1
|
Cook B, Evenden J, Genborg R, Stretton B, Kovoor J, Gibson K, Tan S, Gupta A, Chan WO, Bacchi C, Ittimani M, Cusack M, Maddison J, Gluck S, Gilbert T, McNeill K, Bacchi S. A brief history of ramping. Intern Med J 2024; 54:1577-1580. [PMID: 39086192 DOI: 10.1111/imj.16466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 06/06/2024] [Indexed: 08/02/2024]
Abstract
'Ramping' is a commonly used term in contemporary Australian healthcare. It is also a part of the public and political zeitgeist. However, its precise definition varies among sources. In the published literature, there are distinctions between related terms, such as 'entry overload' and 'Patient Off Stretcher Time Delay'. How ramping is defined and how it came to be defined have significance for policies and procedures relating to the described phenomenon. Through examination of the history of the term, insights are obtained into the underlying issues contributing to ramping and, accordingly, associated possible solutions.
Collapse
Affiliation(s)
- Benjamin Cook
- Lyell McEwin Hospital, Adelaide, South Australia, Australia
- SA Health, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - James Evenden
- SA Health, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- South Australian Ambulance Service, Adelaide, South Australia, Australia
| | - Ruby Genborg
- South Australian Ambulance Service, Adelaide, South Australia, Australia
| | - Brandon Stretton
- SA Health, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joshua Kovoor
- University of Adelaide, Adelaide, South Australia, Australia
- Ballarat Base Hospital, Ballarat, Victoria, Australia
| | - Kieran Gibson
- The University of Queensland, St Lucia, Queensland, Australia
| | - Sheryn Tan
- University of Adelaide, Adelaide, South Australia, Australia
| | - Aashray Gupta
- University of Adelaide, Adelaide, South Australia, Australia
| | - Weng O Chan
- SA Health, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Carol Bacchi
- University of Adelaide, Adelaide, South Australia, Australia
| | - Mana Ittimani
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | | | - John Maddison
- Lyell McEwin Hospital, Adelaide, South Australia, Australia
- SA Health, Adelaide, South Australia, Australia
- Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Samuel Gluck
- Lyell McEwin Hospital, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Tony Gilbert
- Lyell McEwin Hospital, Adelaide, South Australia, Australia
- SA Health, Adelaide, South Australia, Australia
- Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Keith McNeill
- Commission on Excellence and Innovation in Health, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- Lyell McEwin Hospital, Adelaide, South Australia, Australia
- SA Health, Adelaide, South Australia, Australia
- Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
- Flinders University, Adelaide, South Australia, Australia
| |
Collapse
|
2
|
Cooper RJ, Schriger DL. No More Useless Band-aids that Fail to Solve America's Emergency Department Boarding Crisis. Jt Comm J Qual Patient Saf 2023; 49:657-659. [PMID: 37865614 DOI: 10.1016/j.jcjq.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
|
3
|
Wallin K, Bremer A, Fridlund B, Hörberg U, Werkander Harstäde C. The ways specialist nursing students understand the work in the ambulance service - a national Swedish phenomenographic study. Int J Qual Stud Health Well-being 2022; 17:2099023. [PMID: 35799452 PMCID: PMC9272920 DOI: 10.1080/17482631.2022.2099023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Objective Design, sample, and measurements Findings Conclusions
Collapse
Affiliation(s)
- Kim Wallin
- Centre of Interprofessional Cooperation within Emergency Care (CICE), Linnaeus University, Vaxjo, Sweden
- Faculty of Health and Life Sciences, Linnaeus University, Vaxjo, Sweden
| | - Anders Bremer
- Centre of Interprofessional Cooperation within Emergency Care (CICE), Linnaeus University, Vaxjo, Sweden
- Faculty of Health and Life Sciences, Linnaeus University, Vaxjo, Sweden
| | - Bengt Fridlund
- Centre of Interprofessional Cooperation within Emergency Care (CICE), Linnaeus University, Vaxjo, Sweden
| | - Ulrica Hörberg
- Faculty of Health and Life Sciences, Linnaeus University, Vaxjo, Sweden
| | | |
Collapse
|
4
|
Dawson LP, Andrew E, Stephenson M, Nehme Z, Bloom J, Cox S, Anderson D, Lefkovits J, Taylor AJ, Kaye D, Smith K, Stub D. The influence of ambulance offload time on 30-day risks of death and re-presentation for patients with chest pain. Med J Aust 2022; 217:253-259. [PMID: 35738570 PMCID: PMC9545565 DOI: 10.5694/mja2.51613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/15/2022] [Accepted: 03/14/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess whether ambulance offload time influences the risks of death or ambulance re-attendance within 30 days of initial emergency department (ED) presentations by adults with non-traumatic chest pain. DESIGN, SETTING Population-based observational cohort study of consecutive presentations by adults with non-traumatic chest pain transported by ambulance to Victorian EDs, 1 January 2015 - 30 June 2019. PARTICIPANTS Adults (18 years or older) with non-traumatic chest pain, excluding patients with ST elevation myocardial infarction (pre-hospital electrocardiography) and those who were transferred between hospitals or not transported to hospital (eg, cardiac arrest or death prior to transport). MAIN OUTCOME MEASURES Primary outcome: 30-day all-cause mortality (Victorian Death Index data). SECONDARY OUTCOME Transport by ambulance with chest pain to ED within 30 days of initial ED presentation. RESULTS We included 213 544 people with chest pain transported by ambulance to EDs (mean age, 62 [SD, 18] years; 109 027 women [51%]). The median offload time increased from 21 (IQR, 15-30) minutes in 2015 to 24 (IQR, 17-37) minutes during the first half of 2019. Three offload time tertiles were defined to include approximately equal patient numbers: tertile 1 (0-17 minutes), tertile 2 (18-28 minutes), and tertile 3 (more than 28 minutes). In multivariable models, 30-day risk of death was greater for patients in tertile 3 than those in tertile 1 (adjusted rates, 1.57% v 1.29%; adjusted risk difference, 0.28 [95% CI, 0.16-0.42] percentage points), as was that of a second ambulance attendance with chest pain (adjusted rates, 9.03% v 8.15%; adjusted risk difference, 0.87 [95% CI, 0.57-1.18] percentage points). CONCLUSIONS Longer ambulance offload times are associated with greater 30-day risks of death and ambulance re-attendance for people presenting to EDs with chest pain. Improving the speed of ambulance-to-ED transfers is urgently required.
Collapse
Affiliation(s)
- Luke P Dawson
- Royal Melbourne HospitalMelbourneVIC
- Centre for Research and Evaluation, Ambulance VictoriaMelbourneVIC
- Monash UniversityMelbourneVIC
| | - Emily Andrew
- Centre for Research and Evaluation, Ambulance VictoriaMelbourneVIC
- Ambulance VictoriaMelbourneVIC
| | - Michael Stephenson
- Centre for Research and Evaluation, Ambulance VictoriaMelbourneVIC
- Alfred HealthMelbourneVIC
| | - Ziad Nehme
- Centre for Research and Evaluation, Ambulance VictoriaMelbourneVIC
- Alfred HealthMelbourneVIC
| | - Jason Bloom
- Centre for Research and Evaluation, Ambulance VictoriaMelbourneVIC
- Monash UniversityMelbourneVIC
| | | | | | - Jeffrey Lefkovits
- Royal Melbourne HospitalMelbourneVIC
- Centre for Research and Evaluation, Ambulance VictoriaMelbourneVIC
| | - Andrew J Taylor
- Centre for Research and Evaluation, Ambulance VictoriaMelbourneVIC
- Monash UniversityMelbourneVIC
| | - David Kaye
- Monash UniversityMelbourneVIC
- Baker Heart Research Institute (BHRI)MelbourneVIC
| | - Karen Smith
- Ambulance VictoriaMelbourneVIC
- Alfred HealthMelbourneVIC
| | - Dion Stub
- Centre for Research and Evaluation, Ambulance VictoriaMelbourneVIC
- Monash UniversityMelbourneVIC
| |
Collapse
|
5
|
Burns TA, Kaufman B, Stone RM. An EMS Transport Destination Officer is Associated with Reductions in Simultaneous Emergency Department Arrivals. PREHOSP EMERG CARE 2022; 27:941-945. [PMID: 35894867 DOI: 10.1080/10903127.2022.2107126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 10/16/2022]
Abstract
Objective: A centralized transport destination officer (TDO) is one technique used by EMS systems to distribute patients. This retrospective analysis examines the effect of a TDO on simultaneous arrivals and consecutive simultaneous arrivals at emergency departments in a suburban EMS system, and their relationship to transport unit throughput.Methods: Each system hospital arrival from July 1, 2020 to February 28, 2022, at six study hospitals was evaluated. An arrival within 300 seconds of the previous arrival at the same hospital was designated as a simultaneous arrival. Any simultaneous arrival where the previous arrival was also a simultaneous arrival was further designated as a consecutive simultaneous arrival. Simultaneous and consecutive simultaneous arrivals were aggregated by day to produce countywide daily totals. Median and interquartile ranges were calculated and a Wilcoxon rank-sum test was used to compare each outcome, with the presence of the TDO as the grouping variable. A Pearson correlation was used to assess the relationship between daily total simultaneous and consecutive simultaneous arrivals to median daily hospital turnaround interval.Results: Median simultaneous arrivals showed a 15% reduction from 21 [IQR: 17 - 26] to 18 [IQR: 15 - 22] (p < 0.001). Consecutive simultaneous arrivals decreased 33%, from 6 [IQR: 4 - 9] to 4 per day [IQR: 2 - 6] on days when the TDO was in place (p < 0.001). Increased total daily simultaneous and consecutive simultaneous arrivals also showed statistically significant correlation with increased median daily hospital turnaround interval (simultaneous r = 0.488, p < 0.001; consecutive simultaneous r = 0.360 p < 0.001).Conclusions: A centralized EMS transport destination officer is associated with a reduction in simultaneous and consecutive simultaneous arrivals of patients in the emergency department. Further analysis also shows a significant correlation between the number of simultaneous and consecutive simultaneous arrivals and transport unit hospital turnaround interval. This technique to achieve load balancing across transport destinations appears to be effective and can be considered in systems experiencing throughput difficulties.
Collapse
Affiliation(s)
- Timothy A Burns
- Emergency Medical and Integrated Healthcare Services Section, Montgomery County (MD) Fire and Rescue Service, Gaithersburg, Maryland, USA
| | - Benjamin Kaufman
- Emergency Medical and Integrated Healthcare Services Section, Montgomery County (MD) Fire and Rescue Service, Gaithersburg, Maryland, USA
| | - Roger M Stone
- Emergency Medical and Integrated Healthcare Services Section, Montgomery County (MD) Fire and Rescue Service, Gaithersburg, Maryland, USA
| |
Collapse
|
6
|
Dawson LP, Smith K, Cullen L, Nehme Z, Lefkovits J, Taylor AJ, Stub D. Care Models for Acute Chest Pain That Improve Outcomes and Efficiency. J Am Coll Cardiol 2022; 79:2333-2348. [DOI: 10.1016/j.jacc.2022.03.380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
|
7
|
Mills BW, Hill MG, Miles AK, Smith EC, Afrifa-Yamoah E, Reid DN, Rogers SL, Sim MGB. Ability of the Australian general public to identify common emergency medical situations: Results of an online survey of a nationally representative sample. Australas Emerg Care 2022; 25:327-333. [PMID: 35525724 DOI: 10.1016/j.auec.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/20/2022] [Accepted: 04/26/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the Australian general public's ability to identify common medical emergencies as requiring an emergency response. METHODS An online survey asked participants to identify likely medical treatment pathways they would take for 17 hypothetical medical scenarios (eight emergency and nine non-emergency). The number and type of emergency scenarios participants correctly suggested warranted an emergency medical response was examined. Participants included Australian residents (aged >18 years; n = 5264) who had never worked as an Australian registered medical doctor, nurse or paramedic. RESULTS Most emergencies were predominately correctly classified as requiring emergency responses (e.g. Severe chest pain, 95% correct). However, non-emergency medical responses were often chosen for some emergency scenarios, such as a child suffering from a scalp haematoma (67%), potential meningococcal disease (57%), a box jellyfish sting (40%), a paracetamol overdose (37%), and mild chest pain (26%). Participants identifying as Aboriginal or Torres Strait Islander suggested a non-emergency response to emergency scenarios 40% more often compared with non-indigenous participants. CONCLUSIONS Educational interventions targeting specific medical symptoms may work to alleviate delayed emergency medical intervention. This research highlights a particular need for improving symptom identification and healthcare system confidence amongst Aboriginal and Torres Strait Islander populations.
Collapse
Affiliation(s)
- Brennen W Mills
- School of Medical and Health Sciences, Edith Cowan University, Australia.
| | - Michella G Hill
- School of Medical and Health Sciences, Edith Cowan University, Australia
| | - Alecka K Miles
- School of Medical and Health Sciences, Edith Cowan University, Australia
| | - Erin C Smith
- School of Medical and Health Sciences, Edith Cowan University, Australia
| | | | - David N Reid
- School of Medical and Health Sciences, Edith Cowan University, Australia
| | - Shane L Rogers
- School of Arts and Humanities, Edith Cowan University, Australia
| | - Moira G B Sim
- School of Medical and Health Sciences, Edith Cowan University, Australia
| |
Collapse
|
8
|
Cummins NM, Barry LA, Garavan C, Devlin C, Corey G, Cummins F, Ryan D, Cronin S, Wallace E, McCarthy G, Galvin R. The “better data, better planning” census: a cross-sectional, multi-centre study investigating the factors influencing patient attendance at the emergency department in Ireland. BMC Health Serv Res 2022; 22:471. [PMID: 35397588 PMCID: PMC8994521 DOI: 10.1186/s12913-022-07841-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 03/02/2022] [Indexed: 11/24/2022] Open
Abstract
Background Internationally Emergency Department (ED) crowding is a significant health services delivery issue posing a major risk to population health. ED crowding affects both the quality and access of health services and is associated with poorer patient outcomes and increased mortality rates. In Ireland the practising of “Corridor Medicine” and “Trolley Crises” have become prevalent. The objectives of this study are to describe the demographic and clinical profile of patients attending regional EDs and to investigate the factors influencing ED utilisation in Ireland. Methods This was a multi-centre, cross-sectional study and recruitment occurred at a selection of urban and rural EDs (n = 5) in Ireland throughout 2020. At each site all adults presenting over a 24 h census period were eligible for inclusion. Clinical data were collected via electronic records and a questionnaire provided information on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED. Results Demographics differed significantly between ED sites in terms of age (p ≤ 0.05), socioeconomic status (p ≤ 0.001), and proximity of health services (p ≤ 0.001). Prior to ED attendance 64% of participants accessed community health services. Most participants (70%) believed the ED was the “best place” for emergency care or attended due to lack of awareness of other services (30%). Musculoskeletal injuries were the most common reason for presentation to the ED in this study (24%) and almost a third of patients (31%) reported presenting to the ED for an x-ray or scan. Conclusions This study has identified regional and socioeconomic differences in the drivers of ED presentations and factors influencing ED attendance in Ireland from the patient perspective. Improved awareness of, and provision of alternative care pathways could potentially decrease ED attendances, which would be important in the context of reducing ED crowding during the COVID-19 pandemic. New strategies for integration of acute care in the community must acknowledge and plan for these issues as a universal approach is unlikely to be implemented successfully due to regional factors. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07841-6.
Collapse
|
9
|
Walker KJ, Jiarpakdee J, Loupis A, Tantithamthavorn C, Joe K, Ben-Meir M, Akhlaghi H, Hutton J, Wang W, Stephenson M, Blecher G, Buntine P, Sweeny A, Turhan B. Predicting Ambulance Patient Wait Times: A Multicenter Derivation and Validation Study. Ann Emerg Med 2021; 78:113-122. [PMID: 33972127 DOI: 10.1016/j.annemergmed.2021.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/31/2021] [Accepted: 02/05/2021] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE To derive and internally and externally validate machine-learning models to predict emergency ambulance patient door-to-off-stretcher wait times that are applicable to a wide variety of emergency departments. METHODS Nine emergency departments provided 3 years (2017 to 2019) of retrospective administrative data from Australia. Descriptive and exploratory analyses were undertaken on the datasets. Statistical and machine-learning models were developed to predict wait times at each site and were internally and externally validated. RESULTS There were 421,894 episodes analyzed, and median site off-load times varied from 13 (interquartile range [IQR], 9 to 20) to 29 (IQR, 16 to 48) minutes. The global site prediction model median absolute errors were 11.7 minutes (95% confidence interval [CI], 11.7 to 11.8) using linear regression and 12.8 minutes (95% CI, 12.7 to 12.9) using elastic net. The individual site model prediction median absolute errors varied from the most accurate at 6.3 minutes (95% CI, 6.2 to 6.4) to the least accurate at 16.1 minutes (95% CI, 15.8 to 16.3). The model technique performance was the same for linear regression, random forests, elastic net, and rolling average. The important variables were the last k-patient average waits, triage category, and patient age. The global model performed at the lower end of the accuracy range compared with models for the individual sites but was within tolerable limits. CONCLUSION Electronic emergency demographic and flow information can be used to estimate emergency ambulance patient off-stretcher times. Models can be built with reasonable accuracy for multiple hospitals using a small number of point-of-care variables.
Collapse
Affiliation(s)
- Katie J Walker
- Cabrini Emergency Department, Malvern, Melbourne, Victoria, Australia; Cabrini Institute, Malvern, Melbourne, Victoria, Australia; Casey Emergency Department, Berwick, Melbourne, Victoria, Australia; School of Clinical Sciences at Monash Health, Monash University, Clayton, Melbourne, Victoria, Australia.
| | - Jirayus Jiarpakdee
- Department of Software Systems and Cybersecurity, Monash University, Clayton, Melbourne, Victoria, Australia
| | - Anne Loupis
- Cabrini Institute, Malvern, Melbourne, Victoria, Australia; School of Clinical Sciences at Monash Health, Monash University, Clayton, Melbourne, Victoria, Australia
| | - Chakkrit Tantithamthavorn
- Department of Software Systems and Cybersecurity, Monash University, Clayton, Melbourne, Victoria, Australia
| | - Keith Joe
- Cabrini Emergency Department, Malvern, Melbourne, Victoria, Australia; Monash Art, Design and Architecture, Monash University, Caulfield, Melbourne, Victoria, Australia
| | - Michael Ben-Meir
- Cabrini Emergency Department, Malvern, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Hamed Akhlaghi
- Emergency Department, St Vincent's Hospital, Fitzroy, Melbourne, Victoria, Australia
| | - Jennie Hutton
- Emergency Department, St Vincent's Hospital, Fitzroy, Melbourne, Victoria, Australia; Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Melbourne, Victoria, Australia
| | - Wei Wang
- Cabrini Institute, Malvern, Melbourne, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Michael Stephenson
- Ambulance Victoria, Doncaster, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Community Emergency Health and Paramedic Practice, Frankston, Melbourne, Victoria, Australia
| | - Gabriel Blecher
- Cabrini Emergency Department, Malvern, Melbourne, Victoria, Australia; School of Clinical Sciences at Monash Health, Monash University, Clayton, Melbourne, Victoria, Australia; Monash Medical Centre, Emergency Department, Clayton, Melbourne, Victoria, Australia
| | - Paul Buntine
- Emergency Department, Box Hill Hospital, Eastern Health, Box Hill, Melbourne, Victoria, Australia; Eastern Health Clinical School, Monash University, Box Hill, Melbourne, Victoria, Australia
| | - Amy Sweeny
- Emergency Department, Gold Coast University Hospital, Southport, Queensland, Australia; Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Burak Turhan
- Faculty of Information Technology and Electrical Engineering, University of Oulu, Oulu, Finland
| |
Collapse
|
10
|
van Vuuren J, Thomas B, Agarwal G, MacDermott S, Kinsman L, O'Meara P, Spelten E. Reshaping healthcare delivery for elderly patients: the role of community paramedicine; a systematic review. BMC Health Serv Res 2021; 21:29. [PMID: 33407406 PMCID: PMC7789625 DOI: 10.1186/s12913-020-06037-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 12/21/2020] [Indexed: 12/19/2022] Open
Abstract
Background Healthcare systems are overloaded and changing. In response to growing demands on the healthcare systems, new models of healthcare delivery are emerging. Community paramedicine is a novel approach in which paramedics use their knowledge and skills beyond emergency health response to contribute to preventative and rehabilitative health. In our systematic review, we aimed to identify evidence of the community paramedicine role in care delivery for elderly patients, with an additional focus on palliative care, and the possible impact of this role on the wider healthcare system. Methods A systematic review of peer-reviewed literature from MEDLINE, Embase, CINAHL, and Web of Sciences was undertaken to identify relevant full-text articles in English published until October 3, 2019. Additional inclusion criteria were studies focussing on extended care paramedics or community paramedics caring for elderly patients. Case studies were excluded. All papers were screened by at least two authors and underwent a quality assessment, using the Joanna Briggs Institute appraisal checklists for cross sectional, qualitative, cohort, and randomised controlled trial studies to assess the methodological quality of the articles. A process of narrative synthesis was used to summarise the data. Results Ten studies, across 13 articles, provided clear evidence that Community Paramedic programs had a positive impact on the health of patients and on the wider healthcare system. The role of a Community Paramedic was often a combination of four aspects: assessment, referral, education and communication. Limited evidence was available on the involvement of Community Paramedics in palliative and end-of-life care and in care delivery in residential aged care facilities. Observed challenges were a lack of additional training, and the need for proper integration and understanding of their role in the healthcare system. Conclusions The use of community paramedics in care delivery could be beneficial to both patients’ health and the wider healthcare system. They already play a promising role in improving the care of our elderly population. With consistent adherence to the training curriculum and effective integration within the wider healthcare system, community paramedics have the potential to take on specialised roles in residential aged care facilities and palliative and end-of-life care. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-06037-0.
Collapse
Affiliation(s)
- Julia van Vuuren
- Department of Community Health, Rural Health School, La Trobe University, Melbourne, Australia.
| | - Brodie Thomas
- Department of Community Health, Rural Health School, La Trobe University, Melbourne, Australia
| | - Gina Agarwal
- Department of Family Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Sean MacDermott
- Department of Community Health, Rural Health School, La Trobe University, Melbourne, Australia
| | - Leigh Kinsman
- University of Newcastle and Mid-North Coast Local Health District, Port Macquarie Base Hospital, Port Macquarie, Australia
| | - Peter O'Meara
- Department of Paramedicine, Monash University, Peninsula Campus, Melbourne, Australia
| | - Evelien Spelten
- Department of Community Health, Rural Health School, La Trobe University, Melbourne, Australia
| |
Collapse
|
11
|
Delayed flow is a risk to patient safety: A mixed method analysis of emergency department patient flow. Int Emerg Nurs 2020; 54:100956. [PMID: 33360361 DOI: 10.1016/j.ienj.2020.100956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 10/10/2020] [Accepted: 11/25/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Increasing emergency department (ED) demand and crowding has heightened focus on the need for better understanding of patient flow. AIM This study aimed to identify input, throughput and output factors contributing to ED patient flow bottlenecks and extended ED length of stay (EDLOS). METHOD Concurrent nested mixed method study based on retrospective analysis of attendance data, patient flow observational data and a focus group in an Australian regional ED. RESULTS Analysis of 89 013 ED presentations identified increased EDLOS, particularly for patients requiring admission. Mapping of 382 patient journeys identified delays in time to triage assessment (0-39 mins) and extended waiting room stays (0-348 mins). High proportions of patients received care outside ED cubicles. Four qualitative themes emerged: coping under pressure, compromising care and safety, makeshift spaces, and makeshift roles. CONCLUSION Three key findings emerged: i) hidden waits such as extended triage-queuing occur during the input phase; ii) makeshift spaces are frequently used to assess and treat patients during times of crowding; and iii) access block has an adverse effect on output flow. Data suggests arrival numbers may not be a key predictor of EDLOS. This research contributes to our understanding of ED crowding and patient flow, informing service delivery and planning.
Collapse
|
12
|
Man NWY, Forero R, Ngo H, Mountain D, FitzGerald G, Toloo GS, McCarthy S, Mohsin M, Fatovich DM, Bailey P, Bosley E, Carney R, Lai HMX, Hillman K. Impact of the Four-Hour Rule policy on emergency medical services delays in Australian EDs: a longitudinal cohort study. Emerg Med J 2020; 37:793-800. [PMID: 32669320 DOI: 10.1136/emermed-2019-208958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 05/26/2020] [Accepted: 05/29/2020] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Delayed handover of emergency medical services (EMS) patients to EDs is a major issue with hospital crowding considered a primary cause. We explore the impact of the 4-hour rule (the Policy) in Australia, focusing on ambulance and ED delays. METHODS EMS (ambulance), ED and hospital data of adult patients presenting to 14 EDs from 2002 to 2013 in three jurisdictions were linked. Interrupted time series 'Before-and-After' trend analysis was used for assessing the Policy's impact. Random effects meta-regression analysis was examined for associations between ambulance delays and Policy-associated ED intake, throughput and output changes. RESULTS Before the Policy, the proportion of ED ambulances delayed increased between 1.1% and 1.7% per quarter across jurisdictions. After Policy introduction, Western Australia's increasing trend continued but Queensland decreased by 5.1% per quarter. In New South Wales, ambulance delay decreased 7.1% in the first quarter after Policy introduction. ED intake (triage delay) improved only in New South Wales and Queensland. Each 1% ambulance delay reduction was significantly associated with a 0.91% reduction in triage delay (p=0.014) but not ED length of stay ≤4 hours (p=0.307) or access-block/boarding (p=0.605) suggesting only partial improvement in ambulance delay overall. CONCLUSION The Policy was associated with reduced ambulance delays over time in Queensland and only the immediate period in New South Wales. Associations may be due to local jurisdictional initiatives to improve ambulance performance. Strategies to alleviate ambulance delay may need to focus on the ED intake component. These should be re-examined with longer periods of post-Policy data.
Collapse
Affiliation(s)
- Nicola Wing Young Man
- Simpson Centre for Health Services Research, South Western Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia.,National Drug and Alcohol Research Centre, University of New South Wales, Randwick, New South Wales, Australia
| | - Roberto Forero
- Simpson Centre for Health Services Research, South Western Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia .,Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Hanh Ngo
- Division of Emergency Medicine, Faculty of Health and Medical Services, University of Western Australia, Perth, Western Australia, Australia
| | - David Mountain
- Division of Emergency Medicine, Faculty of Health and Medical Services, University of Western Australia, Perth, Western Australia, Australia.,Emergency Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Gerard FitzGerald
- School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Ghasem Sam Toloo
- School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Sally McCarthy
- Emergency Department, Prince of Wales Hospital, Randwick, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia
| | - Mohammed Mohsin
- Psychiatry Research and Teaching Unit, Liverpool Hospital, Liverpool, New South Wales, Australia.,School of Psychiatry, Faculty of Medicine, University of New South Wales, Randwick, New South Wales, Australia
| | - Daniel M Fatovich
- Division of Emergency Medicine, Faculty of Health and Medical Services, University of Western Australia, Perth, Western Australia, Australia.,Emergency Medicine, Royal Perth Hospital, Centre for Clinical Research in Emergency Medicine, Perth, Western Australia, Australia
| | - Paul Bailey
- St John Ambulance Western Australia, Perth, Western Australia, Australia
| | - Emma Bosley
- Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Rosemary Carney
- New South Wales Ambulance Service, Rozelle, New South Wales, Australia
| | - Harry Man Xiong Lai
- New South Wales Ambulance Service, Rozelle, New South Wales, Australia.,Discipline of Psychiatry, University Of Sydney, Sydney, New South Wales, Australia
| | - Ken Hillman
- Simpson Centre for Health Services Research, South Western Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| |
Collapse
|
13
|
Crilly J, Johnston AN, Wallis M, O'Dwyer J, Byrnes J, Scuffham P, Zhang P, Bosley E, Chaboyer W, Green D. Improving emergency department transfer for patients arriving by ambulance: A retrospective observational study. Emerg Med Australas 2019; 32:271-280. [PMID: 31867883 PMCID: PMC7155107 DOI: 10.1111/1742-6723.13407] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 09/20/2019] [Accepted: 09/21/2019] [Indexed: 11/29/2022]
Abstract
Objective Extended delays in the transfer of patients from ambulance to ED can compromise patient flow. The present study aimed to describe the relationship between the use of an Emergency Department Ambulance Off‐Load Nurse (EDAOLN) role, ED processes of care and cost effectiveness. Methods This was a retrospective observational study over three periods of before (T1), during (T2) and after (T3) the introduction of the EDAOLN role in 2012. Ambulance, ED and cost data were linked and used for analysis. Processes of care measures analysed included: time to be seen by a doctor from ED arrival (primary outcome), ambulance‐ED offload compliance, proportion of patients seen within recommended triage timeframe, ED length of stay (LoS), proportion of patients transferred, admitted or discharged from the ED within 4 h and cost effectiveness. Results A total of 6045 people made 7010 presentations to the ED by ambulance over the study period. Several measures improved significantly between T1 and T2 including offload compliance (T1: 58%; T2: 63%), time to be seen (T1: 31 min; T2: 28 min), ED LoS (T1: 335 min; T2: 306 min), ED LoS <4 h (T1: 31%; T2: 33%). Some measures carried over into T3, albeit to a lesser extent. Post‐hoc analyses showed that outcomes improved most for less urgent patients. The annualised net cost of the EDAOLN (if funded from additional resources) of $130 721 could result in an annualised reduction of approximately 3912 h in waiting time to be seen by a doctor. Conclusion With the EDAOLN role in place, slight outcome improvements in several key ambulance and ED efficiency criteria were noted. During times of ED crowding, the EDAOLN role may be one cost‐effective strategy to consider.
Collapse
Affiliation(s)
- Julia Crilly
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast Health, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Amy Nb Johnston
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast Health, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,Department of Emergency Medicine, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,School of Nursing, Midwifery and Social Work, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Marianne Wallis
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Maroochydore DC, Queensland, Australia
| | - John O'Dwyer
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast Health, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,Australian eHealth Research Centre, Herston, Queensland, Australia
| | - Joshua Byrnes
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University Nathan Campus, Brisbane, Queensland, Australia
| | - Paul Scuffham
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University Nathan Campus, Brisbane, Queensland, Australia
| | - Ping Zhang
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Emma Bosley
- Office of the Commissioner, Queensland Ambulance Service, Department of Health, Brisbane, Queensland, Australia
| | - Wendy Chaboyer
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - David Green
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast Health, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University Nathan Campus, Brisbane, Queensland, Australia
| |
Collapse
|
14
|
A Multicenter Observational Prospective Cohort Study of Association of the Prehospital National Early Warning Score 2 and Hospital Triage with Early Mortality. Emerg Med Int 2019; 2019:5147808. [PMID: 31355000 PMCID: PMC6633971 DOI: 10.1155/2019/5147808] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 06/09/2019] [Indexed: 11/18/2022] Open
Abstract
Aim of the Study To evaluate the ability of the prehospital National Early Warning Score 2 scale (NEWS2) to predict early mortality (within 48 hours) after the index event based on the triage priority assigned for any cause in the emergency department. Methods This is a multicenter longitudinal observational cohort study on patients attending Advanced Life Support units and transferred to the emergency department of their reference hospital. We collected demographic, physiological, and clinical variables, main diagnosis, and hospital triage level as well as mortality. The main outcome variable was mortality from any cause within two days of the index event. Results Between April 1 and November 30, 2018, a total of 1054 patients were included in our study. Early mortality within the first 48 hours after the index event affected 55 patients (5.2%), of which 23 cases (41.8%) had causes of cardiovascular origin. In the stratification by triage levels, the AUC of the NEWS2 obtained for short-term mortality varied between 0.77 (95% CI: 0.65-0.89) for level I and 0.94 (95% CI: 0.79-1) for level III. Conclusions The Prehospital Emergency Medical Services should evaluate the implementation of the NEWS2 as a routine evaluation, which, together with the structured hospital triage system, effectively serves to predict early mortality and detect high-risk patients.
Collapse
|