Antenatal care for asylum seekers

Despite the challenges, the provision of high-quality specialist antenatal health care in immigration detention is a constant

Recent commentaries have criticised health care provision in the Australian immigration detention environment, particularly in the areas of antenatal and postnatal care.1,2 As the contracted health care provider, International Health and Medical Services (IHMS) acknowledges the inherent challenges the immigration detention environment presents. It is our wish to contribute current facts and observations to this topical public debate.

Ongoing enhancement to the antenatal and postnatal care of detainees in immigration detention centres on Christmas Island and Nauru has resulted in a specialist supervised obstetric service providing care at a standard comparable to that on the Australian mainland. Maternity care is provided from the diagnosis of pregnancy until the 6-week postnatal check, paralleling Australian community standards and Royal Australian and New Zealand College of Obstetricians and Gynaecologists guidelines.3 Routine assessments, imaging, pathology tests, hospital referrals and referrals to mental health services all occur as per established Australian standards.

Although there are no resident obstetricians on either island, specialist obstetricians have made visits to Christmas Island and Nauru. In the case of Nauru, this has developed into a continued care model involving subspecialist and specialist obstetricians (accompanied by specialist sonographers) providing obstetric services to detainees for 3 days a month, delivering care commensurate with that in Australian communities. This service is supplemented by 4-monthly visits from specialist paediatricians to both islands. The specialist care complements the primary care delivered by resident general practitioners, emergency physicians, midwives and nurses, both paediatric and adult, with the addition of telemedicine as necessary.

Currently, pregnant detainees on Christmas Island and Nauru are transferred to Australia at gestations of 34 and 28 weeks, respectively, to give birth. The former coincides with the gestation at which local residents “traditionally” depart Christmas Island to give birth on the mainland. Earlier transfers occur when there is a clinical need. In Nauru, this arrangement is pending the recruitment of a permanent obstetrician by the Republic of Nauru Hospital, where the hospital surgeon currently performs interventions such as caesarean sections. While it can certainly be stated that the Republic of Nauru Hospital has limited obstetric facilities when compared with secondary-level or metropolitan hospitals, it has two delivery beds, six postnatal beds, a special care baby unit with a neonatal incubator, an infant warmer, neonatal resuscitation equipment, nasogastric feeding capabilities and a dedicated blood bank, with blood supplied by the Australian Red Cross available to pregnant asylum seekers. Overall, the local perinatal capacity is not dissimilar to many rural obstetric services in Australia.

At Darwin immigration detention sites, antenatal care for detainees is provided by IHMS midwives and GPs. There is a close working relationship with the Royal Darwin Hospital, and a shared care arrangement has been established, similar to the delivery of antenatal care in many other centres on mainland Australia. These arrangements are enhanced by regular meetings between Department of Immigration and Border Protection staff, IHMS and the Department of Obstetrics and Gynaecology at the Royal Darwin Hospital, where situation-specific concerns such as security and patient transfers are formally discussed. The operational model in Darwin has been replicated at facilities in Melbourne and Adelaide.

Breastfeeding for all new mothers is actively encouraged by IHMS at all immigration detention sites. IHMS does not distribute welcome packs with bottles and formula, as reported elsewhere,1 and does not endorse this practice.

We recognise that mental health is a concern in all forms of detention environments. Ready access to high-quality mental health services is provided to pregnant women within detention centres. Mental health care is delivered by a multidisciplinary team including GPs, mental health nurses, psychologists, counsellors and psychiatrists in both offshore and mainland centres. When a mental health disorder, including antenatal or postnatal depression, is diagnosed, it is managed according to established guidelines.4

IHMS takes its role as provider of health care within the immigration detention network seriously. We encourage informed commentary and debate among the public and the medical profession, as this helps us to continually improve the delivery of high-quality health care to people living in immigration detention.

Inappropriate pathology ordering and pathology stewardship

An effective system of stewardship is needed to optimise the use of pathology tests

Many hospital clinical pathology laboratories presently experience annual increases in workload of 5%–10%.1 Such increases in demand are often not accompanied by concomitant increases in laboratory resources. This environment presents a significant challenge to laboratories that have no control over test-ordering patterns. Compounding this situation is the fact that many pathology tests are inappropriate or unnecessary, as they have no impact on patient care. The extent of inappropriate pathology test ordering in Australia is unknown, but a United Kingdom report on National Health Service pathology services estimated that 25% of all requests were unnecessary or inappropriate.2 Such tests are ordered for a variety of reasons, often in the belief that more testing equates to better patient care. Unfortunately, this is not always the case, and in some circumstances the opposite may be true.

Ozbug3 is a well established closed and moderated email list largely but not solely restricted to members of the Australasian Society for Infectious Diseases, predominantly comprising Australian and New Zealand infectious diseases physicians but also including registrars, medical microbiologists and infection prevention practitioners. There are about 800 subscribers, who discuss a broad range of topics. I asked the following question on Ozbug: “What microbiology laboratory investigation would you consider to be the one, although requested, results in least patient benefit? or What do you consider to be the most useless of microbiology tests?” The unexpectedly large number of responses (140) to this question and the ensuing rich discussion are the stimuli for this article.

My aim here is to discuss and attempt to understand inappropriate or unnecessary pathology testing, to define the drivers for and impact of such testing, and to suggest interventions to improve the use of pathology services. I will focus on hospital pathology services and provide specific examples from my discipline of microbiology.

Inappropriate pathology test ordering

Tests that are ordered but the results of which are never viewed by the clinician are of no use to the management of the specific patient. Duplicate tests or tests performed before initial testing results are available are unnecessary. Similarly useless tests include those that, no matter what the result, will not impact on patient care. Some serological diagnoses require collection of initial and convalescent sera. In many such circumstances, only a single sample is obtained and this is of no use. Many of the serological tests undertaken for the investigation of fatigue have a low likelihood of a useful result and may give the patient false hope of a result that will lead to a definitive diagnosis and effective therapeutic intervention. A serology test should only be performed when the clinical illness and epidemiology support that diagnosis. Otherwise a false-positive result may complicate patient management. These last two points are exemplified by Lyme disease serology, which is often performed in a setting of vague, non-specific symptoms in a patient who has never visited a known endemic region or country.

For bacterial culture, a dry swab in a specimen jar is unlikely to be useful. A midstream urine specimen that has a normal urinalysis result is most unlikely to identify a pathogen. A recent trend is to swab environmental services or inanimate objects for resistant organisms. This often occurs in the absence of epidemiological evidence to support such a link, and such swabbing should be resisted.

Generally, microbiology tests for clearance, such as repeat throat and nose swabs for respiratory viruses and repeat stool tests for Clostridium difficile, are unnecessary or not recommended.

Other common individual tests suggested by Ozbug correspondents as inappropriate or unnecessary are included in Box 1. Ozbug correspondents acknowledge that for many of the tests mentioned, it is not the test itself that is under scrutiny but the use of that test, and also that these tests may be useful in specific circumstances or jurisdictions. Laboratories also have the responsibility to offer tests that have been validated for the purpose for which they are offered.

Factors contributing to inappropriate pathology ordering

The prime reason for ordering pathology testing is to optimise patient diagnosis and management. Most practitioners agree on the importance of prudent use of pathology services. However, there may be other less apparent drivers for suboptimal pathology test ordering. Such testing may be tied to the patient’s or the family’s expectations rather than to an actual need for such testing. The physician’s anxiety or fear of missing a diagnosis may generate the feeling that something needs to be done, leading to overinvestigation without a clear rationale for that testing. Junior doctors may order according to peer perception or because they are concerned that their consultant may criticise them if the test has not been requested. In some circumstances when a doctor is time pressured, ordering pathology tests may be an easier course than the timely consideration of management options.

Other less than ideal reasons to order pathology tests include: “wouldn’t it be nice to know”, “I cannot find (or have not looked for) the previous result”, “I may want to publish the case in the future” and “I do not believe the result from the first laboratory and I want to send it to a second laboratory”. Some individual factors contributing to suboptimal testing, suggested by Ozbug correspondents, are summarised in Box 2.

Pathology laboratories may also contribute to the number of inappropriate tests. New technology with new testing menus may be introduced before there is evidence that such developments have a favourable impact on patient outcomes.4

Risks of inappropriate pathology ordering

Some tests are not only unnecessary but may be misleading or even harmful. The receipt and subsequent processing of saliva when sputum is ordered may identify transient oral colonising bacteria such as Streptococcus pneumoniae or methicillin-resistant Staphylococcus aureus. This may do a patient harm if the organism is then assumed to be the aetiological cause of the pneumonia, targeted treatment is given and the real cause of pneumonia is overlooked.

When inappropriate or unnecessary tests are ordered, there is a risk of a false-positive result, leading to further unnecessary testing, other investigations and even unnecessary treatments with attendant adverse effects. Ober has described this cascade effect, highlighting that a “normal range” typically includes 95% of all normal subjects, with up to 5% of normal subjects given an abnormal result.5 With modern multichannel analysers, more often used in other pathology disciplines, the chance of a false-positive result is further increased.

Inappropriate pathology testing consumes laboratory resources, both budgetary and labour. This may, especially in more manual disciplines such as microbiology, lead to delays in processing and increase the turnaround time for specimens from the patients in greatest need.

Strategies to improve pathology test ordering

There has been much discussion among the Ozbug group concerning possible strategies to improve microbiology test ordering. Individual strategies suggested by Ozbug correspondents are shown in Box 3. There are a limited number of studies documenting the impact of a strategy targeting a specific test with a decrease in the ordering of that test during the period of observation.6 However, such interventions generally do not tackle the breadth of pathology testing, and the long-term sustainability of such interventions is questionable.

Overall, the Ozbug discussions emphasise the need for an ongoing system of stewardship to ensure the optimal use of pathology resources. To be effective, a system needs to be developed together with all the major stakeholders, have a strong and iterative educational component, be evidence-based, include a system of regular audit with feedback, and especially target those tests that are high cost, resource expensive and frequently used inappropriately. Orders from clinicians should be considered requests for testing as well as for specialist pathologist input. Within my own discipline, the clinical microbiologist should take an active lead in decisions about testing menus and indications, specimen acceptability and acceptance, testing quality, and test interpretation.

Just as antimicrobial stewardship has now become a national standard for hospital accreditation, a system of pathology stewardship would optimise the use of pathology resources. This is not a new concept. In 1922, Peabody wrote:

Good medicine does not consist in the indiscriminate application of laboratory examinations to a patient, but rather in having so clear a comprehension of the probabilities and possibilities of a case as to know what tests may be expected to give information of value.7

1 Ozbug correspondents’ examples of inappropriate microbiology test ordering*

Most extra tests performed on cerebrospinal fluid when no abnormalities were found on microscopy
Routine cultures of vascular catheters
Vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus surveillance cultures in unquarantined patients
Parasites in stools in hospitalised patients
Surveillance blood cultures in asymptomatic patients
Streptococcal, herpes, typhoid fever (eg, Widal test) and Lyme disease serology
Legionella and pneumococcal urinary antigens in patients with normal chest x-ray results
Repeated bacterial surveillance cultures of endoscopy equipment

* Note: In some specific circumstances these tests may be appropriate.

2 Ozbug correspondents’ reports of potential factors contributing to inappropriate test ordering

Suboptimal teaching of undergraduates and graduates
Pressure of work for both clinicians and pathologists
Lack of pathologist input for test menu development and specimen suitability information
Clinicians’ poor understanding of test reliability and validity
Clinicians’ lack of knowledge and concern about pathology costs
Ease of ordering tests electronically or using prestamped request slips
Income generation of some pathology testing
Acceptance of public pathology as a learning environment that encourages more pathology
Fear of litigation

3 Strategies suggested by Ozbug correspondents to improve microbiology test ordering

Enhanced education of medical students and graduates
Pathology ordering audit and feedback
Increased collaboration and engagement with clinicians
Development of rejection rules such as minimum retest intervals
Display of costs of pathology tests with pathology results
Standardisation of investigations for specific clinical syndromes
Development and promulgation of golden rules regarding pathology testing
Pathology rotations for junior medical staff
Prevention of duplicate testing

Termination of pregnancy: a long way to go in the Northern Territory

To the Editor: The Northern Territory’s reproductive health services are fraught with access problems due to remoteness and disadvantage. Staff shortages and high staff turnover in the health workforce are well known.1 With the recent resignation from the public health system of the main termination of pregnancy provider in the Top End of Australia, women’s access to basic reproductive health services could be severely diminished and complicated.

Each year, about 1000 women undergo a termination of pregnancy in the NT. The only remaining services providing termination of pregnancy in the NT include one private hospital (at which a few doctors can provide surgical abortions) and one public hospital (Alice Springs Hospital, at which a couple of doctors can provide surgical abortions). Each week, about 20 women present to the public health system in Darwin for a surgical abortion in their first trimester. These women no longer have public access. The question is who will provide this procedure?

One possibility is that women may have to be flown interstate for this procedure. Some state laws prevent this — for example, South Australian law has residency limits on the provision of termination of pregnancy. Also, interstate travel poses a considerable burden for women and girls in terms of delays, logistics and increased stress, and is not cost-effective for the health system.

How acceptable this arrangement will be to women in the NT is yet to be tested. But we already know that women who feel compelled to end their pregnancies will do anything regardless of how demeaning, undignified or dangerous it is.2,3

Another solution would be to reform the Medical Services Act (NT) as in force at July 2014, which prohibits the practice of early medical abortion using misoprostol and mifepristone outside of a hospital setting, thus precluding ambulatory early medical abortion. Currently, the Act limits provision of abortion to obstetrics and gynaecology specialists and limits the type of procedure to surgical methods only. If the Act were reformed, it would be possible for general practitioners in various primary health care settings to provide information and prescriptions for early medical abortions.

There is overwhelming medical evidence showing that early medical abortions are efficacious, safe and well accepted.4,5 In terms of the health system, shifting the task to GPs and freeing up precious theatre resources would be far more cost-effective than flying patients or doctors interstate.

However, the political reality is that politicians are often reluctant to step into the perceived controversy of reproductive health rights for their constituents.

Ethical challenges for doctors working in immigration detention

To the Editor: Sanggaran and colleagues starkly illustrate the ethical dilemmas of doctors contracted to an organisation delivering substandard medical care to asylum seekers.1 They pose the question of whether doctors should boycott the system.

The same ethical dilemma sometimes faces doctors working in the limited-resource environment of public hospitals in Australia. The following example illustrates how boycotting the system can achieve results.

In May 2003, medical administrators at Sir Charles Gairdner Hospital (a tertiary referral public hospital in Perth) were alerted to looming problems with provision of prostate biopsies, including failing equipment and unacceptable waiting times for urology patients. In April 2006, amid ongoing administrative inaction despite repeated meetings and correspondence, a patient was diagnosed with metastatic prostate cancer while still on a waitlist for a prostate biopsy.2 Four of five urologists consequently resigned, arguing that they could no longer be part of a system that presided over this sort of substandard care. Their en-masse resignations were widely reported in the media, prompting the direct intervention of the then Western Australian Minister for Health. Only by boycotting the system were their concerns properly addressed.

The American Medical Association Code of medical ethics advocates use of ethically appropriate criteria when allocating limited medical resources.3 Most importantly, the treating physician must remain an advocate for patients.

When we find ourselves involved in organisations delivering substandard medical care, all of us must take the lead of Sanggaran et al and continue to speak out — and sometimes boycott the system — to effectively advocate for our patients.

Ethical challenges for doctors working in immigration detention

To the Editor: As psychiatrists and physicians working with adults and children in mandatory, often prolonged, immigration detention, we confirm Sanggaran and colleagues’ account.1

Quality evidence from diverse, independent, multinational sources, including legal and medical investigations over two decades, finds that immigration detention:

contravenes multiple international conventions that Australia has signed;2
harms mental health of detained children and adults, and detention employees, in a process likened to torture;3
incurs vastly greater financial and legal costs than alternatives, and makes profits for multinational companies from desperate, traumatised people;4
fails to deter people from seeking asylum and is unnecessary to prevent their absconding (because they rarely abscond);2
compromises ethics, through mandating secrecy, neutralising advocacy and destroying independent oversight;5 and
fosters conditions for systematic institutional child abuse and its lifelong consequences.6

Immigration detention fails every standard of medicine — science, ethics, health economics, pragmatics and human rights (including freedom from abuse and the right to highest attainable health standards). Yet despite accumulated evidence and established opposition from national professional bodies — including medicine, paediatrics, psychiatry, public health, psychology, nursing, social work and medical students — successive governments deny or rationalise inveterate harms, arguably implicate professionals in legitimating abuses the professionals cannot prevent, and deflect needed policy change.7 The case against immigration detention is irrefutable.

As immigration detention’s damages are unmitigated by any (mental) health intervention, and immigration detention renders clinicians ineffectual, a strong clinical and ethical argument exists for withdrawing services. Rather than health care for asylum seekers and detainees remaining with the Department of Immigration and Border Protection or being outsourced, federal or state health departments should provide and manage services and monitor standards independently. This will not resolve the problem of immigration detention, but it may attenuate some of its worst effects.

Rural emergency departments supplement general practice care

To the Editor: To provide a rural comparison to Nagree and colleagues’ metropolitan study,1 we estimated the number of general practice-type patients attending emergency departments (EDs) in north-west Tasmania.

Ethics approval was granted by the Tasmanian Health and Medical Human Research Ethics Committee.

We used two methods of identifying general practice-type visits to analyse 152 481 ED presentations to the North West Regional Hospital (Burnie) and the Mersey Community Hospital (Latrobe) from January 2011 to December 2013.

The Australasian College for Emergency Medicine (ACEM) method categorises as possibly suitable for a general practice consultation patients who are self-referred, do not arrive by ambulance and have a medical consultation time under 1 hour. Patients who did not wait to be seen by a doctor or had an invalid treatment time are excluded. Over the 3 years, we identified 51 770 general practice-type presentations using this method (34.9%). There were 60 684 presentations included in the ACEM method on weekdays, with 19 541 (32.2%) identified as general practice-type patients (Box). However, ACEM general practice-type patients occupied only 7%–8% of total ED treatment time.

The Australian Institute of Health and Welfare (AIHW) method categorises as general practice-type those patients who: are allocated to an Australasian Triage Scale category of 4 or 5 (specifying 60- and 120-minute maximum waiting times, respectively); do not arrive by ambulance, police, community health or correctional vehicle; are not admitted to hospital; and do not die. Using this method, 82 645 general practice-type patients (54.2% of all ED patients) were identified. Such presentations occupied 25% of total ED treatment time each year.

Our results indicate that the proportion of presentations to EDs in north-west Tasmania that are general practice-type visits is two to three times that in Perth.1

In rural areas, the lack of availability of general practice care at no cost to the patient is a main reason for patients presenting to EDs.2 There are 118 general practitioners in north-west Tasmania, or 104.4 per 100 000 persons; half that of major cities (227.8 per 100 000).3,4 With fewer GPs, residents are likely to appropriately self-refer to EDs to access care. Increasing the supply of GPs in rural areas remains the cornerstone of reducing general practice-type admissions.

As north-west Tasmania is an area of high socioeconomic disadvantage, it is reasonable to expect that cost weighs heavily in many residents’ decisions concerning health care. Implementing a policy such as the $5 general practice copayment may increase ED presentations among the working poor in order to avoid paying.

Different models of care for appropriately managing GP-type presentations to EDs have been suggested. Employing GPs in EDs has been shown to reduce costs,5 but in rural areas with a shortage of GPs this would take them away from their practices. Other models of providing care in less expensive settings than tertiary EDs require exploration. One such model may be a parallel low-acuity service staffed by nurses and overseen by an emergency medicine registrar or specialist.

Number of general practice-type presentations to two emergency departments (EDs) in north-west Tasmania, by method, year and time

Method

2011 (n = 51 048*)

2012 (n = 51 190*)

2013 (n = 50 243*)

ACEM†

Weekday‡

6604/20 046 (32.9%)

6817/20 578 (33.1%)

6120/20 060 (30.5%)

Out of hours§

5489/14 506 (37.8%)

5376/14 604 (36.8%)

4732/14 516 (32.6%)

Weekend

5657/14 777 (38.3%)

5602/14 707 (38.1%)

5373/14 336 (37.5%)

AIHW

Weekday‡

12 431/20 618 (60.3%)

12 481/21 062 (59.3%)

11 454/20 546 (55.7%)

Out of hours§

7455/15 107 (49.3%)

7222/15 047 (48.0%)

6629/14 962 (44.3%)

Weekend

8680/15 323 (56.6%)

8475/15 081 (56.2%)

7818/14 735 (53.1%)

ACEM = Australasian College for Emergency Medicine. AIHW = Australian Institute of Health and Welfare. * Total ED visits (used for the AIHW method). † 4351 patients who did not wait to be seen by a doctor or had an invalid treatment time were excluded from assessment using the ACEM method. ‡ Monday to Friday 08:00 to 17:00. § Monday to Friday 17:01 to 07:59.

Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion

To the Editor: Chen and colleagues associate the reduction in inhospital cardiopulmonary arrest (IHCA) incidence with the introduction of rapid response systems.1 Their population-based study of all patients aged ≥ 14 years in New South Wales found that hospital mortality decreased between 2002 and 2009. During this period, the age of the hospital population increased and patients aged ≥ 75 years were more likely to die in hospital (risk ratio [RR], 28.4), have an IHCA (RR, 8.6), die as a result of cardiac arrest (RR, 11.9), or die within 12 months of discharge (RR, 5.3).1

Australian statistics show that most deaths occur in hospital and that the background mortality rate of the population continued to decline from 1907 to 2012.2 However, there will be a background death rate that is not preventable and is a result of the natural end of life.

Studies show that up to 30% of rapid response team attendance results in limitation of care as a not-for-resuscitation order.3 If these patients continued to decline to death, they would not be considered in the IHCA figures because they are non-preventable deaths. Rather, they would be considered in the hospital mortality figures. This would result in a decrease in IHCA and an improvement in IHCA mortality from better management of end-of-life goals. This is suggested by the modest (1.8%) reduction in overall hospital mortality from the decreased mortality after IHCA.

This study provides excellent evidence for the need for advanced care planning and consideration of treatment goals at the end of life.

Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion

To the Editor: For the study by Chen and colleagues,1 the Journal provided the following taglines: “Early intervention not resuscitation reduces deaths” on the cover of the issue; and “Mortality has decreased due to earlier intervention rather than advances in resuscitation” in the Contents on page 119. These statements contrast with the article’s title and contents, which included: “It is an observational study and, as such, we cannot assume any causality for the relationships identified”.1 Does the Journal believe its taglines accurately represented the article?

The largest randomised controlled trial of rapid response teams was the National Health and Medical Research Council-funded MERIT trial,2 which concluded: “The [medical emergency team] system greatly increases emergency team calling, but does not substantially affect the incidence of cardiac arrest, unplanned [intensive care unit] admissions, or unexpected death.” The MERIT trial was undertaken in the same decade and state as the study by Chen et al.1 Should this conflicting data have been discussed in detail?

In the Appendix to their article,1 the authors presented a 19% increase in hospital admissions during the study period. Hospital mortality was expressed as events per 1000 admissions. Was rapid response system implementation associated with decreased total hospital mortality? Could the apparent reduction in hospital mortality be explained by changed patterns of admissions?

The authors wrote: “To our knowledge, there were no other major changes in the way health care was delivered in hospitals over the study period”.1 How did they satisfy themselves that hospital health care had not changed? Did they not think that an increase in hospital admissions of 19% over the decade must imply a major change in hospital health care delivery?

Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion

In reply: Levinson and Mills focus on one of the most important challenges in health care — the appropriate management of patients at the end of life. It is correct to suggest that the rapid response system-associated reduction in inhospital cardiopulmonary arrest may be due to more than just prevention through early intervention, but may also be due to increased attention to end-of-life care and avoidance of inappropriate resuscitation. Up to 30% of all rapid response calls are for patients with end-of-life issues. Perhaps if we develop ways of identifying these patients earlier, a more appropriate management plan could be developed in cooperation with patients and their carers.

O’Callaghan highlights the fact that the MERIT trial provided no evidence of significant improvement of cardiac arrest, unplanned intensive care unit admissions or unexpected death. However, as discussed in our MERIT publication1 in detail and in our Journal article2 to some degree, the MERIT trial was underpowered and the control hospitals acted in a manner similar to that of hospitals with medical emergency team (MET) systems in place (ie, over 35% of cardiac arrest team calls in control hospitals were made for patients without cardiac arrest). Also, the implementation and uptake of MET systems were not optimal (two-thirds of patients did not have a MET call despite meeting the criteria). Thus, the MERIT trial results are inconclusive but not in conflict with the results presented in our Journal article, as “absence of evidence is not evidence of absence”. Indeed, our follow-up article showed that MET hospitals had significant reduction in mortality outside the intensive care unit compared with non-MET hospitals.3

The increased hospital admissions over the study period were unlikely to explain the reduction in hospital mortality, as the increased admissions mostly occurred among frail older people, who have an increased risk of cardiac arrest and mortality. Our analyses adjusted for age and other possible confounders. The increase in admissions showed the increased severity and complexity of the conditions for which the patients were admitted, not a change in hospital health care delivery.

Chronic suppurative lung disease and bronchiectasis in children and adults in Australia and New Zealand Thoracic Society of Australia and New Zealand guidelines

Guidelines on managing chronic suppurative lung disease (CSLD) and bronchiectasis (unrelated to cystic fibrosis [CF]) in Australian Indigenous children initiated in 20021 were extended to include Indigenous adults in 20082 and children and adults living in urban areas of Australia and New Zealand in 2010.3 Here, we present an updated guideline relevant for all sections of the community. The recommendations in this guideline are targeted principally to primary and secondary care, and are not intended for individualised specialist care. As with all guidelines, they are not a substitute for sound clinical judgement, particularly when investigating and treating such a phenotypically heterogeneous condition as bronchiectasis.4

Key updates

An increasing trend in the health burden of CSLD and bronchiectasis is recognised in both Indigenous and non-Indigenous settings in Australia, New Zealand and worldwide.3,5–7 Some affluent countries report childhood fatalities,7 and there is a growing appreciation of the economic cost.5 Misdiagnosis or coexistence of bronchiectasis with other chronic respiratory diseases is also recognised increasingly. When these comorbidities are present, the prognosis is worse; for example, mortality increases in those with both chronic obstructive pulmonary disease (COPD) and bronchiectasis (hazard ratio, 2.54; 95% CI, 1.16–5.56).6 As many as 9% of newly referred children with chronic cough in Australia have bronchiectasis,8 and 40% of newly referred adults with difficult asthma have bronchiectasis.9 As effective management influences prognosis and quality of life,10 a heightened vigilance by health professionals is needed to ensure an early diagnosis is made and treatment is optimised.

There is still a paucity of data and clinical trials on bronchiectasis, but encouraging trends of better evidence have emerged. These include studies related to defining CSLD in children,10,11 airway clearance, rehabilitation, and use of nebulised and long-term maintenance antibiotics to prevent exacerbations. These studies (obtained through systematic searches12) formed the basis for our updated recommendations. When evidence was lacking, Australian and New Zealand experts (the writing group) developed the recommendations, which were further informed by the voting group using a modified Delphi process and the GRADE (grading of recommendations assessment, development and evaluation) system.13

Of the 32 recommendations, eight are new (3, 8, 10, 14, 25, 30–32), seven unaltered (7, 17–18, 22–24, 29) and the remaining 17 were amended. We refer readers to the Thoracic Society of Australia and New Zealand website for the full guidelines (http://www.thoracic.org.au/professional-information/position-papers-guidelines/bronchiectasis) including information about our guidelines development process, details of the systematic searches, evidence for the recommendations, implications of the strength of recommendations, suggested antibiotic regimens for management and updated references.12

Recommendations

Number

Recommendation

GRADE category

Evidence level

Definitions

a. Bronchiectasis is a clinical syndrome in a child or adult with the symptoms and/or signs outlined below as well as characteristic radiographic features on chest high-resolution computed tomography (c-HRCT).

Symptoms and signs include recurrent wet or productive cough episodes (≥ 3 per year), each lasting for > 4 weeks, with or without other features (for example, exertional dyspnoea, symptoms of airway hyperresponsiveness, recurrent chest infections, growth failure, clubbing, hyperinflation or chest wall deformity).

In children, triggers for referral to a specialist include one or more of:

persistent wet cough not responding to 4 weeks of antibiotics;
≥ 3 episodes of chronic (> 4 weeks) wet cough per year responding to antibiotics;
a chest radiograph abnormality persisting > 6 weeks after appropriate therapy.

Strong

–

b. Chronic suppurative lung disease is a clinical syndrome in children with the symptoms and/or signs outlined above, but who lack a radiographic diagnosis of bronchiectasis.

Investigations of a patient with CSLD or bronchiectasis

a. Patients with symptoms and/or signs suggestive of bronchiectasis require a c-HRCT scan to confirm the diagnosis and to assess the severity and extent of bronchiectasis.

Strong

Moderate

b. In children, seek specialist advice before ordering a c-HRCT scan; child-specific criteria should be used.

c. In both adults and children, a multidetector CT scan with HRCT reconstruction is the preferred technique to diagnose bronchiectasis.

Consider a c-HRCT scan in adults with COPD and either ≥ 3 exacerbations per year, very severe disease (forced expiratory volume in 1 second [FEV1] < 30% predicted or requiring domiciliary oxygen) or whose sputum contains organisms atypical for COPD (ie, Aspergillus species, Pseudomonas aeruginosa or non-tuberculous mycobacteria).

Low

Obtaining further history for specific underlying causes may determine subsequent investigation and management. This includes history of, or suggestive of:

cystic fibrosis (family history, pancreatitis, chronic gastrointestinal symptoms, male infertility);
underlying immune deficiency or ciliary dyskinesia (recurrent sinusitis, extrapulmonary infections, including discharging ears and severe dermatitis, and male infertility);
recurrent aspiration (cough and/or choking with feeds or meals; after bariatric surgery; may be occult);
an inhaled foreign body.

Strong

Moderate

Perform or refer for baseline investigations. Minimum investigations are:

full blood count and major immunoglobulin classes G, A, M, E;sweat test in all children and selected adults (see full guidelines12);culture of airway secretions, including specialised cultures for mycobacteria, particularly non-tuberculous mycobacteria in sputum-producing patients;spirometry and lung volumes (patients aged > 6 years); and serological tests for Aspergillus species.

full blood count and major immunoglobulin classes G, A, M, E;
sweat test in all children and selected adults (see full guidelines12);
culture of airway secretions, including specialised cultures for mycobacteria, particularly non-tuberculous mycobacteria in sputum-producing patients;
spirometry and lung volumes (patients aged > 6 years); and serological tests for Aspergillus species.

In selected patients, other investigations should be considered (see full guidelines12).

Strong

Moderate

Obtain further history to determine markers of severity, impact of illness, comorbidities and modifiable risk factors. History should include frequency of exacerbations and hospitalisations, degree of effort limitation, exposure to tobacco smoke and other pollutants, childhood history, and housing.

Strong

Low

Management

Aim to optimise general wellbeing, symptom control, lung function and quality of life, and to reduce exacerbation frequency and prevent excessive decline in lung function. This may require intensive medical therapy.

Strong

High

Develop treatment plans for exacerbations for each patient, linking them to primary health care and specialist or hospital facilities. When appropriate, this includes individualised and self-initiated management action plans.

Strong

Low

Base antibiotic selection on lower airway culture results (sputum, bronchoscopy washings [adults and older children] or bronchoalveolar lavage [young non-expectorating children]) when available, local antibiotic susceptibility patterns, clinical severity and patient tolerance, including allergy (Appendix).

Strong

Moderate

When P. aeruginosa is first detected, consider discussion with a specialist in this field regarding suitability for eradication treatment.

Weak

Low

In patients not requiring parenteral antibiotics for an acute exacerbation, oral antibiotics are prescribed for at least 10 days based on available airway microbiology results. Close follow-up to assess treatment response is necessary.

Strong

Low

Inadequate response should prompt repeat of lower airway cultures and assessment of whether parenteral antibiotic therapy and hospitalisation are needed.

Strong

Moderate

Patients in whom oral antibiotic therapy for an acute exacerbation fails should receive intensive airway clearance strategies and parenteral antibiotics based on the latest lower airway culture results. Close follow-up is required.

Strong

Moderate

a. In children, this requires supervised treatment for at least 10–14 days.

b. In adults, intravenous antibiotics should be administered for at least 5 days and often need to be followed by oral antibiotics. Conversion from intravenous to oral antibiotics depends on appropriate oral alternatives and whether effective adjunct therapies, such as airway clearance strategies, can be maintained in an ambulatory care setting and with ongoing outpatient review.

Long-term oral antibiotics should not be prescribed routinely. Macrolides (or other antibiotics) can be considered for a therapeutic trial over a limited period (eg, up to 12–24 months) in selected patients (eg, those with frequent exacerbations [≥ 3 exacerbations and/or ≥ 2 hospitalisations in the previous 12 months]).

Before commencing macrolide antibiotics:

seek respiratory/infectious diseases specialist advice;
ensure non-tuberculous mycobacteria infection is excluded in patients capable of providing a sputum specimen;
perform electrocardiography in adults for assessment of QT interval corrected for heart rate.

Strong

Moderate

Long-term nebulised antibiotics should not be prescribed routinely. Consider a therapeutic trial in children and adults with frequent exacerbations and/or P. aeruginosa infection.

Strong

Moderate

Inhaled and oral corticosteroids should not be prescribed routinely unless there is an established diagnosis of coexisting asthma or COPD.

Strong

Low*/ moderate†

Inhaled bronchodilators should not be prescribed routinely but used only on an individual basis.

Strong

Low

Recombinant human deoxyribonuclease is contraindicated in CSLD and bronchiectasis.

Strong

High

Mucoactive agents, including hypertonic saline and mannitol, are currently not recommended for routine use. Consider a therapeutic trial in children and adults with frequent exacerbations.

Weak

Moderate

Airway clearance techniques are recommended and a respiratory physiotherapist’s advice should be sought. Individualise airway clearance therapy.

Strong

Moderate

Adults with bronchiectasis and exercise limitation should receive pulmonary rehabilitation.

Strong

Moderate

Regular physical activity is recommended for children and adults with CSLD or bronchiectasis.

Strong

Low

Assess and optimise nutritional status.

Strong

Moderate

Promote elimination of smoking, including second-hand smoke exposure.

Strong

High

Promote avoidance of environmental airborne pollutants.

Strong

Low

Regularly monitor and manage complications and comorbidities. When present, manage following standard guidelines.

Regular review consists of at least an annual review in adults and 6-monthly review in children. A multidisciplinary team is preferable, especially at the initial evaluation.

Review includes:

assessment of severity, which includes oximetry and spirometry;
sputum culture (when available) for routine bacterial and annual mycobacterial culture;
management of possible complications and comorbidities, particularly gastro-oesophageal reflux disease or aspiration, reactive airway disease or asthma, COPD, otorhinolaryngeal disorders, urinary incontinence, mental health and dental disease. Less commonly, patients require assessments for sleep disordered breathing and cardiac complications;
checking adherence to therapies and knowledge of disease processes and treatments.

Strong

Moderate

Although surgery is not indicated normally, assessment by a multidisciplinary team expert in CSLD and bronchiectasis care may be required in some circumstances.

Strong

Moderate

Public health issues, prevention and appropriate health care delivery

Vaccinate according to the National Immunisation Program Schedule. Ensure timely annual influenza vaccination and that pneumococcal vaccines are administered following national guidelines.

Strong

Moderate

Coordinated care by health care providers is necessary. If bronchiectasis is suspected, specialist evaluation is recommended to confirm the diagnosis, investigate the aetiology, assess severity and develop a management plan. Patients with moderate or severe disease are best managed using a multidisciplinary approach to chronic care with individualised case management. Clinical deterioration should prompt early referral to services with CSLD and bronchiectasis expertise.

Strong

Low

Specialist review should be undertaken for patients with moderate disability or progressive lung disease. This includes consideration for lung transplantation.

Strong

Low

Providing health care for Indigenous people in rural and remote regions requires flexible and adaptive arrangements. However, this should not alter the objective of delivering best-practice treatment to this population.

Strong

Low

Given the high prevalence of CSLD and bronchiectasis in Indigenous Australians, Maori and Pacific Islander children and adults, a high index of suspicion with early diagnostic investigation should be established, as well as best-practice treatment. Interpreters and local health workers should be available for educating patients about the disease and its management.

Strong

Moderate

* For oral corticosteroids. † For inhaled corticosteroids.