Clinical Attachment Report Australia 2011

Clinical Attachment ReportBraeside Hospital Sydney Australia August 2011

Clinical Attachment ReportBraeside Hospital Sydney Australia

Farid Abdul Hadi, MD Fellow of Palliative MedicineLien Foundation –Singapore

Clinical Attachment Report Braeside Hospital Sydney Australia

Farid Abdul Hadi, MD Fellow of Palliative Medicine

– National Cancer Centre

Farid Abdul Hadi, MD Fellow of Palliative Medicine, Lien Foundation – National Cancer

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Clinical Attachment Report 1-26th August, 2011 Braeside Hospital 340 Prairievale Road Prairiewood NSW 2176 Tel: +61 2 9616 8600 Fax: +61 2 9616 8605 Mailing Address: Locked Bag 82, Wetherill Park, NSW 2164 Australia Supervisor: A/Prof. Dr. Meera Agar, Ph.D., FRCP, FAChPM Specialist Staff, Director of Palliative Care Braeside Hospital Teaching Staff, Flinders University, Australia High appreciations and gratitudes are addressed to: Dr. Rosalie Shaw, prominent founding mother of palliative care in Australia and Singapore Prof. Dr. Cynthia Goh, Director of Palliative Medicine, National Cancer Centre Singapore Dr. Angel Lee, Medical Director Dover Park Hospice, Singapore Farid Abdul Hadi, MD Clinical Fellow in Palliative Medicine Lien Foundation – National Cancer Centre Singapore Duke-National University of Singapore (Duke-NUS) – Flinders University Graduate Certificate of Health (Palliative Care) This report was generated as general documentation of personal clinical attachment in Braeside Hospital, Sydney, Australia. The attachment is a part of training program Graduate Certificate in Health (Palliative Care) and Fellowship in Palliative Medicine, Lien Foundation – National Cancer Centre Singapore. Any contents of the report were solely described personal experience and did not reflect any of organizations point of view. Reproduction with or without translation of these copies are permitted to be disseminated in limited circumstances. ©2011 Farid Abdul Hadi, Fellow in Palliative Medicine [email protected]


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Clinical Attachment Report

Braeside Hospital Sydney Australia August 2011

Introduction

This attachment is part of topics called ‘Practicum’ for Graduate Certificate

in Health (Palliative Care) Duke-National University o f Singapore (Duke-

NUS) and Flinders University Australia. The practicum focuses on

developing the ability to explore, reflect, and write on an area of palliative

clinical practice for at least one month duration. The expected outcome

from this practicum is deeper understanding with broader skill and

knowledge of palliative clinical practice, especially in specific topic of

interest. A comprehensive practicum report is generated as part of

course assessment.

The option of practicum was discussed with designated supervisor

from Flinders University during intensive in Singapore and through

electronic corespondencies. It is suggested to perform practicum in the field outside of daily

practice to broaden skill and knowledge. A topic of practicum; ‘Breathlessness Management in

Palliative Setting’ was chosen as reflected in learning contract and practicum report. The

practicum was decided to take place under supervision of A/Prof Meera Agar, Consultant and

Director of Palliative Care Unit Braeside Hospital, Sydney, Australia.

Sydney, New South Wales Australia

Sydney is the largest and most densely

populated city in Australia. Despite Canberra

as the administrative capital of Australia,

Sydney is nation financial capital and states

capital of New South Wales (NSW), one of

seven states in Australia. The city is

surrounded by many suburbs ranging

towards the north, south, and western area.

Locals of Sydney are generally called

Sydneysiders with highly multiracial

composition background.

Flinders – Duke-NUS

Graduate Certificate in

Palliative Care

Australian States and Territories


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The government of New South Wales operates the

public hospitals in the Sydney metropolitan region.

Management of these hospitals and other specialist

health facilities is coordinated by four Area Health

Services: Sydney South West (SSWAHS), Sydney West

(SWAHS), Northern Sydney and Central Coast

(NSCCAHS) and the South Eastern Sydney and

Illawarra (SESIAHS) Area Health Services. There are

also a number of private hospitals in the city, many of

which are aligned with religious organisations.

This practicum took place in Braeside hospital, a public and partially private Christian hospital

situated in Fairfield city, a suburb area 30-km in Sydney South West known for its diversity.

There were at least 156 languages spoken in the city in 2001 and certainly the number is

increasing by now. Australian English remains the primary language with some additional

languages are being formally displayed in public notice. Patients communication is also

supported by official hospital interpreters.

There is accommodation provided within hospital complex, which is highly limited for staffs who

are working or temporarily placed in Braeside or Fairfield hospital. It is a townhouse-style with

shared facilities located only few meters from main ward, make it convenient for this

attachment.

Braeside Hospital

Situated in Fairfield Hospital complex,

Braeside hospital is a 72-bedded

government public hospital which is partly

run by independent Christian charity

organozation Hammondcare provides

inpatient, outpatient, and community

services in Palliative Care,

Psychogeriatrics, and Rehabilitation

Medicine for southwestern area of

Sydney. The palliative care service

comprises acute palliative care service

called Palliative Care Unit (PCU), Day

Hospital, and Community Service. As part

of government facilities, Braeside Hospital

Sydney Opera House

Braeside Hospital, Sydney South West Area Health

Service (SSWAHS)


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is entitled to Australian government health insurance system (Medicare) and hence the services

are free-of-charge basis.

Palliative Care Unit (PCU)

PCU is a 20-bedded acute hospital ward

with eight single rooms and three 4-

bedded cubicles on patient’s need basis.

The PCU runs acute cases of palliative

care patients requiring specialist and

hospital treatments. It aims for short

duration of approximately 1-2 weeks

admission aiming for home or nursing

home discharge with support of day

hospital (follow-up clinic and allied health

support) and community service (home

care). However there are patients with

difficult conditions to be discharged (i.e.

too young to go to nursing home,

homeless, carers are unable to cope,

etc.) then Braeside hospital

accommodates them for longer term

placement, hence it also acts as inpatient hospice for terminal care.

Day Hospital

As the follow-up system of palliative care patients at home,

Day Hospital is arranged to accommodate outpatient service

comprises Palliative Care specialist clinic, physiotherapy,

occupational therapy, diversional therapy, and social worker.

To meet government requirement of day hospital concept,

patients are expected to stay and have treatment for at least

two hours duration within working days. Hospital transfer is

available when necessary.

Sydney south west area community service

Healthcare system in Australia is area-based supported with

main and distric hospitals, including community service

(home care). Fairfield and Braeside hospitals are part of

Sydney South West Area Health Service (SSWAHS) coverage

Upper: Patient transport

service. Lower: Home visit

staff transport service.

(Clockwise from upper left): Fairfield and Braeside

Hospital complex; PCU single rooms corridor; PCU

4-bedded cubicle (all facing garden); Patient room

verandah facing Fairfield golf range complex.


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service. Its strong community palliative care service includes visits by palliative care specialist

physicians, nurses, occupational therapies, physiotherapists, and social workers.

Activities

Ward round

Every morning there is regular ward round run by two palliative care consultants, registrars,

and resident medical officers covering around 20 inpatients. Before round is started, a handover

meeting is held and attended by all disciplines. During this meeting a daily symptom assesment,

palliative care phase, and performance status are discussed.

Multidisciplinary round

The essence of palliative care is multidisciplinary approach towards patient care. Every Monday

afternoon there is a multidisciplinary rounds attended by all divisions and chaired by every

single person on alternate basis. During this attachment, four multidisciplinary rounds were

chaired by physiotherapist, diversional therapy, occupational therapist, and nurse clinician. This

method ensures all divisions are being involved toward successful patient care.

Day hospital

A unique thing in Braeside Hospital is a Day Hospital concept. Instead of opening Palliative Care

clinic for follow up, discharged patients are being followed up multidisciplinarily by medical,

nursing, and allied health team. Although some of the patients don’t require the whole

components, e.g. there are groups of patients who require diversional therapy and don’t require

doctor follow up, but the session is kept for at least two hours for administration purposes.

Beside hospital patients, Braeside day hospital also opens the service for community (home

care) patients under Sydney South West Area Health Service coverage. Hospital transport is

available for those in need. The day hospital service is still in process of expanding its potential

to broader service such as blood transfusion, administration of palliative chemotherapy,

administration of zoledronic acid, etc.

Chaplain service

As a Christian-run organization, Braeside Hospital has a Christian chapel which also function as

quiet room for other religion. A permanent Chaplain staff works to provide spiritual need for

almost all patients regardless their religions. Most of the time the service involves other

(L to R) Morning ward round; Multidisciplinary round; Day hospital clinic; Day hospital allied health service.


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religious leaders/scholars from different ranges of religions to accommodate patient’s need.

Despite the Christian background, the working environment and system are kept to be very

much neutral.

Massage therapy

Touching and massaging are anecdotally proven

to lessen patient’s distress and most of the time it

provides general musculoskeletal relief. There is a

professional massage therapist who usually works

for Day Hospital and for some of inpatients who

require the service.

Diversional therapy

As part of symptom relief, diversional therapy

works interlacing with medical management to

keep patients engaged with activities aiming to

divert their suffering attention. For generally well

patients there are some art producing activities

which enables them to create their own artwork

products and place them in hospital as part of

decorative purposes. There are many other forms

of diversions for patients who required.

Home visit

One of well-established service in SSWAHS is its

community service (home care). Provided with

adequate facilities and clear area of coverage, the

team which consists of doctors, nurses, and allied

health regularly deliver the service door to door.

Doctors are in charge of patients who need

medical care, occupational therapies assess the materials needed to support the care at home

(i.e. railing, ramp, hospital bed, wheelchair, etc.), and nurses are taking care of patients and

carers most of the time. In many cases, urgent admissions were made to hospital for better

symptom control.

Above: Daily volunteer activity serving

snacks, desserts, and beverages. Below: A

solid allied health team of nurses,

chaplain, social worker, and diversional

therapist.


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Experiences

The biggest lesson from this practicum was having exposures of comprehensive palliative care

service (acute hospital, inpatient hospice, and home hospice network) within one roof.

Technically it was so efficient that the centre managed the whole service for sustained solid

coordination. A network of other Palliative Care Unit within one service (greater Sydney) was

also strongly built, ensuring effective comprehensive patient care.

Along with

palliative care

practice in UK,

Australian

maintained the

practice and

medications as

perusal in the

motherland.

Therapeutic

Guidelines

Palliative Care

Australia and

Palliative Care

Formulary (www.palliativedrugs.com) remained simple daily clinical guidelines. Nevertheless,

although considered new branch in medicine, there had been numerous robust palliative care

studies with good government funding made in this continent. Evidence-based medicine was

boldly reflected in daily practice. During this attachment itself there were three ongoing

Randomized Controlled Trials (RCT) with head-to-head comparisons of managements for

delirium, dyspnea, appetite, and ketamine study. An opportunity to observe the study process

was hence a highly valuable experience in this attachment.

The attachment also allowed familiriazing palliative drugs that are not always available in every

country as follow;

Oxycodone was widely used in community and one of familiar strong opioid analgesics for

general practitioners. The widely used conversion is 1 to 1 with oral morphine and reported to

be preferred in terms of less side effects (CNS/sedation, pruritus, nausea, and respiratory

depression), reducing medication error for certain cases, especially in community

(tablet/capsules rather than syrup), and to certain extent it is preferred for patient who has fear

of morphine stereotype addiction.

Left: Hospital pharmacy unit. Right: Medication chart format preserves manual documentation practice nationwide.


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As both morphine and oxycodone are metabolised in liver and excreted in kidney, its use is

limited for patients with good renal function. Common practice in Australia for renal impaired

patients is administration of Hydromorphone, which has conversion of 1 to 5 with oral

morphine. It is extensively used in the ward as many patients come with poor renal function. It

is also slightly cheaper and easier to titrate compared to other renal-friendly opioid, such as

Fentanyl administration.

Management of neuropathic pain remained a big discussion in pain and palliative care

community with different modalities and methods. Everyone had strong arguments regarding

the methods and some differences are generally acceptable. Administration of Methadone for

difficult neuropathic pain in Australia was aiming not to replace baseline opioid. Based on

instability of Methadone absorption, the practice was placing methadone as one of the

adjuvants while keeping main opioid i.e. morphine, hydromorphone, or fentanyl as they have

more proven stable body absorptions. Ketamine remains a question mark to play role as

adjuvant for neuropathic pain. Instead of giving short-term ‘burst Ketamine’ as introduced in

one of latest studies, the

practice in Australia remains

administration in stable dose

via continous infusion or not

to administer at all, as the

ongoing study has been

done (hasn’t been

published) in this hospital to

compare head to head

Ketamine and placebo with

negative result.

Management of secretion or

rattle requires various

methods, including the

medications. Besides

hyoscine hydrobromide

(Hyoscine); glycopyrrolate,

an anti-secretory agent

commonly used in

anesthesia, is also used for

patients who are still alert.

Glycopyrrolate has equal

anticholinergic side effects to

Upper: Evidence-based medicine was routinely discussed and reflected in daily clinical practice. During this attachment there were three ongoing Randomized Controlled Trials (RCT) studies and some other unpublished study results. Lower: A picture with supervisor, a productive clinical scientist who was also Director of Palliative Care Braeside Hospital, A/Prof. Dr. Meera Agar, Ph.D, FRCP, FAChPM


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Buscopan but may be used for alternative or as second line. If the patient has become

unconscious, hyoscine hydrobromide (scopolamine) is commonly used as it provides strong

anti-secretory effect crossing blood brain barrier with strong sedative effect. The attachment

allowed being familirized with both drugs which are not commonly used in palliative care setting

in Singapore.

Other drugs that were also not commonly used are Cyclizine for antiemetic and

Levomepromazine for antiemetic and agitation. This piperazine antihistamine was initially used

for motion sickness that acts centrally provides strong anti-emetic effect. It is currently used as

2nd or 3rd line antiemetic agent in palliative care for nausea. Another strong anti-emetic for

intractable nausea which also acts as anti-agitation for severe agitation and delirium in Australia

is Levomepromazine. It’s a phenotiazine antipsychotic works centrally to control emesis and

strong agent for severe terminal agitation. It provides better tranquilizing effect for patients

who failed with benzodiazepine.

All continous infusions were delivered via syringe driver with medication dose for general

Caucasian body size requirement, which were relatively higher than that Asian people required.

The Graseby syringe driver, which was commonly used in Asia-Pacific, was no longer available

in Australian continent. Use of more specific digital syringe driver i.e. Nikkki was widely used to

provide safer and easier administration. There was one medication error happened via syringe

driver within this attachment, hence continous training for all staff remained necessary.

Having said that Australia is well-developed nation, the information technology system was

relatively persisted in old-fashioned style. A well-dressed physician with tie or coat and pager on

the waist was a daily picture, as staffs held pager for internal communication instead of cellular

phone. Although information system (investigation results, summaries, etc.) was available

online, medication chart nationwide was formally printed in manual hard copy. There were no

Computer on Wheels (COW) around usual ward in public hospitals.

Left: Niki T34 as a standard syringe driver in Australia, leaving classic Graseby type. Right: Oral syringe for administration of oral liquid medicine (i.e. morphine syrup)


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The Australian government had strongly supported organ donation project, especially New

South Wales (NSW) government with Lions NSW Eye Bank initiative on corneal donation. As

palliative care service deals with numerous deaths more than any medical specialties, focus

project in palliative care had been established. Formal informed consent and well-trained staff

for corneal donation were available in Palliative Care Unit. Within this attachment there were

several donations made, involving staffs and Eye Bank medical technician who came and

performed on-site eye enucleation as an organ donor.

Closing

The attachment aimed to gain exposure of palliative care in clinical practice which was expected

to broaden skill and knowledge for daily clinical application. This practicum was held in Braeside

Hospital, one of public hospitals in Sydney, Australia. It covered comprehensive service of acute

hospital, inpatient hospice, and home hospice setting in the community. The facility was well

equipped and the staffs were highly dedicated in service and academic purposes. There were at

least three RCT studies were done during this practicum and evidence-based medicine were

routinely practiced at all time. An attachment in Braeside Hospital Palliative Care Unit is a highly

recommended for those who are interested to gain experience in strong academic and clinical

service of palliative care practice.

The attachment in Sydney offered experience of high standard healthcare system balanced with friendly and laid-back environment.

Clinical Attachment Report Australia 2011

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