Access to safe, high quality, acceptable and sustainable general practice (GP) and primary care services is essential to improved health outcomes and quality of life for people living in residential aged care homes (RACH). There are, however, critically low levels of service availability and a decline in GPs providing RACH services globally, suggesting there is an urgent need for safe and effective models of care. Telehealth, delivered as part of a holistic model of care, offers a solution to address this gap but comprehensive, person-centred research is needed to directly assess its effect on safety and quality of care in RACH settings. This collaborative 4-year project (General practice and Residential Aged CarE: GRACE video-telehealth) will (1) scope current telehealth models of care and their acceptability and person-centredness, including identifying the barriers and enablers experienced by RACH residents, carers, staff, GPs and practice managers; (2) co-design a best-practice model of care with an accompanying suite of digital resources and education materials to improve the uptake of video-telehealth; and (3) implement and evaluate this best-practice model of care. This is a mixed-methods study of residents, carers, RACH staff, GPs and their practice teams that will be conducted across New South Wales, Australia. This protocol describes a staged approach across three phases. In Phase 1, we will collect baseline measures of the frequency of telehealth use in GP practices and RACHs, clinical outcomes (eg, hospitalisations), questionnaires to measure person-centred care, satisfaction and usability of telehealth and qualitative observations and semi-structured interviews. In Phase 2, we will conduct workshops to co-design an intervention that will include developing a model of care to support person-centred video-telehealth, with an accompanying online hub of resources and educational materials to facilitate and support its utilisation. In Phase 3, we will implement and evaluate the intervention. Data will be analysed statistically and thematically and synthesised. Ethics approval has been obtained from the University of Sydney Human Research Ethics Committee (2025/000340) (human.ethics@sydney.edu.au). Prior informed written consent will be obtained from all research participants. Findings from each phase of the study will be submitted for peer-reviewed publication. Project outputs will be disseminated for implementation more widely across New South Wales and Australia.
Achieving high-quality primary healthcare (PHC) remains essential to improving health systems performance and advancing progress towards attainment of universal health coverage, particularly in sub-Saharan Africa (SSA), where gaps in service delivery persist. Capacity-building interventions, such as mentorship, in-service training and supportive supervision, have been widely employed to improve the quality of PHC delivery. The evidence base is, however, fragmented across diverse settings, intervention types and outcome measures. This systematic review will examine the evidence on how capacity-building interventions improve the quality of PHC services in SSA, with a focus on the domains of effectiveness, safety, people-centredness, timeliness, equity, integration and efficiency as propounded by the WHO. We will conduct a systematic review using established evidence synthesis methods and report the findings in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Eligible studies will include peer-reviewed and grey literature published in English between 2000 and 2025, focusing on capacity-building interventions aimed at improving PHC quality in SSA. We will search databases including PubMed, Embase, Web of Science, Scopus, Google Scholar and the African Journals Online. Study selection will follow the Population (PHC providers), Exposure (capacity-building interventions) and Outcome (quality of PHC delivery across WHO domains) framework. Quality assessment will use the Mixed Methods Appraisal Tool (MMAT). Data will be narratively synthesised using Atlas.ti software. Ethical approval is not required because there will be no collection of primary data. Only published studies/records available on peer-reviewed literature and grey sources will be included. Findings will be disseminated through a peer-reviewed journal, academic conferences and stakeholder platforms in SSA. The protocol has been registered in PROSPERO (CRD420251131534) and reported according to PRISMA-P guidelines.
Effective communication is central to safe, ethical maternity care. Women with cross-cultural communication needs are more likely to experience intersecting disadvantage, with poor maternal and infant outcomes. A professionally trained interpreter (PTI) can raise the quality of clinical care for patients to approach or equal that for patients without cross-cultural communication needs. The need to improve interpreter services has been recognised at the strategic level of the NHS to improve safety and personalised care. However, evidence for how to achieve this is limited from the UK context. We explored the experiences of PTIs working in maternity services in England using qualitative interviews. We analysed the data thematically, informed by Critical Race Theory, which argues that inequality is deeply embedded in policy, law and institutional structures and practices. We discussed interim findings with our lived experience group. We interviewed 28 interpreters with a range of qualifications who worked for language agencies or in-house NHS interpreting services. Our analysis constructed three themes: The 'shady' agency; 'You can get anyone and you don't know how experienced they are'; 'you are never part of a team'. We found that institutional practices and outsourcing marginalise interpreters, compromising worker well-being and patient safety. To ensure patient safety, it is essential for the NHS to recognise the professional status of medical interpreters and integrate PTIs into the core clinical team. This will require investment in standardised interpreter training, access to supervision and career development. Embedding interpreters in NHS safety culture is essential for equitable and effective care.
A neglected area of patient safety research is how the characteristics of mental health staff and teams may influence incidents, specifically, through unintended and harmful consequences of clinical care. While the research literature into patient safety has increased, there is still a need to further consider safety on mental health wards, for example, the role of the staff team in containment and conflict. This review aims to explore the question, 'How do staff and team characteristics relate to safety incidents in adult inpatient mental health settings?'. The review will follow Whittemore and Knafl's integrative review framework. CINAHL, Cochrane, Embase, MEDLINE, PsycINFO, Web of Science will be searched. Literature published after 1999, that includes extractable quantitative, qualitative and mixed methods data exploring the relationship between staff and team characteristics on incidents in adult inpatient mental health settings, will be suitable for inclusion. The Mixed Methods Appraisal Tool will be used for quality appraisal and data analysis and will comprise data reduction, display and comparison. No new data or access to participants will be involved in this review. As such, ethical review will not be required. Dissemination will include publication in peer-reviewed journals and presentations at national and international conferences. This review has been registered on PROSPERO (ref. CRD420251119981; https://www.crd.york.ac.uk/PROSPERO/view/CRD420251119981).
Cancer-related fatigue (CRF) affects up to 70.7% of patients with cancer, significantly impairing quality of life and treatment adherence. Methylphenidate (MPH) and its dexmethylphenidate (D-MPH) are commonly used psychostimulants, but evidence regarding their efficacy remains inconsistent. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, we systematically searched PubMed, Cochrane Library, Embase and Web of Science from inception to June 2025. Primary outcomes were CRF improvement and safety. Meta-analysis was performed using R software (V.4.2.1) with random-effects models. Trial sequential analysis (TSA), Bayesian methods for sparse adverse event data and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment were applied. Nine randomised controlled trials (RCTs) involving 668 patients were included. Pooled analysis showed a slight but significant reduction in fatigue for MPH versus placebo (standardised mean difference, SMD=0.23, 95% CI 0.06 to 0.40; I²=0%). Efficacy increased at 6-week follow-up (SMD=0.30, 95% CI 0.08 to 0.52; 3 RCTs). Subgroup analysis indicated that D-MPH significantly improved CRF (SMD=0.29, 95% CI 0.01 to 0.57; 3 RCTs), while racemic MPH did not (SMD=0.19, 95% CI -0.02 to 0.41; 4 RCTs). Safety analysis revealed no significant increase in overall adverse events versus placebo, though non-significant trends towards increased mood changes (OR=3.35) and dizziness (OR=2.66) were observed. TSA indicated insufficient information size to confirm definitive efficacy (cumulative Z-curve crossed traditional boundary but not O'Brien-Fleming boundary). GRADE evidence certainty was moderate for overall MPH and D-MPH efficacy, and low for racemic MPH. MPH demonstrates a modest improvement in CRF, with enhanced effects at 6 weeks. D-MPH shows superior therapeutic potential compared with racemic MPH. However, current evidence is insufficient to support widespread clinical application due to limitations in sample size and heterogeneity. Higher-quality RCTs are needed to confirm efficacy and safety profiles.
The prolonged survival of lung cancer patients is accompanied by an increasing incidence of leptomeningeal metastases (LM). Patients with LM have a poor prognosis, significantly impacting their quality of life and overall survival. Recent studies have shown that while intrathecal pemetrexed (IP) can improve symptoms and confer a survival benefit in non-small cell lung cancer (NSCLC) patients with LM, drug resistance remains a significant challenge. As for systemic therapy, intravenous bevacizumab combined with chemotherapy has demonstrated clinical benefits in NSCLC patients. However, clinical data on intrathecal bevacizumab remain scarce. Therefore, this study aims to preliminarily explore the efficacy and safety of intrathecal pemetrexed and bevacizumab in the treatment of NSCLC patients with LM. This is a single-centre, single-arm, prospective, investigator-initiated phase Ia clinical trial sponsored by Shanghai Chest Hospital, involving patients with advanced NSCLC and LM. Participants will be enrolled and allocated into two predefined cohorts. Cohort A: six participants will receive IP monotherapy for safety exploration. Cohort B: participants will receive intrathecal pemetrexed and bevacizumab. Pemetrexed will be administered at a fixed dose, while the dosage exploration for bevacizumab will employ a combination of a 3+3 design and an accelerated titration design (ATD). The primary endpoint is the safety and the secondary endpoint is the overall survival (OS). This study protocol (Version 1.1, dated 8 October 2024) was approved by the Ethics Commission of Shanghai Chest Hospital (IS24103) on 23 October 2024. Trial results will be published in a peer-reviewed journal. NCT06663306, ClinicalTrials.gov.
After the Taliban took over the Afghan government in August 2021, funds for the public healthcare system were suspended, the economy collapsed and female education and mobility were restricted. We examined the impact of the takeover on the availability, accessibility, acceptability and quality of public healthcare in Afghanistan. We conducted a mixed-methods study to assess the impact of the Taliban takeover on Afghanistan's public healthcare system. Key informant interviews with healthcare workers and managers were combined with interrupted time series analysis on maternal and child health services and the availability of medicines and healthcare workers from January 2019 to September 2023. Disruptions in service provision and availability of healthcare workers were minimal, temporary and mostly due to interrupted funding. Following the political change, more patients visited public healthcare facilities as safety improved accessibility and private healthcare became less affordable. Acceptability and quality of care were affected by continued increased patient load, medicine shortages and insufficient training planning. Healthcare workers reported incidents where chaperones obstructed access to healthcare facilities for female patients and healthcare workers. Afghanistan's public healthcare system showed incredible resilience amidst funding disruptions and conflict until 2023. Healthcare facilities and underserved communities are more accessible due to improved safety, but the increased patient load and economic collapse add pressure to the system. Development partners must safeguard access to and participation in healthcare for women.
To evaluate the efficacy of a clinical decision support system (CDSS) on stroke care quality and clinical outcomes among patients with acute ischaemic stroke. Multicentre, cluster randomised clinical trial. 77 hospitals across China. 77 hospitals (38 randomised to intervention group, 39 to control group) enrolled 21 603 patients with acute ischaemic stroke admitted to hospital within seven days after symptom onset. Hospitals in the intervention group received stroke CDSS support including artificial intelligence assisted imaging analysis, classification of stroke causes, and evidence based treatment recommendations. Hospitals in the control group provided usual care. The primary outcome was a new vascular event (composite of ischaemic stroke, haemorrhagic stroke, myocardial infarction, and vascular death) within three months after initial symptom onset. Secondary outcomes included the composite measure and all-or-none measure of evidence based performance measures for acute ischaemic stroke care quality, a new vascular event at six and 12 months, and disability (modified Rankin Scale score 3-6) and all cause mortality at three, six, and 12 months. Safety outcomes were moderate or severe bleeding events and all bleeding events at three, six, and 12 months. 11 054 patients in the intervention group and 10 549 patients in the control group were enrolled from January 2021 to June 2023. New vascular events at three months occurred in 2.9% (320/11 054) in the intervention group compared with 3.9% (416/10 549) in the control group (adjusted hazard ratio 0.74, 95% confidence interval (CI) 0.58 to 0.93, P=0.01). The CDSS intervention effect remained significant in the cluster level analysis (-0.01, -0.02 to -0.004, P=0.003). Patients in the intervention group were more likely to have a higher composite measure (91.4% (77 049/84 276) v 89.8% (70 794/78 834), adjusted odds ratio 1.21, 95% CI 1.17 to 1.26, P<0.001). New vascular events were significantly lower in the intervention group at 12 months (4.0% (440/11 054) v 5.5% (576/10 549), adjusted hazard ratio 0.73, 95% CI 0.56 to 0.95, P=0.02). No significant differences were found in disability and all cause mortality. Moderate or severe bleeding, and all bleeding did not differ significantly between the two groups. Use of the stroke CDSS in patients with acute ischaemic stroke in China led to a significant decrease in new vascular events at three months. The stroke CDSS intervention was also effective in improving stroke care quality and decreasing long term vascular events. ClinicalTrials.gov NCT04524624.
In the USA, an estimated 40-50 million operations are performed annually, with high rates of adverse events. Since the 1980s, report cards have been used for outcome measures and to improve safety of surgical care. As part of Making Healthcare Safer IV-an initiative aimed at publishing evidence-based reviews as they are completed to help healthcare leaders, researchers and policymakers act more quickly on evidence-supported practices-we performed an updated review on the certainty of evidence on patient safety practices related to the use of surgical report cards and outcome measurements. Systematic review using the Grade of Recommendations Assessment, Development and Evaluation (GRADE) approach. PubMed, Web of Science, Scopus and the Cochrane Library were searched from November 2011 to May 2023. We included primary research studies (randomised control trials or observational studies with a comparison group, including pre-post studies) or observational studies that investigated a surgical report card in adult or paediatric surgical patients at the hospital or surgeon level in inpatient or outpatient settings. Excluded studies included: narrative reviews, scoping reviews, editorials, commentaries, abstracts, studies that measured only patient knowledge or levels of engagement or studies using local surgical dashboard data. Screening and eligibility were done in duplicate, while data extraction was done by one reviewer and checked by a second reviewer. Specific items in the Risk Of Bias In Non-randomised Studies - of Interventions tool and a modification of the National Institutes of Health Tool were used to assess for bias in studies. Two reviewers assessed each study for risk of bias. A modified version of the GRADE framework was used to assess the certainty of evidence. We identified 19 studies that met the inclusion criteria: 13 primary research studies and 6 descriptive studies of surgical collaboratives. Of the primary studies, nine used a pre-post or longitudinal study design and four used a regression discontinuity or concurrent controlled design. Seven of the studies were about the American College of Surgeons National Surgical Quality Improvement Project. Five studies were from single institutions and the remainder included nine to greater than 700 hospitals. Pre-post studies of report cards that prompted quality improvement (QI) programmes all reported improvements in outcomes, longitudinal studies reported benefits in some but not all outcomes and one in four controlled before-and-after studies reported a statistically significant mortality benefit. All studies, except for one, were at moderate or high risk of bias. Six collaboratives were identified with preliminary data. Based on the above evidence, the theoretical rationale and parallel evidence in other settings, we judged that it was moderate certainty that report cards and outcomes measurements can improve surgical outcomes. However, given the evidence from studies where report cards were actively linked to institutional QI initiatives, we recommend that outcome data must be paired with actionable QI efforts to meaningfully improve patient outcomes.
Leadership is often conceptualised within stable healthcare systems, yet its most revealing moments arise when those systems fracture. Humanitarian and emergency care environments-marked by uncertainty, scarcity and cultural complexity-strip leadership of formal scaffolding and expose its human foundations. This reflective narrative explores how leadership understanding was reshaped through humanitarian deployments, with particular attention to psychological safety, humility, adaptability and empowerment, and considers how these behaviours translate into everyday healthcare leadership practice. Using narrative reflection and experiential synthesis, the author draws on de-identified critical incidents from humanitarian deployments in Bangladesh, Myanmar, Afghanistan and Lebanon. These experiences are examined through established frameworks of psychological safety, compassionate leadership, cultural humility and experiential learning-not as empirical case studies, but as sites of transformative professional learning. Across diverse crisis settings, effective leadership emerged less from hierarchy or technical authority than from relational presence and shared vulnerability. Four inter-related behaviours consistently shaped practice: cultivating psychological safety by modelling uncertainty; practising humility to recognise and elevate local expertise; adapting creatively when protocols and resources failed and deliberately transferring agency to others to enable sustainable leadership capacity. These behaviours fostered trust, sustained morale and built capability that endured beyond individual missions. The leadership qualities forged in humanitarian crises are not exclusive to extreme contexts. They offer transferable insights for emergency departments, multidisciplinary teams and healthcare systems operating under sustained pressure. This reflection suggests that leadership in high-stakes environments is fundamentally a human practice-grounded in connection, trust and shared responsibility.
Breast cancer-related insomnia (BCRI) is a common and burdensome sequela. Acupuncture is frequently used, but robust evidence is limited, and previous systematic reviews included few trials yielding imprecise estimates. This updated systematic review and meta-analysis evaluated the efficacy and safety of acupuncture for BCRI. We systematically searched eight databases for randomized controlled trials (RCTs) up to July 1, 2025. RCTs comparing acupuncture with any control for BCRI were eligible. Methodological quality was assessed using the Cochrane Risk of Bias tool (RoB 2.0) and the modified Jadad scale. Meta-analyses employed a random-effects model. Subgroup analyses explored heterogeneity sources, and the GRADE framework rated evidence certainty. Twenty-seven RCTs (n=2,025) were included. Acupuncture significantly reduced Pittsburgh Sleep Quality Index (PSQI) scores (MD= -2.74, 95% CI [-3.92, -1.55], P<0.00001) and increased the overall efficacy rate (RR=1.51, 95% CI [1.27, 1.81], P<0.00001) compared to control, but did not significantly improve Insomnia Severity Index (ISI) scores. Subgroup analyses identified control intervention type and treatment frequency as significant sources of heterogeneity. Adverse events were infrequent and typically mild. GRADE assessments rated the certainty of evidence as low or very low, primarily due to risk of bias and substantial heterogeneity. Current evidence suggests acupuncture may improve sleep in patients with BCRI, with effects moderated by comparator type and treatment frequency. However, conclusions are limited by methodological weaknesses and heterogeneity. Future rigorous RCTs using validated sham controls, standardized protocols, and objective outcomes are needed to confirm efficacy and guide practice.PROSPERO Registration number(ID: CRD42024559828).
Patients who had a stroke often confront the trade-off between timely care at nearby hospitals and potentially higher quality but more distant care. Evidence remains limited on whether bypassing the nearest hospital in favour of a high-quality facility improves health outcomes. This study examines the causal effect of bypass behaviours on case fatality among inpatients who had a stroke and the time-bound survival benefits of bypassing behaviours directed to high-quality healthcare facilities. A retrospective study of 328 206 inpatients who had a stroke admitted via emergency departments in Sichuan Province, China (2017-2019), using complete discharge records. Bypass behaviour was defined as patients bypassing the nearest hospital to attend a more distant facility. Inverse probability weighting and instrumental variable analyses were applied. The differential travel distance between the nearest secondary and tertiary hospitals served as the instrumental variable to evaluate the causal effect of tertiary hospital admission on case fatality for haemorrhagic and ischaemic stroke. Among 328 206 patients, 78% engaged in bypass behaviour. Inverse probability weighting analysis showed that receiving care at tertiary hospitals was associated with significantly lower case-fatality, regardless of whether patients bypassed the nearest facility, with ORs below 0.8 for overall, 7-day and 30-day case fatality. Bypassing to a more distant secondary hospital was not associated with differences in case fatality. Instrumental variable analysis revealed a survival benefit from treatment at tertiary hospitals, with significant reductions in overall case fatality observed among patients who had an ischaemic stroke within 30 min (OR: 0.66, 95% CI 0.46 to 0.94) and patients who had a haemorrhagic stroke within 60 min (OR: 0.23, 95% CI 0.09 to 0.61). Bypassing a nearby hospital to seek care at a distant tertiary hospital was associated with a lower stroke case fatality rate. Favourable outcomes were observed when tertiary hospitals were reachable within 30 min for ischaemic stroke and within 60 min for haemorrhagic stroke.
Social determinants of health (SDoH) influence disease incidence, access to care, experiences, and outcomes. Recognising their importance, researchers and governments have emphasised the need to collect SDoH data in healthcare settings. However, gaps remain in understanding how to collect this information respectfully and equitably. To address these gaps, we aimed to understand local community perspectives on patient-centred SDoH data collection. We held a community engagement session to gather input from equity-denied communities on SDoH questions, response options, preferred methods of answering and appropriate data use. Qualitative data were analysed using content analysis, guided by the Capability, Opportunity and Motivation-Behaviour (COM-B) model. We also collected patient feedback from the first six months of implementing patient-centred SDoH data collection in ambulatory services at a large academic health science centre. This feedback was collected through an anonymous Microsoft Forms survey on comfort, safety and ease of responding to the SDoH questions and was summarised using medians and frequencies. The community engagement session included 22 participants, including eight patient advisors from diverse community organisations. Participants identified COM-B-related barriers to completing the questionnaire, such as unclear terminology, privacy concerns and mistrust of data use. Facilitators included inclusive language, multiple response methods, and transparency, particularly around data use. After integrating this feedback, the early implementation demonstrated high levels of comfort and safety. Additional feedback from the implementation highlighted opportunities to expand response methods, enhance staff engagement and education and establish ongoing partnerships with patients and communities to support the equitable use of SDoH data. Collecting SDoH data in healthcare settings is essential for facilitating equity-informed quality improvement, research, and decision-making. Our project highlights opportunities to overcome barriers by expanding response methods, enhancing staff engagement and education and fostering ongoing partnerships with patients and communities to support equitable SDoH data use and reporting.
Healthcare-associated infections remain a major concern in critical care environments. Hand hygiene (HH) compliance is a key preventive measure, yet maintaining consistent adherence remains challenging. A quality improvement (QI) initiative was undertaken to enhance HH practices among healthcare providers in a tertiary hospital in South India. From August to December 2023, a QI project was implemented in Coronary Care Units (CCU) at KLE's Dr. Prabhakar Kore Hospital. Using the Point of Care Quality Improvement (PoCQI) methodology, a multidisciplinary team applied WHO's multimodal HH strategy through iterative Plan-Do-Study-Act (PDSA) cycles. Interventions included: (1) installation of centralised scrub stations with sterile footwear, (2) bedside multilingual posters, (3) structured staff training with night-shift monitoring and (4) real-time observation with feedback supported by leadership engagement. Weekly HH compliance and infection outcomes were tracked. Five PDSA cycles were conducted. Mean HH compliance improved from a baseline of 63.8% to 80.5% by week 20, reflecting a 26.7% relative increase and remained above 78% through week 30, confirming sustained gains postintervention. No methicillin-resistant Staphylococcus aureus, Pseudomonas or Klebsiella infections were reported during the intervention period. Blood culture positivity after 48 hours of CCU stay remained at 0%. Mortality trends varied and showed no consistent pattern attributable to the intervention. Integrating WHO's multimodal strategy with PoCQI led to a significant, low-cost improvement in HH compliance in a high-risk setting. This team-led approach demonstrated the impact of QI strategies in implementing cost-effective infection prevention practices in critical care settings.
China has the highest global burden of new cancer diagnoses and cancer-related mortality, with approximately 60%-85% of patients with advanced malignancies experiencing moderate-to-severe pain. Although the WHO's analgesic ladder is widely implemented, approximately 20% of cancer-related pain remains refractory. This persistent pain is often further complicated by opioid-induced side effects and the risk of opioid use disorders. Methadone, a potent opioid with distinct pharmacokinetic and pharmacodynamic properties, has shown potential in managing refractory cancer pain; however, there is a lack of standardised and evidence-based protocols for methadone conversion, particularly in patients requiring high-dose opioids. This multicentre, open-label randomised controlled trial will enrol 164 Chinese patients with cancer and oral morphine equivalent daily dose requirements of ≥300 mg. Participants will be randomised to receive either the 3 day switch (3DS) strategy or the National Comprehensive Cancer Network (NCCN)-recommended methadone conversion method. The primary endpoints include time to stable analgesia, methadone conversion efficiency and overall pain relief rate. Secondary endpoints will evaluate pain intensity, frequency of breakthrough pain, corrected QT interval changes, incidence of adverse events and health-related quality of life. This trial is designed to generate high-quality clinical evidence to inform methadone conversion strategies for patients with refractory cancer pain who are dependent on high-dose opioids. By addressing existing gaps in clinical practice and pharmacoeconomic decision-making, the study aims to support the development of standardised methadone protocols. This study was approved by the Medical Ethics Committee of Zhejiang Cancer Hospital (approval number: IRB-2024-314(IIT)) on 3 April 2024 and registered with the Chinese Clinical Trial Registry (ChiCTR2400085332) on 5 June 2024. The outcomes will be disseminated through national and international presentations and peer-reviewed publications. ChiCTR2400085332.
To test whether a unit-level nutrition care bundle that accelerates enteral feed and optimises early caloric delivery improves in-hospital growth in preterm infants. Single-centre pre-post observational study. Tertiary neonatal intensive care unit. Infants born at less than 32 weeks' gestation admitted during two epochs: baseline (1 January 2023-30 April 2024) and post-quality improvement (QI) (1 May 2024-31 August 2025). Complete cases were analysed for each endpoint (growth velocity (GV) cohort: pre n=163, post n=149). A multicomponent nutrition care bundle promoting earlier initiation and advancement of enteral feeds, protocolised fortification and higher early energy delivery. Primary outcome was infant-level average GV (g/kg/day) calculated from weekly GV from week 3 onwards. Secondary outcomes included week-specific GV, change in weight Z-score from birth to discharge (Δ weight Z), discharge anthropometry, feeding process measures (time to full feeds, week 1 calories) and safety outcomes (feeding intolerance and necrotising enterocolitis). Average GV increased from 12.52±2.49 pre-QI to 15.50±2.30 g/kg/day post-QI (mean difference+2.98, 95% CI 2.45 to 3.52; p<0.001). Weekly GV was higher post-QI across weeks 3-12, with the largest difference at week 8 (+4.31 g/kg/day, 95% CI 2.34 to 6.27; p<0.001). Δ weight Z was less negative post-QI (-1.21±0.75 vs -1.43±0.81; difference+0.22, 95% CI 0.05 to 0.39; p=0.012). Discharge weight was higher post-QI (+152 g, 95% CI 13 to 290; p=0.033), while discharge length and head circumference Z-scores were similar between epochs. Time to full feeds decreased by 6.05 days (95% CI -11.77 to -0.33), and mean week 1 caloric intake increased by 11.38 kcal/kg/day (95% CI 6.16 to 16.60). Feeding intolerance and necrotising enterocolitis rates did not differ between periods. Implementation of a care bundle was associated with improved GV and earlier feeding milestones without increased feeding intolerance or necrotising enterocolitis.
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Polypharmacy can increase symptom burden and reduce quality of life in palliative care patients. The Drug Burden Index (DBI) measures patients' exposure to anticholinergic and sedative medications, but has not previously been validated in the palliative care population. This study aimed to quantify the DBI in an older palliative care inpatient population, and examine its associated functional, symptom and delirium outcomes. A retrospective cohort study was conducted on patients aged 65 years and older admitted to a specialist palliative care unit in Sydney, Australia, over a 3-month period. Demographic data, admission characteristics, medication exposure and clinical scores were collected via medical record review. Patients' DBI on admission and at 24 hours post-admission were calculated based on regular and pro re nata (PRN) medications. 79 patients were enrolled, who used a mean of 6.3 (SD 4.4) regular medications on admission, with a corresponding mean DBI of 0.69 (SD 0.55). At 24 hours post-admission, the DBI increased in 37% of patients and the resultant mean DBI was 0.82 (SD 0.58), which increased to 1.01 (SD 0.64) when administered PRN medications were included. There was no significant correlation on univariate analysis between patients' DBI on admission and their functional, symptom or delirium scores or length of hospital stay. Older palliative care patients are frequently exposed to anticholinergic and sedative medications. The DBI is a practical tool which can prompt medication review and inform safe, individualised prescribing in the palliative care setting in line with patients' goals of care.
Donor-funded health programmes strengthen national quality systems in low-income and middle-income countries, but abrupt withdrawal of external support can create institutional gaps and threaten service sustainability. To analyse the impact of sudden donor funding cessation, using the experience of the Health Care Accreditation Council (HCAC) as an illustrative case, and to explore implications for quality infrastructure and health system resilience. This structured case-based policy analysis draws on institutional documentation, administrative records and publicly available reports to examine the effects of funding withdrawal on quality programmes and organisational capacity. Funding cessation led to contraction of technical workforce capacity, scaling back of quality improvement and professional development activities, and disruption of accreditation-related support. The case exposed vulnerabilities associated with donor dependency and insufficient transition planning. Abrupt donor withdrawal can weaken quality systems and patient safety gains. Strengthening resilience requires diversified financing, structured transition frameworks and institutional strategies that embed quality governance within nationally owned systems.