a whole service 2. Cost of maintaining support of non-generalists on generalist roster 3. Uncertainty of available positions and sta at RHM SMO level 4. Credibility of the RHM qualification 5. Departure of key managers 6. Single tier vs two tier system 7. Patient care: no Caesarean section or urgent surgery availability

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Table 4: Available physical and human resources.

2008 2017 Change

FTE medical sta : Total 15 14 -1 (-7%) SMO 10 6 -4 (-40%) RMO/MOSS 5 8 +3 (+60%)

Number of beds: Total 76 53 -23 (-30%) Acute medical 21 21 0 Surgical 25 0 -25 (-100%) Rehab 15 19 +4 (+27%) Maternity 6 5 -1 (-17%) Acute assessment unit 9 8 -1 (-11%)

*Figures derived from hospital management records from 2008 and 2017, and clinical sta consultation.

Changes in overall hospital indices of long-stay patients, non-weight-bearing and outcomes as conservative or post-operative ortho- paedic management. Acute medical beds, In terms of human and physical resource AAU beds and maternity beds have changed change, outlined in Table 4, most notable little. While overall medical workforce was the complete loss of surgical inpa- FTE numbers were decreased by one, the tient beds, with only a few day procedures proportion of SMOs in relation to RMOs remaining. The rehabilitation ward had four decreased considerably. extra beds, and a much greater proportion

Table 5: Output indicators (from CDHB Decision Support Unit).

2008 2017 Change Population catchment* 28,420 33,130 + 4,710 (+16.6%)

Bed days and occupancy Acute medical 4,852; 63% 4,839; 63% -13; 0% Rehabilitation 3,041; 56% 5,782; 83% +2,741; +17% Surgical 456 0 -456

Length of stay Total average 2.0 3.1 +1.1 (+55%) Acute medical ward 3.9 3.2 -0.7 (-18%)

Annual admissions 2,355 2,278 -77 (-3%)

Annual acute presentations Total 3,518** 7,236 +3,718 (+106%) Triage 1+2 262** 659 +397 (+152%)

Acute admissions to Christchurch of Ashburton domiciled patients 278 450 +172 (+62%)

Transfers to Christchurch Hospital 404 454 +50 (+12%)

In hospital deaths 55 69 +14 (+25%)

*Population based on Statistics New Zealand online database figures,13 projected between and beyond the 2006 and 2013 census figures to obtain estimates for 2008 and 2017, based on a constant linear progression. **Figures from 2010, (earliest year available).

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Table 5 shows several indicators of generation of rural doctors. Transitioning hospital service, comparing 2008 and 2017. to the RHM model of care in Ashburton Acute medical occupancy was unchanged allowed for more comprehensive SMO between the two periods at 63%, while support around-the-clock in some respects rehabilitation occupancy has risen from than previously. In particular, paediatric 56 to 83%. The total average length of stay management in Ashburton was ‘out of has increased from 2.0 to 3.1 days, infl u- scope’ for physicians prior to the transition, enced heavily by the loss of day-stay surgical and it took several years for paediatric patients and an increase in rehabilitation admissions to reach acceptance among all patients, in particular the non-weight- hospital staff. bearing patients. A more comparable The challenge faced around credibility of fi gure of length of stay is for acute medical the RHM qualifi cation has lessened since patients, where the duration has decreased nationally, as the qualifi cation is now widely from an average of 3.9 to 3.2 days. While recognised and respected, and governing population increased by 17%, annual admis- bodies are more aware of the need for sions decreased slightly from 2,355 to 2,278. rural exposure in undergraduate and post- However, total emergency presentations graduate training. While some changes to the AAU rose from 3,518 in 2010 (the in Ashburton Hospital’s transition were earliest year that these fi gures are available) considered and made following extensive to 7,326 in 2017. Triage 1 and 2 presenta- consultation, others occurred suddenly and tions increased from 262 to 659 during the unavoidably, which often had the ripple same period. Transfers to Christchurch effect of further staff losses, uncertainty also increased, but not to the same degree, regarding future workforce and services, from 404 in 2008 to 454 in 2017. Direct and public perception of hospital down- acute admissions to Christchurch Hospital grades. Perhaps the most important lesson of people domiciled in Ashburton rose learned through this transition process from 278 to 450. While general practitioner to a rural generalist model is that it takes (GP) referrals to Christchurch Hospital for time, and requires a long-term strategic specialist care will represent some of this commitment to change on the part of increase, most patients are still referred to key stakeholders. It is hoped that some Ashburton Hospital. Self-presentations to potential resistance to a process of change hospital increased over the period, espe- in the direction of rural generalism can cially since the end of 2016 when general be mitigated by exposure to this and other practice after-hours cover was no longer examples of rural generalist medical models provided after 8pm (previously 11pm). In of care in New Zealand hospitals. addition, GPs no longer covered overnight calls to age-related care facilities. Overall deaths in hospital increased from 55 to 69. Discussion We believe this has been a demon- Lessons learned strably successful transition from a The primary reason for change to secondary specialist to a generalist model Ashburton Hospital’s medical model, was of care in a New Zealand rural hospital, the vulnerability of its medical workforce. over an extended period of 10 years. The Workforce stability has been signifi - medical workforce became more stable, cantly enhanced with virtually no current and commitment to training in this rural reliance on locum medical staff, following setting promises increased sustainability. the transition. The opportunity for, and The new generalist model serves more promotion of, Ashburton Hospital as a site acute (including high acuity) patients and a to undertake ‘community attachments’ for similar number of inpatients compared to PGY2 RMOs has aided RMO recruitment, the previous model. The decreased length with the RMO roster routinely fully staffed. of stay in acute medical inpatients can be PGY2 employment has had implications seen as a marker for increased effi ciency for increased, on-site SMO supervisory in this setting. This may refl ect the benefi ts requirements. However, this has added of the integrated generalist model, with no to job satisfaction for SMOs and hope- specialist ‘silos’ or compartments, where a fully contributes to the training of a new

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small clinical team provides greater conti- differences in drivers and constraints of nuity of patient care from admission to change, geographical distances from tertiary discharge. A trend in medicine over the past centres, population size and community decade has been for shorter length of stays, needs. Developing the most appropriate but this is unlikely to account for all of the model for each rural hospital is a key stra- reduction at Ashburton.14 tegic and shared task for management, This successful transition to a rural gener- senior medical staff, community representa- alist model is not an isolated case. There has tives and other stakeholders in rural areas. been a global move in recent years towards Limitations enhancing generalism, both in primary care This study represents the viewpoint of as well as within specialist domains, such RHM fellows, with current appointments as surgery and medicine.15,16 In a systematic in Ashburton, based on their experience review in 2007, Pashen et al found a rural of the transition and available documents. generalist model to be the most effective This is not a systematic sampling of a broad and suitable model for delivery of health range of clinical and non-clinical infor- services to rural Australia.17 Benefi ts of a mants affected by the transition such as generalist model of care on health services specialists, other RMOs, other hospital staff include: enlarged and inclusive scope and managers, GPs and community repre- of practice, holistic approach to patient sentatives for their opinions and for data care, responsiveness to local context and regarding the transition and its outcomes. improved patient access to services.18 Statements made about historical move- Rural community hospitals can provide ments in staff, their drivers, and signifi cance effective and effi cient care equivalent to have not been derived from or checked larger hospitals, with improved patient with all of those staff members, and would experiences.19 In addition, with appropriate have benefi tted from a wider consultation training, rural generalists can safely deliver process. In addition, only a superfi cial a wide range of low-volume specialised analysis of output indicators has been services.17 possible, and the impact of the transition on Many of the medical workforce shortage the wider hospital community is not clear. problems described in Ashburton Hospital’s Furthermore, the fi nancial implications of transition will be common to other rural a changed medical model of care would health services elsewhere in New Zealand. require a much more detailed analysis, The DRHM training pathway offers an considering all related infl ation adjusted ongoing pipeline for new SMOs appropri- costs in comparison with outputs. ately trained for rural hospitals, that helps address shortages in a generalist model, Conclusion which has inherent fl exibility to adapt to The transition of Ashburton Hospital’s local needs and priorities. The potential medical model of care from a secondary for hospitals to recruit registrars who are specialist to a rural generalist model over training for these roles, or RMOs who are 10 years has been successful. Key indicators doing their foundational ‘community’ of this include moving from high locum attachments, also represents an opportunity dependence to a stable, sustainable RHM for meeting service provision goals, while SMO and RMO workforce and an effi cient decreasing reliance on locums. However, it use of human and other resources, fl exible is important to consider the wider implica- enough to cope with a changing workload. tions of such a two-tier system, including Key factors in the success have been the the necessary commitment to super- new and increasingly recognised RHM qual- vision and training and potential increase ifi cation, the support of key stakeholders in medical staffi ng required, alongside and long-term strategic commitment to anticipated positive outcomes for future change. Challenges faced have been consid- workforce sustainability. erable, and lessons learned may help others Alternative generalist or mixed specialist/ negotiate similar transitions. The rural generalist models of care are being generalist hospital model is a viable option proposed and/or trialled at various New to serve rural and provincial communities Zealand rural and provincial hospitals, with of New Zealand.

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Competing interests: Dr Kiuru and Dr Withington report grants from Advance Ashburton Trust during the conduct of the study. Author information: Steve Withington, Senior Clinical Lecturer, Rural Health Academic Centre, and Rural Hospi- tal Medicine Fellow, Ashburton Hospital, Ashburton; Sampsa Kiuru, Senior Clinical Lecturer, Rural Health Academic Centre, and Rural Hospital Medicine Fellow, Dunstan Hospital, Clyde; Scott Wilson, Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton; John Lyons, Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton; Alexander Feberwee, Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton; Janine Lander, Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton. Corresponding author: Dr Steve Withington, Senior Clinical Lecturer, Rural Health Academic Centre, and Rural Hospital Medicine Fellow, Ashburton Hospital, 28 Elizabeth St, Ashburton 7700. [email protected] URL: www.nzma.org.nz/journal-articles/transition-of-the-medical-model-of-care-at-ashburton- hospital-over-10-years-the-perspective-of-rural-generalists

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Census/2013-census/ 15. Turnberg L. Survival of the Generalism versus profi le-and-summary-reports/ General Physician. BMJ. subspecialization: changes quickstats-about-a-place.aspx- 2000; 320(7232):438–40. necessary in medical ?request_value=14909&tab- 16. Loefl er IJP. The Renais- education. Can J Rural name=Population- sance of General Surgery. Med. 2006; 11(2):126–8. anddwellings BMJ. 2000; 320(7232):436–8. 19. Davidson D, Paine AE, 14. Kaboli PJ, Go JT, Hocken- 17. Pashen D, Murray R, Chater Glasby J, et al. Analysis berry J, et al. Associations B, et al. The expanding of the profi le, character- between reduced hospital role of the rural generalist istics, patient experience length of stay and 30-day in Australia-a systematic and community value of readmission rate and review. Australian Primary community hospitals: a mortality: 14-year experi- Health Care Research multimethod study. Health ence in 129 Veterans Affairs Institute. Brisbane, 2007. Services and Delivery hospitals. Ann Intern Med. Research. 2019; 7(1 ). 18. Albritton W, Bates 2012; 157(12):837–45. J, Brazeau M, et al.

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Neoliberalism: what it is, how it affects health and what to do about it Pauline Barnett, Philip Bagshaw

ABSTRACT Since the 1970s, neoliberalism has been the dominant economic and political philosophy among global institutions and some Western governments. Its three main strategies are: privatisation and competitive markets; reduced public expenditure on social services and infrastructure; and deregulation to enhance economic activity and ensure freedom of ‘choice’. Generally, these measures have negatively a ected the health and wellbeing of communities. In New Zealand, privatisation and competition led to income inequality and an unequal distribution of the ‘determinants of health’, a burden borne disproportionately by children, the poor, and by Māori and Pacific people. Limiting health expenditure led to inequalities in access to services with restructuring in the 1990s, subverting the service culture of the health system. Failure to regulate for the protection of citizens has undermined health and safety systems, the security of work and collective approaches to health improvement. There has been some retreat from neoliberalism in New Zealand, but we can do more to focus on ‘upstream’ health initiatives, to recognise that social investment, including adequate funding of services, returns benefits far in excess of any costs, and to make sure that social and cultural equity goals are achieved.

his paper sets out the consequences refl ected in laissez-faire economic policies of neoliberalism for health. Among that encouraged industrialisation and new Thealth workers, including doctors, models of labour and capital, in short, nurses and managers, there are some with a the modern economy. Classical liberalism poor understanding of neoliberalism or who relied on the market with minimum inter- assume that this is the only way to organise ference from the state, either by regulation our economies and institutions. Neoliber- or taxation. Government’s role was to keep alism has been described as the ‘idea that order, protect property and create a secure swallowed the world’.1 We argue that the environment for the pursuit of commerce.2 world also ‘swallowed’ (uncritically accept- The liberal model fell into disfavour in the ed) neoliberalism, and that this should be mid-twentieth century when the upheaval challenged. We trace the rise of neoliberal- of the Great Depression suggested a greater ism, including its emergence in New Zealand role for governments in managing econ- and its implications for health. Finally, we omies. Drawing on the economic theories of suggest some changes that could mitigate JM Keynes, Western governments accepted the worst consequences of neoliberalism for the idea of intervention in economic health and ensure responsiveness to grow- management and promoting prosperity ing and unmet need. through welfare states.3 Early international The rise of neoliberalism examples included New Deal policies in Classical liberalism is an ideology and the US in the 1930s to address impacts of policy model that emphasises personal the Great Depression and comprehensive and economic freedom and a small role for welfare state legislation in New Zealand the state, allowing individuals to pursue in 1938. Over subsequent decades alter- their own interests.2 Originating among native versions of welfare states emerged in eighteenth century philosophers, through Western countries. The three main types are the nineteenth century, liberalism was set out in Table 1 (adapted from Schrecker and Bambra,4 with permission).

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Table 1: Main types of welfare states.

Social democratic (the ‘Nordic’ Model) This includes countries such as Norway, Finland, Sweden, Denmark and Iceland. Income support and social services, including health, are funded predominantly from taxation. Bismarckian (Social Insurance Model) This model is typical of continental European countries such as France, Germany, Italy, Netherlands. Income support, social and health services are largely funded through employer and personal contri- butions with access guaranteed. Liberal systems These are typical of the US, UK, Australia and New Zealand. Income support, social and health services are less comprehensive and only partially funded. This has encouraged the emergence of two-tiered systems with significantly greater levels of income inequality and access. NB There are other ways of classifying welfare states, but the one used here is the most simple and useful.

While welfare states proliferated in Thatcher (UK prime minister 1979–1990) the the 1940s and 1950s, there was a counter ‘uptake’ of neoliberalism was widespread argument that state intervention would internationally, and reinforced by fi nancial lead to totalitarianism. In the 1960s Milton institutions such as the International Friedman and others rejected the view Monetary Fund (IMF) and the World Bank. that government intervention could lead to These organisations, throughout the 1980s improved economic performance. Friedman and 1990s forced unwilling but indebted articulated again the primacy of markets countries to restructure their economies and competition, and a lesser role for the along neoliberal lines. state as the way to improve productivity Neoliberalism in New Zealand and effi ciency.3 By the 1970s this thinking As a liberal welfare state New Zealand had crystallised into the political/economic was well-positioned to move along the model known as neoliberalism, with the continuum to neoliberalism. Surprisingly, following key elements: it was a Labour government, elected in Economic restructuring, markets and 1984, that thrust neoliberal policies onto an privatisation—increased competition; unsuspecting public. Through two terms removal of the state from commercial of government (1984–90) the neoliberal activity, greater openness to international approach, called ‘Rogernomics’ after Finance trade and investment, freedom of movement Minister Roger Douglas, was introduced of capital, labour and goods (‘globalisation’). quickly and without effective opposition.5 Limiting public expenditure on Minister Douglas himself stated: “Once the social services, including healthcare and program begins to be implemented, don’t education, and infrastructure, with debt stop until you have completed it. The fi re of reduction the major goal (later called opponents is much less accurate if they have ‘austerity’ policies). to shoot at a moving target”.6 Deregulation and promotion of indi- Neoliberal reform focused on monetary vidual responsibility—limiting government policy and on restructuring the commercial regulation that might inhibit economic and service activities of the state. The activity, despite risks to personal health and exchange rate was fl oated, fi nancial markets safety or the environment; giving priority to deregulated and most producer subsidies individual responsibility and ‘choice’ over and import tariffs phased out. Many state concepts of ‘public good’ or ‘community’. commercial activities were corporatised Led by conservative politicians, a ‘great and privatised. The Government reformed reversal’3 occurred, with Keynesianism the public sector based on a preference for replaced by neoliberalism. Led by Ronald what were perceived to be private models of Reagan (US president 1981–89) and Margaret management, with a preference for private

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provision, competition, labour fl exibility indicates that increased capital move- and contractual arrangements. In deference ments and income inequality are positively to its traditional supporters it did not correlated across all countries.11 In addition, attempt major labour or welfare reform. It international lending programmes that did, however, attempt to create a market for required reduced public spending were also healthcare but this was resisted by Labour associated with increased income inequality. supporters and health professionals.5 From the 1980s, such ‘structural adjust- The new National government (1990–96) ments’ were a condition of international pressed on with neoliberal policies. Severe loans, forcing countries to reduce public cuts to welfare occurred in 1991 along services, with poor social and economic with legislation to deregulate and create consequences. Research from 1985–2014 a more ‘effi cient’ labour market.7 The indicates that structural adjustment aim of health reform policy (1991) was to continues to inhibit the ability of govern- 12 increase effi ciency through privatisation ments to plan and provide public services. and a competitive market, and opportu- In New Zealand, the impacts of the nities for innovation.5 The development of reforms were catastrophic, with over not-for-profi t (NFP) organisations providing 111,000 jobs lost between 1986 and 1996.14 health services to Māori, Pasifi ka, youth The cuts to welfare benefi ts created extra and mentally ill people were important fi nancial pressures on families with innovations to benefi t the community, children. Child poverty rose dramati- but otherwise there was a retreat from cally after the 1991 budget and persisted, the excesses of the 1991 policy, fi rst under with 28% of children in poverty, including a coalition government (1997–99) and a 20% in severe poverty in 2015.14 In 2015 Labour government 2000–2009. Never- New Zealand, previously considered a theless, as the theory and practice of the low-inequality country, experienced one New Public Management became consol- of the more signifi cant rises in economic idated in the 1990s, its business culture inequality in the OECD since the 1980s, became embedded in the health system similar to that of the US. 15 where it still pervades language and the The impact of neoliberalism on planning and delivery of services.8 health The general impacts of Inequalities and health neoliberalism The link between social and economic Despite growth in world economic inequality and ill-health is well established. activity from the 1990s onwards, research On virtually all health indicators across appraisals of the impact of neoliberalism countries of all types, health outcomes from are mixed. Some say that there is ‘much to the most obvious (such as mortality rates and 9 cheer about’, claiming that globalisation life expectancy) to the more subtle (mental removed many people worldwide from health problems and chronic disease) are poverty and that privatisation of state enter- related to levels of inequality.16 The graph prises increased effi ciency and lowered the (Figure 1; published with permission) from fi scal burden on governments. Nevertheless, Wilkinson and Pickett powerfully demon- research suggests that there have been poor strates the relationship between increasing outcomes for the most vulnerable econ- income inequality and a rise in the index of omies, with most middle- and low-income health and social problems. countries experiencing slower economic Research worldwide has shown how poor growth and reduced progress on social health outcomes are related to deterioration indicators from 1980–2005, compared with in the social and economic determinants previous decades.10 of health, such as income, housing, food There are two areas of exceptionally poor security, employment, stress and educational outcomes: income inequalities arising from opportunities.17 Poor social conditions are uncontrolled capital movements (globali- not accidental, but result from neoliberal sation), and service failure from austerity policies that affect not only mortality but 9 measures, leading to further inequality. also morbidities such as obesity, mental Research into 140 countries from 1970–2014 health and health risk behaviours. In New

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Figure 1: Health and social problems are worse in more unequal countries.

Zealand these relationships have been minants of health. The second is through demonstrated over decades,18 with health the direct impact on health services. For risks from neoliberalism borne dispropor- example, after the Global Financial Crisis of tionately by Māori and Pacifi c people19 and 2008, health outcomes for countries where exacerbated by the experience of cultural health budgets were reduced compared loss, colonisation and racism.20 unfavourably with countries that protected 23 Poor health outcomes are ‘downstream’ spending on public services. In New effects, but tackling ‘upstream’ causes Zealand, health service impact is caused requires policies to improve levels of social by both persistent underinvestment in and economic wellbeing that will help services, competitive approaches and the people to live healthy lives. This involves marginalisation of health professionals in recognising the continuing presence of decision-making. income and social inequality: in New Underinvestment in health services Zealand in the 1980s someone in the richest Government claims of overfunding in 10% earned fi ve times as much as someone health services in the late 1980s were in the poorest 10%; now they earn eight rejected by professional economists,24 times as much.21 but the narrative of ‘overfunding’ was Austerity policies and health sector reinforced by self-interested private organ- reform isations and neoliberal governments. In fact, there is no indication of unsustainable Besides the poor economic performance funding between 2000–2015.25 Measures of associated with austerity,10 there is also a health expenditure for 2009–2018, adjusted negative relationship between austerity for infl ation and population change, based and health. First, as already discussed, is on Treasury models, indicated a cumu- the ‘social risk effect’, or ‘risk-shifting’22 lative decline.26 The result was an effective where those already disadvantaged bear the reduction in funding for health services. consequences of deterioration in the deter-

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Persistent district health board defi cits are complicated tendering processes. The use of most likely due to chronic underfunding of private facilities for contracting out services legitimate and growing needs by an esti- was encouraged and still persists, despite mated $2.5 billion over the last 10 years.25,26 evidence that this may weaken elements of A further consequence of underinvestment both public and private sectors.32 over several decades is a demoralised Despite some retreat from neoliber- workforce that found health workers in alism after the year 2000, there has been understaffed teams and poorly remu- persistent marginalisation of health profes- 27 28 nerated. Hospital doctors and nurses sionals through the dominance of rules and report stress, burnout and “intense, unre- guidelines over clinical judgment. Since the lenting work-loads”. late 1990s, for example, the National Waiting Privatisation, corporatisation and Times Project has given priority to rationing inequalities in access criteria over clinical decision-making in The 1991 health reforms were imple- allocating elective surgery. These criteria mented specifi cally to create effi ciencies by and fi nancial ‘thresh-holds’ have led, two attempting to ‘mimic’ a private market in the decades on, to explicit concerns about 33,34 public sector. This was unsuccessful because unmet need. Those with means can of community and professional scepticism. access private surgery while those without The introduction of ‘user pays’ for hospital are often unable to access the care they need stays in the early 1990s drew public ridicule through public hospitals. In 2018, private and was abandoned. There was encour- hospitals reported performing 50% of all agement of private insurance models, but elective procedures (http://www.nzpsha.org. these received critical opposition.29 The nz). Problems of access, however, go beyond corporate model failed to improve hospital surgical services. In primary care, cost fi nancial performance and as early 1996 barriers to access originate in the resistance the government’s own monitoring agency of general practice to participating fully in reported that “the pace of performance Welfare State legislation in New Zealand in improvement seems … to have weakened 1938. The long-term consequences of this since the reforms”.30 are seen in multi-country studies of primary care from 1998–2016 where the proportion By attempting to drive unrealistic fi nancial of New Zealanders unable to access a GP goals, aggressive management subverted each year because of cost was on average health professional/management relation- 21%, second only to that of the US (34%).35 ships, creating mistrust that compromised service quality and culture. This was seen Regulation for health protection notably in Canterbury where a group of Using regulation to improve population concerned clinicians released a report health is the cornerstone of public health ‘Patients are Dying’. An investigation by the action. Neoliberal governments often Health and Disability Commissioner (1996) downplay their regulatory responsibilities, explicitly blamed some patient deaths on citing the paramountcy of ‘personal respon- systems changes and inadequacies, and led sibility’ and ‘personal choice’. In this they to some tempering of the excesses of the fi nd willing partners among commercial reforms.31 interests. While the public health sector was The deregulation of the labour market not privatised and remained in public has impacts for health. Research in both ownership, private sector business prac- rich and poor countries shows that workers tices and culture were embedded in in ‘precarious,’ ‘casual’ or ‘zero hours’ public organisations. The experience of work have poorer health outcomes.36 The the next two decades refl ected continuing growth of the ‘Precariat’ is a worldwide underinvestment, the transaction costs of phenomenon with up to one-sixth of contracting in the ‘fake’ market and the working age people in New Zealand in determination of funders to push fi nancial this group.37 The lives of the ‘Precariat’ are risk onto local services or the community. dominated by poor pay and lack of security, For example, NFP community organisations with stress a likely health outcome of ‘low were made to compete against each other in personal control’ over work environments.36 Similarly, neoliberal deregulation of work

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and safety practices create health risks. In eralism in our psyche; language exerts a New Zealand, a review of the Pike River powerful infl uence as the persistence of the Mine tragedy in which 29 coal miners died ‘nanny state’ critique shows. in 2010 indicated serious regulatory failure Clearly there was some retreat from 38 attributed to neoliberal infl uences. neoliberalism under a Labour government In terms of housing, the desire to see between 2000–2008, but push-back from business work in an unfettered way led to National occurred from 2009–2016. The self-regulation of the construction industry present prime minister, Jacinda Ardern has through the Building Act 1991, resulting in declared that neoliberalism has failed,43 poor standards of construction and 40,000 with the Government moving to strengthen ‘leaky buildings’. This created health and the social determinants of health and raise fi nancial consequences and required re-reg- income levels. Health services have received ulation to raise construction standards. In some modest additional funding to improve contrast, research indicates how regulation primary care access, resource mental health and interventions to ensure housing insu- and assist district health boards with capital lation can lead to important health benefi ts charges. 39 by improving energy performance. To do better, we must reject old-fashioned In the social sphere, the neoliberal economic thinking that spending on health position is that individuals usually make the or other services is a burdensome cost. best ‘choices’ for themselves, with regulatory In fact, it represents a great investment; approaches characterised as ‘nanny state’. producing signifi cant social benefi ts and The entire apparatus of ‘health promotion’ promoting economic growth.41 Risks from appears to have lurched in this individual government spending in developed coun- direction, despite evidence that education tries with little debt (such as New Zealand) alone may not be particularly effective in are low, and even the IMF now acknowl- areas such as alcohol consumption, injury edges the past economic damage from prevention, tobacco control and dietary austerity and that investment in public change.40 This is another instance of trying services/works provides both social and to change ‘downstream’ behaviour instead economic returns. Research into health of working on ‘upstream’ determinants of spending in 25 European Union countries health inequalities or taking a responsible 1995–2010 indicates that the ‘multiplier’ approach to providing a regulatory envi- effect (ie, the fi nancial benefi ts) from ronment that can support behaviour change. government spending was 1.61 overall, but Particularly damaging is the way in health spending achieved a multiplier of 44 which ‘personal responsibility’ and ‘choice’ 4.9. Therefore, for every dollar invested in have led to the stigmatisation of the most health, there is a return of nearly $5 to the vulnerable, blaming individuals for their economy overall. poverty, precarious employment and poor A focus on ‘upstream’ solutions through health. Nevertheless, there is optimism in non-precarious employment and modest the evidence that regulation and combined income re-distribution to create a ‘propor- regulatory/personal approaches for health tionate universalism’ (a balance between gain can be effective.41 targeted and population approaches)45 can Reappraisal and moving forward: address existing and prevent future inequal- ities. It will be important to rectify chronic health funding is an investment, health services underfunding by further not a cost increasing allocations, but we also need As a ‘liberal’ welfare state (Figure 1), New to address defi ciencies within the health Zealand was vulnerable to and fell head- system.46,47 The recent health and disability fi rst into the neoliberal ‘trap’, and we have systems review suggests that some reor- found it diffi cult to climb out. Neoliberalism ganisation is required to address problems persists when it seems so obviously bad of inequity, including poor Māori health for us, perpetuated by the ‘haves’ who are outcomes, and lack of leadership, and hints clearly doing quite well. There is an ‘infra- at the need for rationalisation of struc- 42 structure of persuasion’ that includes tures.46 There is increasing acceptance that relentless messages that embed neolib- there are too many DHBs and that these

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add little value. Stronger central policy order to reverse it in New Zealand, a sea leadership and support for the integration change is needed in philosophy, policy and of all aspects of primary, secondary, NFP practice with: (i) the immediate objective of community organisations and particu- equity of health outcomes for all citizens; larly the long-neglected population health (ii) bold re-investment in health and social services will be required. security; (iii) the explicit rejection of the In conclusion, the national (and interna- marginalisation of health professionals in tional) impact of neoliberalism on health decision-making, and (iv) a move to a more and healthcare remains enormous. In streamlined, ambitious and integrated health system.

Competing interests: Nil. Author information: Pauline Barnett, Adjunct Associate Professor, School of Health Sciences, University Canterbury, Christchurch; Philip Bagshaw, Chair, Canterbury Charity Hospital Trust, Christchurch; Clinical Associate Professor, University of Otago, Christchurch. Corresponding author: Philip Bagshaw, Chair, Canterbury Charity Hospital Trust, PO Box 20409, Christchurch 8543. [email protected] URL: www.nzma.org.nz/journal-articles/neoliberalism-what-it-is-how-it-affects-health-and-what- to-do-about-it

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imperils health and what in the health sector Review - Interim Report. to do about it. J Epide- promote or inhibit Hauora Manaaki ki miol Community Health. economic growth? Global Aotearoa Whā nui–Pūrongo 2016; 70(3):312–18. Health. 2013; 9:43. mō Tē nei Wā. Welling- 42. Monbiot, G. How did we 45. Carey G, Crammond B, De ton: HDSR. 2019. get into this mess? London: Leeuw E. Towards health 47. Goodyear-Smith F, Ashton Verso Books; 2017:1. equity: a framework for T. New Zealand health 43. Cooke H. Jacinda Ardern the application of propor- system: universalism says neoliberalism tionate universalism. Int J struggles with persist- has failed. Stuff 12th Equity Health. 2015; 14:81. ing inequities. Lancet. September 2017. 46. Health and Disability 2019; 394:432–42. 44. Reeves A, Basu S, McKee System Review. Health M, et al. Does investment and Disability System

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A consensus statement on the use of angiotensin receptor blockers and angiotensin converting enzyme inhibitors in relation to COVID-19 (corona virus disease 2019) Hari Talreja, Jasmine Tan, Matt Dawes, Sharen Supershad, Kannaiyan Rabindranath, James Fisher, Sajed Valappil, Veronica van der Merwe, Lisa Wong, Walter van der Merwe, Julian Paton

ABSTRACT There has been a lot of speculation that patients with coronavirus disease 2019 (COVID-19) who are receiving angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) may be at increased risk for adverse outcomes. We reviewed the available evidence, and have not found this to be the case. We recommend that patients on such medications should continue on them unless there is a clinical indication to stop their use.

here has been an unprecedented We reviewed the evidence supporting interest generated in the medical com- this hypothesis, and would like to make the Tmunity and on social media around following observations: the interaction of coronavirus (SARS-CoV2) 1. The studies from China report higher and ACE inhibitors (ACEi) and angiotensin prevalence of hypertension in those receptor blockers (ARB), and whether these who developed severe COVID-19 medications increase the risk of COVID-19. disease.3,4 However, a conclusion This was triggered by correspondences cannot be drawn that hypertension published in high-impact medical journals, results in severe infection as these Lancet Respiratory Medicine and BMJ.1,2 analyses were unadjusted for They observed that the COVID-19 patients confounders such as age, and there with comorbidities such as hypertension was no reported data on ACEi and ARB and diabetes, had more severe symptoms. use in these studies. Another recently The authors hypothesised that diabetes and published study evaluating cardiovas- hypertension treatment with ACE2-stimu- cular implications of COVID-19 did not lating drugs increases the risk of developing fi nd any association between use of severe and fatal COVID-19. They suggest that ACEi/ARB and mortality.5 ACEi and ARB can increase ACE2, which is an 2. Previous animal studies6 showed that enzyme used by the virus to gain entry into ACEi and ARB increase ACE2 activity. host cells. Therefore, these drugs could poten- Based on this, Fang et al proposed tially increase the risk of severe infection. that this would enhance infectivity of

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the SARS CoV2 virus.1 However, other to change therapy. These commonly used studies did not fi nd any change in medications confer benefi ts in patients with ACE2 mRNA expression in rat heart cardiovascular disease, kidney disease and cells treated with an ACEi7 and no diabetes, and should not be changed unless change in plasma ACE2 activity in the clinically indicated. The current evidence presence of either ACEi or ARBs in on COVID-19 and hypertension, and ACEi humans.8 Therefore, it is questionable or ARB medication is inadequately adjusted whether these drugs increase either and prone to bias, and therefore remains the expression or enzymatic activity inconclusive. of ACE2 in tissues to cause severe Our recommendation to prescribed use of viral infection. ACEi and ARBs is consistent with the view- 3. To the contrary, there is evidence that point of numerous societies from around ACEi might confer protection in some the world including the American College of viral pneumonias.9 Based on this, Cardiology, American Heart Association, and there are ongoing trials studying the Heart Failure Society of America, European effect of Losartan (an ARB) in patients Society of Cardiology, the International with COVID-19 in outpatient and inpa- Society for Hypertension, European Renal tient settings.10,11 Association and European Dialysis and Therefore, given the available evidence, Transplant Association. we DO NOT advise patients on ACEi or ARB

Competing interests: Nil. Author information: Hari Talreja, Consultant Nephrologist, Counties Manukau DHB; Jasmine Tan, Consultant Nephrologist, Waitematā DHB; Matt Dawes, Cardiovascular Physician/Clinical Pharmacologist, Auckland DHB and Sr lecturer, University of Auckland; Sharen Supershad, Consultant Nephrologist, Northland DHB; Kannaiyan Rabindranath, Consultant Nephrologist, Waikato DHB; James Fisher, Department of Physiology, University of Auckland; Sajed Valappil, Consultant Nephrologist, Waitematā DHB; Veronica van der Merwe, Nurse Specialist, The Hypertension Clinic, Auckland; Lisa Wong, Research Operations Manager, Manaaki Mānawa – The Heart Research Centre; Walter van der Merwe, Consultant Hypertension Specialist, The Hypertension Clinic, Auckland; Julian Paton, Director, Manaaki Mānawa – The Heart Research Centre, and Department of Physiology, University of Auckland; The consensus has also been supported by Professor Rob Doughty (Heart Foundation Chair, ADHB, University of Auckland) and Associate Professor Gerry Devlin (Medical Director, Heart Foundation). Corresponding author: Dr Hari Talreja, Consultant Renal Physician, Dept of Renal Medicine, Counties Manukau Health, 100 Hospital Road, Otahuhu, Auckland 1640. [email protected] URL: www.nzma.org.nz/journal-articles/a-consensus-statement-on-the-use-of-angiotensin- receptor-blockers-and-angiotensin-converting-enzyme-inhibitors-in-relation-to-covid-19- corona-virus-disease-2019

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REFERENCES: 1. Fang L, Karakiulakis 5. Guo T, Fan Y, Chen M, plasma angiotensin G, Roth M. (2020). Are et al. Cardiovascular converting enzyme 2 patients with hyper- Implications of Fatal activity is associated with tension and diabetes Outcomes of Patients with atrial fi brillation and mellitus at increased risk Coronavirus Disease 2019 more advanced left atrial for COVID-19 infection? (COVID-19). JAMA Cardiol. structural remodelling. Lancet Respir Med. 2020 Published online March Europace. 2017 Aug 1; Mar 11; doi: 10.1016/ 27, 2020. doi:10.1001/ 19(8):1280–1287. doi: S2213-2600(20)30116-8. jamacardio.2020.1017 10.1093/europace/euw246. [Epub ahead of print] 6. Ferrario CM, Jessup J, 9. Henry C, Zaizafoun M, 2. Sommerstein R. Re: Chappell MC, et al. Effect Stock E et al. Impact of Preventing a covid-19 of angiotensin-converting angiotensin-converting pandemic: ACE inhibitors enzyme inhibition and enzyme inhibitors and as a potential risk factor angiotensin II receptor statins on viral pneumonia. for fatal Covid-19. BMJ blockers on cardiac Proc (Bayl Univ Med Cent). 2020; 368:m810 angiotensin-converting 2018 Oct 26; 31(4):419–423. 3. Yang X, Yu Y, Xu J, et enzyme 2. Circulation. doi: 10.1080/08998280.2018. al. Clinical course and 2005 May 24; 111(20):2605- 1499293. outcomes of critically ill 10. Epub 2005 May 16. 10. Randomized Controlled patients with SARS-CoV-2 7. Burrell L, Risvanis J, Trial of Losartan for pneumonia in Wuhan, Kubota E, et al. Myocar- Patients With COVID-19 China: a single-centered, dial infarction increases Not Requiring Hospital- retrospective, observation- ACE2 expression in rat ization. ClinicalTrials.gov al study. Lancet Respir Med and humans, European Identifi er: NCT04311177. 2020; published online Feb Heart Journal, Volume 11. Randomized Controlled 24. http://doi.org/10.1016/ 26, Issue 4, February Trial of Losartan for S2213-2600(20)30079-5. 2005, Pages 369–375, Patients With COVID-19 4. Guan W, Ni Z, Hu Y, et al. http://doi.org/10.1093/ Requiring Hospitaliza- Clinical characteristics of eurheartj/ehi114 tion. Clinica lTrials.gov coronavirus disease 2019 8. Walters TE, Kalman JM, Identifi er: NCT04312009. in China. N Engl J Med Patel SK et al. Angiotensin 2020; published online converting enzyme 2 Feb 28. DOI:10.1056/ activity and human atrial NEJMoa2002032. fi brillation: increased

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Bilateral vertebral artery dissection and cerebellar stroke: a rare complication of massage William Birkett, Pourya Pouryahya, Alistair D McR Meyer

ABSTRACT Dissection of a cervical artery is a well-known cause of stroke, especially in younger patients. We describe the case of a 39-year-old male, who presented to our emergency department a er a one-day history of headache and vomiting, with associated sudden onset posterior neck pain and cerebellar signs following a massage. Computed tomography angiogram and brain demonstrated bilateral vertebral artery dissection and cerebellar stroke. He was admitted to hospital for monitoring and conservative management with antiplatelet therapy, resulting in a good outcome. This is the first reported case of bilateral vertebral artery dissection and stroke to be associated with massage. This case also suggests, unlike many reports in the literature, that significant vascular pathology can result from massage even without cervical spine manipulation.

n vertebral artery dissection (VAD), a tear tation. His past medical history consisted occurs in the intimal wall of the vertebral only of common migraine; however, this Iartery. The tear can be either sponta- presentation was atypical of his usual neous or traumatic and allows blood to col- migraine attacks. The patient did not report lect in the wall of the vessel as an intramural any fevers, photophobia, vertigo, abdominal haematoma.1 This can result in either direct pain or other gastrointestinal symptoms. haemodynamic compromise of the artery or The patient was an ex-smoker, self-em- thromboembolism affecting a downstream ployed chef, living independently with his 2 vessel. As the vertebral arteries supply the wife and child, with no signifi cant family posterior circulation of the brain, a signifi - history. Of note, he regularly received Thai cant consequence of this pathology can be massage. cerebral ischaemia and stroke.1 Many ac- On physical examination, the patient counts of VAD have been published support- was apyrexial, with a blood pressure of ing the aetiology of this condition as a result 150/90mmHg, heart rate of 103bpm, respi- of high-velocity forces affecting the cervical ratory rate of 18bpm and oxygen saturation spine. Here, we present a case supporting of 99% on room air. He was alert and orien- potential aetiology arising from a low-ener- tated and had no dysarthria. His abdomen gy intervention to a patient’s neck. was soft and non-tender. He had a full, pain-free, cervical range of motion without Case report any stiffness or midline cervical spine A 39-year-old male presented to our tenderness. The cranial nerve examination emergency department (ED) after a one-day was unremarkable and he had normal history of bitemporal, gradual-onset peripheral tone, power, sensation and deep headache with associated nausea and tendon refl exes. On cerebellar examination, vomiting. He also complained of posterior the patient demonstrated left-sided past neck pain, which had started suddenly pointing and an ataxic gait, falling to his left during a massage two days prior to presen- side on ambulation.

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Figure 1: MRI neck T1 axial view. Reduced caliber of the vertebral arteries with surrounding T1 hyperintensity (positive crescent sign), consistent with vertebral artery dissection.

Blood results showed an unremarkable The patient was commenced on anti- urea electrolytes and creatinine (UEC), platelet therapy in ED with aspirin 300mg however a full blood examination (FBE) was loading dose. He subsequently was notable for a white cell count of 14.7x109/L admitted under the stroke unit for medical (normal range 4.0–11.0), with a predominant management, with ongoing daily aspirin neutrophilia. (100mg) and atorvastatin (80mg). Following Investigation with computed tomography a four-day admission, including intensive (CT) angiography demonstrated bilateral physiotherapy, he was discharged home. dissection of the cervical segments of the At six-month follow-up, the patient had vertebral arteries, with complete occlusion remained symptom-free, with complete of the left vessel, as well as evolving recovery of his abnormal neurological infarction of the left cerebellar hemisphere. fi ndings, allowing him to return to his normal These fi ndings were confi rmed on magnetic work. Repeat MRI demonstrated signifi cant resonance imaging (MRI) of the brain and improvement in the vertebral arteries and cervical arteries (Figures 1–3). appropriate evolution of the stroke.

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Figure 2: MRI angiography (maximum intensity projection) of the vertebral ar- teries. Narrowing of the vertebral artery lumens bilaterally with no fl ow above dissected segment on left (arrow).

Figure 3: MRI brain T2 TSE TRA, axial-section. Left cerebellar acute infarct.

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to the neck or manipulation of the cervical Discussion spine. This suggests that the even application Dissection of a cervical artery is a major of low-energy therapies to the neck, such as cause of stroke in young patients, and is massage or stretching, could result in this reported to cause up to 25% of strokes in vascular pathology, which could potentially patients under 45 years old.1 Trauma is be fatal.1 the most signifi cant predisposing factor For young patients presenting with a for VAD,3 which can range from sporting syndrome consistent with a posterior circu- injuries to high-speed motor vehicle acci- lation stroke, VAD is a signifi cant differential dents. The pathology has also previously diagnosis, especially in the presence of neck been associated with cervical manipulation pain or recent trauma. This should include therapy, as performed by chiropractors.1 possible low-energy mechanisms of injury Other risk factors include hypertension, including massage. If clinicians are suspi- migraine, use of oral contraceptives and cious of this pathology, they should proceed connective tissue disorders.1,3 Our patient to urgent CT or MRI angiography.1 had several of these risk factors. Vertebral artery dissection is typically Our review of the PubMed® database using treated conservatively, with either anti- the search terms ‘massage’ and ‘vertebral platelet or anticoagulant therapy. This artery dissection’ revealed only two similar aims to reduce thrombus propagation and cases, reported in China4 and India.5 We embolism to prevent stroke.1,8 Thrombolysis believe that this is the fi rst reported case can be considered for acute ischaemic of bilateral vertebral artery dissection and stroke, without signifi cant risk of expansion stroke to be associated with massage. It is of the intramural haematoma.8 There are also the fi rst case of VAD associated with also case reports of successful endovascular massage reported in Australasia. stenting to restore perfusion through an Massage is a common alternative occluded vertebral artery.1 medicine, which is gaining popularity in New Zealand.6 National regulation of the Conclusion industry however remains limited, with no mandatory licensing or registration Vertebral artery dissection is an important requirements.6,7 As a result, some massage cause of stroke in young patients. This case therapists may have no qualifi cations or suggests that the application of even low-ve- limited experience. locity force to the cervical spine can cause signifi cant vascular injury. Massage is a Our case is notable as unlike most reported common alternative therapy, and may be a cases of VAD, massage typically does not previously underappreciated contributing involve the application of high-velocity force factor for this pathology.

Competing interests: Nil. Author information: William Birkett, Department of Anaesthesia and Perioperative Medicine, Monash Health; Casey Hospital Emergency Department, Monash Health; Pourya Pouryahya, Casey Hospital Emergency Department, Monash Health; Faculty of Medicine, Nursing and Health Sciences, Monash University; Alistair D McR Meyer, Casey Hospital Emergency Department, Monash Health; Faculty of Medicine, Nursing and Health Sciences, Monash University. Corresponding author: Dr William Birkett, Department of Anaesthesia and Perioperative Medicine, Monash Health; Casey Hospital Emergency Department, Monash Health. [email protected] URL: www.nzma.org.nz/journal-articles/bilateral-vertebral-artery-dissection-and-cerebellar- stroke-a-rare-complication-of-massage

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REFERENCES: 1. Biller J, Sacco RL, Albu- 4. Chen W, Qiao H, Fang G, Survey of Practitioners. Int querque FC, Demaerschalk Zhong X. Vertebral Artery J Ther Massage Bodywork. B, Fayad P, Long P, et al. Dissection Probably 2018 Jun; 11(2):11–24. Cervical Arterial Dissec- Caused by Massage: A 7. Smith JM, Sullivan SJ, tions and Association With Case Report. Chin Med Baxter GD. A Descriptive Cervical Manipulative Sci J 2019; 34(1):65–68. Study of the Practice Therapy. Stroke. 2014 5. Dutta G, Jagetia A, Srivas- Patterns of Massage New Aug; 45(10):3155. tava AK, Singh D, Singh H, Zealand Massage 2. Morel A, Naggara O, Touze Saran RK. “Crick” in Neck Therapists. Int J Ther E, Raymond J, Mas JL, Followed by Massage Led to Massage Bodywork. Meder JF, et al. Mechanism Stroke: Uncommon Case of 2011 Mar; 4(1):18–27. of Ischemic Infarct in Vertebral Artery Dissection. 8. Zinkstok SM, Vergouwen Spontaneous Cervical World Neurosurgery. MD, Engelter ST, Lyrer PA, Artery Dissection. Stroke. 2018 Jul; 115(1):41–3. Bonati LH, Arnold M, et 2012 May; 43(5):1354–61. 6. Cottingham P, Adams J, al. Safety and Functional 3. Debette S, Leys D. Vempati R, Dunn J, Sibbritt Outcomes of Thrombolysis Cervical-artery dissec- D. The Characteristics, in Dissection-Related tions: predisposing Experiences and Percep- Ischemic Stroke. Stroke. factors,diagnosis, and tions of Registered Massage 2011; 42(9):2515–20. outcome. Lancet Neurol. Therapists in New Zealand: 2009 Jul; 8(7):668–78. Result from a National

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DRESS syndrome due to iodinated contrast medium Yassar Alamri, Blake Hsu

n 82-year-old woman presented to revealed an acute kidney injury (creatinine the emergency department after 218μmol/L). Her liver functions tests were Adeveloping a generalised rash. She normal. had a background of diffuse large B-cell A punch biopsy of the skin revealed severe lymphoma, which was successfully treated epidermal spongiosis and microvesicu- with a reduced-dose bendamustine-ritux- lation, with infi ltrate of lymphocytic and imab combination therapy (the last dose of eosinophilic infi ltrates (Figure 2). Peripheral which was six weeks prior to presentation). eosinophilia developed on the third day of She had been on her regular medications for admission. The peak eosinophil count was at least four months prior to presentation, 2.9x109 (on the sixth day of admission). and denied starting any new medications Upon reviewing her history, it was noted (including over-the-counter) in the interven- that she had undergone a re-staging CT ing period. scan four days prior to admission, in which On presentation, she was febrile she received iohexol contrast. This was o (temperature 39.1 C) and had an erythem- her second exposure to iodinated contrast atous blanching morbiliform eruption material (the fi rst of which was at the that covered >90% of her body-surface time of the diagnostic CT scan fi ve months area (Figure 1A and 1B). Her blood tests preceding the current presentation). Drug

Figure 1A: Erythroderma covering the patient’s torso (a), and limbs (b).

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Figure 1B: Erythroderma covering the patient’s torso (a), and limbs (b).

Figure 2: Histological examination of punch biopsy revealed a vesicular spongiotic reaction, with light eosinophilic and lymphocytic infi ltrates.

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reaction with eosinophilia and systemic DRESS is a rare, but recognised, side-effect symptoms (DRESS) was diagnosed.1 The of iodinated contrast media exposure.2 Our patient required a short stay in the intensive patient fulfi lled the RegiSCAR diagnostic care unit for blood pressure support. She criteria for DRESS.3 Due to the vigorous made a full recovery, and was discharged systemic infl ammatory response, multi- after 10 days with a home-based rehabili- organ dysfunction may ensue. Reported tation programme. Her rash had completely mortality rates can reach as high as 10%.4 resolved at follow-up four weeks after her The cornerstones of treatment is cessation discharge, and she was advised to avoid of the implicated causative agent, and contrast agents in the future. supportive care.

Competing interests: Nil. Author information: Yassar Alamri, Department of Medicine, Canterbury District Health Board, Christchurch; Blake Hsu, Haematology, Canterbury District Health Board, Christchurch. Corresponding author: Dr Yassar Alamri, Department of Medicine Canterbury District Health Board, Christchurch. [email protected] URL: www.nzma.org.nz/journal-articles/dress-syndrome-due-to-iodinated-contrast-medium

REFERENCES: 1. Peyrière H, Dereure O, involving 2 unrelated exist? Br J Dermatol. 2007 Breton H, et al. Variability substances: imipenem and Mar; 156(3):609–11. in the clinical pattern of iodinated contrast media. 4. Walsh SA, Creamer cutaneous side-effects J Investig Allergol Clin D. Drug reaction with of drugs with systemic Immunol. 2013; 23(1):56–7. eosinophilia and systemic symptoms: does a DRESS 3. Kardaun SH, Sidoroff A, symptoms (DRESS): a syndrome really exist? Valeyrie-Allanore L, et al. clinical update and review Br J Dermatol. 2006 Variability in the clinical of current thinking. Clin Aug; 155(2):422–8. pattern of cutaneous Exp Dermatol. 2011 Jan; 2. Macías EM1, Muñoz-Bellido side-effects of drugs with 36(1):6–11. doi: 10.1111/j.1365- FJ, Velasco A, Moreno E, systemic symptoms: does 2230.2010.03967.x. Dávila I. DRESS syndrome a DRESS syndrome really

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Educational interventions on contraceptive methods in adolescents: face-to-face or virtual? Victor Moquillaza Alcántara, Angela Yauyo Puquio, Xiomara Marquez Lopez, Pamela Villegas Yaranga

espite the decline in teenage pregnan- This is aggravated in Andean environments cy rates it is still a public health prob- such as those in Latin America, where rural Dlem. Previous reviews have shown areas are characterised by poor access to that the situation is getting worse in Latin health services or institutions where these America, where during the last 20 years face-to-face educational interventions are there have been few interventions that seek provided, due to the distance between estab- to increase the use of family planning meth- lishments and homes.6,7 1,2 ods. In countries like Peru, during 2018 the In Table 1 we show characteristics that proportion of teenage pregnancy reached could be considered before evaluating the 12.6%, although there are regions that come investment of resources in an investigation 3 to present 32%. that poses an educational intervention. In These high percentages are explained by it we can highlight the scope that a virtual the factors that predispose their existence, intervention can have thanks to the internet, among which is the low knowledge about which breaks the temporary limitations contraceptive methods, a characteristic that (since it does not require a specifi c schedule) begins in adolescence and remains until and geographical (because one can access adulthood.4 Studies in Germany have shown them from anywhere). Although it is also that, although adolescents may know the necessary to consider that the web content existence of certain contraceptive methods, is restricted to the quality of the expert many do not identify when they should be who validated the content, and this must be administered and how they could access updated from time to time. them. Also, that the adolescent is in a school A recent systematic review where the of lower academic level or being of immi- impact of educational interventions for grant origin were characteristics that are the use of contraceptives was evaluated 5 associated with less knowledge. reported that only those that include audio Faced with this problem, educational inter- or videos manage to reduce the rate of ventions have been generated that seek to teenage pregnancy over time, likewise, resolve doubts regarding the use of contra- those that also include text messages ceptive methods; however, many of the manage to maintain the continued use of studies suggest a face-to-face intervention, contraceptive methods. On the other hand, which may not present the advantages those that are face-to-face and use written offered by providing the same knowledge material only increase knowledge, but do under a virtual system such as a web page. not guarantee its use.8

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Table 1: Characteristics of face-to-face and virtual educational interventions.

Face-to-face Virtual Requirements Professionals who go to the place where Electronic elements (HTML text, videos the intervention and support material or audios) with information validated by (physical or electronic audio-visual) will a team of experts. be generated.

Permanence The support elements can be reused, The electronic elements are publicly in time but the professional must come every accessible and possible to be used time an intervention is generated. anywhere.

Investment The payment to the human resource for A single payment to the human each intervention should be considered. resource is generated for the advice in the elaboration of the electronic elements, then it is invested only in the maintenance of the hosting.

Benefits There may be a direct feedback with the It can reach any audience in any exhibitor for any questions. geographical area due to the internet, likewise no specific time is required to participate.

Limitations Generating an intervention requires The content provided will be “current” managing the layout of the exhibitors, for the time in which the audio-visual likewise, its replica only reaches resource was generated. Also, the a limited group of people. Finally, necessary learning curve, servers modesty can be a barrier to consulting a and hosting maintenance should be particular topic. considered.

Therefore, we seek to help researchers environments where there are barriers to or those who design interventions in the access to education or healthcare, since fi eld of distance education for the reduction the internet can be an agile, common and of teenage pregnancy. These interven- benefi cial means for the adolescent popu- tions can be subsidised by the government lation, reaching large masses and therefore through public funds and executed by being a contribution to the public health of university research groups; especially in countries.

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Competing interests: Nil. Author information: Victor Moquillaza Alcántara, Midwife, Biomedical Informatics Program in Global Health, Universidad Peruana Cayetano Heredia, Lima, Perú; Angela Yauyo Puquio, Midwifery Student, Professional Midwifery School, Universidad Nacional Mayor de San Marcos, Lima, Perú; Xiomara Marquez Lopez, Midwifery Student, Professional Midwifery School, Universidad Nacional Mayor de San Marcos, Lima, Perú; Pamela Villegas Yaranga, Midwifery Student, Professional Midwifery School, Universidad Nacional Mayor de San Marcos, Lima, Perú. Corresponding author: Victor Hugo Moquillaza Alcántara, Av. Honorio Delgado 430, San Martín de Porres, Lima, Perú. [email protected] URL: www.nzma.org.nz/journal-articles/educational-interventions-on-contraceptive-methods-in- adolescents-face-to-face-or-virtual

REFERENCES:

1. Santidad N. A global publicaciones_digitales/ reto para la reforma de perspective on adoles- Est/Lib1656/index1.html salud en el Perú. Anales de cent pregnancy. Int J 4. Guzzo KB, Hayford S. la Facultad de Medicina. Nurs Pract. 2015; 21(5): Adolescent Reproductive 2018; 73(1). DOI: http:// 677–81. DOI: http://dx.doi. and Contraceptive Knowl- dx.doi.org/10.15381/ org/10.1111/ijn.12278 edge and Attitudes and anales.v79i1.14595 2. Caffe S, Plesons M, Adult Contraceptive Behav- 7. Martínez M. Acceso y Camacho AV, Brumana L, ior. Matern Child Health uso de tecnologías de la Abdool S, Huaynoca S, et al. J. 2018; 22(1):32–40. DOI: información y comuni- Looking Back and Moving http://dx.doi.org/10.1007/ cación en México: factores Forward: Can We Acceler- s10995-017-2351-7 determinantes. Revista de ate Progress on Adolescent 5. Von Rosen FT, Von Rosen tecnología y sociedad. 2018; Pregnancy in the Amer- AJ, Muller F, Tinnemann P. 8(14). DOI: http://dx.doi. icas? Reprod Health. Awareness and knowledge org/10.18381/pk.a8n14.316 2017; 14 (83):1–8, DOI: regarding emergency 8. Pazol K, Zapata L, http://dx.doi.org/10.1186/ contraception in Berlin Dehlendorf C, Malcolm N, s12978-017-0345-y adolescents. Eur J Contra- Rosmarin R, Frederiksen 3. Instituto Nacional de cept Reprod Health Care. B. Impact of Contraceptive Estadística e Informática. 2017; 22(1):45–52. DOI: Education on Knowledge Encuesta Demográfi ca y de http://dx.doi.org/10.1080/ and Decision Making: Salud Familiar: Embarazo 13625187.2016.1269162 An Updated Systematic adolescente. [Página web] 6. Gutierrez C, Romaní-Ro- Review. American Journal [Citado el 26 de Noviembre maní F, Wong P, Del of Preventive Medicine. del 2019] Disponible en: Carmen J. Brecha entre 2018; 55(5):703–7015. DOI: http://www.inei.gob.pe/ cobertura poblacional y https://doi.org/10.1016/J. media/MenuRecursivo/ prestacional en salud: un AMEPRE.2018.07.012

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Type A aortic dissections: challenges of atypical presentation in remote New Zealand Varun J Sharma, Minesh Prakash, Francesco Pirone, Brian Chan, Zaw Lin

lobe infarct. Given poor neurological prog- Clinical vignette nosis and gross end-organ malperfusion, SM, a 62 year-old male of Māori descent, there was a consensus for palliation after was seen by ambulance for right hemipa- discussion with the family. resis with no signifi cant medical history. At the scene, he deteriorated into ventricular Discussion fi brillation, requiring cardiopulmonary resuscitation and cardioversion, eventually This case highlights the challenges of reverting back into sinus rhythm. He was emergency management of TAAD in New transferred to the Gisborne Hospital with Zealand. TAADs are time-critical with an bag-and-mask ventilation and Glasgow immediate mortality rate of 40%, rising Coma Scale of 3. 1–2% per hour after onset of symptoms, and a 48-hour mortality rate of up to He was intubated on arrival, maintaining 70%.1–5 Tertiary referral centres in New a systolic blood pressure of 80. Inves- Zealand typically serve large geographical tigations showed evidence of coronary areas; WDHB, for example, serves a region (Troponin 45, ST elevation in leads III, aVF comprising of approximately 900,000 (20% with reciprocal changes) and end-organ of New Zealand population) people across (eGFR 60, Lactate 2.4, pH 7.24) malper- fi ve district health boards. This represents a fusion. A widened mediastinum on chest logistic challenge, as successful management x-ray instigated computed tomography is predicated on prompt diagnosis and (CT) scans, demonstrating type A aortic awareness by fi rst-point clinicians and dissection (TAAD) extending from the aortic excellent portals of communication with root, across the aortic arch and down the WDHB. Transfer times can be exacerbated aorta into external iliac arteries. Poor fl ow by diffi cult geographical terrain, tortuous was noted in right subclavian, vertebral and road ambulance access and tough air common carotid with a right renal artery transfer conditions. occlusion. The CT brain was normal. He was accepted and transferred to Waikato District There may also be cultural impediments Health Board (WDHB). to seeking medical attention. In WDHB’s population, 24–40% of the population is of On arrival to WDHB, his cardiac (Troponin Māori descent, representing approximately 7,982, dynamic ST changes), renal (eGFR 216,000 people or 34% of the Māori Popu- 37) and neurologic (non-responsive pupils) lation in New Zealand. There is evidence status deteriorated. The aortic team was that the Māori population have a higher convened; at our centre, this is a multidis- predisposition towards TAADs, presenting ciplinary meeting of the cardiothoracic at a younger age with higher morbidity.1,6 and vascular surgical teams, interventional This is compounded by the possibility of radiology, intensive care unit and anaes- atypical presenting symptoms, with the iRAD thetic department. A decision for repeat CT registry showing that neurological (17%) and imaging for neurological prognostication syncopal (9%) symptoms are common,7 albeit and assessment of coronary ostia was made, unfounded in the New Zealand population. demonstrating a large acute right parietal

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Therefore fi rst-point of care clinicians practice at our centre, is vital:8 in this case, (eg, paramedics, emergency physicians the concurrent interventional radiology, or general practitioners) must be aware anaesthetic and intensive care assessment of of idiosyncrasies of TAAD presentation in neurological and end-organ prognosis while New Zealand, and have it as a potential the surgical teams were planning operative diagnosis for any chest pain or atypical intervention allowed a timely decision for neurological symptoms, and involve the palliation, avoiding what would have been tertiary referral centres as soon possible. a futile operative intervention if the patient The urgent access of radiological imaging had been accepted straight for theatre from through a picture archiving and commu- Gisborne. Trends of TAAD in the Māori nication system (PACS) is crucial; there is population warrant further investigation also scope for a centralised form of medical into the pathophysiology of why this popu- imaging that can reduce the time to transfer lation has a higher incidence and lower images. A multi-disciplinary aortic team survival, and the factors which are impedi- (described above), which is the standard of ments to treatment.

Competing interests: Nil. Author information: Varun J Sharma, Department of Cardiothoracic Surgery, Waikato District Health Board, Hamilton; Waikato Institute of Surgical Education and Research, Hamilton; Minesh Prakash, Department of Cardiothoracic Surgery, Waikato District Health Board, Hamilton; Waikato Institute of Surgical Education and Research, Hamilton; Department of Intensive Care, Waikato District Health Board, Hamilton; Francesco Pirone, Department of Cardiothoracic Surgery, Waikato District Health Board, Hamilton; Brian Chan, Department of Anaesthetics, Waikato District Health Board, Hamilton; Zaw Lin, Department of Cardiothoracic Surgery, Waikato District Health Board, Hamilton. Corresponding author: Dr Varun Sharma, Department of Cardiothoracic Surgery, Waikato District Health Board, Hamilton. [email protected] URL: www.nzma.org.nz/journal-articles/type-a-aortic-dissections-challenges-of-atypical- presentation-in-remote-new-zealand

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REFERENCES: 1. Gupta A, Subramaniam P, et al. Evidence, lack of A Aortic Dissection Presen- Subramaniam P, Hulme K. evidence, controversy, and tation and Outcomes. The sharp end of cardio- debate in the provision and Heart, Lung and Circula- vascular disease in New performance of the surgery tion. 2019; 28:S59–S60. Zealand: A review of acute of acute type A aortic 7. Evangelista A, Isselbacher type A aortic dissections dissection. J Am Coll Cardi- EM, Bossone E, Gleason TG, of the Waikato. N Z Med ol. 2011; 58(24):2455–74. Eusanio MD, Sechtem U, et J. 2015; 128(1419):22–8. 4. Tsai TT, Nienaber CA, al. Insights From the Inter- 2. Harris KM, Strauss CE, Eagle KA. Acute aortic national Registry of Acute Eagle KA, Hirsch AT, syndromes. Circulation. Aortic Dissection. Circula- Isselbacher EM, Tsai TT, et 2005; 112(24):3802–13. tion. 2018; 137(17):1846–60. al. Correlates of delayed 5. Meszaros I, Morocz J, Szlavi 8. Harris KM, Strauss recognition and treatment J, Schmidt J, Tornoci L, CE, Duval S, Unger BT, of acute type A aortic Nagy L, et al. Epidemiology Kroshus TJ, Inampudi S, dissection: the Internation- and clinicopathology of et al. Multidisciplinary al Registry of Acute Aortic aortic dissection. Chest. Standardized Care for Dissection (IRAD). Circula- 2000; 117(5):1271–8. Acute Aortic Dissection. tion. 2011; 124(18):1911–8. 6. Wang TKM, Wei D, Evans T, Circulation: Cardiovascular 3. Bonser RS, Ranasinghe Haydock D, Ramanathan T. Quality and Outcomes. AM, Loubani M, Evans Ethnic Comparisons of Type 2010; 3(4):424–30. JD, Thalji NM, Bachet JE,

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Bullying and harassment in ophthalmology: a trainee survey Neeranjali S Jain, Hannah K Gill, Hannah M Kersten, Stephanie L Watson, Helen V Danesh-Meyer

ullying, harassment and gender-based in surgical training in Australia and New discrimination within the medi- Zealand (24%, 54% and 12% respectively).2 Bcal workforce in New Zealand has Male ophthalmologists were cited as received signifi cant media and academic at- more frequent sources of these behaviours tention in recent years. Considering this, we than female ophthalmologists (35% vs 12%, completed a survey in which ophthalmol- p=0.005). Other reported sources of these ogy trainees in New Zealand and Australia behaviours were other medical consultants responded on bullying, discrimination and (26%), hospital administration staff (24%) sexual harassment experiences. It is import- and nursing staff (24%). ant to assess the prevalence and extent of A frequent form of gender-based discrim- discrimination and sexual harassment, as ination reported was receiving less respect these experiences can signifi cantly limit job based on gender from medical team satisfaction and career advancement. We members (reported by 40% of women vs wanted to further our understanding of the 0% of men, p<0.001). Women also reported prevalence of these experiences within the experiencing discrimination for making fi eld of ophthalmology. family-centred choices (57% vs 20% for A 35-question survey was sent to all men, p>0.05) and reported child-bearing Australian and New Zealand ophthal- had slowed their career progression (80% mology trainees registered with RANZCO vs 30% of men, p=0.035). The gender-based in May 2017 (n=185, 65 female, 120 male). discrimination reported in our study could Four questions explored experiences of be a barrier to career progression3 and could discrimination and sexual harassment in the have contributed to the perception reported workplace, derived from the RACS survey, among two-thirds of women that it was created by the Australian Surgical Focus more diffi cult for women to achieve career 1 Group. The response rate was 31% overall, success in ophthalmology than men. Limita- with 32 responses from female trainees tions of this study include potential response (49%) and 23 from male trainees (19%). bias associated with a self-reported survey The majority (56%) of trainees had and the low response rate. experienced some form of bullying, These data provide a baseline to measure discrimination, harassment and/or sexual future progress for initiatives commenced harassment during training, with no signif- by The Royal Australian and New Zealand icant difference between male and female College of Ophthalmologists, including trainees (43% vs 66%, p>0.05). The rates education programmes for trainees and of discrimination, bullying and sexual consultants, support services and promoting harassment (21%, 49% and 9% respectively) diversity in college leadership roles.4 were similar to those recently described

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Competing interests: Nil. Author information: Neeranjali S Jain, Prince of Wales Hospital Clinical School, University of New South Wales, Sydney, Australia; Hannah K Gill, Department of Ophthalmology, Auckland District Health Board, Auckland; Hannah M Kersten, School of Optometry and Vision Science, The University of Auckland, Auckland; Stephanie L Watson, Prince of Wales Hospital Clinical School, University of New South Wales, Sydney, Australia; Helen Danesh-Meyer, Department of Ophthalmology, University of Auckland, Auckland. Corresponding author: Prof Helen V Danesh-Meyer, Department of Ophthalmology, University of Auckland, Auckland. [email protected] URL: www.nzma.org.nz/journal-articles/bullying-and-harassment-in-ophthalmology-a-trainee- survey

REFERENCES: 1. Royal Australasian College 2. Crebbin W, Campbell G, Academic Medicine. of Surgeons. Expert Hillis D, et al. Prevalence 2014; 89(5):817–27. advisory group on discrimi- of bullying, discrimination 4. RANZCO. Ranzco: Update nation, bullying and sexual and sexual harassment in on the elimination of harassment. Background surgery in australasia. ANZ discrimination, harass- briefi ng. Melbourne: RACS; journal of surgery. 2015; 85. ment and bullying 2018 2015 [Available from: 3. Fnais N, Soobiah C, Chen [Available from: http:// http://www.surgeons. MH, et al. Harassment and ranzco.edu/ArticleDocu- org/media/21827232/ discrimination in medical ments/176/DHB booklet. background-briefi ng- training: A systematic pdf.aspx?Embed=Y 16-june-15-fi nal.pdf review and meta-analysis.

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Presidential Address, 1920 By DR. H. LINDO FERGUSON

r. Irving (the retiring President) said and standards. Things would never be the the profession was accustomed to same again as before the war. In surgery, Dlook on Dunedin as the seat of medi- in medicine, in public health, more strides cal learning, and he congratulated the Otago had been made in four years of war than Division on the number of members it had in 40 years of peace, because extensive attracted here. One could not help feeling experiments and scientifi c research had saddened when one remembered how many been carried out under the stress of great old friends would be there no more. It might emergency, and with the whole fi nancial be invidious to mention names, but he could resources of the associated Powers behind it. not help thinking that that grand old veter- Governments were realising that it paid to an, Dr. Batchelor, would have been glad to spend money in research. ln sanitation our have been there that night. They might be knowledge of public health had increased thankful that so many of the profession had in leaps and bounds, from the way in which made good and come back to them again. medical men learnt to deal with epidemics Dr. Colquhoun, who had done so much for in camps. In no war had there been such a the medical profession in New Zealand, was, small loss from sickness as in the great war unfortunately, unable to accept the presi- now fortunately ended. Never before had dency at the last moment, but his place had there not been greater fatality from sickness been fi lled by Dr. Ferguson. Dr. Ferguson than from bullets. If there was one thing he needed no introduction from him. Anyone would say they had to learn, it was the value who had worked with him knew that he had of team work. A single man could not do the welfare of the profession and of the asso- what a body of men could accomplish. ciation very much at heart. (Applause.) One At the outbreak of war we had an of the most important things on the Confer- organised territorial force, but practically ence paper was the suggested establishment no organisation for the Medical Corps, and of a State medical service. Dr. Ferguson, as so had to depend upon the civilian men to Dean of the Medical School, looked at the do it for us. The organisation grew up in question, he thought, rather differently from the face of great diffi culties, and the men those who had graduated many years ago, responsible for it deserved credit for their and he thought it was good that Dr. Fergu- work. The civilian medical practitioners son would preside, because he would look who volunteered for service also deserved at it more from the point of view of the man the gratitude of the community. No doubt who was just getting through. mistakes had been made, but the work of Dr. Ferguson, who was received with the New Zealand Medical Corps was very applause, remarked that there had been no highly spoken of by those in a position to meeting of the Association in Dunedin for judge. The Dental Department had earned a 13 years, and that he was Chairman of the name that put in the shade the name of any last meeting of the old Association, held in other department of the forces involved. 1896, at which arrangements were made by It was the fi rst time the Dental Association which they became voluntarily merged in had been associated with their Conference, the British Medical Association. It had been and he thought it was an innovation of his ambition to be the fi rst President of the which they might be proud. Referring to new Association, but delays and diffi culties the outbreak of the war, Dr. Ferguson, as resulted in the fi nal formation of the Asso- Dean of the Medical School, said that his ciation not being effected till the following teachers then all wanted to shut the school year, when another became President. and go to the front. His students, too, were This meeting was important in that it was being taken by the Minister of Defence. the fi rst since the war, and war had made General Henderson deserved great credit an enormous difference to medical work and gratitude for the stand he had taken in

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the matter. He had come down when the public and Government were recognising students were rampant for war, and pacifi ed the value of team work, “and as sure as the them by showing that they would be of more sun rises tomorrow,” said Dr. Ferguson, “we value as medical men to heal wounds than are going to have a State medical service. We if they went out and tried to infl ict them. have got to face the fact of a State medical The result was that they had completely service. On the result of your deliberations educated over 160 men who they were able this week will largely depend what form to send forward. Touching on the effect that medical service will take. If it takes such of conscription on the profession and the a form that the profession has a voice in assistance rendered by the British Medical the direction of its future, things will go on Association in that respect. the speaker said all right; but if it is forced on the profession that owing to the tact and consideration against its will, it will assuredly mean shown by General Henderson the scheme disaster for everyone.” He concluded by worked well, and they were able to send 400 expressing the hope that benefi cial results men and yet keep up the work at home. The would follow the Conference.

URL: www.nzma.org.nz/journal-articles/presidential-address-1920

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