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Harnett PJ. Improvement attributes in healthcare: implications for integrated care. Int J Health Care Qual Assur 2018; 31:214-227. [PMID: 29687756 DOI: 10.1108/ijhcqa-07-2016-0097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose Healthcare quality improvement is a key concern for policy makers, regulators, carers and service users. Despite a contemporary consensus among policy makers that integrated care represents a means to substantially improve service outcomes, progress has been slow. Difficulties achieving sustained improvement at scale imply that methods employed are not sufficient and that healthcare improvement attributes may be different when compared to prior reference domains. The purpose of this paper is to examine and synthesise key improvement attributes relevant to a complex healthcare change process, specifically integrated care. Design/methodology/approach This study is based on an integrative literature review on systemic improvement in healthcare. Findings A central theme emerging from the literature review indicates that implementing systemic change needs to address the relationship between vision, methods and participant social dynamics. Practical implications Accommodating personal and professional network dynamics is required for systemic improvement, especially among high autonomy individuals. This reinforces the need to recognise the change process as taking place in a complex adaptive system where personal/professional purpose/meaning is central to the process. Originality/value Shared personal/professional narratives are insufficiently recognised as a powerful change force, under-represented in linear and rational empirical improvement approaches.
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Affiliation(s)
- Patrick John Harnett
- National Integrated Care Programme, Older Persons, Social Care Division, Health Service Executive, Dublin, Ireland
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Nahidi S, Forero R, McCarthy S, Man N, Gibson N, Mohsin M, Mountain D, Fatovich D, Fitzgerald G, Toloo G(S. Qualitative analysis of perceptions and experiences of emergency department staff in relation to implementation and outcomes of the Four‐Hour Rule/National Emergency Access Target in Australia. Emerg Med Australas 2018; 31:378-386. [DOI: 10.1111/1742-6723.13166] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 07/25/2018] [Accepted: 07/27/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Shizar Nahidi
- Simpson Centre for Health Services ResearchSouth Western Sydney Clinical School, The University of New South Wales Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research Sydney New South Wales Australia
| | - Roberto Forero
- Simpson Centre for Health Services ResearchSouth Western Sydney Clinical School, The University of New South Wales Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research Sydney New South Wales Australia
| | - Sally McCarthy
- Prince of Wales Clinical SchoolThe University of New South Wales Sydney New South Wales Australia
- Emergency Care InstituteAgency for Clinical Innovation Sydney New South Wales Australia
| | - Nicola Man
- Simpson Centre for Health Services ResearchSouth Western Sydney Clinical School, The University of New South Wales Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research Sydney New South Wales Australia
| | - Nick Gibson
- School of Nursing and MidwiferyEdith Cowan University Perth Western Australia Australia
| | - Mohammed Mohsin
- Psychiatry Research and Teaching UnitSouth Western Sydney Local Health District Sydney New South Wales Australia
- School of PsychiatryFaculty of Medicine, The University of New South Wales Sydney New South Wales Australia
| | - David Mountain
- Emergency DepartmentSir Charles Gairdner Hospital Perth Western Australia Australia
- Division of Emergency Medicine, Faculty of Health and Medical SciencesThe University of Western Australia Perth Western Australia Australia
| | - Daniel Fatovich
- Division of Emergency Medicine, Faculty of Health and Medical SciencesThe University of Western Australia Perth Western Australia Australia
- Centre for Clinical Research in Emergency MedicineHarry Perkins Institute of Medical Research Perth Western Australia Australia
- Emergency DepartmentRoyal Perth Hospital Perth Western Australia Australia
| | - Gerard Fitzgerald
- School of Public Health and Social WorkQueensland University of Technology Brisbane Queensland Australia
| | - Ghasem (Sam) Toloo
- School of Public Health and Social WorkQueensland University of Technology Brisbane Queensland Australia
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Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: A systematic review of causes, consequences and solutions. PLoS One 2018; 13:e0203316. [PMID: 30161242 PMCID: PMC6117060 DOI: 10.1371/journal.pone.0203316] [Citation(s) in RCA: 570] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 08/17/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Emergency department crowding is a major global healthcare issue. There is much debate as to the causes of the phenomenon, leading to difficulties in developing successful, targeted solutions. AIM The aim of this systematic review was to critically analyse and summarise the findings of peer-reviewed research studies investigating the causes and consequences of, and solutions to, emergency department crowding. METHOD The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A structured search of four databases (Medline, CINAHL, EMBASE and Web of Science) was undertaken to identify peer-reviewed research publications aimed at investigating the causes or consequences of, or solutions to, emergency department crowding, published between January 2000 and June 2018. Two reviewers used validated critical appraisal tools to independently assess the quality of the studies. The study protocol was registered with the International prospective register of systematic reviews (PROSPERO 2017: CRD42017073439). RESULTS From 4,131 identified studies and 162 full text reviews, 102 studies met the inclusion criteria. The majority were retrospective cohort studies, with the greatest proportion (51%) trialling or modelling potential solutions to emergency department crowding. Fourteen studies examined causes and 40 investigated consequences. Two studies looked at both causes and consequences, and two investigated causes and solutions. CONCLUSIONS The negative consequences of ED crowding are well established, including poorer patient outcomes and the inability of staff to adhere to guideline-recommended treatment. This review identified a mismatch between causes and solutions. The majority of identified causes related to the number and type of people attending ED and timely discharge from ED, while reported solutions focused on efficient patient flow within the ED. Solutions aimed at the introduction of whole-of-system initiatives to meet timed patient disposition targets, as well as extended hours of primary care, demonstrated promising outcomes. While the review identified increased presentations by the elderly with complex and chronic conditions as an emerging and widespread driver of crowding, more research is required to isolate the precise local factors leading to ED crowding, with system-wide solutions tailored to address identified causes.
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Affiliation(s)
- Claire Morley
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Maria Unwin
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Tasmanian Health Service–North, Launceston, Tasmania, Australia
| | - Gregory M. Peterson
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Jim Stankovich
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
| | - Leigh Kinsman
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Tasmanian Health Service–North, Launceston, Tasmania, Australia
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Eriksson J, Gellerstedt L, Hillerås P, Craftman ÅG. Registered nurses' perceptions of safe care in overcrowded emergency departments. J Clin Nurs 2018; 27:e1061-e1067. [PMID: 29076280 DOI: 10.1111/jocn.14143] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2017] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To explore registered nurses' perceptions of safe practice in care for patients with an extended length of stay in the emergency department. BACKGROUND Extended length of stay and overcrowding in emergency departments are described internationally as one of the most comprehensive challenges of modern emergency care. An emergency department is not designed, equipped or staffed to provide care for prolonged periods of time. This context, combined with a high workload, poses a risk to patient safety, with additional medical errors and an increased number of adverse events. From this perspective, it is important to extend our knowledge and to describe registered nurses' experiences of safe practice. DESIGN A qualitative, inductive and descriptive study. METHODS Qualitative interview study carried out in five emergency departments. Data were analysed using a qualitative content analysis with a latent approach. RESULTS Patient safety meets obstacles in the clinical environment involving experiencing deficiencies regarding patient safety in the clinical setting and the impact of working procedures and routines. Moreover, nurses are challenged in their professional responsibilities involving balancing essential nursing care and actual workload; it is common to experience emotional reactions based on feelings of loss of control. CONCLUSIONS From the nurses' perspective, a prolonged stay in the emergency department may lead to negative consequences for both patient safety and care as well as registered nurses' psychosocial experiences. An extended length of stay significantly reduces the level of nursing and caring that registered nurses can perform in the emergency department. RELEVANCE TO CLINICAL PRACTICE This study indicates that emergency departments should review their procedures to avoid both deviations from normal practice and moral stress among registered nurses. This can contribute to an increased understanding and insight about the challenge of patient safety in an emergency department setting.
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Affiliation(s)
- Julia Eriksson
- Sophiahemmet University, Stockholm, Sweden.,Infektionskliniken, Karolinska University Hospital, Solna, Sweden
| | - Linda Gellerstedt
- Sophiahemmet University, Stockholm, Sweden.,Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Pernilla Hillerås
- Sophiahemmet University, Stockholm, Sweden.,Swedish Red Cross University College.,Department of NEUROTEC, Karolinska Institutet, Stockholm
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Unwin M, Crisp E, Rigby S, Kinsman L. Investigating the referral of patients with non-urgent conditions to a regional Australian emergency department: a study protocol. BMC Health Serv Res 2018; 18:647. [PMID: 30126396 PMCID: PMC6102868 DOI: 10.1186/s12913-018-3411-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 07/23/2018] [Indexed: 11/10/2022] Open
Abstract
Background Australia’s only island state, Tasmania, experiences one of the nation’s highest incidences of non-urgent emergency department (ED) presentations in a healthcare system regularly faced with service demands that exceed resource availability. Service-demand mismatches are acknowledged to contribute to ED crowding which in turn, has been documented to have a correlation with poorer patient outcomes. Crowding within EDs is complex, non-urgent presentations alone are not the primary cause, but have been reported to be a contributing factor. In 2015–16 Tasmania recorded over 153,000 ED attendances, 55% of these fell into the two least urgent triage categories. Recent research in the State’s North established that 29% of non-urgent presentations were referred, formally or informally, from primary healthcare providers and that, for many patients (39%), the ED was not their first choice of service provider. This study aims to identify the service needs of patients referred to a regional Australian ED and subsequently triaged as non-urgent. Method In order to achieve this aim, three objectives have been identified. The first two objectives use an explanatory sequential mixed-method approach while the third objective will incorporate an implementation science approach. These three objectives are: first, a retrospective analysis of seven years of routinely collected hospital data to identify trends in referral of patients with non-urgent conditions; second, focus group interviews with patients and primary care providers to further understand perceived need and service requirements of those referred to the ED, and third, translation of findings into local health service recommendations. Discussion Identification of the needs of patients referred to the ED with non-urgent conditions will inform future service planning aiming to facilitate access to the right service at the right time and in the right place.
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Affiliation(s)
- Maria Unwin
- College of Health and Medicine, University of Tasmania c/- Level 2, Northern Integrated Care Services, 41 Frankland St, Launceston, TAS, 7250, Australia. .,Emergency Department, Launceston General Hospital, Tasmanian Health Service, 274-280 Charles St, Launceston, Tasmania, Australia.
| | - Elaine Crisp
- College of Health and Medicine, University of Tasmania, 1 Newham Close, Newnham, Tasmania, 7248, Australia
| | - Scott Rigby
- Emergency Department, Launceston General Hospital, Tasmanian Health Service, 274-280 Charles St, Launceston, Tasmania, Australia
| | - Leigh Kinsman
- College of Health and Medicine, University of Tasmania c/- Level 2, Northern Integrated Care Services, 41 Frankland St, Launceston, TAS, 7250, Australia.,Tasmanian Health Service c/-Level 2, Northern Integrated Care Services, 41 Frankland St, Launceston, Tasmania, 7250, Australia
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57
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Forero R, Man N, Ngo H, Mountain D, Mohsin M, Fatovich D, Toloo GS, Celenza A, FitzGerald G, McCarthy S, Richardson D, Xu F, Gibson N, Nahidi S, Hillman K. Impact of the four-hour National Emergency Access Target on 30 day mortality, access block and chronic emergency department overcrowding in Australian emergency departments. Emerg Med Australas 2018; 31:58-66. [DOI: 10.1111/1742-6723.13151] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 06/27/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Roberto Forero
- Simpson Centre for Health Services Research; The University of New South Wales; Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research; Sydney New South Wales Australia
| | - Nicola Man
- Simpson Centre for Health Services Research; The University of New South Wales; Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research; Sydney New South Wales Australia
| | - Hanh Ngo
- Division of Emergency Medicine; Faculty of Health and Medical Sciences, The University of Western Australia; Perth Western Australia Australia
| | - David Mountain
- Division of Emergency Medicine; Faculty of Health and Medical Sciences, The University of Western Australia; Perth Western Australia Australia
- Emergency Department; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Mohammed Mohsin
- Psychiatry Research and Teaching Unit; South Western Sydney Local Health District; Sydney New South Wales Australia
- School of Psychiatry; Faculty of Medicine, The University of New South Wales; Sydney New South Wales Australia
| | - Daniel Fatovich
- Division of Emergency Medicine; Faculty of Health and Medical Sciences, The University of Western Australia; Perth Western Australia Australia
- Emergency Department; Royal Perth Hospital; Perth Western Australia Australia
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth Western Australia Australia
| | - Ghasem Sam Toloo
- School of Public Health and Social Work; Queensland University of Technology; Brisbane Queensland Australia
| | - Antonio Celenza
- Division of Emergency Medicine; Faculty of Health and Medical Sciences, The University of Western Australia; Perth Western Australia Australia
- Emergency Department; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Gerry FitzGerald
- School of Public Health and Social Work; Queensland University of Technology; Brisbane Queensland Australia
| | - Sally McCarthy
- Emergency Care Institute; Agency for Clinical Innovation; Sydney New South Wales Australia
- Emergency Department; Prince of Wales Hospital; Sydney New South Wales Australia
| | - Drew Richardson
- Medical School, Australian National University, Canberra; Australian Capital Territory Australia
- Emergency Department; Canberra Hospital, Canberra; Australian Capital Territory Australia
| | - Fenglian Xu
- Simpson Centre for Health Services Research; The University of New South Wales; Sydney New South Wales Australia
| | - Nick Gibson
- School of Nursing and Midwifery; Edith Cowan University; Perth Western Australia Australia
| | - Shizar Nahidi
- Simpson Centre for Health Services Research; The University of New South Wales; Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research; Sydney New South Wales Australia
| | - Ken Hillman
- Simpson Centre for Health Services Research; The University of New South Wales; Sydney New South Wales Australia
- Ingham Institute for Applied Medical Research; Sydney New South Wales Australia
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Forero R, Man N, McCarthy S, Richardson D, Mohsin M, Toloo GS, FitzGerald G, Ngo H, Mountain D, Fatovich D, Celenza A, Gibson N, Xu F, Nahidi S, Hillman K. Impact of the National Emergency Access Target policy on emergency departments' performance: A time-trend analysis for New South Wales, Australian Capital Territory and Queensland. Emerg Med Australas 2018; 31:253-261. [PMID: 30043403 DOI: 10.1111/1742-6723.13142] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/30/2018] [Accepted: 06/13/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the impact of the Australian National Emergency Access Target (NEAT) policy introduced in 2012 on ED performance. METHODS A longitudinal cohort study of NEAT implementation using linked data, for 12 EDs across New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD) between 2008 and 2013. Segmented regression in a multi-level model was used to analyse ED performance over time before and after NEAT introduction. The main outcomes measures were ED length of stay ≤4 h, access block, number of ED presentations, short-stay admission (≤24 h), >24 h admissions, unplanned ED re-attendances within 7 days and 'left at own risk' (including 'did not wait for assessment'). RESULTS Two years after NEAT introduction, ED length of stay ≤4 h increased in NSW and QLD (odds ratio [OR] = 2.48 and 3.24; P < 0.001) and access block decreased (OR = 0.41 and 0.22; P < 0.001), but not in ACT (OR = 1.28; P > 0.05). ED presentations increased over time before and after NEAT introduction with a significant increase above the projected trend in NSW after NEAT (mean ratio = 1.07). Short-stay admissions increased in QLD (OR = 2.60), ACT (OR = 1.68) and NSW (OR = 1.35). Unplanned ED re-attendances did not change significantly. Those who left at their own risk decreased significantly in NSW and QLD (OR = 0.38 and 0.67). CONCLUSION ED presentations continued to increase over time in all jurisdictions. NSW and QLD, but not ACT, showed significant improvements in time-based measures. Significant increases in short-stay admissions suggest a strategic change in ED process associated with NEAT implementation. Rates of unplanned ED re-attendances and those leaving at their own risk showed no evidence for adverse effects from NEAT.
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Affiliation(s)
- Roberto Forero
- Simpson Centre for Health Services Research, The University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Nicola Man
- Simpson Centre for Health Services Research, The University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Sally McCarthy
- Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
| | - Drew Richardson
- Medical School, Australian National University, Canberra, Australian Capital Territory, Australia.,Emergency Department, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Mohammed Mohsin
- Psychiatry Research and Teaching Unit, South Western Sydney Local Health District, Sydney, New South Wales, Australia.,School of Psychiatry, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Ghasem Sam Toloo
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Gerry FitzGerald
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Hanh Ngo
- Division of Emergency Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - David Mountain
- Division of Emergency Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Emergency Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Daniel Fatovich
- Division of Emergency Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Emergency Department, Royal Perth Hospital, Perth, Western Australia, Australia.,Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - Antonio Celenza
- Division of Emergency Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Emergency Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Nick Gibson
- School of Nursing and Midwifery, Edith Cowan University, Perth, Western Australia, Australia
| | - Fenglian Xu
- Simpson Centre for Health Services Research, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shizar Nahidi
- Simpson Centre for Health Services Research, The University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Ken Hillman
- Simpson Centre for Health Services Research, The University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
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Li M, Vanberkel P, Carter AJE. A review on ambulance offload delay literature. Health Care Manag Sci 2018; 22:658-675. [PMID: 29982911 DOI: 10.1007/s10729-018-9450-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 06/18/2018] [Indexed: 11/25/2022]
Abstract
Ambulance offload delay (AOD) occurs when care of incoming ambulance patients cannot be transferred immediately from paramedics to staff in a hospital emergency department (ED). This is typically due to emergency department congestion. This problem has become a significant concern for many health care providers and has attracted the attention of many researchers and practitioners. This article reviews literature which addresses the ambulance offload delay problem. The review is organized by the following topics: improved understanding and assessment of the problem, analysis of the root causes and impacts of the problem, and development and evaluation of interventions. The review found that many researchers have investigated areas of emergency department crowding and ambulance diversion; however, research focused solely on the ambulance offload delay problem is limited. Of the 137 articles reviewed, 28 articles were identified which studied the causes of ambulance offload delay, 14 articles studied its effects, and 89 articles studied proposed solutions (of which, 58 articles studied ambulance diversion and 31 articles studied other interventions). A common theme found throughout the reviewed articles was that this problem includes clinical, operational, and administrative perspectives, and therefore must be addressed in a system-wide manner to be mitigated. The most common intervention type was ambulance diversion. Yet, it yields controversial results. A number of recommendations are made with respect to future research in this area. These include conducting system-wide mitigation intervention, addressing root causes of ED crowding and access block, and providing more operations research models to evaluate AOD mitigation interventions prior implementations. In addition, measurements of AOD should be improved to assess the size and magnitude of this problem more accurately.
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Affiliation(s)
- Mengyu Li
- Faculty of Engineering, Department of Industrial Engineering, Dalhousie University, Halifax, NS, Canada.
| | - Peter Vanberkel
- Faculty of Engineering, Department of Industrial Engineering, Dalhousie University, Halifax, NS, Canada
| | - Alix J E Carter
- Department of Emergency Medicine, Division of EMS, Dalhousie University, Halifax, NS, Canada
- Emergency Health Services, Dartmouth, NS, Canada
- Nova Scotia Health Authority, Sydney, NS, Canada
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Paton A, Mitra B, Considine J. Longer time to transfer from the emergency department after bed request is associated with worse outcomes. Emerg Med Australas 2018; 31:211-215. [DOI: 10.1111/1742-6723.13120] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 05/22/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Andrew Paton
- Adult Retrieval Victoria Melbourne Victoria Australia
| | - Biswadev Mitra
- Emergency and Trauma Centre, The Alfred Hospital Melbourne Victoria Australia
- National Trauma Research Institute, Monash University Melbourne Victoria Australia
- Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
| | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety ResearchDeakin University Melbourne Victoria Australia
- Centre for Quality and Patient Safety ResearchEastern Health Partnership Melbourne Victoria Australia
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Considine J, Curtis K, Shaban RZ, Fry M. Consensus-based clinical research priorities for emergency nursing in Australia. Australas Emerg Care 2018; 21:43-50. [PMID: 30998874 DOI: 10.1016/j.auec.2018.03.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 03/18/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Research is vital to responding to contemporary challenges of providing safe, high quality emergency nursing care, yet the research priorities for emergency nursing practice in Australia are unknown. This study aimed to establish research priorities for emergency nursing in Australia. METHODS A two-stage descriptive, exploratory study was conducted. First, research themes were identified through a survey of 232 emergency nurses the Delphi Technique (2 rounds) was used to rank and prioritise the research themes. RESULTS There were five research themes with a CVI≥0.90: (i) recognising and responding to deteriorating ED patients; (ii) effect of access block on clinical care of admitted ICU patients; (iii) effects of ED overcrowding on clinical care; (iv) scope of practice of specialist emergency nurses; and (v) effect of access block on clinical care of admitted ward patients. These are reflected in four broad research priority areas: professional issues, patient safety, emergency care of vulnerable populations, and healthcare system issues. CONCLUSION Future research should focus on these priority areas in partnership with other emergency disciplines to enable safe, high quality emergency care, and, to inform the practice of emergency nursing in Australia.
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Affiliation(s)
- Julie Considine
- Deakin University, Geelong: School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, Victoria, Australia; Centre for Quality and Patient Safety Research - Eastern Health Partnership, Box Hill, Victoria, Australia.
| | - Kate Curtis
- Sydney Nursing School, The University of Sydney, Clinical Nurse Consultant - Emergency, Illawarra Shoalhaven Local Health District, Camperdown, New South Wales, Australia.
| | - Ramon Z Shaban
- Sydney Nursing School and Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney and Western Sydney Local Health District, Westmead Institute for Medical Research, 179 Hawkesbury Road, Westmead, NSW, Australia.
| | - Margaret Fry
- Nursing and Midwifery Directorate Northern Sydney Local Health District, St Leonards, NSW, Australia; Faculty of Health, University of Technology Sydney, Sydney, Australia.
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Velt KB, Cnossen M, Rood PPM, Steyerberg EW, Polinder S, Lingsma HF. Emergency department overcrowding: a survey among European neurotrauma centres. Emerg Med J 2018; 35:447-448. [DOI: 10.1136/emermed-2017-206796] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 03/05/2018] [Accepted: 03/06/2018] [Indexed: 11/03/2022]
Abstract
BackgroundED overcrowding is an increasing problem worldwide that may negatively affect quality of care and patient outcomes. We aimed to study ED overcrowding across European centres.MethodsQuestionnaires on structure and process of care, including crowding, were distributed to 68 centres participating in a large European study on traumatic brain injury (Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury).ResultsOf the 65 centres included in the analysis, 32 (49%) indicated that overcrowding was a frequent problem and 28 (43%) reported that patients were placed in hallways ‘multiple times a day’; 27 (41%) stated that multiple times a day, there was no bed available when a patient needed to be admitted. Ambulance diversion rarely occurred in the participating centres.ConclusionSimilar to reports from other parts of the world, ED crowding appears to be a considerable problem in Europe. More research is needed to determine effective ways to reduce overcrowding.
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Forero R, Nahidi S, De Costa J, Mohsin M, Fitzgerald G, Gibson N, McCarthy S, Aboagye-Sarfo P. Application of four-dimension criteria to assess rigour of qualitative research in emergency medicine. BMC Health Serv Res 2018; 18:120. [PMID: 29454350 PMCID: PMC5816375 DOI: 10.1186/s12913-018-2915-2] [Citation(s) in RCA: 227] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 02/06/2018] [Indexed: 11/25/2022] Open
Abstract
Background The main objective of this methodological manuscript was to illustrate the role of using qualitative research in emergency settings. We outline rigorous criteria applied to a qualitative study assessing perceptions and experiences of staff working in Australian emergency departments. Methods We used an integrated mixed-methodology framework to identify different perspectives and experiences of emergency department staff during the implementation of a time target government policy. The qualitative study comprised interviews from 119 participants across 16 hospitals. The interviews were conducted in 2015–2016 and the data were managed using NVivo version 11. We conducted the analysis in three stages, namely: conceptual framework, comparison and contrast and hypothesis development. We concluded with the implementation of the four-dimension criteria (credibility, dependability, confirmability and transferability) to assess the robustness of the study, Results We adapted four-dimension criteria to assess the rigour of a large-scale qualitative research in the emergency department context. The criteria comprised strategies such as building the research team; preparing data collection guidelines; defining and obtaining adequate participation; reaching data saturation and ensuring high levels of consistency and inter-coder agreement. Conclusion Based on the findings, the proposed framework satisfied the four-dimension criteria and generated potential qualitative research applications to emergency medicine research. We have added a methodological contribution to the ongoing debate about rigour in qualitative research which we hope will guide future studies in this topic in emergency care research. It also provided recommendations for conducting future mixed-methods studies. Future papers on this series will use the results from qualitative data and the empirical findings from longitudinal data linkage to further identify factors associated with ED performance; they will be reported separately. Electronic supplementary material The online version of this article (10.1186/s12913-018-2915-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Roberto Forero
- The Simpson Centre for Health Services Research, South Western Sydney Clinical School and the Ingham Institute for Applied Research, Liverpool Hospital, UNSW, Liverpool, NSW, 1871, Australia.
| | - Shizar Nahidi
- The Simpson Centre for Health Services Research, South Western Sydney Clinical School and the Ingham Institute for Applied Research, Liverpool Hospital, UNSW, Liverpool, NSW, 1871, Australia
| | - Josephine De Costa
- The Simpson Centre for Health Services Research, South Western Sydney Clinical School and the Ingham Institute for Applied Research, Liverpool Hospital, UNSW, Liverpool, NSW, 1871, Australia
| | - Mohammed Mohsin
- Psychiatry Research and Teaching Unit, Liverpool Hospital, NSW Health, Sydney, Australia.,School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Gerry Fitzgerald
- School - Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, Qld, Australia.,Australasian College for Emergency Medicine (ACEM), Melbourne, VIC, Australia
| | - Nick Gibson
- School of Nursing and Midwifery, Edith Cowan University (ECU), Perth, WA, Australia
| | - Sally McCarthy
- Australasian College for Emergency Medicine (ACEM), Melbourne, VIC, Australia.,Emergency Care Institute (ECI), NSW Agency for Clinical Innovation (ACI), Sydney, Australia
| | - Patrick Aboagye-Sarfo
- Clinical Support Directorate, System Policy & Planning Division, Department of Health WA, Perth, WA, Australia
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64
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Quantifying patient flow and utilization with patient flow pathway and diagnosis of an emergency department in Singapore. Health Syst (Basingstoke) 2017. [DOI: 10.1057/hs.2015.15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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65
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Patient physiological status during emergency care and rapid response team or cardiac arrest team activation during early hospital admission. Eur J Emerg Med 2017; 24:359-365. [DOI: 10.1097/mej.0000000000000375] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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66
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Tenbensel T, Chalmers L, Jones P, Appleton-Dyer S, Walton L, Ameratunga S. New Zealand's emergency department target - did it reduce ED length of stay, and if so, how and when? BMC Health Serv Res 2017; 17:678. [PMID: 28950856 PMCID: PMC5615466 DOI: 10.1186/s12913-017-2617-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 09/13/2017] [Indexed: 11/10/2022] Open
Abstract
Background In 2009, the New Zealand government introduced a hospital emergency department (ED) target – 95% of patients seen, treated or discharged within 6 h - in order to alleviate crowding in public hospital EDs. While these targets were largely met by 2012, research suggests that such targets can be met without corresponding overall reductions in ED length-of-stay (LOS). Our research explores whether the NZ ED time target actually reduced ED LOS, and if so, how and when. Methods We adopted a mixed-methods approach with integration of data sources. After selecting four hospitals as case study sites, we collected all ED utilisation data for the period 2006 to 2012. ED LOS data was derived in two forms-reported ED LOS, and total ED LOS - which included time spent in short-stay units. This data was used to identify changes in the length of ED stay, and describe the timing of these changes to these indicators. Sixty-eight semi-structured interviews and two surveys of hospital clinicians and managers were conducted between 2011 and 2013. This data was then explored to identify factors that could account for ED LOS changes and their timing. Results Reported ED LOS reduced in all sites after the introduction of the target, and continued to reduce in 2011 and 2012. However, total ED LOS only decreased from 2008 to 2010, and did not reduce further in any hospital. Increased use of short-stay units largely accounted for these differences. Interview and survey data showed changes to improve patient flow were introduced in the early implementation period, whereas increased ED resources, better information systems to monitor target performance, and leadership and social marketing strategies mainly took throughout 2011 and 2012 when total ED LOS was not reducing. Conclusions While the ED target clearly stimulated improvements in patient flow, our analysis also questions the value of ED targets as a long term approach. Increased use of short-stay units suggests that the target became less effective in ‘standing for’ improved timeliness of hospital care in response to increasing acute demand. As such, the overall challenges in managing demand for acute and urgent care in New Zealand hospitals remain. Electronic supplementary material The online version of this article (10.1186/s12913-017-2617-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tim Tenbensel
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, 92019, Auckland, 1142, New Zealand.
| | - Linda Chalmers
- Nursing Development Unit, Auckland City Hospital, Private Bag 92024, Auckland, 1142, New Zealand
| | - Peter Jones
- Adult Emergency Department, Auckland City Hospital, Private Bag 92024, Auckland, 1142, New Zealand
| | - Sarah Appleton-Dyer
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, 92019, Auckland, 1142, New Zealand
| | - Lisa Walton
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, 92019, Auckland, 1142, New Zealand
| | - Shanthi Ameratunga
- Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, 92019, Auckland, 1142, New Zealand
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Jones P, Wells S, Ameratunga S. Towards a best measure of emergency department crowding: Lessons from current Australasian practice. Emerg Med Australas 2017; 30:214-221. [PMID: 28941074 DOI: 10.1111/1742-6723.12868] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/02/2017] [Accepted: 08/21/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Despite extensive literature, how crowding in EDs should be measured is still debated. The present study aimed to describe crowding metrics used in Australasia, what they were used for, the perceived extent and frequency of crowding and the challenges faced when trying to measure crowding. METHODS A survey of ED clinical directors was undertaken between December 2014 and July 2015. Free-text responses were categorised and thematically coded. Quantitative data were analysed descriptively and with logistic regression. RESULTS There were 113 of 145 responses (78%). Crowding was considered a major problem by 84 of 113 (74%) and not rare by 88 of 111 participants (79%). These constructs were correlated; G = -0.851, P < 0.001. Levels 1-3 EDs were less likely to report crowding as a major problem than Level 4 EDs; odds ratio 0.15 (0.03-0.69), P = 0.02. Sixteen current metrics were identified and categorised into 'time', 'occupancy' and 'workload' metrics. These categories of metric were used differently, and multiple metrics had more uses than single metrics. Previously described complex crowding metrics were infrequently recognised (<20%). Common challenges to measuring crowding were lack of an agreed metric (40%) and lack of buy-in by inpatient teams or hospital management (35%). CONCLUSION ED crowding remains a common and important problem in Australasia. Crowding is multifaceted, so a single metric might not capture all important elements of crowding or be relevant to all stakeholders. However, a metric like Access Block, which encompasses elements of time, occupancy and workload and is relevant to stakeholders outside the ED, might hold the most promise.
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Affiliation(s)
- Peter Jones
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand.,Department of Surgery, Faculty of Health and Medical Sciences, The University of Auckland, Auckland, New Zealand
| | - Susan Wells
- Department of Epidemiology and Biostatistics, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Shanthi Ameratunga
- Department of Epidemiology and Biostatistics, School of Population Health, The University of Auckland, Auckland, New Zealand
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Validation of the RETRIEVE (REverse TRIage EVEnts) Criteria for Same Day Return of Non-ST Elevation Acute Coronary Syndrome Patients to Referring Non-PCI Centres. Heart Lung Circ 2017; 27:792-797. [PMID: 28919071 DOI: 10.1016/j.hlc.2017.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 07/29/2017] [Accepted: 08/04/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND There are continuing bed constraints in percutaneous coronary intervention centres (PCI) so efficient patient triage from referral hospitals is pivotal. To evaluate a strategy of PCI centre (PCIC) bed-sparing we examined return of patients to referral hospitals screened by the RETRIEVE (REverse TRIage EVEnts) criteria and validated its use as a tool for screening suitability for same day transfer of non-ST-elevation acute coronary syndrome (NSTEACS) patients post PCI to their referring non-PCI centre (NPCIC). METHODS From May 2008 to May 2011, 433 NSTEACS patients were prospectively screened for suitability for same day transfer back to the referring hospital at the completion of PCI. Of these patients, 212 were excluded from same day transfer using the RETRIEVE criteria and 221 patients met the RETRIEVE criteria and were transferred back to their NPCIC. RESULTS Over the study period, 218 patients (98.6%) had no major adverse events. The primary endpoint (death, arrhythmia, myocardial infarction, major bleeding event, cerebrovascular accident, major vascular site complication, or requirement for return to the PCIC) was seen in only three transferred patients (1.4%). CONCLUSIONS The RETRIEVE criteria can be used successfully to identify NSTEACS patients suitable for transfer back to NPCIC following PCI. Same day transfer to a NPCIC using the RETRIEVE criteria was associated with very low rates of major complications or repeat transfer and appears to be as safe as routine overnight observation in a PCIC.
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69
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He J, Hou XY, Toloo GS, FitzGerald G. Patients' choice between public and private hospital emergency departments: a cross-sectional survey. Emerg Med Australas 2017; 29:635-642. [PMID: 28929641 DOI: 10.1111/1742-6723.12841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 05/28/2017] [Accepted: 06/27/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to understand what factors influence patients' choice between public and private hospital ED and the relative weight of those factors among adult patients with private health insurance in Australia. METHODS A survey of 280 patients was conducted in four public and private hospitals' EDs in Brisbane between May and August 2015. The survey included information about respondent's demographics, nature of illness, decision-making, attitudes and choice. Independent t-test and Pearson's χ²-test were used to identify binary associations, and logistic regression was used to determine what factors influence patients' choice. RESULTS Patients who agreed that 'long waiting time is a barrier to access public hospital ED' were twice as likely to choose private hospitals (odds ratio [OR] 2.172, P = 0.001). Alternatively patients who did not consider that 'there were long waiting times in public hospital ED' were less likely to access private hospitals (OR 0.200, P = 0.003). More public hospital patients (70.7%) than private hospital patients (56.4%) (P = 0.015) agreed that 'out-of-pocket payment is a barrier to accessing private hospital ED'. Patients attending private hospitals rated the quality of service higher than those attending public hospitals (OR 1.26, P = 0.001). CONCLUSION Longer waiting times in public EDs is the principal issue considered by patients choosing private EDs and the out-of-pocket payment for accessing private EDs is the principal issue considered by public ED patients. The study suggests that addressing the out-of-pocket payments will attract more patients with private health insurance to access private EDs.
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Affiliation(s)
- Jun He
- School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Xiang-Yu Hou
- School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ghasem Sam Toloo
- School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Gerry FitzGerald
- School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia
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70
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Schwarz M, Coccetti A, Murdoch A, Cardell E. The impact of aspiration pneumonia and nasogastric feeding on clinical outcomes in stroke patients: A retrospective cohort study. J Clin Nurs 2017; 27:e235-e241. [PMID: 28618137 DOI: 10.1111/jocn.13922] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2017] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To determine presence of clinical complications related to dysphagia and to explore their operational outcomes. BACKGROUND Dysphagia is a common complication of stroke. The management of poststroke dysphagia is multidisciplinary with nurses playing a key role in screening for dysphagia risk, monitoring tolerance of food and fluids and checking for the development of complications such as fever, dehydration and change in medical status. Dysphagia often results in further complications including aspiration pneumonia and the need for nasogastric feeding. Dysphagia-related complications have been shown to have a significant impact on morbidity and mortality, length of stay and cost of admission. DESIGN Retrospective cohort study. METHODS A total of 110 patients presenting with an ischaemic stroke were chart-audited. RESULTS Aspiration pneumonia poststroke was found to be significantly associated with increased overall length of stay, poorer functional outcomes poststroke as well as being associated with a high risk of mortality. The presence of a nasogastric tube was also associated with reduced functional outcomes poststroke and increased risk of death. CONCLUSION High prevalence and cost of complications associated with stroke highlight the complexity of providing nursing and allied health care to this patient population. This provides a snapshot of dysphagia-related complications experienced by stroke patients. RELEVANCE TO CLINICAL PRACTICE This paper highlights that poststroke complications can significantly impact on patient outcomes and operational factors such as cost of admission; therefore, poststroke care requires a multidisciplinary approach to management. Furthermore, preventing and managing complications poststroke is a key element of nursing care and has the potential to significantly reduce incidence of mortality, length of stay and cost of hospital admission.
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Affiliation(s)
| | | | | | - Elizabeth Cardell
- Menzies Health Institute Queensland, School of Allied Health Sciences, Griffith University, Southport, Qld, Australia
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72
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Zeitz K, Watson D. Principles of capacity management, applied in the mental health context. AUST HEALTH REV 2017. [PMID: 28637582 DOI: 10.1071/ah17007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective The aim of the paper was to describe a suite of capacity management principles that have been applied in the mental health setting that resulted in a significant reduction in time spent in two emergency departments (ED) and improved throughput. Methods The project consisted of a multifocal change approach over three phases that included: (1) the implementation of a suite of fundamental capacity management activities led by the service and clinical director; (2) a targeted Winter Demand Plan supported by McKinsey and Co.; and (3) a sustainability of change phase. Descriptive statistics was used to analyse the performance data that was collected through-out the project. Results This capacity management project has resulted in sustained patient flow improvement. There was a reduction in the average length of stay (LOS) in the ED for consumers with mental health presentations to the ED. At the commencement of the project, in July 2014, the average LOS was 20.5h compared with 8.5h in December 2015 post the sustainability phase. In July 2014, the percentage of consumers staying longer than 24h was 26% (n=112); in November and December 2015, this had reduced to 6% and 7 5% respectively (less than one consumer per day). Conclusion Improving patient flow is multifactorial. Increased attendances in public EDs by people with mental health problems and the lengthening boarding in the ED affect the overall ED throughput. Key strategies to improve mental health consumer flow need to focus on engagement, leadership, embedding fundamentals, managing and target setting. What is known about the topic? Improving patient flow in the acute sector is an emerging topic in the health literature in response to increasing pressures of access block in EDs. What does this paper add? This paper describes the application of a suite of patient flow improvement principles that were applied in the mental health setting that significantly reduced the waiting time for consumers in two EDs. What are the implications for practitioners? No single improvement will reduce access block in the ED for mental health consumers. Reductions in waiting times require a concerted, multifocal approach across all components of the acute mental health journey.
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Affiliation(s)
- Kathryn Zeitz
- University of Adelaide, Adelaide, SA 5005, Australia
| | - Darryl Watson
- University of Adelaide, Adelaide, SA 5005, Australia
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Samaranayake P, Dadich A, Fitzgerald A, Zeitz K. Developing an evaluation framework for clinical redesign programs: lessons learnt. J Health Organ Manag 2017; 30:950-70. [PMID: 27681027 DOI: 10.1108/jhom-07-2015-0109] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The purpose of this paper is to present lessons learnt through the development of an evaluation framework for a clinical redesign programme - the aim of which was to improve the patient journey through improved discharge practices within an Australian public hospital. Design/methodology/approach The development of the evaluation framework involved three stages - namely, the analysis of secondary data relating to the discharge planning pathway; the analysis of primary data including field-notes and interview transcripts on hospital processes; and the triangulation of these data sets to devise the framework. The evaluation framework ensured that resource use, process management, patient satisfaction, and staff well-being and productivity were each connected with measures, targets, and the aim of clinical redesign programme. Findings The application of business process management and a balanced scorecard enabled a different way of framing the evaluation, ensuring measurable outcomes were connected to inputs and outputs. Lessons learnt include: first, the importance of mixed-methods research to devise the framework and evaluate the redesigned processes; second, the need for appropriate tools and resources to adequately capture change across the different domains of the redesign programme; and third, the value of developing and applying an evaluative framework progressively. Research limitations/implications The evaluation framework is limited by its retrospective application to a clinical process redesign programme. Originality/value This research supports benchmarking with national and international practices in relation to best practice healthcare redesign processes. Additionally, it provides a theoretical contribution on evaluating health services improvement and redesign initiatives.
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Affiliation(s)
| | - Ann Dadich
- School of Business, Western Sydney University , Parramatta, Australia
| | - Anneke Fitzgerald
- Griffith Business School, Griffith University , Southport, Australia
| | - Kathryn Zeitz
- Patient Pathways, Royal Adelaide Hospital, Adelaide, Australia
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74
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Cameron P, Mitra B, Smit D. The National Emergency Access Target performance and all that!! Emerg Med Australas 2017; 29:260-261. [DOI: 10.1111/1742-6723.12801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Peter Cameron
- Emergency and Trauma Centre, Alfred Health; Monash University; Melbourne Victoria Australia
| | - Biswadev Mitra
- Emergency and Trauma Centre, Alfred Health; Monash University; Melbourne Victoria Australia
| | - DeVilliers Smit
- Emergency and Trauma Centre, Alfred Health; Monash University; Melbourne Victoria Australia
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Richardson DB, Brockman K, Abigail A, Hollis GJ. Effects of a hospital-wide intervention on emergency department crowding and quality: A prospective study. Emerg Med Australas 2017; 29:415-420. [PMID: 28378942 DOI: 10.1111/1742-6723.12771] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 02/09/2017] [Accepted: 02/20/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The objective of this study was to determine the impact of a management-supported, multimodal, hospital-wide intervention on ED crowding and quality measures. METHODS This is a prospective descriptive study of the first 20 weeks of the intervention, with 3 years of historical controls. The study was conducted in a 600 bed adult/paediatric tertiary hospital with 80 000 ED presentations annually. ED information system data were collected on all presentations in matched 20 week periods. Multiple interventions included ED Navigator role, ED Medical Staff teaming, corporate focus with key performance indicators and dashboards, appointment of a Director of Operations, Long Length of Stay Committee and reorganisation of the flow (bed management) unit. Process outcomes were 4 h performance as a proportion of all patients and mean daily length of crowding with more than 10 inpatients awaiting beds expressed as a time. Quality outcomes were proportions of patients who did not wait and who re-presented within 72 h. RESULTS There was a 9.1% increase in presentations and a 22.6% decrease in mean ED occupancy over the previous year. The 4 h performance improved from 56.1% (95% confidence interval [CI] 55.5-56.7) to 68.8% (95% CI 68.3-69.3) and daily crowding with more than 10 inpatients improved from 6:34 (95% CI 5:32-7:37) to 0:29 (95% CI 0:15-0:42). Did not wait improved significantly from 5.1 to 3.0% and rate of representation did not change. CONCLUSION This prospective study shows significant improvement in ED flow without compromise in quality measures from a hospital-wide intervention requiring minimal additional resources. Further research is required on sustainability and patient outcomes beyond the ED.
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Affiliation(s)
- Drew B Richardson
- Medical School, Australian National University, Canberra, Australian Capital Territory, Australia.,Emergency Department, Canberra Hospital and Health Services, Canberra, Australian Capital Territory, Australia
| | - Kate Brockman
- Healthcare Reform Consulting, Canberra, Australian Capital Territory, Australia
| | - Angela Abigail
- Emergency Department, Canberra Hospital and Health Services, Canberra, Australian Capital Territory, Australia
| | - Gregory J Hollis
- Emergency Department, Canberra Hospital and Health Services, Canberra, Australian Capital Territory, Australia
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Varndell W, Fry M, Elliott D. A systematic review of observational pain assessment instruments for use with nonverbal intubated critically ill adult patients in the emergency department: an assessment of their suitability and psychometric properties. J Clin Nurs 2017; 26:7-32. [PMID: 27685422 DOI: 10.1111/jocn.13594] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2016] [Indexed: 01/24/2023]
Abstract
AIM AND OBJECTIVE To examine the psychometric properties and suitability of the available observational pain instruments for potential use with nonverbal critically ill adult patients in the emergency department. BACKGROUND In the emergency department, assessing pain in critically ill patients is challenging, especially those unable to communicate the presence of pain. Critically ill patients are commonly unable to verbally communicate pain due to altered oral communication (e.g. endotracheal intubation) and/or diminished consciousness (e.g. sedation, delirium), placing them at great risk of inadequate pain management. Over half of intensive care critically ill intubated patients experience moderate-to-severe pain whilst intubated and mechanically ventilated. DESIGN Systematic review. DATA SOURCES The CINAHL, EMBASE, MEDLINE, ProQuest databases, and the Cochrane Library and the National Institute of Clinical Excellence were also searched from their date of inception to April 2016, with no language restrictions applied. REVIEW METHOD Studies were identified using predetermined inclusion criteria. Data were extracted and summarised and underwent evaluation using published classification of psychometric tests for consistency of interpretation. RESULTS Twenty-six studies evaluating five observational pain assessment instruments that had been used with critically ill intubated patients were identified. All five instruments included behavioural indicators, with two including physiologic indicators. All five instruments have undergone validity and reliability testing involving nonverbal critically ill intubated patients, three were examined for feasibility, and one instrument underwent sensitivity and specificity testing. None have been tested within the emergency department with nonverbal critically ill intubated adult patients. CONCLUSION The use of an appropriate and valid observational pain assessment instrument is fundamental to detecting and optimising pain management in nonverbal critically ill intubated patients in the emergency department. Of the observational pain assessment instruments reviewed, the Critical-Care Pain Observation Tool was identified as most appropriate for testing in a prospective trial in an emergency department setting.
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Affiliation(s)
- Wayne Varndell
- Prince of Wales Hospital Emergency Department, Randwick, NSW, Australia.,Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia
| | - Margaret Fry
- Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia
| | - Doug Elliott
- Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia
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77
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Backay A, Bystrzycki A, Smit DV, Keogh M, O'Reilly G, Mitra B. Accuracy of rapid disposition by emergency clinicians. AUST HEALTH REV 2017. [DOI: 10.1071/ah15052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objectives Rapid disposition protocols are increasingly being considered for implementation in emergency departments (EDs). Among patients presenting to an adult tertiary referral hospital, this study aimed to compare prediction accuracy of a rapid disposition decision at the conclusion of history and examination, compared with disposition following standard assessment. Methods Prospective observational data were collected for 1 month between October and November 2012. Emergency clinicians (including physicians, registrars, hospital medical officers, interns and nurse practitioners) filled out a questionnaire within 5 min of obtaining a history and clinical examination for eligible patients. Predicted patient disposition (representing ‘rapid disposition’) was compared with final disposition (determined by ‘standard assessment’). Results There were 301 patient episodes included in the study. Predicted disposition was correct in 249 (82.7%, 95% confidence interval (CI) 78.0–86.8) cases. Accuracy of predicting discharge to home appeared highest among emergency physicians at 95.8% (95% CI 78.9–99.9). Overall accuracy at predicting admission was 79.7% (95% CI 67.2–89.0). The remaining 20.3% (95% CI 11.0–32.8) were not admitted following standard assessment. Conclusion Rapid disposition by ED clinicians can predict patient destination accurately but was associated with a potential increase in admission rates. Any model of care using rapid disposition decision making should involve establishment of inpatient systems for further assessment, and a culture of timely inpatient team transfer of patients to the most appropriate treating team for ongoing patient management. What is known about the topic? In response to the National Emergency Access Targets, there has been widespread adoption of rapid-disposition-themed care models across Australia. Although there is emerging data that clinicians can predict disposition accurately, this data is currently limited. What does this paper add? Results of this study support the previously limited evidence that ED practitioners can accurately predict disposition early in the patient journey through ED, and that accuracy is similar across clinician groups. In addition to overall prediction accuracy, admission, discharge and treating team predictions were separately measured. These additional outcomes lend insight into safety and performance aspects relating to a rapid disposition model of care. What are the implications for practitioners? This study offers practical insights that could aid safe and efficient implementation of a rapid disposition model of care.
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Madavan Nambiar KT, Nedungalaparambil NM, Aslesh OP. Studying the Variability in Patient Inflow and Staffing Trends on Sundays versus Other Days in the Academic Emergency Department. J Emerg Trauma Shock 2017; 10:121-127. [PMID: 28855774 PMCID: PMC5566018 DOI: 10.4103/jets.jets_139_16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Resource limitation, staff deficiency, and variability in patient inflow contribute to emergency department (ED) overcrowding, associated with delayed care, poor care, and poor patient outcomes. This study seeks to describe and analyze patient inflow variability and staffing trends on Sundays versus other days in a tertiary academic ED from South India. Methods: Patient inflow and staffing data for 2 years were collected from hospital records, cross-checked, and statistically analyzed using Epi Info 7.0. Results: Significant increase in patient inflow (45.6%) was noted on Sundays compared to other days (155.9 [95% confidence interval (CI): 152.75–159.05] vs. 107.1 [95% CI: 105.98–108.22]; P < 0.001), with higher inflow in the morning shifts (67.4 [95% CI: 65.41–69.45] vs. 32.1 [95% CI: 31.45–32.70]; P < 0.001). All categories of ED staff were deficient across all shifts (2.1 [95% CI: 2.05–2.15] tier-2 physicians, 4.9 [95% CI: 4.86–4.94] nurses, and 1.9 [95% CI: 1.88–1.92] nurse assistants on an average), especially tier-1 physicians (0.3 [95% CI: 0.24–0.36] on Sundays and 0.5 [95% CI: 0.48–0.52] on other days; P < 0.001). Patient-per-hour (PPH)-per-provider based on patient arrival rate was generally high. PPH per tier-1 physician was the highest, being 10.6 (95% CI: 9.95–11.14) versus 5.4 (95% CI: 5.26–5.59; P < 0.001) in the morning and 7.2 (95% CI: 6.95–7.45) versus 6.6 (95% CI: 6.43–6.74; P = 0.08) in the evening shifts on Sundays and other days, respectively. Conclusions: There were deficiencies in all categories of ED staff on all days, and this was pronounced on Sundays due to significantly higher patient inflow. Inadequate ED staffing, especially due to a significant dearth of tier-1 physicians is a pointer toward quality compromise in developing EDs. Authors recommend adequate staff deployment in developing EDs for optimum quality care. This should be implemented such that staffing is based on expected patient inflow so that a PPH-per-provider goal of 2.5 is targeted across all shifts.
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Affiliation(s)
- K T Madavan Nambiar
- Department of Emergency Medicine, Academy of Medical Sciences, Kannur, Kerala, India
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‘Care in a chair’ – The impact of an overcrowded Emergency Department on the time to treatment and length of stay of self-presenting patients with abdominal pain. Int Emerg Nurs 2016; 29:9-14. [DOI: 10.1016/j.ienj.2016.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 08/01/2016] [Accepted: 08/14/2016] [Indexed: 11/20/2022]
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80
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Emergency nursing workload and patient dependency in the ambulance bay: A prospective study. ACTA ACUST UNITED AC 2016; 19:210-216. [DOI: 10.1016/j.aenj.2016.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 09/16/2016] [Accepted: 09/17/2016] [Indexed: 11/23/2022]
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81
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Mustafa F, Gilligan P, Obu D, O'Kelly P, O'Hea E, Lloyd C, Kelada S, Heffernan A, Houlihan P. 'Delayed discharges and boarders': a 2-year study of the relationship between patients experiencing delayed discharges from an acute hospital and boarding of admitted patients in a crowded ED. Emerg Med J 2016; 33:636-40. [PMID: 27352789 DOI: 10.1136/emermed-2015-205039] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 06/06/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Many believe that hospital crowding manifesting in the ED with the boarding of admitted patients is a result of significant numbers of acute hospital beds being occupied by patients awaiting discharge to nursing homes, step-down facilities or home with or without additional support. This observational study was performed to establish the actual relationship between boarders in the ED and patients experiencing delayed discharge. METHODS Data relating to the number of patients in the ED and their points in their patient pathway were entered into a logbook on a daily basis by the most senior doctor on duty. 630 days of observations of patients boarded in the ED were compared with the number of inpatients with delayed discharges, obtained from the hospital information system, to see if large numbers of inpatients with delayed discharges are associated with crowding in the ED. RESULTS Two years of data showed an annual ED census of more than 47 000, with a daily mean ED admission rate of 29.85 patients and a daily mean ED boarding figure of 29 patients. A mean of 15.4% of the 823 hospital beds was occupied by patients with delayed discharges, and the hospital ran at, or near, full capacity (99%-105%) all the time. Results obtained highlighted a statistically significant relationship between delayed discharges in the hospital and ED crowding as a result of boarders (p value<0.001, with a regression coefficient of 0.16, 95% CI 0.12 to 0.20). The study also showed that the number of boarders was related to the number of ED admissions in the preceding 24 hours (p=0.036, with a regression coefficient of 0.14, 95% CI 0.05 to 0.28). CONCLUSIONS Delayed hospital discharges significantly contribute to crowding in the ED. Healthcare systems should target timely discharge of inpatients experiencing delayed discharge in an urgent and efficient manner to improve timely access to acute hospital beds for patients requiring emergency admission.
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Affiliation(s)
- Farah Mustafa
- Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland
| | - Peadar Gilligan
- Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland
| | - Deborah Obu
- Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland
| | | | - Eimear O'Hea
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Sherif Kelada
- Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland
| | | | - Patricia Houlihan
- Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland
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82
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Standaert B, Alwan A, Strens D, Raes M, Postma MJ. Improvement in hospital Quality of Care (QoC) after the introduction of rotavirus vaccination: An evaluation study in Belgium. Hum Vaccin Immunother 2016; 11:2266-73. [PMID: 25902371 PMCID: PMC4635727 DOI: 10.1080/21645515.2015.1029212] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
During each winter period hospital emergency rooms and pediatric wards are often overwhelmed by high patient influx with infectious diseases leading to chaotic conditions with poor quality of care (QoC) delivery as a consequence. The conditions could be improved if we were able to better control the influx by introducing for instance better prevention strategies against some of the most frequent infectious diseases. New prevention strategies using vaccination against rotavirus infection were introduced in Belgium in November 2006. We developed a measure of hospital QoC suitable for assessing the impact of pediatric rotavirus vaccination. The study is retrospective collecting routine data on bed and staff management in one pediatric hospital in Belgium. The data were divided in pre- and post-vaccination periods during rotavirus-epidemic and non-epidemic periods. The scores were constructed using Explanatory Factor Analysis (EFA). All patients enrolled were admitted to the pediatric ward over the period from 1 January 2004 to 31 December 2009. The results of the epidemic period indicated that bed-day occupancy, bed-day turnover and unplanned readmissions for acute gastroenteritis were lower in the post-vaccination compared with the pre-vaccination periods. The QoC scores were therefore significantly lower (indicating improved QoC) after the introduction of rotavirus vaccination, compared with pre-vaccination. The data suggests that the reduction in the winter peak of rotavirus-related hospitalizations after the introduction of the vaccine reduces pressure on hospital resources and improves the quality of hospital care. The findings should be further tested in similar settings.
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83
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Dinh MM, Bein KJ. The end of emergency medicine as we know it. Emerg Med Australas 2016; 28:242-3. [DOI: 10.1111/1742-6723.12540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/15/2015] [Accepted: 12/08/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Michael M Dinh
- Emergency Department; Royal Prince Alfred Hospital; Sydney New South Wales Australia
- Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
| | - Kendall J Bein
- Emergency Department; Royal Prince Alfred Hospital; Sydney New South Wales Australia
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84
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Aldridge ES, Rogers IR, Bailey PM, Rogers JR. Emergency department 'undercrowding' is associated with decreased waiting times. Emerg Med Australas 2016; 28:268-72. [PMID: 26995265 DOI: 10.1111/1742-6723.12569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 01/19/2016] [Accepted: 01/31/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the effect of a sudden and sustained decrease in patient presentations on waiting times and other measures of workload and flow following the opening of a large, greenfields ED adjacent to our own. METHOD A descriptive study involving all patients presenting to a private urban district hospital ED for two 60 day periods, immediately before and after the opening of the tertiary hospital ED. Changes in median waiting time, case-mix distribution, method of arrival, total admissions and total waiting time were compared pre-opening and post-opening. Non-normally distributed variables were analysed using Mann-Whitney U-tests. Categorical variables were compared using χ(2) analyses. RESULTS Patient presentations decreased by 28% with a parallel decline in median waiting time of 15 min (from 26 to 11 min) (P < 0.001). Total waiting time was approximately 29 h less per day in the post-opening period. Patient urgency by triage category did not change significantly (P = 0.316), whereas the proportion of presentations by ambulance decreased 15.9% (P = 0.048) and admission rate increased from 29.1% to 32.6% (P = 0.002). CONCLUSIONS Patient presentation numbers are strongly associated with and likely impact on median waiting time. Understanding that controlling demand can lead to significant benefits in patient processing, flow and overall patient perceived level of care and satisfaction is relevant to any discussion on ED overcrowding and the deleterious effects of access block.
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Affiliation(s)
- Emogene S Aldridge
- Emergency Department, St John of God Murdoch Hospital, Perth, Western Australia, Australia
| | - Ian R Rogers
- Emergency Department, St John of God Murdoch Hospital, Perth, Western Australia, Australia.,University of Notre Dame Australia, Perth, Western Australia, Australia
| | - Paul M Bailey
- Emergency Department, St John of God Murdoch Hospital, Perth, Western Australia, Australia
| | - Jeremy R Rogers
- Emergency Department, St John of God Murdoch Hospital, Perth, Western Australia, Australia
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85
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He J, Toloo GS, Hou XY, FitzGerald G. Qualitative study of patients' choice between public and private hospital emergency departments. Emerg Med Australas 2016; 28:159-63. [DOI: 10.1111/1742-6723.12530] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/09/2015] [Accepted: 11/23/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Jun He
- School of Public Health and Social Work; Queensland University of Technology; Brisbane Queensland Australia
| | - Ghasem-Sam Toloo
- School of Public Health and Social Work; Queensland University of Technology; Brisbane Queensland Australia
| | - Xiang-Yu Hou
- School of Public Health and Social Work; Queensland University of Technology; Brisbane Queensland Australia
| | - Gerry FitzGerald
- School of Public Health and Social Work; Queensland University of Technology; Brisbane Queensland Australia
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86
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Cheek C, Allen P, Shires L, Parry D, Ruigrok M. Low-acuity presentations to regional emergency departments: What is the issue? Emerg Med Australas 2015; 28:145-52. [PMID: 26708775 DOI: 10.1111/1742-6723.12526] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 10/12/2015] [Accepted: 11/04/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To explore GP-referrals and self-referrals to EDs and factors associated with patients seeking low-acuity care at ED. METHOD Retrospective analysis of all ED presentations to Mersey Community Hospital and North West Regional Hospital (Tasmania) between 1 January 2009 and 31 December 2013. Cross-sectional survey of patients presenting to the EDs for care triaged as low-acuity. RESULTS There were 255,365 ED presentations in the retrospective data: 11,252 (4.4%) GP-referrals and 218,205 (85.4%) self-referrals. At ED 49% of GP-referrals were triaged ATS 4 or 5 and 35% of self-referrals were triaged ATS 1-3. There were 138 (84.2%) low-acuity patients who completed the survey; predominantly, all attended for acute injury or illness. Single point-of-care convenience was most commonly selected (71%) as a reason for attending ED. CONCLUSIONS Over 85% of patients who seek emergency care in this region self-refer, so understanding health-seeking behaviour is important. Most low-acuity patients are acutely injured or unwell, and the decision to go to ED is based on their perception of accessibility of expertise aligned with their need. The term 'GP-type' is misleading in this context and should not be used. Providing low-acuity care in parallel with providing a specialised emergency service meets the needs of the local community and is likely to be the lowest cost model in a regional and rural area. Funding models must reflect the actual cost of delivering this important service rather than presentation types.
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Affiliation(s)
- Colleen Cheek
- Rural Clinical School, University of Tasmania, Burnie, Tasmania, Australia
| | - Penny Allen
- Rural Clinical School, University of Tasmania, Burnie, Tasmania, Australia
| | - Lizzi Shires
- Rural Clinical School, University of Tasmania, Burnie, Tasmania, Australia
| | - Denise Parry
- Tasmanian Health Organisation North West, North West Regional Hospital, Burnie, and Mersey Community Hospital, Latrobe, Tasmania, Australia
| | - Marielle Ruigrok
- Tasmanian Health Organisation North West, North West Regional Hospital, Burnie, and Mersey Community Hospital, Latrobe, Tasmania, Australia
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87
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Kelen G, Peterson S, Pronovost P. In the Name of Patient Safety, Let's Burden the Emergency Department More. Ann Emerg Med 2015; 67:737-740. [PMID: 26707360 DOI: 10.1016/j.annemergmed.2015.11.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Gabor Kelen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Susan Peterson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Peter Pronovost
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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88
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Perimal-Lewis L, Hakendorf PH, Thompson CH. Characteristics favouring a delayed disposition decision in the emergency department. Intern Med J 2015; 45:155-9. [PMID: 25370171 DOI: 10.1111/imj.12618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 10/17/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND The working hours of a hospital affects efficiency of care within the emergency department (ED). Understanding the influences on ED time intervals is crucial for process redesign to improve ED patient flow. AIM To assess characteristics that affect patients' transit through an ED. METHODS Retrospective cohort study from 2004 to 2010 of 268 296 adult patients who presented to the ED of an urban tertiary-referral Australian teaching hospital. RESULTS After adjustment for Australasian Triage Scale (ATS) category, every decade increase in age meant patients spent an additional 2 min in the ED waiting to be seen (P < 0.001) and an extra 29-min receiving treatment (P < 0.001). For every additional 10 patients in the ED, the 'waiting time' (WT) phase duration increased by 20 min (P < 0.001) and the 'Assessment and Treatment Time' (ATT) phase duration increased by 26 min (P < 0.001). When patients arrived outside working hours, the WT phase duration increased by 20 min (P < 0.001). When seen outside working hours, the ATT phase duration increased by 34.5 min (P < 0.001). CONCLUSION Extrinsic to the patients themselves and in addition to ED overcrowding, the working hours of the hospital affected efficiency of care within the ED. Not only should the whole of the hospital be involved in improving efficient and safe transit of patients through an ED, but the whole of the day and every day of the week deserve attention.
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Affiliation(s)
- L Perimal-Lewis
- School of Computer Science, Engineering and Mathematics, Flinders University, Adelaide, South Australia, Australia
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89
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Rathlev NK, Bryson C, Samra P, Garreffi L, Li H, Geld B, Wu RY, Visintainer P. Reducing patient placement errors in emergency department admissions: right patient, right bed. West J Emerg Med 2015; 15:687-92. [PMID: 25247044 PMCID: PMC4162730 DOI: 10.5811/westjem.2014.5.21663] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 05/04/2014] [Accepted: 05/27/2014] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Because lack of inpatient capacity is associated with emergency department (ED) crowding, more efficient bed management could potentially alleviate this problem. Our goal was to assess the impact of involving a patient placement manager (PPM) early in the decision to hospitalize ED patients. The PPMs are clinically experienced registered nurses trained in the institution-specific criteria for correct unit and bed placement. METHODS We conducted two pilot studies that included all patients who were admitted to the adult hospital medicine service: 1) 10/24 to 11/22/2010 (30 days); and 2) 5/24 to 7/4/2011 (42 days). Each pilot study consisted of a baseline control period and a subsequent study period of equal duration. In each pilot we measured: 1) the number of "lateral transfers" or assignment errors in patient placement, 2) median length of stay (LOS) for "all" and "admitted" patients and 3) inpatient occupancy. In pilot 2, we added as a measure code 44s, i.e. status change from inpatient to observation after patients are admitted, and also equipped all emergency physicians with portable phones in order to improve the efficiency of the process. RESULTS In pilot 1, the number of "lateral transfers" (incorrect patient placement assignments) during the control period was 79 of the 854 admissions (9.3%) versus 27 of 807 admissions (3.3%) during the study period (P<0.001). We found no statistically significant differences in inpatient occupancy or ED LOS for "all" or for "admitted" patients. In pilot 2, the number of "lateral transfers" was 120 of 1,253 (9.6%) admissions in the control period and 42 of 1,229 (3.4%) admissions in the study period (P<0.001). We found a 49-minute (352 vs. 401 minutes) decrease in median LOS for "admitted" ED patients during the study period compared with the control period (P=0.04). The code 44 rates, median LOS for "all" patients and inpatient occupancy did not change. CONCLUSION Inclusion of the PPM in a three-way handoff conversation between emergency physicians and hospitalist providers significantly decreased the number of "lateral transfers." Moreover, adding status determination and portable phones for emergency physicians improved the efficiency of the process and was associated with a 49 (12%) minute decrease in LOS for admitted patients.
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Affiliation(s)
| | | | - Patty Samra
- Baystate Medical Center, Springfield, Massachusetts
| | | | - Haiping Li
- Baystate Medical Center, Springfield, Massachusetts
| | - Bonnie Geld
- Baystate Medical Center, Springfield, Massachusetts
| | - Roger Y Wu
- Rhode Island Hospital, Department of Emergency Medicine, Providence, Rhode Island
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90
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Ben-Yakov M, Kapral MK, Fang J, Li S, Vermeulen MJ, Schull MJ. The Association Between Emergency Department Crowding and the Disposition of Patients With Transient Ischemic Attack or Minor Stroke. Acad Emerg Med 2015; 22:1145-54. [PMID: 26398233 DOI: 10.1111/acem.12766] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 02/13/2015] [Accepted: 05/25/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Emergency department (ED) crowding has been associated with adverse events, including short-term death and hospitalization among discharged patients. The mechanisms are poorly understood, but may include altered physician decision-making about ED discharge of higher-risk patients. One example is patients with transient ischemic attack (TIA) and minor stroke, who are at high risk of subsequent stroke. While hospitalization is frequently recommended, little consensus exists on which patients require admission. OBJECTIVES The authors sought to determine the association of ED crowding with the disposition of patients with minor stroke or TIA. METHODS This was a retrospective cohort study of prospectively collected data from the Registry of the Canadian Stroke Network at 12 EDs in Ontario, Canada, between 2003 and 2008, linked to administrative health databases. A hierarchical logistic regression model was used to determine the association between crowding at the time the patient was seen in the ED (defined as mean ED length of stay) and patient disposition (admission/discharge), after adjusting for patient and hospital-level variables. RESULTS The study cohort included 9,759 patients (4,607 with TIA and 5,152 with minor stroke); 49.5% were discharged from the ED. The mean (±SD) age of study patients was 70.78 (±13.40) years, with 52.9% being male, 37.3% arriving by emergency medical services, and 92.3% triaged as emergent or urgent. Greater severity of ED crowding was associated with a lower likelihood of discharge, regardless of ED size. CONCLUSIONS These results suggest that crowding may influence clinical decision-making in the disposition of patients with TIA or minor stroke and that, as crowding worsens, the likelihood of hospitalization increases.
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Affiliation(s)
- Maxim Ben-Yakov
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Department of Emergency Medicine Sick Kids Hospital; Toronto Ontario Canada
| | - Moira K. Kapral
- Division of General Internal Medicine; University Health Network; Institute for Clinical Evaluative Sciences; Institute for Health Policy, Management and Evaluation; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Canadian Stroke Network; Ottawa Ontario Canada
| | - Jiming Fang
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Sunnybrook Research Institute; Institute for Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Shudong Li
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Sunnybrook Research Institute; Institute for Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Marian J. Vermeulen
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Sunnybrook Research Institute; Institute for Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Clinical Epidemiology Unit; Sunnybrook Health Sciences Centre; Toronto Ontario Canada
| | - Michael J. Schull
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Clinical Epidemiology Unit; Sunnybrook Health Sciences Centre; Toronto Ontario Canada
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91
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Varndell W, Fry M, Elliott D. Emergency nurses' perceptions of sedation management practices for critically ill intubated patients: a qualitative study. J Clin Nurs 2015; 24:3286-95. [PMID: 26249169 DOI: 10.1111/jocn.12932] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2015] [Indexed: 01/03/2023]
Abstract
AIMS AND OBJECTIVES The aim of this study was to explore factors influencing practices in assessing, titrating and managing sedation for the critically ill intubated patients, from the perspective of emergency nurses. BACKGROUND The number of critically ill patients presenting to Australian public Emergency Departments has increased by over 30% since 1980. Emergency nurses are increasingly relied upon to manage sedation of critically ill intubated patients. There is little evidence within international literature relating to how emergency nurses accomplish this. DESIGN Descriptive qualitative study. METHOD A purposive sample of 15 experienced emergency nurses participated in semi-structured face-to-face interviews. Transcribed data were analysed using thematic analysis. RESULTS The qualitative analysis yielded five themes: becoming the resuscitation nurse; becoming confident as the resuscitation nurse; communicating about sedation; visual cues and the vanishing act. The safety and quality of sedation experienced by critically ill intubated patients in ED was the responsibility of emergency nurses, yet uncertainties and barriers were evident. CONCLUSION Patient continuity of care, including optimisation of comfort relies upon the knowledge, skills and expertise of the emergency nurse allocated to the resuscitation area. For most nurses transitioning into the resuscitation nurse role, it represents the first time they will have had contact with patients with highly complex needs and sedation. The use of self-directed clinical workbooks and supervised clinical practice alone may be insufficient to adequately prepare nurses for the spectrum of critically ill sedated patients managed in the resuscitation area; a situation made worse in the presence of poor team communication. RELEVANCE TO CLINICAL PRACTICE The findings of this study should assist in the development of policy and formal education of emergency nurses transitioning into the resuscitation area and the management of continuous intravenous sedation to critically ill mechanically ventilated patients is required.
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Affiliation(s)
- Wayne Varndell
- Emergency Department, Prince of Wales Hospital, Randwick, NSW, Australia.,Faculty of Health, University of Technology, Sydney, Broadway, NSW, Australia
| | - Margaret Fry
- Faculty of Health, University of Technology, Sydney, Broadway, NSW, Australia
| | - Doug Elliott
- Faculty of Health, University of Technology, Sydney, Broadway, NSW, Australia
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92
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Wu D, Zhou X, Ye L, Gan J, Zhang M. Emergency department crowding and the performance of damage control resuscitation in major trauma patients with hemorrhagic shock. Acad Emerg Med 2015. [PMID: 26205164 DOI: 10.1111/acem.12726] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Uncontrolled hemorrhagic shock is the leading cause of potentially preventable death in major trauma patients. Damage control resuscitation (DCR), a strategy combining the techniques of permissive hypotension, hemostatic resuscitation, and damage control surgery, has been highly recommended for trauma patients. This study investigated whether emergency department (ED) crowding was associated with poor performance of the DCR strategies in treating hemorrhagic shock trauma patients. METHODS This was a retrospective cohort study in an urban tertiary hospital conducted from January 2010 to December 2013. Major trauma patients who presented to the ED with hemorrhagic shock were included. ED crowding, measured by ED occupancy rate, was categorized into three groups (low, medium, and high). The performance of DCR and inpatient outcomes were analyzed using multivariate logistic analysis. RESULTS Of the 3,037 major trauma patients assessed, 852 met the inclusion criteria and were enrolled in the study. Patients in the high-crowding group had delayed initiation of transfusion (high vs. medium and low, 2.5 hours vs. 2.1 hours and 1.0 hours, respectively, p = 0.01), received less blood products in the ED (both comparisons p < 0.01), and experienced delays in procedures (4.5 hours vs. 3.3 hours and 2.4 hours, p < 0.01). However, the amount of crystalloid solution was similar among patients in all three groups (p = 0.17). In multivariate analysis, more patients from the high-crowding group developed traumatic coagulopathy in the intensive care unit (29.7% vs. 24.1% and 16.3%, p < 0.01), while no clear relationship was found between ED crowding and 30-day mortality or early lactate clearance rate (p > 0.05). CONCLUSIONS ED crowding was associated with poor performance of DCR for major trauma patients in the ED. New strategies should be implemented to ameliorate crowded conditions and potential adverse outcomes.
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Affiliation(s)
- Dingqian Wu
- Departments of Emergency Medicine; Second Affiliated Hospital; School of Medicine & Institute of Emergency Medicine; Zhejiang University; Hangzhou China
| | - Xiaoxia Zhou
- Hangzhou XiXi Hospital; affiliated hospital of Zhejiang Chinese Medical University; Hangzhou China
| | - Ligang Ye
- Departments of Emergency Medicine; Second Affiliated Hospital; School of Medicine & Institute of Emergency Medicine; Zhejiang University; Hangzhou China
| | - Jianxin Gan
- Hangzhou XiXi Hospital; affiliated hospital of Zhejiang Chinese Medical University; Hangzhou China
| | - Mao Zhang
- Departments of Emergency Medicine; Second Affiliated Hospital; School of Medicine & Institute of Emergency Medicine; Zhejiang University; Hangzhou China
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93
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Elder E, Johnston AN, Crilly J. Review article: systematic review of three key strategies designed to improve patient flow through the emergency department. Emerg Med Australas 2015. [PMID: 26206428 DOI: 10.1111/1742-6723.12446] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To explore the literature regarding three key strategies designed to promote patient throughput in the ED. CINAHL, Medline, PubMed, Scopus and Australian Government databases were searched for articles published between 1980 and 2014 using the key search terms ED flow/throughput, ED congestion, crowding, overcrowding, models of care, physician-assisted triage, medical assessment units, nurse practitioner, did not wait (DNW) and ED length of stay (LOS). Abstracts and articles not published in English and articles published before 1980 were excluded from the review. Quantitative and qualitative studies were considered for inclusion. The National Health Medical Research Council (NHMRC) Level of Evidence Hierarchy (2009) was applied to included studies. Twenty-one articles met criteria for review. The level of evidence assessed using the NHMRC guidelines of studies ranged from I to IV, with the majority falling into the Level II-2 (n = 6) and III-3 (n = 9) range. ED LOS was the outcome most often reported. Study quality was limited with few studies adjusting for confounding factors. Only one level I systematic review was included in this review. Advanced practice nursing roles, physician-assisted triage and medical assessment units are models of care that can positively impact ED throughput. They have been shown to decrease ED LOS and DNW rates. Confounding factors, such as site specific staffing requirements, patient acuity and rest-of-hospital processes, can also impact on patient throughput through the ED.
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Affiliation(s)
- Elizabeth Elder
- School of Nursing and Midwifery, Griffith Health, Gold Coast Campus, Griffith University, Brisbane, Queensland, Australia
| | - Amy Nb Johnston
- Department of Emergency Medicine and Griffith Health Institute, Gold Coast Hospital and Health Service and Griffith University, Gold Coast, Queensland, Australia
| | - Julia Crilly
- Department of Emergency Medicine and Griffith Health Institute, Gold Coast Hospital and Health Service and Griffith University, Gold Coast, Queensland, Australia
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Le Fevre J, Ardagh M, Mountain D, Parke T, Geelhoed G. Perspectives on the evolution of time-based targets and their impact on emergency medicine training. Emerg Med Australas 2015; 27:351-4. [PMID: 26095504 DOI: 10.1111/1742-6723.12437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2015] [Indexed: 11/26/2022]
Affiliation(s)
- James Le Fevre
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand.,Auckland Helicopter Emergency Medical System, Auckland Rescue Helicopter Trust/Auckland District Health Board, Auckland, New Zealand
| | - Michael Ardagh
- Department of Surgery, University of Otago, Christchurch, New Zealand.,Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - David Mountain
- Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Western Australia, Australia.,Emergency Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Tim Parke
- Emergency Department, South Glasgow University Hospital, Glasgow, United Kingdom
| | - Gary Geelhoed
- Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Western Australia, Australia.,Department of Health, Perth, Western Australia, Australia
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95
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Aboagye-Sarfo P, Mai Q, Sanfilippo FM, Preen DB, Stewart LM, Fatovich DM. Growth in Western Australian emergency department demand during 2007-2013 is due to people with urgent and complex care needs. Emerg Med Australas 2015; 27:202-9. [DOI: 10.1111/1742-6723.12396] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Patrick Aboagye-Sarfo
- Clinical Modelling; Health System Improvement Unit; Innovation and Health System Reform; Department of Health; Perth Western Australia Australia
| | - Qun Mai
- Clinical Modelling; Health System Improvement Unit; Innovation and Health System Reform; Department of Health; Perth Western Australia Australia
- Centre for Health Services Research, School of Population Health; The University of Western Australia; Perth Western Australia Australia
| | - Frank M Sanfilippo
- Clinical Epidemiology Unit; School of Population Health; The University of Western Australia; Perth Western Australia Australia
| | - David B Preen
- Centre for Health Services Research, School of Population Health; The University of Western Australia; Perth Western Australia Australia
| | - Louise M Stewart
- Centre for Population Health Research, Curtin University; Perth Western Australia Australia
| | - Daniel M Fatovich
- Emergency Medicine; Royal Perth Hospital; The University of Western Australia; Perth Western Australia Australia
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96
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Nguyen A, Straney L, Cameron P, Lowthian J. Synthesised geriatric assessment in the Emergency Department setting: is it NEAT? AUST HEALTH REV 2015; 38:370-6. [PMID: 25055343 DOI: 10.1071/ah13217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Accepted: 05/06/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the time taken to complete a Synthesised Geriatric Assessment (SGA) in an Emergency Department (ED) and to determine what secondary patient characteristics affect results. METHODS A convenience sample of 25 patients aged over 65 from an Australian single-centre ED was used for this pilot study. Primary outcome measures included the overall time taken as well as the times for individual screening instruments. Data regarding patient characteristics were taken as secondary outcome measures to assess impact on times. For each of the screening instruments, the mean, median, interquartile range and the 90th percentile for the test duration was calculated. Linear regression was used to evaluate univariate associations between times and patient characteristics. P-values<0.05 were considered as statistically significant. RESULTS Time required for completion of the SGA by 90% of the study population was 20 min and 40s. This represents approximately 8.6% of new 4-h ED targets. Secondary characteristics that affected the time taken for screening included patients from non-English-speaking backgrounds (P<0.05). CONCLUSIONS Use of the SGA for intra-ED geriatric risk stratification is feasible and practical in the time-critical National Emergency Access Target (NEAT) environment. The relatively short amount of time used for screening this vulnerable demographic has implications for interdisciplinary management and potentially represents an efficient intervention to reduce future re-presentations and overcrowding in Australian EDs. Future high-quality trials are required to assess the clinical benefit of the SGA.
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Affiliation(s)
- Alan Nguyen
- Monash University, School of Public Health and Preventive Medicine, Level 6 Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia
| | - Lahn Straney
- Monash University, School of Public Health and Preventive Medicine, Level 6 Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia
| | - Peter Cameron
- Monash University, School of Public Health and Preventive Medicine, Level 6 Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia
| | - Judy Lowthian
- Monash University, School of Public Health and Preventive Medicine, Level 6 Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia
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97
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Can the Introduction of Point-of-Care Testing for Renal Function in the Emergency Department Reduce Overcrowding? POINT OF CARE 2015. [DOI: 10.1097/poc.0000000000000048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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98
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Allen P, Cheek C, Foster S, Ruigrok M, Wilson D, Shires L. Low acuity and general practice-type presentations to emergency departments: a rural perspective. Emerg Med Australas 2015; 27:113-8. [PMID: 25720647 DOI: 10.1111/1742-6723.12366] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To estimate the number of general practice (GP)-type patients attending a rural ED and provide a comparative rural estimate to a metropolitan study. METHODS Analysis of presentations to the two EDs in Northwest Tasmania from 1 January 2009 to 31 December 2013 using the Diagnosis, Sprivulis, Australian College of Emergency Medicine (ACEM) and the Australian Institute of Health and Welfare (AIHW) methods to estimate the number of GP-type presentations. RESULTS There were 255,365 ED presentations in Northwest Tasmania during the study period. There were 86,973 GP-type presentations using the ACEM method, 142,006 using the AIHW method, 174,748 using the Diagnosis method and 28,922 low acuity patients identified using the Sprivulis method. CONCLUSIONS The proportion of GP-type presentations identified using the four methods ranged from 15% to 69%. The results suggest that triage status and self-referral are not reliable indicators of low acuity in this rural area. In rural areas with a shortage of GPs, it is likely that many people appropriately self-refer to ED because they cannot access a GP. The results indicate that the ACEM method might be most useful for identifying GP-type patients in rural ED. However, this requires validation in other regions of Australia.
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Affiliation(s)
- Penny Allen
- Rural Clinical School, University of Tasmania, Burnie, Tasmania, Australia
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99
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Pediatric emergency department management benefits from appropriate early redirection of nonurgent visits. Pediatr Emerg Care 2015; 31:95-100. [PMID: 25654674 DOI: 10.1097/pec.0000000000000348] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIMS Overcrowding at pediatric emergency departments (EDs) may result in delayed clinical management and higher risks of medical error. This study was designed to prospectively evaluate what parents of sick children seek emergency care for and how these patients are being assessed and managed. METHODS Patients aged 0 to 17 years seeking ED care at an urban Swedish university hospital, from 8 AM to 9 PM on 25 consecutive days, were included. Clinical urgency and further level of medical care were determined by experienced nurses based on individual clinical signs and vital parameters. Information on presenting problem, medical priority, gender, age, waiting time, day of week, time of day, and further management was recorded. RESULTS Among 1057 included children, two thirds were assessed by physicians, whereas one third were referred directly by nurses for other ED (n = 54) or primary care (n = 114), or sent home with medical advice (n = 176), more often during evenings and weekends. Of primarily referred patients, 7.6% returned within 72 hours, and three of them were admitted. Young infants, patients with respiratory or neurological problems, and sicker patients with fever or infections were mainly assessed by physicians, within desired priority time. DISCUSSION More than one fourth of pediatric ED patients might rapidly, appropriately, and safely be referred for primary care or sent home by experienced pediatric nurses soon after arrival, thereby facilitating management of urgent and more appropriate patients. Evaluations by physicians were primarily required in young infants and for urgent medical conditions demanding qualified pediatric skills.
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100
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Jung H, Do YK, Kim Y, Ro J. The impact of an emergency fee increase on the composition of patients visiting emergency departments. J Prev Med Public Health 2014; 47:309-16. [PMID: 25475198 PMCID: PMC4263005 DOI: 10.3961/jpmph.14.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 10/27/2014] [Indexed: 12/22/2022] Open
Abstract
Objectives: This study aimed to test our hypothesis that a raise in the emergency fee implemented on March 1, 2013 has increased the proportion of patients with emergent symptoms by discouraging non-urgent emergency department visits. Methods: We conducted an analysis of 728 736 patients registered in the National Emergency Department Information System who visited level 1 and level 2 emergency medical institutes in the two-month time period from February 1, 2013, one month before the raise in the emergency fee, to March 31, 2013, one month after the raise. A difference-in-difference method was used to estimate the net effects of a raise in the emergency fee on the probability that an emergency visit is for urgent conditions. Results: The percentage of emergency department visits in urgent or equivalent patients increased by 2.4% points, from 74.2% before to 76.6% after the policy implementation. In a group of patients transferred using public transport or ambulance, who were assumed to be least conscious of cost, the change in the proportion of urgent patients was not statistically significant. On the other hand, the probability that a group of patients directly presenting to the emergency department by private transport, assumed to be most conscious of cost, showed a 2.4% point increase in urgent conditions (p<0.001). This trend appeared to be consistent across the level 1 and level 2 emergency medical institutes. Conclusions: A raise in the emergency fee implemented on March 1, 2013 increased the proportion of urgent patients in the total emergency visits by reducing emergency department visits by non-urgent patients.
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Affiliation(s)
- Hyemin Jung
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
| | - Young Kyung Do
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea ; Institute of Health Policy and Management, Seoul National University Medical Research Center, Seoul, Korea
| | - Yoon Kim
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea ; Institute of Health Policy and Management, Seoul National University Medical Research Center, Seoul, Korea
| | - Junsoo Ro
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
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