Impact of the four-hour National Emergency Access Target on 30 day mortality, access block and chronic emergency department overcrowding in Australian emergency departments

Factors associated with mental health representations to the emergency department within six months

BACKGROUND/OBJECTIVE

ED representation places a tremendous drain on resources with mental health (MH) representation among the most common. This study aimed to identify patient and clinical factors associated with 28-day and six-month ED MH representation of an index MH ED presentation.

METHOD

All MH related ED presentations from 1 January 2017 to 30 June 2019 were extracted from routinely collected administrative data. Cox regression and multinomial logistic regression models tested associations between patient characteristics and risk of representation.

RESULTS

For the 8,010 patients, 28-day and six-month representations were 8 % and 16 % respectively. Self-identifying with a MH problem at index presentation (28-day hazard ratio (HR) = 1.48, 95 % CI = 1.19-1.84; six-month HR = 1.52, 95 % CI = 1.29-1.78), leaving ED before completing treatment (28-day HR = 4.13, 95 % CI = 3.36-5.08; six-month HR = 2.52, 95 % CI = 2.12-2.99), no private health insurance (six-month HR = 1.34, 95 % CI = 1.08-1.66), and hospital admission within one year prior to index (six month MH-related admission vs non-MH, HR = 1.59, 95 % CI = 1.19-2.13) were associated with increased risk of representation. Being uninsured was associated with frequent six-month representation among adults aged 16-39 years (OR = 3.16, 95 %CI = 1.59-6.25).

CONCLUSION

Self-identifying with a MH problem, leaving ED prematurely, being uninsured and prior hospitalisation are areas for in-depth investigation for improved understanding of unplanned representations.

Effect of access block on emergency department crowding calculated by NEDOCS score

OBJECTIVE

Emergency department (ED) crowding poses a significant challenge in healthcare systems globally, leading to delays in patient care and threatening public health and staff well-being. Access block, characterized by delays in admitting patients awaiting hospitalization, is a primary contributor to ED overcrowding. To address this issue, the National Emergency Department Overcrowding Study (NEDOCS) score provides an objective framework for assessing ED crowding severity. This study aims to evaluate the impact of access block on ED crowding using the NEDOCS score and to explore strategies for mitigating overcrowding through scenarios over a 39-day period.

METHODS

A single-center, prospective, observational study was conducted in an urban tertiary care referral center. The NEDOCS score was collected six times daily, including variables like total ED patients, ventilated patients, boarding patients, the longest waiting times, and durations of boarding patients. NEDOCS scores were recorded, and calculations were performed to assess the potential impact of eliminating access block in scenarios.

RESULTS

NEDOCS scores ranged from 62.4 to 315, with a mean of 146, indicating consistent overcrowding. Analysis categorized ED conditions into different levels, revealing that over 81.2% of the time, the ED was at least overcrowded. The longest boarding patient's waiting duration was identified as the primary contributor to NEDOCS (48.8%). Scenarios demonstrated a significant decrease in NEDOCS when access block was eliminated through timely admissions. Shorter boarding times during non-working hours suggest the potential mitigating effect of external factors on the access barrier. Additionally, daytime measurements were associated with lower patient admissions and shorter wait times for initial assessment.

CONCLUSION

Although ED crowding is a multifactorial problem, our study has shown that access block contribute significantly to this problem. The study emphasizes that eliminating access block through timely admissions could substantially alleviate crowding, highlighting the importance of addressing this issue to enhance ED efficiency and overall healthcare delivery.

The Association between Emergency Department Length of Stay and In-Hospital Mortality in Older Patients Using Machine Learning: An Observational Cohort Study

The association between emergency department (ED) length of stay (EDLOS) with in-hospital mortality (IHM) in older patients remains unclear. This retrospective study aims to delineate the relationship between EDLOS and IHM in elderly patients. From the ED patients (n = 383,586) who visited an urban academic tertiary care medical center from January 2010 to December 2016, 78,478 older patients (age ≥60 years) were identified and stratified into three age subgroups: 60-74 (early elderly), 75-89 (late elderly), and ≥90 years (longevous elderly). We applied multiple machine learning approaches to identify the risk correlation trends between EDLOS and IHM, as well as boarding time (BT) and IHM. The incidence of IHM increased with age: 60-74 (2.7%), 75-89 (4.5%), and ≥90 years (6.3%). The best area under the receiver operating characteristic curve was obtained by Light Gradient Boosting Machine model for age groups 60-74, 75-89, and ≥90 years, which were 0.892 (95% CI, 0.870-0.916), 0.886 (95% CI, 0.861-0.911), and 0.838 (95% CI, 0.782-0.887), respectively. Our study showed that EDLOS and BT were statistically correlated with IHM (p < 0.001), and a significantly higher risk of IHM was found in low EDLOS and high BT. The flagged rate of quality assurance issues was higher in lower EDLOS ≤1 h (9.96%) vs. higher EDLOS 7 h <t≤ 8 h (1.84%). Special attention should be given to patients admitted after a short stay in the ED and a long BT, and new concepts of ED care processes including specific areas and teams dedicated to older patients care could be proposed to policymakers.

Experience-based codesign approach to improve care in Australian emergency departments for complex consumer cohorts: the MyED project protocol, Stages 1.1-1.3

INTRODUCTION

Emergency department (ED) care must adapt to meet current and future demands. In Australia, ED quality measures (eg, prolonged length of stay, re-presentations or patient experience) are worse for older adults with multiple comorbidities, people who have a disability, those who present with a mental health condition, Indigenous Australians, and those with a culturally and linguistically diverse (CALD) background. Strengthened ED performance relies on understanding the social and systemic barriers and preferences for care of these different cohorts, and identifying viable solutions that may result in sustained improvement by service providers. A collaborative 5-year project (MyED) aims to codesign, with ED users and providers, new or adapted models of care that improve ED performance, improve patient outcomes and improve patient experience for these five cohorts.

METHODS AND ANALYSIS

Experience-based codesign using mixed methods, set in three hospitals in one health district in Australia. This protocol introduces the staged and incremental approach to the whole project, and details the first research elements: ethnographic observations at the ED care interface, interviews with providers and interviews with two patient cohorts-older adults and adults with a CALD background. We aim to sample a diverse range of participants, carefully tailoring recruitment and support.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Western Sydney Local Health District Human Research Ethics Committee (2022/PID02749-2022/ETH02447). Prior informed written consent will be obtained from all research participants. Findings from each stage of the project will be submitted for peer-reviewed publication. Project outputs will be disseminated for implementation more widely across New South Wales, Australia.

Intensive care unit admission from the emergency department in the setting of National Emergency Access Targets

Purpose

Since the introduction of National Emergency Access Targets (NEATs) in 2012 there has been little research examining patients admitted to the intensive care unit (ICU).We assessed differences in baseline characteristics and outcomes of patients admitted from the Emergency Department (ED) to the ICU within 4 hours compared with patients who were not.

Methods

This retrospective observational study included all adults (≥18 years old) admitted to the ICU from the ED of Austin Hospital, Melbourne, Australia, between 1 January 2017 and 31st December 2019 inclusive.

Results

1544 patients were admitted from the ED to the ICU and 65% had an ED length of stay (EDLOS) > 4 hour. Such patients were more likely to be older, female, with less urgent triage category scores and lower illness severity. Sepsis and respiratory admission diagnoses, and winter presentations were significantly more prevalent in this group.After adjustment for confounders, patients with an EDLOS > 4 hours had lower hospital mortality; 8% v 21% (p = 0.029; OR, 1.62), shorter ICU length of stay 2.2 v 2.4 days (p = 0.043), but a longer hospital length of stay 6.2 v 6.8 days (p = < 0.001).

Conclusion

Almost two thirds of patients breached the NEAT of 4 hours. These patients were more likely to be older, female, admitted in winter with sepsis and respiratory diagnoses, and have lower illness severity and less urgent triage categories. NEAT breach was associated with reduced hospital mortality but an increased hospital length of stay.

Groundhog Day in the emergency department: A systematic review of 20 years of news coverage in Australia

This study examined how the Australian news media have portrayed public hospital Emergency Departments (EDs) over the last two decades. A systematic review and media frame analysis, searching Factiva and Australia and New Zealand News Stream for digital and print news articles published between January 2000 and January 2020. Eligibility criteria were (1) discussed EDs in public hospitals; (2) the primary focus of the article was the ED; (3) focused on the Australian context; (4) were published by one of the Australian state-based news outlets (e.g., The Sydney Morning Herald, Herald Sun). A pair of reviewers independently screened 242 articles for inclusion according to the pre-established criteria. Discrepancies were resolved via discussion. 126 articles met the inclusion criteria. Pairs of independent reviewers identified frames in 20% of the articles using an inductive approach to develop a framework for coding the remaining articles. News media rely heavily on reporting problems within and with the ED, while also proposing a cause. Praise for EDs was minimal. Opinions were primarily from government spokespeople, professional associations, and doctors. ED performance was often reported as fact, with no reference to the source of the information. Rhetorical framing devices, such as hyperbole and imagery, were used to emphasise dominant themes. The negative bias inherent in news media reporting of EDs could potentially damage public awareness of ED functioning, with implications for the likelihood of the public's accessing ED services. Like in the film Groundhog Day, news media reporting is stuck in a loop reporting the same narrative over and over again.

Length-of-Stay in the Emergency Department and In-Hospital Mortality: A Systematic Review and Meta-Analysis

The effect of emergency department (ED) length of stay (EDLOS) on in-hospital mortality (IHM) remains unclear. The aim of this systematic review and meta-analysis was to determine the association between EDLOS and IHM. We searched the PubMed, Medline, Embase, Web of Science, Cochrane Controlled Register of Trials, CINAHL, PsycInfo, and Scopus databases from their inception until 14−15 January 2022. We included studies reporting the association between EDLOS and IHM. A total of 11,337 references were identified, and 52 studies (total of 1,718,518 ED patients) were included in the systematic review and 33 in the meta-analysis. A statistically significant association between EDLOS and IHM was observed for EDLOS over 24 h in patients admitted to an intensive care unit (ICU) (OR = 1.396, 95% confidence interval [CI]: 1.147 to 1.701; p < 0.001, I2 = 0%) and for low EDLOS in non-ICU-admitted patients (OR = 0.583, 95% CI: 0.453 to 0.745; p < 0.001, I2 = 0%). No associations were detected for the other cut-offs. Our findings suggest that there is an association between IHM low EDLOS and EDLOS exceeding 24 h and IHM. Long stays in the ED should not be allowed and special attention should be given to patients admitted after a short stay in the ED.

Prioritizing and meeting life-threateningly ill patients' fundamental care needs in the emergency room-An interview study with registered nurses

Aim

To explore how registered nurses in the emergency room describe their work approach and prerequisites for meeting life‐threateningly ill patients' care needs from the perspective of a person‐centred fundamental care framework.

Design

A descriptive, qualitative interview study.

Method

Individual interviews were carried out with 14 registered nurses with experience of working in an emergency room in Sweden, during 2019. Data were analysed using thematic analysis, according to Braun and Clarke. The COREQ checklist was used for reporting the findings.

Results

Three themes were identified: Task‐oriented nursing care based on structured guidelines and checklists; Fundamental care not being promoted or prioritized in the emergency room; and The organization and responsibilities for providing person‐centred fundamental care are unclear. Results showed that registered nurses structure their work approach based on prevailing organizational prerequisites as well as personal ones. Meeting patients' fundamental care needs was not always prioritized; their physical needs were met to a greater extent than their relational and psychosocial needs. Registered nurses did not prioritize fundamental care when the organization did not.

Conclusion

From the registered nurses' perspective, they structured their work based on the prevailing conditions for meeting patients' fundamental care needs. The organizational structure does not clearly state that fundamental care should be performed in the emergency room, and the registered nurses' work approach there for meeting patients' fundamental care needs is not adapted to provide patients with person‐centred care.

Impact

To date, little is known about registered nurses' work approach and prerequisites in meeting life‐threateningly ill patients' fundamental care needs in the emergency room. Our findings indicate that the organizational structure is pivotal in supporting registered nurses to provide person‐centred fundamental care. The knowledge from this study can be used in emergency care settings to facilitate person‐centred fundamental care and thereby avoid fundamental care being missed.

Improving emergency departments during COVID-19 pandemic: a simulation and MCDM approach with MARCOS methodology in an uncertain environment

The coronavirus disease (COVID-19) pandemic forced healthcare systems to quickly modify to swapping healthcare essentials. The emergency department (ED) decision-making condition is complex and particularly unstable order for care in a stated period conducts decision-makers to attempt to alter assets to touch the demand. ED managers are generally enforced to discover strategies and improving scenarios for decreasing transfer of patients. For this end, the proposed framework of this study is first developed to integrate the simulation model of the flow process of the COVID-19 patients with the Measurement of Alternatives and Ranking according to COmpromise Solution (MARCOS) methodology in Spherical fuzzy context to assess and prioritize scenarios based on desired performance measures. As a contribution, the proposed framework determined the importance of the performance measures based on Spherical fuzzy sets. The proposed SF-MARCOS approach takes the performance measures weights from the expert’s team based on spherical fuzzy theory and the performance measures values from the simulation model, and rank the improving scenarios. Finally, a real-life study in a private hospital in Tehran, Iran, illustrates the effectiveness and feasibility of the proposed framework. The analysis of the results shows that the patients’ transfer rate can be reduced by applying new strategies with sensible expenditure.

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.

Review article: Has the implementation of time-based targets for emergency department length of stay influenced the quality of care for patients? A systematic review of quantitative literature

Time-based targets (TBTs) for ED stays were introduced to improve quality of care but criticised as having harmful unintended consequences. The aim of the review was to determine whether implementation of TBTs influenced quality of care. Structured searches in medical databases were undertaken (2000-2019). Studies describing a state, regional or national TBTs that reported processes or outcomes of care related to the target were included. Harvest plots were used to summarise the evidence. Thirty-three studies (n = 34 million) were included. In some settings, reductions in mortality were seen in ED, in hospital and at 30 days, while in other settings mortality was unchanged. Mortality reductions were seen in the face of increasing age and acuity of presentations, when short-stay admissions were excluded, and when pre-target temporal trends were accounted for. ED crowding, time to assessment and admission times reduced. Fewer patients left prior to completing their care and fewer patients re-presented to EDs. Short-stay admissions and re-admissions to wards within 30 days increased. There was conflicting evidence regarding hospital occupancy and ward medical emergency calls, while times to treatment for individual conditions did not change. The evidence for associations was mostly low certainty and confidence in the findings is accordingly low. Quality of care generally improved after targets were introduced and when compliance with targets was high. This depended on how targets were implemented at individual sites or within jurisdictions, with important implications for policy makers, health managers and clinicians.

The 4-hour target in the emergency department, in-hospital mortality, and length of hospitalization: A single center-retrospective study

BACKGROUND

The four-hour (4 h') rule in the emergency department (ED) is a performance-based measure introduced with the objective to improve the quality of care. We evaluated the association between time in the ED with in-hospital mortality and hospital length of stay (LOS).

METHODS

This was a retrospective study performed in one public hospital with over 100,000 ED referrals per year. Hospitalizations from the ED during 2017 were analyzed. We defined time in the ED as either: until a decision was made (DED); or total time in the ED (TED). In-hospital mortality and LOS were evaluated for patients with DED or TED within and beyond 4 h'.

RESULTS

Compared to patients with TED or DED within 4 h', in-hospital mortality did not increase in patients with TED beyond 4 h' (2.8% vs. 3.1%, non-significant), or DED beyond 4 h' (2.1% vs. 3.2%, p < 0.001). LOS did increase in patients with either DED or TED beyond 4 h' (p < 0.001). In-hospital mortality increased with increasing DED-TED intervals for patients hospitalized in the internal medicine departments: 3.7% (0-1 h'), 5.1% (1-2 h'), 5.7% (2-3 h'), and 7.1% (>3 h') (p < 0.001).

CONCLUSIONS

In-hospital mortality was not associated with time in the ED beyond 4 h'. LOS, however, was increased in this group of patients. Decreased LOS observed in patients with time in the ED within 4 h', does not support patients' risk as a contributing factor leading to higher trends in mortality observed in this patient group. In-hospital mortality was associated with an increase in DED-TED intervals in patients hospitalized in the internal medicine departments.

Review article: Have emergency department time-based targets influenced patient care? A systematic review of qualitative literature

Time-based targets for ED length of stay were introduced in England in 2000, followed by the rest of the UK, Canada, Ireland, New Zealand, and Australia after ED crowding was associated with poor quality of care and increased mortality. This systematic review evaluates qualitative literature to see if ED time-based targets have influenced patient care quality. We included 13 studies from four countries, incorporating 617 interviews. We conclude that time-based targets have impacted on the quality of emergency patient care, both positively and negatively. Successful implementation depends on whole hospital resourcing and engagement with targets.

The accumulation of, and associations between, nurses' activity levels within their shift in the emergency department

The aim of this study was to examine emergency nurses' activity levels and associations between hourly activity levels within-shifts. Fifty emergency nurses (45 females, 5 males) wore ActiGraph accelerometers and completed work diaries for up to 4 weeks. A sub-group (n = 42) also wore activPALs. Multilevel analyses examined temporal associations between hourly periods. In any hourly period, increased time spent in moderate- to vigorous-intensity physical activity (MVPA) was associated with less time spent in MVPA in the following hourly period. In any afternoon hourly period, increased time spent in MVPA was associated with more time spent in light-intensity physical activity in the following hourly period. No other associations were significant. Emergency nurses maintain activity levels within-shifts, except when more time spent in MVPA was associated with less time spent in MVPA in the following hour; a potential recovery strategy. Future research should determine how emergency nurses maintain their activity levels within-shifts. Practitioner Summary: Emergency nursing is physically demanding; however, it is unknown how active they are during hourly periods within-shifts. Emergency nurses' activity levels were maintained within hourly periods of a shift. Except for an increase in MVPA in 1 h was associated with a decrease in MVPA in the following hour. Abbreviations: CPR: cardiopulmonary resusitation; LPA: light-intensity physical activity; MPA: moderate-intenisty physical activity; MVPA: moderate- to vigorous-intensity physical activity; SED: sedentary.

Measuring organizational context in Australian emergency departments and its impact on stroke care and patient outcomes

BACKGROUND

Emergency departments (ED) are challenging environments but critical for early management of patients with stroke.

PURPOSE

To identify how context affects the provision of stroke care in 26 Australian EDs.

METHOD

Nurses perceptions of ED context was assessed with the Alberta Context Tool. Medical records were audited for quality of stroke care and patient outcomes.

FINDINGS

Collectively, emergency nurses (n = 558) rated context positively with several nurse and hospital characteristics impacting these ratings. Despite these positive ratings, regression analysis showed no significant differences in the quality of stroke care (n = 1591 patients) and death or dependency (n = 1165 patients) for patients in EDs with high or low rated context.

DISCUSSION

Future assessments of ED context may need to examine contextual factors beyond the scope of the Alberta Context Tool which may play an important role for the understanding of stroke care and patient outcomes in EDs.

The Effect of Patient Observation on Cranial Computed Tomography Rates in Children With Minor Head Trauma

BACKGROUND

Management of children with minor blunt head trauma often includes a period of observation to determine the need for cranial computed tomography (CT). Our objective was to estimate the effect of planned observation on CT use for each Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) risk group among children with minor head trauma.

METHODS

This was a secondary analysis of a prospective observational study at 10 emergency departments (EDs) in Australia and New Zealand, including 18,471 children < 18 years old, presenting within 24 hours of blunt head trauma, with Glasgow Coma Scale scores of 14 to 15. The planned observation cohort was defined by those with planned observation and no immediate plan for cranial CT. The comparison cohort included the rest of the patients who were either not observed or for whom a decision to obtain a cranial CT was made immediately after ED assessment. The outcome clinically important TBI (ciTBI) was defined as death due to head trauma, neurosurgery, intubation for > 24 hours for head trauma, or hospitalization for ≥ 2 nights in association with a positive cranial CT scan. We estimated the odds of cranial CT use with planned observation, adjusting for patient characteristics, PECARN TBI risk group, history of seizure, time from injury, and hospital clustering, using a generalized linear model with mixed effects.

RESULTS

The cranial CT rate in the total cohort was 8.6%, and 0.8% had ciTBI. The planned observation group had 4,945 (27%) children compared to 13,526 (73%) in the no planned observation group. Cranial CT use was significantly lower with planned observation (adjusted odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.1 to 0.1), with no difference in missed ciTBI rates. There was no difference in the odds of cranial CT use with planned observation for the group at very low risk for ciTBI (adjusted OR = 0.9, 95% CI = 0.5 to 1.4). Planned observation was associated with significantly lower cranial CT use in patients at intermediate risk (adjusted OR = 0.2, 95% CI = 0.2 to 0.3) and high risk (adjusted OR = 0.1, 95% CI = 0.0 to 0.1) for ciTBI.

CONCLUSIONS

Even in a setting with low overall cranial CT rates in children with minor head trauma, planned observation was associated with decreased cranial CT use. This strategy can be safely implemented on selected patients in the PECARN intermediate- and higher-risk groups for ciTBI.

[Emergency overcrowding and hospital organization: Causes and solutions]

Emergency Department (ED) overcrowding is a silent killer. Thus, several studies in different countries have described an increase in mortality, a decrease in the quality of care and prolonged hospital stays associated with ED overcrowding. Causes are multiple: input and in particular lack of access to lab test and imaging for general practitioners, throughput and unnecessary or time-consuming tasks, and output, in particular the availability of hospital beds for unscheduled patients. The main cause of overcrowding is waiting time for available beds in hospital wards, also known as boarding. Solutions to resolve the boarding problem are mostly organisational and require the cooperation of all department and administrative levels through efficient bed management. Elderly and polypathological patients wait longer time in ED. Internal Medicine, is the ideal specialty for these complex patients who require time for observation and evaluation. A strong partnership between the ED and the internal medicine department could help to reduce ED overcrowding by improving care pathways.

Emergency medicine's COVID future: Facing the triple challenge after flattening the curve

After successfully avoiding the situations experienced by some countries, Australasian EDs now face a future in which the ongoing threat of COVID-19 is added to the traditional challenges in providing quality emergency care. The contribution of emergency medicine to the national containment strategy adds a new dimension to the demands placed on emergency medicine in Australia and similarly, to the elimination strategy employed in New Zealand. These demands will best be met by a considered, planned and resourced approach that will challenge traditional measures of 'ED efficiency'.

Practice priorities for acute care nursing: A Delphi study

AIMS AND OBJECTIVES

To describe the risk and frequency of challenges in acute care nursing, and the practice priorities in Australian hospital wards based upon expert consensus.

BACKGROUND

Health care is facing increasing demands that are negatively impacting upon the safety and quality of nursing care.

DESIGN

Delphi Method.

METHOD

A three-round electronic Delphi method was used to collect and synthesise expert consensus opinion of 30 participants in Rounds One and Two of the survey, and 12 participants in Round Three. The study was carried out from July to December 2016. This study complied with the STROBE checklist.

RESULTS

High patient acuity or complexity, as well as inadequate bed space on wards, are "very high" risks that occur "often" and "very often," respectively. The pressure to admit patients, delayed medical review and patient boarding are all "high" risks that occur "often." Though only occurring "sometimes," inadequate numbers and skill mix of staff, suboptimal communication and early or inappropriate discharge all pose a "very high" risk to patient care.

CONCLUSION

The key practice priorities for nurse managers should include the design, implementation and evaluation of sustainable system-wide frameworks, processes and models of care that address patient boarding, communication and discharge processes, job satisfaction, staffing numbers and expertise.

RELEVANCE TO CLINICAL PRACTICE

This study provides a description of the challenges that face acute care nursing in the provision of safe and high-quality care.

Patients with life-limiting illness presenting to the emergency department

OBJECTIVE

To examine characteristics, outcomes and flow for patients over the age of 45 years with a life-limiting illness (LLI) presenting to a regional ED.

METHODS

Retrospective, observational cohort study of patients with LLI in an Australian regional ED over a 15-day period. Eligible patients were 45 years of age or older who fulfilled criteria for having an LLI. Data included demographics, diagnosis for current presentation, presence of advance care documentation, LLI category, admission and discharge destination from ED, ED and hospital length of stay and outcome for patients admitted to the acute hospital.

RESULTS

A total of 152 (12%) patients had an LLI. The LLI group were older, had a significantly longer median length of stay in the ED (5.9 [interquartile range 4.0-8.4] vs 3.9 h [interquartile range 2.5-6.3], P < 0.0001) and were less likely to leave the ED within 4 h (26% vs 51.5%, P < 0.0001). Forty-six percent of patients with an LLI had some form of advanced care documentation. Patients with an LLI were more likely to require hospital admission. In relation to illness trajectory, the frailty/dementia trajectory group had comparatively the longest ED length of stay with less than 10% leaving the ED within 4 h. This group were more likely to be discharged to a residential care facility.

CONCLUSION

A significant proportion of patients 45 years or older had an LLI which had implications for their length of ED stay and discharge destination.