Do clinical pathways enhance access to evidence-based acute myocardial infarction treatment in rural emergency departments?

Multicomponent Intervention to Improve Acute Myocardial Infarction Care in Tanzania: Protocol for a Pilot Implementation Trial

BACKGROUND

Although the incidence of acute myocardial infarction (AMI) is rising in sub-Saharan Africa, the uptake of evidence-based care for the diagnosis and treatment of AMI is limited throughout the region. In Tanzania, studies have revealed common misdiagnosis of AMI, infrequent administration of aspirin, and high short-term mortality rates following AMI.

OBJECTIVE

This study aims to evaluate the implementation and efficacy outcomes of an intervention, the Multicomponent Intervention to Improve Acute Myocardial Infarction Care (MIMIC), which was developed to improve the delivery of evidence-based AMI care in Tanzania.

METHODS

This single-arm pilot trial will be conducted in the emergency department (ED) at a referral hospital in northern Tanzania. The MIMIC intervention will be implemented by the ED staff for 1 year. Approximately 400 adults presenting to the ED with possible AMI symptoms will be enrolled, and research assistants will observe their care. Thirty days later, a follow-up survey will be administered to assess mortality and medication use. The primary outcome will be the acceptability of the MIMIC intervention, which will be measured by the Acceptability of Intervention Measurement (AIM) instrument. Acceptability will further be assessed via in-depth interviews with key stakeholders. Secondary implementation outcomes will include feasibility and fidelity. Secondary efficacy outcomes will include the following: the proportion of participants who receive electrocardiogram and cardiac biomarker testing, the proportion of participants with AMI who receive aspirin, 30-day mortality among participants with AMI, and the proportion of participants with AMI taking aspirin 30 days following enrollment.

RESULTS

Implementation of MIMIC began on September 1, 2023. Enrollment is expected to be completed by September 1, 2024, and the first results are expected to be published by December 31, 2024.

CONCLUSIONS

This study will be the first to evaluate an intervention for improving AMI care in sub-Saharan Africa. If MIMIC is found to be acceptable, the findings from this study will inform a future cluster-randomized trial to assess effectiveness and scalability.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04563546; https://clinicaltrials.gov/study/NCT04563546.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59917.

Strengthening facility-based integrated emergency care services for time sensitive emergencies at all levels of healthcare in India: An implementation research study protocol

BACKGROUND

The healthcare system in India is tiered and has primary, secondary and tertiary levels of facilities depending on the complexity and severity of health challenges at these facilities. Evidence suggests that emergency services in the country is fragmented. This study aims to identify the barriers and facilitators of emergency care delivery for patients with time-sensitive conditions, and develop and implement a contextually relevant model, and measure its impact using implementation research outcomes.

METHODS

We will study 85 healthcare facilities across five zones of the country and focus on emergency care delivery for 11 time-sensitive conditions. This implementation research will include seven phases: the preparatory phase, formative assessment, co-design of Model "Zero", co-implementation, model optimization, end-line evaluation and consolidation phase. The "preparatory phase" will involve stakeholder meetings, approval from health authorities and the establishment of a research ecosystem. The "formative assessment" will include quantitative and qualitative evaluations of the existing healthcare facilities and personnel to identify gaps, barriers and facilitators of emergency care services for time-sensitive conditions. On the basis of the results of the formative assessment, context-specific implementation strategies will be developed through meetings with stakeholders, providers and experts. The "co-design of Model 'Zero'" phase will help develop the initial Model "Zero", which will be pilot tested on a small scale (co-implementation). In the "model optimization" phase, iterative feedback loops of meetings and testing various strategies will help develop and implement the final context-specific model. End-line evaluation will assess implementation research outcomes such as acceptability, adoption, fidelity and penetration. The consolidation phase will include planning for the sustenance of the interventions.

DISCUSSION

In a country such as India, where resources are scarce, this study will identify the barriers and facilitators to delivering emergency care services for time-sensitive conditions across five varied zones of the country. Stakeholder and provider participation in developing consensus-based implementation strategies, along with iterative cycles of meetings and testing, will help adapt these strategies to local needs. This approach will ensure that the developed models are practical, feasible and tailored to the specific challenges and requirements of each region.

Adapting an Intervention to Improve Acute Myocardial Infarction Care in Tanzania: Co-Design of the MIMIC Intervention

Background

Uptake of evidence-based care for acute myocardial infarction (AMI) is suboptimal in Tanzania, but there are currently no published interventions to improve AMI care in sub-Saharan Africa.

Objectives

Co-design a quality improvement intervention for AMI care tailored to local contextual factors.

Methods

An interdisciplinary design team consisting of 20 physicians, nurses, implementation scientists, and administrators met from June 2022 through August 2023. Half of the design team consisted of representatives from the target audience, emergency department physicians and nurses at a referral hospital in northern Tanzania. The design team reviewed multiple published quality improvement interventions focusing on ED-based AMI care. After selecting a multicomponent intervention to improve AMI care in Brazil (BRIDGE-ACS), the design team used the ADAPT-ITT framework to adapt the intervention to the local context.

Findings

The design team audited current AMI care processes at the study hospital and reviewed qualitative data regarding barriers to care. Multiple adaptations were made to the original BRIDGE-ACS intervention to suit the local context, including re-designing the physician reminder system and adding patient educational materials. Additional feedback was sought from topical experts, including patients with AMI. Draft intervention materials were iteratively refined in response to feedback from experts and the design team. The finalized intervention, Multicomponent Intervention to Improve Myocardial Infarction Care in Tanzania (MIMIC), consisted of five core components: physician reminders, pocket cards, champions, provider training, and patient education.

Conclusion

MIMIC is the first locally tailored intervention to improve AMI care in sub-Saharan Africa. Future studies will evaluate implementation outcomes and efficacy.

A prospective multi-centre study assessing the safety and effectiveness following the implementation of an accelerated chest pain pathway using point-of-care troponin for use in New Zealand rural hospital and primary care settings

Aims

Most rural hospitals and general practices in New Zealand (NZ) are reliant on point-of-care troponin. A rural accelerated chest pain pathway (RACPP), combining an electrocardiogram (ECG), a structured risk score (Emergency Department Assessment of Chest Pain Score), and serial point-of-care troponin, was designed for use in rural hospital and primary care settings across NZ. The aim of this study was to evaluate the safety and effectiveness of the RACPP.

Methods and results

A prospective multi-centre evaluation following implementation of the RACPP was undertaken from 1 July 2018 to 31 December 2020 in rural hospitals, rural and urban general practices, and urgent care clinics. The primary outcome measure was the presence of 30-day major adverse cardiac events (MACEs) in low-risk patients. The secondary outcome was the percentage of patients classified as low-risk that avoided transfer or were eligible for early discharge. There were 1205 patients enrolled in the study. 132 patients were excluded. Of the 1073 patients included in the primary analysis, 474 (44.0%) patients were identified as low-risk. There were no [95% confidence interval (CI): 0–0.3%] MACE within 30 days of the presentation among low-risk patients. Most of these patients (91.8%) were discharged without admission to hospital. Almost all patients who presented to general practice (99%) and urgent care clinics (97.6%) were discharged to home directly.

Conclusion

The RACPP is safe and effective at excluding MACEs in NZ rural hospital and primary care settings, where it can identify a group of low-risk patients who can be safely discharged home without transfer to hospital.

Study protocol for an observational study to evaluate an accelerated chest pain pathway using point-of-care troponin in New Zealand rural and primary care populations

INTRODUCTION Accelerated diagnostic chest pain pathways are used widely in urban New Zealand hospitals. These pathways use laboratory-based troponin assays with good analytical precision. Widespread implementation has not occurred in many of New Zealand's rural hospitals and general practices as they are reliant on point-of-care troponin assays, which are less sensitive and precise. An accelerated chest pain pathway using point-of-care troponin has been adapted for use in rural settings. A pilot study in a low-risk rural population showed no major adverse cardiac events at 30 days. A larger study is required to be confident that the pathway is safe. AIMS To assess the safety and effectiveness of an accelerated chest pain pathway adapted for rural settings and general practice using point-of-care troponin to identify low-risk patients and allow early discharge. METHODS This is a prospective observational study of an accelerated chest pain pathway using point-of-care troponin in rural hospitals and general practices in New Zealand. A total of 1000 patients, of whom we estimate 400 will be low risk, will be enrolled in the study. OUTCOME MEASURES The primary outcome is the proportion of patients identified by the pathway as low risk for a 30-day major adverse cardiac event. Secondary outcomes include the proportion of low-risk patients who were discharged directly from general practice or rural hospitals, the proportion of patients reclassified as having acute myocardial infarction by the pathway and the proportion of patients with low and intermediate risk safely managed in the rural hospital.

The effect of acute coronary syndrome care pathways on in-hospital patients: A systematic review

BACKGROUND

Health care institutions need to construct management strategies for patients diagnosed with acute coronary syndrome (ACS) that focus on evidence-based treatments, adherence to treatment guidelines, and organized care. These help to reduce variations as well as the mortality and morbidity rates, which indicates the critical need for standardized care and adherence to evidence-based practices for patients hospitalized with ACS. The care pathways translate research and guidelines into clinical practice to close the gap between the guidelines and the clinical practices.

OBJECTIVES

This review focuses on identifying the indicators used to evaluate ACS care pathways and their effect on the care process and clinical outcomes.

METHODS

This review follows the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The systematic research was conducted using five research databases. Two groups were created by dividing the studies according to their year of publication. The first group included those studies published from 1997 to 2007 ("Group 1"), while the second included those published from 2008 to 2018 ("Group 2"). Selected studies were screened using the Effective Public Health Practice Project (EPHPP) quality assessment tool.

RESULTS

Seventeen studies were included in this review. One study was a randomized controlled trial, 14 were predesigns and postdesigns, and two were longitudinal observational designs. The Group 1 studies demonstrated that ACS care pathways had a positive effect on reducing the length of the hospital stay and the door-to-balloon times. Similar effects were observed for the Group 2 studies.

CONCLUSION

Implementing ACS care pathway helps to organize care processes and decrease treatment delays as well as improve the patient outcomes without adverse consequences for patients or additional resources and costs. While the current level of evidence is inadequate to warrant a formal recommendation, there is a need for more studies with an emphasis on well-designed randomization to measure patient outcomes.

Hospital-Based Quality Improvement Interventions for Patients With Acute Coronary Syndrome: A Systematic Review

BACKGROUND

Quality improvement initiatives have been developed to improve acute coronary syndrome care largely in high-income country settings. We sought to synthesize the effect size and quality of evidence from randomized controlled trials (RCTs) and nonrandomized studies for hospital-based acute coronary syndrome quality improvement interventions on clinical outcomes and process of care measures for their potential implementation in low- and middle-income country settings.

METHODS AND RESULTS

We conducted a bibliometric search of databases and trial registers and a hand search in 2016 and performed an updated search in May 2018 and May 2019. We performed data extraction, risk of bias assessment, and quality of evidence assessments in duplicate. We assessed differences in outcomes by study design comparing RCTs to nonrandomized quasi-experimental studies and by country income status. A meta-analysis was not feasible due to substantial, unexplained heterogeneity among the included studies, and thus, we present a qualitative synthesis. We screened 5858 records and included 32 studies (14 RCTs [n=109 763] and 18 nonrandomized quasi-experimental studies [n=54-423]). In-hospital mortality ranged from 2.1% to 4.8% in the intervention groups versus 3.3% to 5.1% in the control groups in 5 RCTs (n=55 942). Five RCTs (n=64 313) reported 3.0% to 31.0% higher rates of reperfusion for patients with ST-segment-elevation myocardial infarction in the intervention groups. The effect sizes for in-hospital and discharge medical therapies in a majority of RCTs were 3.0% to 10.0% higher in the intervention groups. There was no significant difference in 30-day mortality evaluated by 4 RCTs (n=42 384), which reported 2.5% to 15.0% versus 5.9% to 22% 30-day mortality rates in the intervention versus control groups. In contrast, nonrandomized quasi-experimental studies reported larger effect sizes compared to RCTs. There were no significant consistent differences in outcomes between high-income and middle-income countries. Low-income countries were not represented in any of the included studies.

CONCLUSIONS

Hospital-based acute coronary syndrome quality improvement interventions have a modest effect on process of care measures but not on clinical outcomes with expected differences by study design. Although quality improvement programs have an ongoing and important role for acute coronary syndrome quality of care in high-income country settings, further research will help to identify key components for contextualizing and implementing such interventions to new settings to achieve their desired effects. Systematic Review Registration: URL: https://www.crd.york.ac.uk/PROSPERO/. Unique identifier: CRD42016047604.

Effectiveness of interventions to improve cardiovascular healthcare in rural areas: a systematic literature review of clinical trials

The objective of this systematic literature review is to examine the impact of interventions to improve cardiovascular disease healthcare provided to people living in rural areas. Systematic electronic searches were conducted in Medline, CINAHL, Embase, Scopus, and Web of Knowledge in July 2018. We included clinical trials assessing the effectiveness of interventions to improve cardiovascular disease healthcare in rural areas. Study eligibility assessment, data extraction, and critical appraisal were undertaken by two reviewers independently. We identified 18 trials (18 interventions). They targeted myocardial infarction (five interventions), stroke (eight), and heart failure (five). All the interventions for myocardial infarction were based on organizational changes (e.g. implementation of mobile coronary units). They consistently reduced time to treatment and decreased mortality. All the interventions for heart failure were based on the provision of patient education. They consistently improved patient knowledge and self-care behaviour, but mortality reductions were reported in only some of the trials. Among the interventions for stroke, those based on the implementation of telemedicine (tele-stroke systems or tele-consultations) improved monitoring of stroke survivors; those based on new or enhanced rehabilitation services did not consistently improve mortality or physical function; whereas educational interventions effectively improved patient knowledge and behavioural outcomes. In conclusion, a number of different strategies (based on enhancing structures and providing patient education) have been proposed to improve cardiovascular disease healthcare in rural areas. Although available evidence show that these interventions can improve healthcare processes, their impact on mortality and other important health outcomes still remains to be established.

Review of implementation strategies to change healthcare provider behaviour in the emergency department

OBJECTIVES

Advances in emergency medicine research can be slow to make their way into clinical care, and implementing a new evidence-based intervention can be challenging in the emergency department. The Canadian Association of Emergency Physicians (CAEP) Knowledge Translation Symposium working group set out to produce recommendations for best practice in the implementation of a new science in Canadian emergency departments.

METHODS

A systematic review of implementation strategies to change health care provider behaviour in the emergency department was conducted simultaneously with a national survey of emergency physician experience. We summarized our findings into a list of draft recommendations that were presented at the national CAEP Conference 2017 and further refined based on feedback through social media strategies.

RESULTS

We produced 10 recommendations for implementing new evidence-based interventions in the emergency department, which cover identifying a practice gap, evaluating the evidence, planning the intervention strategy, monitoring, providing feedback during implementation, and desired qualities of future implementation research.

CONCLUSIONS

We present recommendations to guide future emergency department implementation initiatives. There is a need for robust and well-designed implementation research to guide future emergency department implementation initiatives.

Patient healthcare trajectory. An essential monitoring tool: a systematic review

BACKGROUND

Patient healthcare trajectory is a recent emergent topic in the literature, encompassing broad concepts. However, the rationale for studying patients' trajectories, and how this trajectory concept is defined remains a public health challenge. Our research was focused on patients' trajectories based on disease management and care, while also considering medico-economic aspects of the associated management. We illustrated this concept with an example: a myocardial infarction (MI) occurring in a patient's hospital trajectory of care. The patient follow-up was traced via the prospective payment system. We applied a semi-automatic text mining process to conduct a comprehensive review of patient healthcare trajectory studies. This review investigated how the concept of trajectory is defined, studied and what it achieves.

METHODS

We performed a PubMed search to identify reports that had been published in peer-reviewed journals between January 1, 2000 and October 31, 2015. Fourteen search questions were formulated to guide our review. A semi-automatic text mining process based on a semantic approach was performed to conduct a comprehensive review of patient healthcare trajectory studies. Text mining techniques were used to explore the corpus in a semantic perspective in order to answer non-a priori questions. Complementary review methods on a selected subset were used to answer a priori questions.

RESULTS

Among the 33,514 publications initially selected for analysis, only 70 relevant articles were semi-automatically extracted and thoroughly analysed. Oncology is particularly prevalent due to its already well-established processes of care. For the trajectory thema, 80% of articles were distributed in 11 clusters. These clusters contain distinct semantic information, for example health outcomes (29%), care process (26%) and administrative and financial aspects (16%).

CONCLUSION

This literature review highlights the recent interest in the trajectory concept. The approach is also gradually being used to monitor trajectories of care for chronic diseases such as diabetes, organ failure or coronary artery and MI trajectory of care, to improve care and reduce costs. Patient trajectory is undoubtedly an essential approach to be further explored in order to improve healthcare monitoring.

Implementation of effective practices in health facilities: a systematic review of cluster randomised trials

Background

The capacity for health systems to support the translation of research in to clinical practice may be limited. The cluster randomised controlled trial (cluster RCT) design is often employed in evaluating the effectiveness of implementation of evidence-based practices. We aimed to systematically review available evidence to identify and evaluate the components in the implementation process at the facility level using cluster RCT designs.

Methods

All cluster RCTs where the healthcare facility was the unit of randomisation, published or written from 1990 to 2014, were assessed. Included studies were analysed for the components of implementation interventions employed in each. Through iterative mapping and analysis, we synthesised a master list of components used and summarised the effects of different combinations of interventions on practices.

Results

Forty-six studies met the inclusion criteria and covered the specialty groups of obstetrics and gynaecology (n=9), paediatrics and neonatology (n=4), intensive care (n=4), internal medicine (n=20), and anaesthetics and surgery (n=3). Six studies included interventions that were delivered across specialties. Nine components of multifaceted implementation interventions were identified: leadership, barrier identification, tailoring to the context, patient involvement, communication, education, supportive supervision, provision of resources, and audit and feedback. The four main components that were most commonly used were education (n=42, 91%), audit and feedback (n=26, 57%), provision of resources (n=23, 50%) and leadership (n=21, 46%).

Conclusions

Future implementation research should focus on better reporting of multifaceted approaches, incorporating sets of components that facilitate the translation of research into practice, and should employ rigorous monitoring and evaluation.

The effectiveness of emergency nurse practitioner service in the management of patients presenting to rural hospitals with chest pain: a multisite prospective longitudinal nested cohort study

BACKGROUND

Health reforms in service improvement have included the use of nurse practitioners. In rural emergency departments, nurse practitioners work to the full scope of their expanded role across all patient acuities including those presenting with undifferentiated chest pain. Currently, there is a paucity of evidence regarding the effectiveness of emergency nurse practitioner service in rural emergency departments. Inquiry into the safety and quality of the service, particularly regarding the management of complex conditions is a priority to ensure that this service improvement model meets health care needs of rural communities.

METHODS

This study used a prospective, longitudinal nested cohort study of rural emergency departments in Queensland, Australia. Sixty-one consecutive adult patients with chest pain who presented between November 2014 and February 2016 were recruited into the study cohort. A nested cohort of 41 participants with suspected or confirmed acute coronary syndrome were identified. The primary outcome was adherence to guidelines and diagnostic accuracy of electrocardiograph interpretation for the nested cohort. Secondary outcomes included service indicators of waiting times, diagnostic accuracy as measured by unplanned representation rates, satisfaction with care, quality-of-life, and functional status. Data were examined and compared for differences for participants managed by emergency nurse practitioners and those managed in the standard model of care.

RESULTS

The median waiting time was 8.0 min (IQR 20) and length-of-stay was 100.0 min (IQR 64). Participants were 2.4 times more likely to have an unplanned representation if managed by the standard service model. The majority of participants (91.5%) were highly satisfied with the care that they received, which was maintained at 30-day follow-up measurement. In the evaluation of quality of life and functional status, summary scores for the SF-12 were comparable with previous studies. No differences were demonstrated between service models.

CONCLUSIONS

There was a high level of adherence to clinical guidelines for the emergency nurse practitioner service model and a concomitant high level of diagnostic accuracy. Nurse practitioner service demonstrated comparable effectiveness to that of the standard care model in the evaluation of the service indicators and patient reported outcomes. These findings provide a foundation for the beginning evaluation of rural emergency nurse practitioner service in the delivery of safe and effective beyond the setting of minor injury and illness presentations.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12616000823471 (Retrospectively registered).

Impact of a care pathway for COPD on adherence to guidelines and hospital readmission: a cluster randomized trial

PURPOSE

Current in-hospital management of exacerbations of COPD is suboptimal, and patient outcomes are poor. The primary aim of this study was to evaluate whether implementation of a care pathway (CP) for COPD improves the 6 months readmission rate. Secondary outcomes were the 30 days readmission rate, mortality, length of stay and adherence to guidelines.

PATIENTS AND METHODS

An international cluster randomized controlled trial was performed in Belgium, Italy and Portugal. General hospitals were randomly assigned to an intervention group where a CP was implemented or a control group where usual care was provided. The targeted population included patients with COPD exacerbation.

RESULTS

Twenty-two hospitals were included, whereof 11 hospitals (n=174 patients) were randomized to the intervention group and 11 hospitals (n=168 patients) to the control group. The CP had no impact on the 6 months readmission rate. However, the 30 days readmission rate was significantly lower in the intervention group (9.7%; 15/155) compared to the control group (15.3%; 22/144) (odds ratio =0.427; 95% confidence interval 0.222-0.822; P=0.040). Performance on process indicators was significantly higher in the intervention group for 2 of 24 main indicators (8.3%).

CONCLUSION

The implementation of this in-hospital CP for COPD exacerbation has no impact on the 6 months readmission rate, but it significantly reduces the 30 days readmission rate.

Knowledge translation studies in paediatric emergency medicine: A systematic review of the literature

AIM

Systematic review of knowledge translation studies focused on paediatric emergency care to describe and assess the interventions used in emergency department settings.

METHODS

Electronic databases were searched for knowledge translation studies conducted in the emergency department that included the care of children. Two researchers independently reviewed the studies.

RESULTS

From 1305 publications identified, 15 studies of varied design were included. Four were cluster-controlled trials, two patient-level randomised controlled trials, two interrupted time series, one descriptive study and six before and after intervention studies. Knowledge translation interventions were predominantly aimed at the treating clinician, with some targeting the organisation. Studies assessed effectiveness of interventions over 6-12 months in before and after studies, and 3-28 months in cluster or patient level controlled trials. Changes in clinical practice were variable, with studies on single disease and single treatments in a single site showing greater improvement.

CONCLUSIONS

Evidence for effective methods to translate knowledge into practice in paediatric emergency medicine is fairly limited. More optimal study designs with more explicit descriptions of interventions are needed to facilitate other groups to effectively apply these procedures in their own setting.

Prevention of cardiovascular disease in rural Australian primary care: an exploratory study of the perspectives of clinicians and high-risk men

Rural primary care services have the potential to play a major role in reducing the gap in cardiovascular disease (CVD) outcomes between rural and metropolitan Australians, particularly in men at high risk of CVD. The aim of this study was to explore the self-reported behaviours and satisfaction with their general practice/practitioner of men at high risk of CVD, and attitudes of rural primary care clinicians regarding the role of primary care in CVD prevention. This observational research was addressed through survey questionnaires with rural men at high risk of CVD and semi-structured interviews with rural primary care clinicians. Fourteen rural primary care practices from towns with populations less than 25000 participated. One hundred and fifty-eight high-risk men completed the questionnaire. Their responses demonstrated poorly controlled risk factors despite a willingness to change. Alternatively, rural primary care clinicians (n=20) reported that patients were unlikely to change and that illness-based funding models inhibited cardiovascular preventive activities. Australians living in rural areas have worse CVD outcomes. In addition, there is a disparity in the assumptions of health providers and male patients at high risk of CVD in rural areas. This necessitates innovative rural primary care models that include a blended payment system that incentivises or funds preventive care alongside an emphasis on lifestyle advice, as well as an explicit strategy to influence clinician and patient behaviour to help address the disparity.

The quality of cardiovascular disease prevention in rural primary care

Objective

Design

Setting

Participants

Main outcome measures

Results

Conclusions

Effectiveness of an emergency nurse practitioner service for adults presenting to rural hospitals with chest pain: protocol for a multicentre, longitudinal nested cohort study

INTRODUCTION

Chest pain is common in emergency department (ED) patients and represents a considerable burden for rural health services. Health services reforms to improve access to care need appropriately skilled and supported clinicians in the delivery of safe and effective care, including the use of emergency nurse practitioners (ENPs). Despite increasing use of ENPs, little is known about the safety and quality of the service in the rural ED context. The aims of this study are (1) to examine the safety and quality of the ENP service model in the provision of care in the rural environment and (2) to evaluate the effectiveness of the service in the management of patients presenting with undifferentiated chest pain.

METHODS AND ANALYSIS

This is the protocol for a prospective longitudinal nested cohort study to compare the effectiveness of ENP service with that of standard care. Adults presenting to three rural EDs in Queensland, Australia with a primary presenting complaint of atraumatic chest pain will be eligible for enrolment. We will measure (1) clinician's use of evidence-based guidelines (2) diagnostic accuracy of ECG interpretation for the management of patients with suspected or confirmed ACS (3) service indicators of waiting times, length-of-stay and did-not-wait rates and (4) clinician's diagnostic accuracy as measured by rates of unplanned representation within 7 days (5) satisfaction with care, (6) quality-of-life and (7) functional status. To assess these outcomes we will use a combination of measures collected from routinely collected data, medical record review and questionnaires (with 30-day follow-up).

ETHICS AND DISSEMINATION

Queensland Health Human Research Ethics Committee (HREC) has approved this protocol. The results will be published in peer-reviewed scientific journals and presented at one or more scientific conferences.

What small rural emergency departments do: a systematic review of observational studies

OBJECTIVE

Small rural emergency facilities are an important part of emergency care in many countries. We performed a systematic review of observational studies to determine what is known about the patients these small rural emergency facilities treat, what types of interventions they undertake and how well they perform.

METHODS

Pubmed/Medline and Embase databases were systematically reviewed between 1980 and the present. Studies were included if they described hospital-affiliated emergency care facilities which were open 24-hours every day, and described themselves as rural, non-urban or non-metropolitan. Studies were excluded if facilities saw more than 15,000 patients annually. Study quality was assessed using 12 previously described indicators. Key activity and performance data were reported for individual studies but not numerically combined between studies.

RESULTS

The search strategy found 19 studies that included quantitative data on activity and performance. Nine studies were from Canada, six were from Australia and four from the United States. The settings and scales used varied widely. Few studies adhered to methodological recommendations. The most common presentation was for injury or poisoning (30-53%). The number of patients requiring attention within 15 min was small (2.5-2.8%). Nurses treated many patients without physician input.

CONCLUSIONS

There is only enough evidence in the literature to make the most basic inferences about what small rural emergency departments do. To allow evidence-based improvement, descriptive studies must employ measures and methods validated in the wider emergency medicine literature, and other research techniques should be considered.