Emergency department staff opinion on newly introduced phlebotomy services in the department. A cross-sectional study incorporating thematic analysis

OBJECTIVES

The demand for ED services, both in terms of patient numbers and complexity has risen over the past decades. According to reports, there has been an increase in the ED patient presentation rate from 330 per 1000 to 334 per 1000 between 2018-2019 and 2022-2023. Consequently, new care models have been introduced to address this surge in demand, mitigate associated risks and improve overall safety. Among these models is the concept of 'front loading' clinical care, involving the initiation of interventions at the point of arrival. The present study evaluates the impact of introducing phlebotomists at triage.

METHODS

We conducted a cross-sectional survey using purposive sampling at a single quaternary metropolitan ED with an annual census of greater than 90 000, encompassing all clinical staff in the ED. The survey data were analysed quantitatively and complemented by a thematic analysis.

RESULTS

The response rate for the questionnaire was 61% (n = 207), with good representation from all ED craft groups. Nearly all the staff (99.5%) reported being aware of the presence of phlebotomists in the ED, whereas only 57% of the staff reported working in triage (P = 0.05, 0.00 to 0.04). 'Valuable/vital resource' featured as a common response. Early decision-making, patient safety, staff and patient satisfaction emerged as consistent themes.

CONCLUSIONS

Staff expressed satisfaction that patient care now begins in the waiting room, especially after extended waiting periods prior to cubicle allocation. They assert that this improvement significantly enhances timely treatment and disposition decisions, as well as overall patient satisfaction.

Attitudes of the public and medical professionals toward nurse prescribing: A text-mining study based on social medias

Objectives

This study aimed to explore the public and medical professionals' concerns and attitudes toward nurse prescribing using text-mining method to analyze social media data.

Methods

Python was used to automatically mine data related to the keywords "nurse prescribing" and "prescription" that were posted on four Chinese internet platforms between January 1, 2017, and November 1, 2022. The four Chinese internet platforms included social media sites such as Zhihu and Weibo, as well as medical forums like Aiaiyi Medical Hotspot and Dingxiangyuan Medicine. We conducted personnel, topic, and sentiment analysis techniques using SnowNLP, Bayesian Latent Dirichlet Allocation (LDA), and BosonNLP. Finally, we conducted content analysis using Nvivo 11 based on the results of the topic and sentiment analysis to obtain comprehensive and insightful results.

Results

We acquired 2,823 comments totaling 92,859 words on the four Internet platforms to conduct analysis. The analyze result showed that many public and medical professionals held a negative attitude toward nurse prescribing, and few had a prudent positive attitude. The public is concerned about the impact of nurse prescribing on medical professionals and the competency requirements for nurses. Medical professionals are concerned about the current and future status of nurse prescribing in China and the difficulties in implementing nurse prescribing.

Conclusion

Nurses should gradually gain recognition for their expertise and win the acceptance of the public and medical professionals on their ability of nursing prescribing by striving to enhance their professional capacity and self-authorization capabilities. Nurse administrators and educators need to recognize the advantages of nurse prescribing and address the challenges and issues in its implementation through promoting legislation, education, and heightening public awareness of its benefits.

A Physiotherapy-Led Transition to Home Intervention for Older Adults Following Emergency Department Discharge: A Pilot Feasibility Randomised Controlled Trial (ED PLUS)

Background

Older adults frequently attend the emergency department (ED) and experience high rates of subsequent adverse outcomes including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. Our aim was to evaluate the feasibility of a physiotherapy-led integrated care intervention for older adults discharged from the ED (ED PLUS).

Patients and Methods

Older adults presenting to the ED of a university teaching hospital with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED PLUS. ED PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient's home. Feasibility and acceptability were assessed quantitatively and qualitatively. All clinical and process outcomes were assessed by a research nurse blinded to group allocation. Data analyses were primarily descriptive.

Results

Twenty-nine participants were recruited indicating a 67% recruitment rate. At 6 months, there was 100% retention in the usual care group, 88% in the CGA group and 90% in the ED PLUS group. ED PLUS participants expressed positive feedback, and there was a trend towards improved function and quality of life and less ED revisits and unscheduled hospitalisations in the ED PLUS group.

Conclusion

ED PLUS bridges the transition of care between the index visit to the ED and the community and is feasible using systematic recruitment strategies. Despite recruitment challenges in the context of COVID-19, the intervention was successfully delivered and well received by participants. There was a lower incidence of functional decline and improved quality of life in the ED PLUS group.

Trial Registration

The trial was registered in Clinical Trials Protocols and Results System as of 21st July 2021, with registration number NCT04983602.

A short multi-factor screening tool to assess falls-risk in older people presenting to an Australian emergency department: A feasibility study

OBJECTIVE

The purpose of this study was to evaluate use of a short multi-factor falls-risk screening tool for older people within the emergency department, to enable rapid identification of falls-risk and triggers for multidisciplinary referral for further falls-specific assessment.

METHODS

Older people, aged ≥70 years, presenting to the emergency department with a fall-related injury or disease (n = 137) were recruited by a research nurse following randomisation. A short multi-factor screening tool was completed, comprised of 14 falls-risk-related assessment components.

RESULTS

Only one participant did not generate any referrals. Participants generated most referrals for medications (85.4%), social and housing (84.6%), vision (67.2%), podiatry (66.9%), or function and mobility (54.7%). Based on our results, the screening tool could be reduced to eleven components. The median time-to-screen was 11 min (IQR 9-15), with 736 triggers generated for referral and further assessment of falls-risk.

CONCLUSION

Falls are a major cause of ED presentation for older people. A short multi-factor screening tool with eleven components could be adapted to local familiar falls-risk tools and be completed in less than 10 min. Further research to trial the feasibility of completing ED referrals based on screening results is required to confirm the usefulness of such screening and referral within the ED.

The Experience of Families Accompanying a Senior to the Emergency Department: A Scoping Review

INTRODUCTION

Seniors are often accompanied by a family member to the emergency department. Families advocate for their needs and contribute to the continuity of care. However, they often feel excluded from care. To improve the quality and safety of care for seniors, it is necessary to consider the experience of families in the emergency department. The aim was to identify and synthesize the available scientific literature dealing with the experience of families accompanying a senior to the emergency department. To identify and synthesize the available scientific literature dealing with the experience of families accompanying a senior to the emergency department.

METHODS

A scoping review was conducted using the Arksey and O'Malley framework. Six databases were targeted. A description of the identified scientific literature and an inductive content analysis were performed.

RESULTS

Of the 3082 articles retrieved, 19 met the inclusion criteria. Most articles (89%) were published since 2010, were from nursing (63%), and used a qualitative research design (79%). The content analysis identified 4 main categories related to the experience of families accompanying a senior to the emergency department: (1) process leading to the emergency department, families feel uncertainty and ambiguity with the decision to go to the emergency department; (2) staying in the emergency department, families' experiences are influenced by the triage, the ED environment, and the interactions with ED personnel; (3) discharge from the emergency department, families consider that they should be part of the discharge planning; and (4) recommendations and possible solutions, there is a paucity of recommendations specifically focused on families.

DISCUSSION

The experience of families of seniors in the emergency department is multifactorial and part of a trajectory of care and health services.

Is There Evidence of an Association Between Acute Health Care Utilization and Function in Older Adults Over Time? A Population-Based Cohort Study

Background and Objectives

Acute health care use varies by age, with older adults the highest users of acute health care services. Using data from The Irish Longitudinal Study on Ageing (TILDA), the aim of this study was to investigate the association between acute health care utilization (emergency department [ED] visit with or without hospitalization) at baseline and subjective and objective measures of function measured at 4-year follow-up.

Research Design and Methods

This study represents a secondary analysis of a prospective cohort study, where data from Wave 1 (baseline) and Wave 3 of TILDA were analyzed in conjunction with a public and patient involvement group of older adults. Acute health care utilization was defined as an ED visit with or without hospitalization in the previous 12 months. Function was assessed objectively using the Timed Up and Go (TUG) test and a measure of grip strength, and subjectively using self-report limitations in activities of daily living (ADL) and instrumental ADL (IADL).

Results

A total of 1 516 participants met the study inclusion criteria. Mean age was 70.9 ± 4.6 years and 48% were male. At baseline, 1 280 participants reported no acute health care use. One hundred and eighteen indicated an ED visit but no hospitalization in the previous 12 months and 118 reported both an ED visit and hospitalization. Adjusting for all covariates, compared to those with no acute health care utilization, those with an ED visit with no hospital admission had poorer TUG performance at follow-up (β = 0.67, 95% confidence interval: 0.34, 1.29, p = .039).

Discussion and Implications

This paper supports previous research that acute health care events, specifically ED usage, are associated with reduced function for older adults as assessed by TUG at follow-up. No associations were observed for grip strength, ADL, or IADL. Further research is required in this area, exploring ED visits and the possible benefits of evaluating older adults at this stage.

A whole-of-health system approach to improving care of frail older persons

The population is aging, with frailty emerging as a significant risk factor for poor outcomes for older people who become acutely ill. We describe the development and implementation of the Frail Older Persons' Collaborative Program, which aims to optimise the care of frail older adults across healthcare systems in Queensland. Priority areas were identified at a co-design workshop involving key stakeholders, including consumers, multidisciplinary clinicians, senior Queensland Health staff and representatives from community providers and residential aged care facilities. Locally developed, evidence-based interventions were selected by workshop participants for each priority area: a Residential Aged Care Facility acute care Support Service (RaSS); improved early identification and management of frail older persons presenting to hospital emergency departments (GEDI); optimisation of inpatient care (Eat Walk Engage); and enhancement of advance care planning. These interventions have been implemented across metropolitan and regional areas, and their impact is currently being evaluated through process measures and system-level outcomes. In this narrative paper, we conceptualise the healthcare organisation as a complex adaptive system to explain some of the difficulties in achieving change within a diverse and dynamic healthcare environment. The Frail Older Persons' Collaborative Program demonstrates that translating research into practice and effecting change can occur rapidly and at scale if clinician commitment, high-level leadership, and adequate resources are forthcoming.

Frequent users of health services among community‐based older Australians: Characteristics and association with mortality

OBJECTIVES

To investigate characteristics of frequent users of general practice (GP; ≥21 visits in a year), medical specialist (≥10 visits), emergency department (ED; ≥2 presentations) and hospital services (≥2 overnight hospitalisations) and the association with mortality for people aged over 75 years.

METHODS

The study included residents from Central and Eastern Sydney, Australia, aged over 75 years who participated in a large community-dwelling cohort study. Demographic, social and health characteristics data were extracted from the 45 and Up Study survey. Health service (GP, medical specialist, ED and hospitalisations) use and mortality data were extracted from linked administrative data. We calculated adjusted prevalence ratios to identify independent characteristics associated with frequent users of services at baseline (approx. 2008) and adjusted hazard ratios to assess the association between frequent users of services and mortality.

RESULTS

Frequent users of services (GPs, medical specialists, EDs and hospitals) were more likely to be associated with ever having had heart disease and less likely to be associated with reporting good quality of life. Characteristics varied by service type. Frequent users of services were 1.5-2.0 times more likely to die within 7 years compared to those who were less frequent service users after controlling for all significant factors.

CONCLUSIONS

Our analysis found that frequent service users aged over 75 years had poorer quality of life, more complex health conditions and higher mortality and so their health service use was not inappropriate. However, better management of these frequent service users may lead to better health outcomes.

'I knew I'd be taken care of': Exploring patient experiences in the Emergency Department

Aims

To explore adult Emergency Department patient experiences to inform the development of a new Emergency Department patient‐reported experience measure.

Design

Descriptive, exploratory qualitative study using semi‐structured individual interviews with adult Emergency Department patients.

Methodology

Participants were recruited across two Emergency Departments in Southeast Queensland, Australia during September and October 2020. Purposive sampling based on maximum variation was used. Participants were recruited during their Emergency Department presentation and interviewed in 2‐weeks via telephone. Inductive thematic analysis followed the approach proposed by Braun and Clarke (2012).

Results

Thirty participants were interviewed, and four themes were inductively identified: Caring relationships between patients and Emergency Department care providers; Being in the Emergency Department environment; Variations in waiting for care; and Having a companion in the Emergency Department. Caring relationships between patients and Emergency Department care providers included being treated like a person and being cared for, being informed about and included in care, and feeling confident in care providers. Being in the Emergency Department environment included being around other patients, feeling comfortable and having privacy. Variations in waiting for care included expecting a longer wait, waiting throughout the Emergency Department journey and receiving timely care. Having a companion in the Emergency Department included not feeling alone, and observing care providers engage with companions.

Conclusion

Patient experiences in the Emergency Department are multifaceted, and themes are not mutually exclusive. These findings demonstrate consistency with the core experiential themes identified in the international literature.

Impact

Strategies to improve patient engagement in shared decision‐making, and communication between patients and care providers about wait times will be critical to optimizing Emergency Department patient experiences, and person‐centred practice. These findings holistically conceptualize patient experiences in the Emergency Department which is the first step to developing a new Emergency Department patient‐reported experience measure.

Factors associated with risk, perception and knowledge of falls in elderly people

OBJECTIVE

To verify the factors associated with risk, perception, and knowledge of falls; and pain among older adults.

METHOD

A cross-sectional study carried out in the Emergency Service of a teaching hospital in the city of São Paulo between September 2019 and March 2020. We selected 197 older adults aged 65 and over, who were not disoriented or confused, of both genders. The instruments Awareness Questionnaire on the Risk of Falls, Morse Fall Scale and Numerical Pain Scales were applied. Mann-Whitney and Kruskal-Wallis tests were used.

RESULTS

Interviewees with a high risk of falls in older adults (p = 0.0041); those with a support network had a lower perception and knowledge about the risk of falls (p = 0.0025) and lower percentage of severe pain (p = 0.0033).

CONCLUSION

Factors associated with risk, perception and knowledge of falls and pain among older adults were age, family income, number of dependents, caregiver, support network, hypertension, impaired walking, antihypertensive medication, lipid-lowering medication, level of education, comorbidities and religion.

A physiotherapy-led transition to home intervention for older adults following emergency department discharge: protocol for a pilot feasibility randomised controlled trial

Background

Older adults frequently attend the emergency department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. This paper reports a protocol designed to evaluate the feasibility of conducting a three arm randomised controlled trial (RCT) within the ED setting and in the patient’s home. The interventions are comprehensive geriatric assessment (CGA), ED PLUS and usual care.

Methods

The ED PLUS pilot trial is designed as a feasibility RCT conducted in the ED and Acute Medical Assessment Unit of a university teaching hospital in the mid-west region of Ireland. We aim to recruit 30 patients, aged 65 years and over presenting to the ED with undifferentiated medical complaints and discharged within 72 h of index visit.

Patients will be randomised by a computer in a ratio of 1:1:1 to deliver usual care, CGA or ED PLUS during a 6-month study period. A randomised algorithm is used to perform randomization. CGA will include a medical assessment, medication review, nursing assessment, falls assessment, assessment of mobility and stairs, transfers, personal care, activities of daily living (ADLs), social supports and baseline cognition. ED PLUS, a physiotherapist led, multidisciplinary intervention, aims to bridge the transition of care between the index visit to the ED and the community by initiating a CGA intervention in the ED and implementing a 6-week follow-up self-management programme in the patient’s own home following discharge from the ED. The outcomes will be parameters of the feasibility of the intervention and trial methods and will be assessed quantitatively and qualitatively.

Discussion

Rising ED visits and an ageing population with chronic health issues render ED interventions to reduce adverse outcomes in older adults a research priority. This feasibility RCT will generate data and experience to inform the conduct and delivery of a definite RCT.

Trial registration

The trial was registered in Clinical Trials Protocols and Results System as of 21^st July 2021, with registration number NCT049836020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00954-5.

Association between emergency department length of stay and patient outcomes: A systematic review

In this review, we investigate associations between time spent in the emergency department (ED) and patient reported outcomes. ED staff provide initial assessment, treatment and referral to patients presenting with an acute status to the hospital 24 h a day. ED length of stay, including ED boarding, and treatment received in the ED may affect patient outcomes. In this review we considered published studies that explored the association of ED length of stay of individuals of any age with their subsequent outcomes, including mortality and inpatient length of stay (IPLOS). Joanna Briggs Institute methods for systematic reviews of association were followed. Search strategies were developed to identify studies published in English since 2000 for inclusion. Two reviewers assessed the studies for inclusion and methodological quality and extracted data independently. In total, 34 studies were included in the review, including one case-control, one analytical cross-sectional, and 32 retrospective cohort studies, with a total sample size of 2,308,840 patients. Overall, there were variable associations of time spent in the ED and mortality, IPLOS, time-to-treatment and adverse events. However, findings indicated that older people are at risk for longer ED stays. They may also experience higher mortality. Specific focus should be placed upon elderly people in the ED, to reduce their exposure to the ED environment where possible and to implement focused initiatives that address their specific and complex treatment needs. We conclude that the diversity of individual settings and health systems will require locally defined and relevant solutions to locally identified issues.

Retrospective identification of latent subgroups of emergency department patients: A machine learning approach

OBJECTIVE

This research aims to (i) identify latent subgroups of ED presentations in Australian public EDs using a data-driven approach and (ii) compare clinical, socio-demographic and time-related characteristics of ED presentations broadly using the subgroups.

METHODS

We examined presentations to four public hospital EDs in Queensland from 2009 to 2014. An unsupervised machine learning algorithm, Clustering Large Applications, was used to cluster ED presentations.

RESULTS

There were six subgroups common across the EDs, primarily distinguishable by age, and subsequently by triage category, ED length of stay, arrival mode, departure status and several time-related attributes. Around 10% to 30% of the total presentations had high resource utilisation, with half of these from older patients (55+ years). ED resource utilisation per population was highest among the oldest cohort (75+ years). Children and young adults more frequently presented to the ED outside general-practitioner hours, mostly on Sundays. Older persons were more likely to present at any time, rather than specific hours, days or seasons. ED service performance measured against commonly used access-target indicators were rarely satisfied for older people and frequently satisfied for children.

CONCLUSION

Clustering Large Applications is effective in finding latent groups in large-scale mixed-type data, as demonstrated in the present study. Six types of ED presentations were identified and described using clinically relevant characteristics. The present study provides evidence for policy makers in Australia to develop alternative ED models of care tailored around the care needs of the differing groups of patients and thereby supports the sustainable delivery of acute healthcare.

Evidence-informed implementation of nurse prescribing under supervision: An integrative review

AIM

To explore evidence reporting facilitators and barriers to implementation of nurse prescribing and provide practical recommendations for evidence-informed implementation and adoption of nurse prescribing under a supervision model.

BACKGROUND

As demand for access to quality health care services increases, health professional roles are expanding to meet population needs. Nurse prescribing has been effective in some countries and is being considered globally to address growing health care demand. Successful implementation of health service models requires careful planning and consideration. No existing reviews have examined implementation factors in the literature.

DESIGN

Integrative review.

DATA SOURCES

CINAHL, MEDLINE, PubMed and EMBASE databases were searched from inception to 15 April 2020.

REVIEW METHODS

This integrative review is guided by Whittemore and Knafl and adheres to PRISMA reporting guidelines. The sustainability of innovation framework was used to synthesize data concerning implementation and sustainability factors (i.e. innovation, organizational, political, workforce and financial) for nurse prescribing.

RESULTS

A total of 39 articles were reviewed with literature predominantly reporting findings related to non-medical and nurse prescribing under various models. Variable evidence was found to inform nurse prescribing across five implementation and sustainability factors identifying several areas that require in-depth consideration. Very little evidence is available on nurse prescribing under supervision.

CONCLUSION

Introduction of service reform is often costly. This review highlights gaps in the literature and raises areas for consideration prior to implementation of this new service delivery model. The introduction of nurse prescribing must be planned and informed by available evidence to support effective adoption, practice and patient outcomes.

IMPACT

There are significant gaps in evidence related to nurse prescribing under a supervision model. Based on the evidence synthesized in this review, this paper provides practical recommendations for health service providers, managers, clinicians, educators and researchers to support implementation and adoption of nurse prescribing.

Injury-Related Emergency Department Presentations Among Residential Aged Care Residents in Victoria, Australia

OBJECTIVE

This study aimed to quantify and describe the characteristics of emergency department (ED) injury presentations and subsequent hospital admissions among residents of residential aged-care facilities (RACFs) in Victoria, Australia between 2008 and 2018.

METHODS

This study comprised a single jurisdiction population-based study of consecutive injury-related ED presentations of RACFs residents using the Victorian Emergency Minimum Dataset (VEMD).

RESULTS

The rate of ED injury presentations per 100,000 population decreased by .8% per year over 10 years (P = .03); however, the rate per 100,000 RACF bed days increased by .6% per year (P = .05). The proportion of presentations subsequently admitted to hospital increased 4.0% per year (P<.0001). The majority of presentations were due to falls (82.5%), with fracture(s) being the most common injury type (34.0%).

DISCUSSION

The increased rate of ED visits and hospital admissions in RACFs residents highlights the need to design specialized emergency care services and/or provide better direct access to hospital care for this vulnerable population.

Trends in emergency department use by older people during the COVID-19 pandemic

Aim

To examine changing trends in presentation of older people to the emergency department during the COVID-19 pandemic compared to 2018/2019.

Findings

On average 4 fewer people aged ≥70 years presented to the ED in the first 6 months of the COVID-19 pandemic (March-August 2020). There was a 20% reduction in presentations of stroke and cardiac complaints but a 25% increase in falls/injuries following easing of lockdown restrictions.

Message

It is imperative that we consider enabling strategies to ensure older people access unscheduled care in a timely manner when necessary.

Purpose

Reports suggest that many older people deferred seeking healthcare during the COVID-19 pandemic due to fear of contracting COVID-19. The aim of this study was to examine trends of emergency department (ED) use by older people during the first wave of the COVID-19 pandemic compared to previous years.

Methods

The study site is a 1000-bed university teaching hospital with annual ED new-patient attendance of > 50,000. All ED presentations of patients aged ≥ 70 years from March to August 2020, 2019 and 2018 inclusive (n = 13,989) were reviewed and compared for presenting complaint, Manchester Triage Score, and admission/discharge decision.

Results

There was a 16% reduction in presentations across the 6 months in 2020 compared to the average of 2018/2019. On average, 4 fewer people aged ≥ 70 years presented to the ED per day in 2020. Much of this was concentrated in March (33% fewer presentations) and April (31% fewer presentations), when the country was in ‘lockdown’, i.e. non-essential journeys were banned. There was a 20% reduction in patients presenting with stroke and cardiac complaints. In the 3 months following easing of restrictions, there was a 25% increase in falls and orthopaedic injuries when compared to 2018/2019.

Conclusion

This study demonstrates a significant decline in the number of older people presenting to the ED for unscheduled care, including for potentially time-dependent illnesses such as stroke or cardiac complaints. Given the possibility of further lockdowns, it is imperative that we consider enabling strategies to ensure older people access unscheduled care in a timely manner when necessary.

Comparison of Japan nurse practitioner-led care and physician trainee-led care on patients' length of stay in a secondary emergency department: A retrospective study

Aim

We compared Japan nurse practitioner‐led care and physician trainee‐led care in terms of patients' length of stay in a secondary emergency department in Japan.

Methods

This was a retrospective observational study, utilizing medical records. Participants (n = 1419; mean age = 63.9 ± 23.4 years; 52.3% men) were patients transferred to the emergency department by ambulance between April 2016 and March 2018 in western Tokyo. Multiple linear regression analyses were performed, with length of stay as the dependent variable and factors related to the length of stay, including medical care leaders, as the independent variable.

Results

Approximately half of the patients (n = 763; 53.8%) received Japan nurse practitioner‐led care. Patients' length of stay was significantly shorter, by 6 min, in the Japan nurse practitioner‐led care group, compared with the physician trainee‐led care group (unstandardized coefficient: −6.81; 95% confidence interval: −13.35 to −0.26; p < 0.05).

Conclusion

Patients' shorter length of stay in the Japan nurse practitioner group, compared with the physician trainee group, suggests that Japan nurse practitioners are not inferior to physician trainees in terms of the time spent to manage patients.

Implementation of advanced practice nursing for minor orthopedic injuries in the emergency care context: A non-inferiority study

AIMS

To evaluate the implementation of advanced practice nursing for patients with minor orthopedic injuries, including comparison of outcomes in relation to advanced practice nurse versus standard (physician-led) care models.

DESIGN

A non-inferiority study was performed in an emergency department in Norway, where advanced practice nursing is in an initial stage of implementation. The non-inferiority design was chosen to test whether the new advanced practice nursing model does not compromise quality of care compared to the standard care model already in use.

METHODS

Patients with minor orthopedic injuries were assessed and treated by either advanced practice nursing or standard (physician-led) care models. Participating patients were assigned to the professional available at presentation. In the nursing model, registered nurses worked at an advanced level/applied advanced practice nursing following in-house-training. Senior orthopedic specialists evaluated the diagnostic and treatment accuracy in both models. Data were collected in a tool developed for this study, from May to October 2019.

RESULTS

In total, 335 cases were included, of which 167 (49.9%) were assessed and treated in the nursing model. Overall, correct diagnosis was found in 97.3% (n = 326) of the cases, and correct treatment was found in 91.3% (n = 306) of the cases. In comparison of missed diagnosis between advanced practice nurse and the standard (physician-led) care model showed inconclusive results (risk ratio: 0.29, 95% CI: 0.06-1.36). In comparison of treatment outcomes, the results showed that the advanced practice nursing model was non-inferior (risk ratio: 0.45, 95% CI: 0.21-0.97).

CONCLUSION

Advanced practice nursing care models can be used to diagnose and treat minor orthopedic injuries without compromising quality of care. Further implementation of the advanced practice nurse care model is encouraged.

Assessment of advance care planning documentation for residents of residential aged care facilities presenting to the emergency department

Objective This study assessed the availability and quality of advance care planning (ACP) documentation among older residential aged care facility (RACF) residents who presented to the emergency department (ED). Methods A prospective review of the medical records of RACF residents aged ≥75 years who presented to the ED from May to June 2018 was conducted. Availability of ACP was determined based on the presence of an ACP document inclusive of an advance care directive (ACD) in the medical record. The quality of ACP documentation was determined based on the presence of nine key components. Results In all, 48.8% of patients presented to the ED with either ACP or an ACD. However, only a mean total of 3.8 (out of 9) ACP components were documented in these documents. Conclusions Just under half (48.8%) of RACF residents presented to the ED with ACP documentation. There was limited coverage of core ACP components needed to guide clinical decision making. What is known about the topic? RACF residents are in the last years of their life and commonly lack capacity to make decisions regarding health care. Residents are at high risk of dying when acutely unwell in hospital. ACP documentation, when readily available, helps provide appropriate end-of-life care and improves both patient and family satisfaction. What does this paper add? Less than half the residents reporting to the ED from an RACF had ACP documentation available for clinicians. For those who presented to the ED with ACP documentation, most lacked sufficient information needed to provide care in full accordance with the patient's preferences. What are the implications for practitioners? There is a need to encourage, initiate, actively engage and develop systems for ACP conversations, documentation and availability when acutely unwell for people living in RACFs to provide sufficient information to guide clinical decision making. Without quality ACP, the provision of patient-centred health care may be compromised.

Emergency department presentations with a mental health diagnosis in Australia, by jurisdiction and by sex, 2004-05 to 2016-17

OBJECTIVES

To examine trends in ED presentations with a mental health diagnosis (MH_dx ) in Australia by jurisdiction and by sex, between 2004-05 and 2016-17.

METHODS

Data were captured in the National Non-Admitted Patient Emergency Department Care Database. Outcomes were the proportion of ED presentations with a principal diagnosis of ICD-10-AM F00-F99 (MH_dx ), and the rate of all ED and MH_dx presentations per 10 000 population.

RESULTS

Between 2004-05 and 2016-17, MH_dx presentations experienced compounding annual growth of 5.9% nationally, and increased from 3.3% to 3.7% of all ED presentations with a diagnosis. Most growth occurred between 2010-11 and 2015-16. Northern Territory (NT) had the highest level of MH_dx presentations per 10 000 population, more than double the Australian average. The proportion of MH_dx presentations was highest in South Australia (SA) in most years, and the average annual proportion of MH_dx presentations was statistically significantly higher than the national average in SA, Queensland (QLD) and Western Australia (WA). The proportion of MH_dx presentations increased in each jurisdiction, with significant increases for Victoria, QLD, WA, Australian Capital Territory and NT. Males experienced greater numbers and rates of all ED and MH_dx presentations, while the proportion of MH_dx presentations was 8% higher for females.

CONCLUSIONS

The proportion of ED presentations for MH conditions, narrowly defined, has increased in all Australian jurisdictions between 2004-05 and 2016-17, but particularly since 2010-11. Differences between jurisdictions indicate jurisdictional specific issues. However, significant or upward trend of MH_dx presentations across all jurisdictions indicates generic issues necessitating concern and policy development at a national level.

Evaluation of elderly care dynamics in an emergency care unit

OBJECTIVE

understand elderly care dynamics of an emergency care unit.

METHOD

this is a case study evaluation, using a qualitative approach and the theoretical-methodological reference of a fourth generation evaluation. Data collection was conducted between February and September 2017, through 460 hours of participant observation, interviews with 33 social actors among health professionals, elderly people and their relatives of an emergency care unit located in a municipality in the northwest of Paraná, as well as negotiation meetings with participants.

RESULTS

the evaluation showed the elderly care dynamics is mainly influenced by nursing actions that articulate care practices based on priority, frailty, autonomy, independence and family context of the elderly patients.

FINAL CONSIDERATIONS

an evaluation of how the emergency care unit operates helps improve elderly care in urgent and emergency services.

Calling for confirmation, reassurance, and direction: Investigating patient compliance after accessing a telephone triage advice service

Understanding the influence of a telephone triage advice service (TTAS) on patients seeking care is critical to realize enhancements in patient care, functioning of emergency departments (EDs), and effectiveness of the health system. This study addresses the question: what influence does a TTAS have on a patient's attendance at an ED and the wider health system? Records from 2016 to 2017 of 12,741 calls from a national TTAS were linked to 72,577 ED presentations to a hospital in regional Australia, retrospectively. Matching criteria included patient within the hospital's statistical local area code, age, gender, and ED attendance within 8 hours of TTAS call. Five statistical analyses of the data were conducted. There were 2857 matches. TTAS patients accessing the ED had a slightly higher proportion of women and a greater proportion of children under 4 years than usual. When TTAS confirmed callers' inclination for ED care, however only up to 69% subsequently attended the ED. When TTAS redirected others initially less inclined to more urgent care, up to 62% attended the ED. TTAS empowers vulnerable patients to access appropriate and timely services and promotes clinical and functional integration of care. Improvements of TTAS can come through investigation of callers' compliance factors.

Variations in older people's use of general practitioner consultations and the relationship with mortality rate in Vantaa, Finland in 2003-2014

Objective: It is generally expected that the growth of the older population will lead to an increase in the use of health care services. The aim was to examine the changes in the number of visits made to general practitioners (GP) by the older age groups, and whether such changes were associated with changes in mortality rates.Design and setting: A register-based observational study in a Finnish city where a significant increase in the older population took place from 2003 to 2014. The number of GP visits made by the older population was calculated, the visits per person per year in two-year series, together with respective mortality rates.Subjects: The study population consisted of inhabitants aged 65 years and older (65+) in Vantaa that visited a GP in primary health care.Main outcome measures: The number of GP visits per person per year in the whole older population during the study years.Results: In 2009-2010, there was a sudden drop in GP visits per person in the younger (65-74 years) age groups examined. In the population aged 85+, use of GP visits remained at a fairly constant level. The mortality rate decreased until the year 2008. After that, the positive trend ended and the mortality rate plateaued.Conclusions: Simultaneously with the decline in GP visits per person in the older population, the mortality rate leveled off from its positive trend in 2009-2010. Factors identified being associated with the number of GP consultations were organizational changes in primary health care, economic recession causing retrenchment, and even vaccinations during the swine flu epidemic.Key pointsAlong with an increasingly ageing population, concern over the supply of publicly funded health care has become more pronounced.The amount of GP visits of 65+ decreased in primary health care, especially in the youngest groups.However, in the oldest age groups (85+), the use of GPs remained unchanged regardless of changes in service supply.As the rate of GP visits among the population of 65+ declined, the positive trend in the mortality rate ceased.

Reasons for choosing or refusing care from a nurse practitioner: Results from a national population-based survey

AIM

To understand the public's willingness or lack thereof, to be seen and treated by a nurse practitioner (NP) as the first point of contact when accessing healthcare services.

DESIGN

This cross-sectional, population-based survey study used computer assisted telephone interviewing to elicit public opinions on the topic.

METHODS

Data were collected in July and August 2015 from calls randomly placed to Australian households. Survey questions were developed from previous surveys and pilot tested. Summative content analysis was used to analyse open-ended responses.

RESULTS

Most respondents were always, or in some situations, willing to receive care from a nurse practitioner. The main themes identified from those willing to be seen by a nurse practitioner in any situation were, (a) appropriately qualified nurse practitioners, (b) the knowledge and experience to refer on if necessary. Description of situations from those unwilling to be seen by a nurse practitioner related to concern about appropriate care in a life-threatening condition.

CONCLUSION

Respondents unwilling to consider any care from a nurse practitioner or care in an emergency situation, reveal a lack of understanding of their role in the wider healthcare team. As the number of nurse practitioners increase, professional groups and community awareness programmes should be focused on explaining and promoting their essential role.

IMPACT

This study addresses the increasing healthcare requirements of ageing populations through understanding acceptance by society to the provision of care from health professionals other than medical practitioners. Most respondents were willing to be seen by a nurse practitioner for all or most of their healthcare needs. Lack of understanding of their scope of practice and role in the wider healthcare team, particularly in emergency situations, was reflected in responses. Those who would refuse care from a NP were in the minority. Appropriateness and acceptability of the roles of health professionals to provide quality care collaboration need consideration by policy makers.

Evaluation of RESPOND, a patient-centred program to prevent falls in older people presenting to the emergency department with a fall: A randomised controlled trial

BACKGROUND

Falls are a leading reason for older people presenting to the emergency department (ED), and many experience further falls. Little evidence exists to guide secondary prevention in this population. This randomised controlled trial (RCT) investigated whether a 6-month telephone-based patient-centred program-RESPOND-had an effect on falls and fall injuries in older people presenting to the ED after a fall.

METHODS AND FINDINGS

Community-dwelling people aged 60-90 years presenting to the ED with a fall and planned for discharge home within 72 hours were recruited from two EDs in Australia. Participants were enrolled if they could walk without hands-on assistance, use a telephone, and were free of cognitive impairment (Mini-Mental State Examination > 23). Recruitment occurred between 1 April 2014 and 29 June 2015. Participants were randomised to receive either RESPOND (intervention) or usual care (control). RESPOND comprised (1) home-based risk assessment; (2) 6 months telephone-based education, coaching, goal setting, and support for evidence-based risk factor management; and (3) linkages to existing services. Primary outcomes were falls and fall injuries in the 12-month follow-up. Secondary outcomes included ED presentations, hospital admissions, fractures, death, falls risk, falls efficacy, and quality of life. Assessors blind to group allocation collected outcome data via postal calendars, telephone follow-up, and hospital records. There were 430 people in the primary outcome analysis-217 randomised to RESPOND and 213 to control. The mean age of participants was 73 years; 55% were female. Falls per person-year were 1.15 in the RESPOND group and 1.83 in the control (incidence rate ratio [IRR] 0.65 [95% CI 0.43-0.99]; P = 0.042). There was no significant difference in fall injuries (IRR 0.81 [0.51-1.29]; P = 0.374). The rate of fractures was significantly lower in the RESPOND group compared with the control (0.05 versus 0.12; IRR 0.37 [95% CI 0.15-0.91]; P = 0.03), but there were no significant differences in other secondary outcomes between groups: ED presentations, hospitalisations or falls risk, falls efficacy, and quality of life. There were two deaths in the RESPOND group and one in the control group. No adverse events or unintended harm were reported. Limitations of this study were the high number of dropouts (n = 93); possible underreporting of falls, fall injuries, and hospitalisations across both groups; and the relatively small number of fracture events.

CONCLUSIONS

In this study, providing a telephone-based, patient-centred falls prevention program reduced falls but not fall injuries, in older people presenting to the ED with a fall. Among secondary outcomes, only fractures reduced. Adopting patient-centred strategies into routine clinical practice for falls prevention could offer an opportunity to improve outcomes and reduce falls in patients attending the ED.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12614000336684).

How much emergency department use by vulnerable populations is potentially preventable?: A period prevalence study of linked public hospital data in South Australia

OBJECTIVES

To quantify emergency department (ED) presentations by individuals within vulnerable populations compared with other adults and the extent to which these are potentially preventable.

DESIGN

Period prevalence study from 2005-2006 to 2010-2011.

SETTING

Person-linked, ED administrative records for public hospitals in South Australia.

PARTICIPANTS

Adults aged 20 or more in South Australia's metropolitan area presenting to ED and categorised as Refugee and Asylum Seeker Countries of birth (RASC); Aboriginal; those aged 75 years or more; or All others.

MAIN OUTCOME MEASURES

Unadjusted rates of ambulatory care sensitive condition (ACSC), general practitioner (GP)-type presentations and associated direct ED costs among mutually exclusive groups of individuals.

RESULTS

Disparity between RASC and All others was greatest for GP-type presentations (423.7 and 240.1 persons per 1000 population, respectively) with excess costs of $A106 573 (95% CI $A98 775 to $A114 371) per 1000 population. Aboriginal had highest acute ACSC presenter rates (125.8 against 51.6 per 1000 population) with twice the risk of multiple presentations and $A108 701 (95% CI $A374 to $A123 029) per 1000 excess costs. Those aged 75 or more had highest chronic ACSC presenter rates (119.7vs21.1 per 1000), threefold risk of further presentations (incidence rate ratio 3.20, 95% CI 3.14 to 3.26) and excess cost of $A385 (95% CI $A178 160 to $A184 609) per 1000 population.

CONCLUSIONS

Vulnerable groups had excess ED presentations for a range of issues potentially better addressed through primary and community healthcare. The observed differences suggest inequities in the uptake of effective primary and community care and represent a source of excess cost to the public hospital system.

Comparative emergency department resource utilisation across age groups

Objectives The aim of the present study was to assess comparative emergency department (ED) resource utilisation across age groups. Methods A retrospective analysis of data collected in the National Non-admitted Patient Emergency Department Care Database was undertaken to assess comparative ED resource utilisation across six age groups (0–14, 15–35, 36–64, 65–74, 75–84 and ≥85 years) with previously used surrogate markers of ED resource utilisation. Results Older people had significantly higher resource utilisation for their individual ED episodes of care than younger people, with the effect increasing with advancing age. Conclusion With ED care of older people demonstrated to be more resource intensive than care for younger people, the projected increase in older person presentations anticipated with population aging will have a magnified effect on ED services. These predicted changes in demand for ED care will only be able to be optimally managed if Australian health policy, ED funding instruments and ED models of care are adjusted to take into account the specific care and resource needs of older people. What is known about the topic? Current Australian ED funding models do not adjust for patient age. Several regional studies have suggested higher resource utilisation of ED patients aged ≥65 years. Anticipated rapid population aging mandates that contribution of age to ED visit resource utilisation be further explored. What does this paper add? The present study of national Australian ED presentations compared ED resource utilisation across age groups using surrogate markers of ED cost. Older people were found to have significantly higher resource utilisation in the ED, with the effect increasing further with advancing age. What are the implications for practitioners? The higher resource utilisation of older people in the ED warrants a review of current ED funding models to ensure that they will continue to meet the needs of an aging population.

An assistant workforce to improve screening rates and quality of care for older patients in the emergency department: findings of a pre- post, mixed methods study

Background

Older people who present to the Emergency Department (ED) experience high rates of prevalent and incident delirium. This study aimed to determine whether an assistant workforce in the ED could effectively conduct screening to inform assessment and care planning for older people as well as enhance supportive care activities for prevention of delirium.

Methods

Using a pre-post design, data was collected before and after the introduction of Older Person Technical Assistants (OPTAs) in the ED. OPTA activity was recorded during the intervention period and a medical record audit undertaken prior to and 9 months after implementation.

Data were analysed using descriptive statistics for OPTA activities. Weighted Kappa scores were calculated comparing concordance in screening scores between OPTAs and Aged Services Emergency Team Registered Nurses. Changes in the rates of documented screening and supportive care were analysed using Chi-square tests.

Focus groups were conducted to explore clinicians’ experiences of the OPTA role.

Results

Three thousand five hundred fourty two people were seen by OPTAs in 4563 ED Presentations between 1st July 2011 and 2012. The reproducibility of all screening tools were found to be high between the OPTAs and the RNs, with Kappas and ICCs generally all above 0.9.

The medical record audit showed significant improvement in the rates of documented screening, including cognition from 1.5 to 38% (p < 0.001) and review of pain from 29 to 75% (p < 0.001). Supportive care such as being given fluids or food also improved from 13 to 49% (p < 0.001) and pressure care from 4.8 to 30% (p < 0.001). This was accomplished with no increase in ED length of stay among this age group.

Focus group interviews described mixed responses and support for the OPTA role.

Conclusions

An assistant workforce in an ED setting was found to provide comparable screening results and improve the rates of documented screening and supportive care provided to older people with or at risk of developing delirium in the ED. There is a need for a shared philosophy to the care of older people in the ED.

Trial registration

Australian New Zealand Clinical Trials Registration number is ACTRN12617000742370. It was retrospectively registered on 22nd May 2017.

Quality indicators in the care of older persons in the emergency department: A systematic review of the literature

OBJECTIVE

A systematic review of the literature was undertaken to assess the methodological quality of existing quality indicators (QIs) for the emergency department (ED) care of older persons.

METHODS

MEDLINE, CINAHL, EMBASE and grey literature were searched. Articles were included if they addressed ED care of persons aged ≥65 years and defined a QI amenable to influence by ED providers. The methodological quality of QIs was assessed using relevant items from the Appraisal of Indicators through Research and Evaluation and the QUALIFY tools.

RESULTS

Sixty-one articles were included in the review, with identification of 50 QIs meeting predefined inclusion criteria. Thirty-six of fifty ED QIs for older persons were process indicators. The appraisal instruments' total ratings ranged from 39 to 67%, with only 18 QIs scoring 50% or more for all five domains.

CONCLUSION

There is a need for a balanced, methodologically robust set of QIs for care of older persons in the ED.