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Cleak H, Osborne SR, de Looze JWM. Exploration of clinicians’ decision-making regarding transfer of patient care from the emergency department to a medical assessment unit: A qualitative study. PLoS One 2022; 17:e0263235. [PMID: 35113942 PMCID: PMC8812931 DOI: 10.1371/journal.pone.0263235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 01/16/2022] [Indexed: 11/18/2022] Open
Abstract
Background Hospitals face immense pressures in balancing patient throughput. Medical assessment units have emerged as a commonplace response to improve the flow of medical patients presenting to the emergency department requiring hospital admission and to ease overcrowding in the emergency department. The aim of this study was to understand factors influencing the decision-making behaviour of key stakeholders involved in the transfer of care of medical patients from one service to the other in a large, tertiary teaching hospital in Queensland, Australia. Methods We used a qualitative approach drawing on data from focus groups with key informant health and professional staff involved in the transfer of care. A theoretically-informed, semi-structured focus group guide was used to facilitate discussion and explore factors impacting on decisions made to transfer care of patients from the emergency department to the medical assessment unit. Thematic analysis was undertaken to look for patterns in the data. Results Two focus groups were conducted with a total of 15 participants. Four main themes were identified: (1) we have a process—we just don’t use it; (2) I can do it, but can they; (3) if only we could skype them; and (4) why can’t they just go up. Patient flow relies on efficiency in two processes—the transfer of care and the physical re-location of the patient from one service to the other. The findings suggest that factors other than clinical reasoning are at play in influencing decision-making behaviour. Conclusions Acknowledgement of the interaction within and between professional and health staff (human factors) with the organisational imperatives, policies, and process (system factors) may be critical to improve efficiencies in the service and minimise the introduction of workarounds that might compromise patient safety.
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Affiliation(s)
- Helen Cleak
- School of Allied Health, Human Service and Sport, College of Science, Health & Engineering, La Trobe University, Melbourne, Victoria, Australia
| | - Sonya R. Osborne
- School of Nursing and Midwifery, Faculty of Health, Engineering and Sciences, Centre for Health Research, Institute for Resilient Regions, University of Southern Queensland, Ipswich, Queensland, Australia
- * E-mail:
| | - Julian W. M. de Looze
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women’s Hospital, Metro North Hospital and Health Service, Herston, Queensland, Australia
- School of Medicine, The University of Queensland, St. Lucia, Queensland, Australia
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2
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Ibrahim H, Mohamad MK, Adi AAK, Kamour AM, Harhara T. The Impact of an Acute Medical Unit in Internal Medicine on Resident Education. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2022; 9:23821205221091037. [PMID: 35399787 PMCID: PMC8984854 DOI: 10.1177/23821205221091037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/08/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Medical trainees are expected to provide care for increasingly sick and treatment intensive patients. To improve patient care, hospitals worldwide have developed acute medical units (AMUs), dedicated medical wards that provide care for patients during the first 24 to 72 hours of an emergency medical hospital admission. A distinguishing feature of these units is that they are supervised by senior clinicians and offer multidisciplinary patient-centered care. Little is known about the impact of AMUs on trainee supervision and education. METHODS In this educational case study, we describe the evolution, process and structure of our AMU service. We also provide resident and teaching faculty perceptions of the impact of this intervention on education and supervision. RESULTS Questionnaire results showed that residents and teaching attendings believed that supervision and education were improved on the AMU, as compared to the traditional medical ward model. Residents also felt that their knowledge and clinical skills in managing acute patients improved. Procedure skills were less impacted by the intervention. A small number of residents believed that the AMU model worsened supervision and education. CONCLUSION Integrating medical trainees into an AMU allowed for early evaluation and input from senior clinicians and increased opportunities to work in and learn from multidisciplinary teams, contributing to improved resident supervision and education. Future studies are needed to assess the long-term impact of the AMU on educational outcomes.
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Affiliation(s)
- Halah Ibrahim
- Khalifa University College of Medicine and Health Sciences, Abu
Dhabi, United Arab Emirates
| | - Mohamad Kasem Mohamad
- Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi,
United Arab Emirates
| | - Abd Al Kareem Adi
- Education Institute, Sheikh Khalifa Medical City, Abu Dhabi, United
Arab Emirates
| | - Ashraf M. Kamour
- Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi,
United Arab Emirates
| | - Thana Harhara
- Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi,
United Arab Emirates
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3
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Osborne S, Cleak H, White N, Lee X, Deacon A, de Looze JWM. Effectiveness of clinical criteria in directing patient flow from the emergency department to a medical assessment unit in Queensland, Australia: a retrospective chart review of hospital administrative data. BMC Health Serv Res 2021; 21:527. [PMID: 34051765 PMCID: PMC8164739 DOI: 10.1186/s12913-021-06537-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
Background Medical Assessment Units (MAUs) have become a popular model of acute medical care to improve patient flow through timely clinical assessment and patient management. The purpose of this study was to determine the effectiveness of a consensus-derived set of clinical criteria for patient streaming from the Emergency Department (ED) to a 15-bed MAU within the highly capacity-constrained environment of a large quaternary hospital in Queensland, Australia. Methods Clinically coded data routinely submitted for inter-hospital benchmarking purposes was used to identify the cohort of medical admission patients presenting to the ED in February 2016 (summer) and June 2016 (winter). A retrospective review of patient medical records for this cohort was then conducted to extract MAU admission data, de-identified patient demographic data, and clinical criteria. The primary outcome was the proportion of admissions that adhered to the MAU admission criteria. Results Of the total of 540 included patients, 386 (71 %) patients were deemed to meet the MAU eligibility admission criteria. Among patients with MAU indications, 66 % were correctly transferred (95 % CI: 61 to 71) to the MAU; this estimated sensitivity was statistically significant when compared with random allocation (p-value < 0.001). Transfer outcomes for patients with contraindications were subject to higher uncertainty, with a high proportion of these patients incorrectly transferred to the MAU (73 % transferred; 95 % CI: 50 to 89 %; p-value = 0.052). Conclusions Based on clinical criteria, approximately two-thirds of patients were appropriately transferred to the MAU; however, a larger proportion of patients were inappropriately transferred to the MAU. While clinical criteria and judgement are generally established as the process in making decisions to transfer patients to a limited-capacity MAU, our findings suggest that other contextual factors such as bed availability, time of day, and staffing mix, including discipline profile of decision-making staff during ordinary hours and after hours, may influence decisions in directing patient flow. Further research is needed to better understand the interplay of other determinants of clinician decision making behaviour to inform strategies for improving more efficient use of MAUs, and the impact this has on clinical outcomes, length of stay, and patient flow measures in MAUs.
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Affiliation(s)
- Sonya Osborne
- School of Nursing and Midwifery, Centre for Health Research, Institute of Resilient Regions, University of Southern Queensland, 4305, Ipswich, Queensland, Australia. .,Australian Centre for Health Services Innovation, School of Public Health and Social Work, Queensland University of Technology, Queensland, 4059, Kelvin Grove, Australia.
| | - Helen Cleak
- Department of Community and Clinical Health, La Trobe University, 3086, Melbourne, Victoria, Australia
| | - Nicole White
- Australian Centre for Health Services Innovation, School of Public Health and Social Work, Queensland University of Technology, Queensland, 4059, Kelvin Grove, Australia
| | - Xing Lee
- Australian Centre for Health Services Innovation, School of Public Health and Social Work, Queensland University of Technology, Queensland, 4059, Kelvin Grove, Australia
| | - Anthony Deacon
- Department of Internal Medicine and Aged Care, Metro North Hospital and Health Service, Royal Brisbane and Women's Hospital, 4029, Herston, Queensland, Australia.,School of Medicine, The University of Queensland, 4067, St. Lucia, Queensland, Australia.,School of Electrical Engineering and Computer Science, Queensland University of Technology, Queensland, 4059, Kelvin Grove, Australia
| | - Julian W M de Looze
- Department of Internal Medicine and Aged Care, Metro North Hospital and Health Service, Royal Brisbane and Women's Hospital, 4029, Herston, Queensland, Australia.,School of Medicine, The University of Queensland, 4067, St. Lucia, Queensland, Australia
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Khan U, Menezes CN, Govind N. Patterns and outcomes of admissions to the medical acute care unit of a tertiary teaching hospital in South Africa. Afr J Emerg Med 2021; 11:26-30. [PMID: 33318914 PMCID: PMC7725673 DOI: 10.1016/j.afjem.2020.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 11/17/2020] [Accepted: 11/22/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND A Medical Acute Care Unit (MACU) was established at Chris Hani Baragwanath Academic Hospital (CHBAH) to provide comprehensive medical specialist care to the patients presenting with acute medical emergencies. Improved healthcare delivery systems at the MACU may result in shorter hospital stays, better outcomes, and less mortality. OBJECTIVES The study's objective was to describe the demographics, diagnoses, disease patterns, and outcomes, including patient's mortality, admitted to the MACU at CHBAH. METHODS Records of 200 patients admitted, between March 2015 to August 2015, to the MACU at CHBAH were reviewed. Patient demographics, diagnosis at admission, duration of stay, and outcomes were documented. Patients transferred to the medical ward, the Intensive Care Unit (ICU), or discharge. The leading causes of mortality were documented. RESULTS Of the 200 patients, 59% were females. The patients' mean age was 46 (17.2) years, and the mean duration of stay at the MACU was 1.45 (1.25) days. Non-communicable diseases accounted for 76% of admissions. The most frequently diagnosed conditions included: diabetic ketoacidosis acidosis (DKA) and hyperosmolar non-ketotic (HONK) (17.5%), non-accidental self-poisoning (16%), hypertensive emergencies (9.5%), decompensated cardiac failure (8%) and ischemic heart disease (7%). Infectious diseases comprised 14% of the diagnoses, of which cases of pneumonia were the most common (5%). Most patients (77.5%) were transferred to medical wards, 12% to ICU, while 10% demised at the MACU. The leading causes of death included sepsis (25%), DKA/HONK (20%), non-accidental self-poisoning (10%), and cardiac failure (10%). CONCLUSION Non-communicable diseases, particularly diabetic emergencies, were the leading causes of admission to the MACU at CHBAH. During the study period, high rates of case improvement, patient discharge, shorter hospital stay, and less mortality were observed. The leading cause of mortality was sepsis related.
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Sim MA, Lee SH, Phan PH, Lateef A. Quality improvement at an acute medical unit in an Asian Academic Center: A mixed methods study of nursing work dynamics. Nurs Outlook 2020; 68:169-183. [PMID: 32044102 DOI: 10.1016/j.outlook.2019.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 09/07/2019] [Accepted: 09/18/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The acute medical unit (AMU) provides early specialist care to emergency department patients before inpatient admission. The workflows and skills for successful AMU nursing comprise a hybrid of internal and emergency medicine. PURPOSE To understand nursing work dynamics in the AMU. METHODS AMU at a 1,250-bed tertiary academic center in Singapore with 14,000 ED presentations monthly. Retrospective mixed methods study using focus group discussions and surveys. Fifteen nurses across three focus group discussions. Thirty-two physicians and 54 nurses responded to a validated questionnaire. FINDINGS Focus group discussions transcripts content analyzed by two researchers. Survey items factor analyzed and attitudinal differences between AMU physicians and nurses, and among nurses compared using Student's t- and one-way ANOVA tests. DISCUSSION AMU nursing staff faced obstacles of inadequate patient information, emergency department onboarding, unbalanced workload, and coworker conflicts, which led to them to develop processes and checklists to manage patient information, patient expectations, and teamwork. CONCLUSION AMU nursing requires a combination of specialist internal medicine and emergency medicine skills. Training should familiarize nurse workforce with managing patient expectations and multidisciplinary teamwork.
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Affiliation(s)
- Ming Ann Sim
- National University Health System, Singapore, The Republic of Singapore
| | | | | | - Aisha Lateef
- National University of Singapore, Singapore, The Republic of Singapore
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6
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Hurley E, McHugh S, Browne J, Vaughan L, Normand C. A multistage mixed methods study protocol to evaluate the implementation and impact of a reconfiguration of acute medicine in Ireland's hospitals. BMC Health Serv Res 2019; 19:766. [PMID: 31665004 PMCID: PMC6819558 DOI: 10.1186/s12913-019-4629-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 10/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To address deficits in the delivery of acute services in Ireland, the National Acute Medicine Programme (NAMP) was established in 2010 to optimise the management of acutely ill medical patients in the hospital setting, and to ensure their supported discharge to primary and community-based care. NAMP aims to reduce inappropriate hospital admissions, reduce length of hospital stay and ensure patients receive timely treatment in the most appropriate setting. It does so primarily via the development of Acute Medical Assessment Units (AMAUs) for the rapid assessment and management of medical patients presenting to hospitals, as well as streamlining the care of those admitted for further care. This study will examine the impact of this programme on patient care and identify the factors influencing its implementation and operation. METHODS We will use a multistage mixed methods evaluation with an explanatory sequential design. Firstly, we will develop a logic model to describe the programme's outcomes, its components and the mechanisms of change by which it expects to achieve these outcomes. Then we will assess implementation by measuring utilisation of the Units and comparing the organisational functions implemented to that recommended by the NAMP model of care. Using comparative case study research, we will identify the factors which have influenced the programme's implementation and its operation using the Consolidated Framework for Implementation Research to guide data collection and analysis. This will be followed by an estimation of the impact of the programme on reducing overnight emergency admissions for potentially avoidable medical conditions, and reducing length of hospital stay of acute medical patients. Lastly, data from each stage will be integrated to examine how the programme's outcomes can be explained by the level of implementation. DISCUSSION This formative evaluation will enable us to examine whether the NAMP is improving patient care and importantly draw conclusions on how it is doing so. It will identify the factors that contribute to how well the programme is being implemented in the real-world. Lessons learnt will be instrumental in sustaining this programme as well as planning, implementing, and assessing other transformative programmes, especially in the acute care setting.
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Affiliation(s)
- E Hurley
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland.
| | - S McHugh
- School of Public Health, University College Cork, Cork, Ireland
| | - J Browne
- School of Public Health, University College Cork, Cork, Ireland
| | | | - C Normand
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
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7
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Reid LEM, Pretsch U, Jones MC, Lone NI, Weir CJ, Morrison Z. The acute medical unit model: A characterisation based upon the National Health Service in Scotland. PLoS One 2018; 13:e0204010. [PMID: 30281643 PMCID: PMC6169877 DOI: 10.1371/journal.pone.0204010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 08/31/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Acute medical units (AMUs) receive the majority of acute medical patients presenting to hospital as an emergency in the United Kingdom (UK) and in other international settings. They have emerged as a result of local service innovation in the context of a limited evidence base. As such, the AMU model is not well characterised in terms of its boundaries, patient populations and components of care. This makes service optimisation and development through strategic resource planning, quality improvement and research challenging. AIM This study aims to evaluate a national set of AMUs with the intent of characterising the AMU model. METHODS Twenty-nine AMUs in Scotland were identified. Data were collected by semi-structured interviews with multidisciplinary healthcare professionals working in each AMU. A draft report was produced for each unit and verified by a unit representative. The unit reports were then analysed to develop a conceptual framework of key components of AMUs and a service definition of the boundaries of acute medical care. RESULTS Acute medical care in Scotland can be described as being delivered in "acute medical services" rather than geographically distinct AMUs. Twelve key components of AMU care were identified: care areas, functions, populations, patient flow, support services, communication, nurse care, allied healthcare professional care, non-consultant medical care, consultant care, patient assessment and specialty care. DISCUSSION This empirically derived characterisation of the AMU model is likely to be of utility to practitioners, managers, policy makers and researchers: it is relevant on an operational level, will aid quality improvement and is a foundation to needed further research into how best to deliver care in AMUs. This is important given the central role AMUs play in the journey of the majority of patients presenting to hospital acutely in Scotland, the UK and internationally.
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Affiliation(s)
- Lindsay E. M. Reid
- Development and Delivery Department, Ko Awatea Health Systems Innovation and Improvement, Auckland, New Zealand
- Quality, Research and Standards, Royal College of Physicians of Edinburgh, Edinburgh, United Kingdom
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Ursula Pretsch
- Quality, Research and Standards, Royal College of Physicians of Edinburgh, Edinburgh, United Kingdom
| | - Michael C. Jones
- Quality, Research and Standards, Royal College of Physicians of Edinburgh, Edinburgh, United Kingdom
| | - Nazir I. Lone
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Christopher J. Weir
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
- Edinburgh Clinical Trials Unit; University of Edinburgh, Edinburgh, United Kingdom
| | - Zoe Morrison
- Business School, University of Aberdeen, Aberdeen, United Kingdom
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8
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Reid LEM, Crookshanks AJF, Jones MC, Morrison ZJ, Lone NI, Weir CJ. How is it best to deliver care in acute medical units? A systematic review. QJM 2018; 111:515-523. [PMID: 29025141 DOI: 10.1093/qjmed/hcx161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Indexed: 11/12/2022] Open
Abstract
The majority of medical patients presenting to hospital in the UK are cared for in acute medical units (AMUs). Such units are also increasingly present internationally. Care delivery varies across units: this review aims to examine the evidence for how best to deliver AMU care.Six electronic databases and grey literature were searched. Inclusion criteria comprised interventions applied to undifferentiated patients in AMU settings. All studies were quality assessed. A narrative approach was undertaken.Nine studies, all conducted in the UK or Ireland, evaluated 1.3 million episodes, 3617 patients and 49 staff. There was single study evidence for beneficial effects of: enhanced pharmacy care, a dedicated occupational therapy service, an all-inclusive consultant work pattern, a rapid-access medical clinic and formalized handovers. Two studies found increased consultant presence was associated with reduced mortality; one of these studies found an association with a reduction in 28-day readmissions; and the other found an association with an increased proportion of patients discharged on the day they were admitted. Three studies provide evidence of the beneficial effects of multiple interventions developed from local service reviews.Overall, the quality of the evidence was limited. This review has identified operationally relevant evidence that increased consultant presence is associated with improved outcomes of care; has highlighted the potential to improve outcomes locally through service reviews; and has demonstrated an important knowledge gap of how best to deliver AMU care. These findings have importance given the challenges acute services currently face.
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Affiliation(s)
- L E M Reid
- Ko Awatea Health Systems Innovation and Improvement, Middlemore Hospital, 54/100 Hospital Road, Auckland 2025, New Zealand
- Royal College of Physicians of Edinburgh, 9 Queen Street, Edinburgh EH2 1JQ, UK
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK
| | - A J F Crookshanks
- The Queen Elizabeth University Hospital, 1345 Govan Road, Govan, G51 4TF, Glasgow, UK
| | - M C Jones
- Royal College of Physicians of Edinburgh, 9 Queen Street, Edinburgh EH2 1JQ, UK
| | - Z J Morrison
- Business School, University of Aberdeen, Edward Wright Building, Dunbar Street, Aberdeen AB24 3QY, UK
| | - N I Lone
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK
| | - C J Weir
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK
- Edinburgh Clinical Trials Unit, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK
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Ebker-White A, Bein KJ, Dinh MM. Extending the Sydney Triage to Admission Risk Tool (START+) to predict discharges and short stay admissions. Emerg Med J 2018; 35:471-476. [PMID: 29914922 DOI: 10.1136/emermed-2017-207227] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 04/22/2018] [Accepted: 05/09/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study aims to validate previously reported triage tool titled Sydney Triage to Admission Risk Tool (START+) and investigate whether an extended version of the tool could be used to identify and stream appropriate short stay admissions to ED observation units or specialised short stay inpatient wards. METHODS This was a prospective study at two metropolitan EDs in Sydney, Australia. Consecutive triage encounters were observed by a trained researcher and START scores calculated. The primary outcome was length of stay <48 hours. Multivariable logistic regression was used to estimate area under curve of receiver operator characteristic (AUROC) for START scores. The original START tool was then extended to include frailty and multiple or major comorbidities as additional variables to assess for further predictive accuracy. RESULTS There were 894 patients analysed during the study period. Of the 894 patients, there were 732 patients who were either discharged from ED or admitted for <2 days. The AUROC for the original START+ tool was 0.80 (95% CI 0.77 to 0.83). The presence of frailty was found to add a further five points and multiple comorbidities added another four points on top of the START score, and the AUROC for the extended START score 0.84 (95% CI 0.81 to 0.88). CONCLUSION The overall performance of the extended ED disposition prediction tool that included frailty and multiple medical comorbidities significantly improved the ability of the START tool to identify patients likely to be discharged from ED or require short stay admission <2 days. TRIAL REGISTRATION NUMBER ACTRN12618000426280.
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Affiliation(s)
| | - Kendall J Bein
- Royal Prince Alfred Hospital, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael M Dinh
- Discipline of Emergency Medicine, The University of Sydney, Sydney, New South Wales, Australia
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Reid LEM, Lone NI, Morrison ZJ, Weir CJ, Jones MC. The provision of seven day multidisciplinary staffing in Scottish acute medical units: a cross-sectional study. QJM 2018; 111:295-301. [PMID: 29408979 DOI: 10.1093/qjmed/hcy024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Acute medical units (AMUs) are a central component of the admission pathway for the majority of medical patients presenting to hospital in the United Kingdom and other international settings. Detail on multidisciplinary staffing provision on weekdays and weekends is lacking. Equity of staffing across 7 days is a strategic priority for national health services in the United Kingdom. AIM To evaluate weekday compared with weekend multidisciplinary staffing in a national set of AMUs. DESIGN Cross-sectional survey. METHODS Twenty-nine Scottish AMUs were identified and all were included in the study population. Data were collected by semi-structured interviews with nursing, pharmacy, therapy, non-consultant medical and consultant staff. Staffing was quantified in staff hours. A correction factor of 0.5 was applied to non-dedicated staff. The percentage of weekend/weekday staffing was calculated for each unit and the mean of these percentages was calculated to give a summary measure for each professional group. RESULTS As a percentage of weekday staffing levels, weekend staffing across the units was 93.8% for nursing staff; 2.2% for pharmacy staff; 13.1% for therapy staff; 69.6% for non-consultant staff and 65.0% for consultant staff. CONCLUSIONS There is a contrast between weekday and weekend staffing on the AMU, with reductions at weekends in total staff hours, the proportion of dedicated vs. undedicated staff and the seniority of nursing staff. The weekday/weekend difference was far more pronounced for allied healthcare professional staff than any other group. These findings have potential implications for patient outcomes, quality of care, hospital flow and workforce planning.
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Affiliation(s)
- L E M Reid
- Department of Development and Delivery, Ko Awatea Health Systems Innovation and Improvement, Middlemore Hospital, 54/100 Hospital Rd, Auckland 2025, New Zealand
- Quality, Research and Standards, Royal College of Physicians of Edinburgh, 9 Queen Street, Edinburgh EH2 1JQ, UK
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK
| | - N I Lone
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK
| | - Z J Morrison
- Business School, University of Aberdeen, Edward Wright Building, Dunbar Street, Aberdeen AB24 3QY, UK
| | - C J Weir
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK
- Edinburgh Clinical Trials Unit, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK
| | - M C Jones
- Quality, Research and Standards, Royal College of Physicians of Edinburgh, 9 Queen Street, Edinburgh EH2 1JQ, UK
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11
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Ting J. Collaborative research between emergency medicine and physicians. Intern Med J 2018; 48:379-381. [PMID: 29623997 DOI: 10.1111/imj.13749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 11/19/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Joseph Ting
- Department of Emergency Medicine, Mater Hospital Brisbane, South Brisbane, Queensland, Australia.,Department of Emergency Medicine, Ipswich Hospital, Brisbane, Queensland, Australia.,School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
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13
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van Galen LS, Lammers EMJ, Schoonmade LJ, Alam N, Kramer MHH, Nanayakkara PWB. Acute medical units: The way to go? A literature review. Eur J Intern Med 2017; 39:24-31. [PMID: 27843036 DOI: 10.1016/j.ejim.2016.11.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 11/01/2016] [Accepted: 11/02/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Acute healthcare chains in the Netherlands are increasingly under pressure because of rising emergency department (ED) admissions, relative bed shortages and government policy changes. In order to improve acute patient flow and quality of care through hospitals, an acute medical unit (AMU) might be a solution, as demonstrated in the UK. However, limited information is available concerning AMUs in the Netherlands. Therefore, the aims of this study were to METHODS: A systematic literature search was performed searching 3 electronic databases: PubMed, Cochrane and EMBASE. All 106 hospitals in the Netherlands were contacted, inquiring about the status of an ED, the AMU or future plans to start one. RESULTS The literature search resulted in 31 studies that met inclusion criteria. In general, these studies reported significant benefits on number of admissions, hospital length of stay (LOS), mortality, other wards and readmissions. Among the Dutch hospitals with an ED, 33 out of 93 implemented an AMU or similar ward, these are however organized heterogeneously. Following current trends, more AMUs are expected to be realized in the future. CONCLUSION In order to improve the current strain on the Dutch acute healthcare system, an AMU could potentially provide benefits. However, uniform guideline is warranted to optimize and compare quality of care throughout the Netherlands.
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Affiliation(s)
- L S van Galen
- VU University Medical Centre, Section Acute Medicine, Department of Internal Medicine, Amsterdam, The Netherlands
| | - E M J Lammers
- VU University Medical Centre, Section Acute Medicine, Department of Internal Medicine, Amsterdam, The Netherlands
| | - L J Schoonmade
- VU University Medical Centre, Medical Library, VU University, Amsterdam, The Netherlands
| | - N Alam
- VU University Medical Centre, Section Acute Medicine, Department of Internal Medicine, Amsterdam, The Netherlands
| | - M H H Kramer
- VU University Medical Centre, Section Acute Medicine, Department of Internal Medicine, Amsterdam, The Netherlands
| | - P W B Nanayakkara
- VU University Medical Centre, Section Acute Medicine, Department of Internal Medicine, Amsterdam, The Netherlands.
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Rushton C, Crilly J, Adeleye A, Grealish L, Beylacq M, Forbes M. Scoping review of medical assessment units and older people with complex health needs. Australas J Ageing 2016; 36:19-25. [DOI: 10.1111/ajag.12353] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Carole Rushton
- Subacute and Aged Nursing; Gold Coast Hospital and Health Services; Gold Coast Queensland Australia
- School of Nursing and Midwifery; Griffith University; Menzies Health Institute; Gold Coast Queensland Australia
| | - Julia Crilly
- Emergency Care; School of Nursing and Midwifery; Menzies Health Institute; Griffith University; Gold Coast Queensland Australia
- Gold Coast Hospital and Health Services; Gold Coast Queensland Australia
| | - Adeniyi Adeleye
- School of Nursing and Midwifery; Central Queensland University; Mackay Queensland Australia
| | - Laurie Grealish
- Subacute and Aged Nursing; Gold Coast Hospital and Health Services; Gold Coast Queensland Australia
- School of Nursing and Midwifery; Griffith University; Menzies Health Institute; Gold Coast Queensland Australia
- The Education for Practice Institute; Charles Stuart University; Sydney New South Wales Australia
| | - Mandy Beylacq
- Aged Services; Gold Coast Hospital and Health Services; Robina Health Precinct; Gold Coast Queensland Australia
| | - Mark Forbes
- Diagnostics, Emergency and Medical Services; Gold Coast Hospital and Health Services; Gold Coast Queensland Australia
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Reid LEM, Dinesen LC, Jones MC, Morrison ZJ, Weir CJ, Lone NI. The effectiveness and variation of acute medical units: a systematic review. Int J Qual Health Care 2016; 28:433-46. [PMID: 27313174 DOI: 10.1093/intqhc/mzw056] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2016] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To evaluate the evidence for the effectiveness of acute medical units (AMUs) compared with other models of care and compare the components of AMU models. DATA SOURCES Six electronic databases and grey literature sources searched between 1990 and 2014. STUDY SELECTION Studies reporting on AMUs as an intervention for unplanned medical presentations to hospital with the inclusion of all outcome measures/study designs/comparators. DATA EXTRACTION Data on study characteristics/outcomes/AMU components were extracted by one author and confirmed by a second. DATA SYNTHESIS Seventeen studies of 12 AMUs across five countries were included. The AMU model was associated with a reduction in-hospital length of stay (LOS) in all analyses ranging from 0.3 to 2.6 days; and a reduction in mortality in 12 of the 14 analyses with the change ranging from a 0.1% increase to a 8.8% reduction. Evidence relating to readmissions and patient/staff satisfaction was less conclusive. There was variation in the following components of AMUs: admission criteria, entry sources, functions and consultant work patterns. CONCLUSION This review provides evidence that AMUs are associated with reductions in-hospital LOS and, less convincingly, mortality compared with other models of care when implemented in European and Australasian settings. Reported estimates may be affected by residual confounding. This review reports heterogeneity in components of the AMU model. Further work to identify what constitutes the key components of an AMU is needed to improve the quality and effectiveness of acute medical care. This is of particular importance given the escalating demand on acute services.
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Affiliation(s)
- Lindsay E M Reid
- The Royal College of Physicians of Edinburgh, Quality, Research and Standards Office, 9 Queen Street, EH2 1JQ Edinburgh, UK Centre for Population Health Sciences, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | | | - Michael C Jones
- The Royal College of Physicians of Edinburgh, Quality, Research and Standards Office, 9 Queen Street, EH2 1JQ Edinburgh, UK
| | | | - Christopher J Weir
- Centre for Population Health Sciences, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK Edinburgh Clinical Trials Unit, Edinburgh, UK
| | - Nazir I Lone
- Centre for Population Health Sciences, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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Abstract
Acute medicine and acute medical units are relatively new innovations. The evolving evidence base is demonstrating the effectiveness of these in improving care given to patients with acute medical illness. This article reviews the available evidence.
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Affiliation(s)
- Mike Jones
- Acute Medicine, University Hospital of North Durham, Durham, UK
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Abstract
The complex undifferentiated patient, often elderly, is not obviously the responsibility of a clinician who specialises in single-system pathology. A clinician with more general skills and an ability to work in a multidisciplinary team is required. New partnerships are developing for these clinicians outside the Royal Australasian College of Physicians. A workforce expert in traditional skills for patient care as well as in new skills, away from the bedside, will help the future Australasian hospital care for these complicated patients. International perspectives could be of value.
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Elder E, Johnston AN, Crilly J. Review article: systematic review of three key strategies designed to improve patient flow through the emergency department. Emerg Med Australas 2015. [PMID: 26206428 DOI: 10.1111/1742-6723.12446] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To explore the literature regarding three key strategies designed to promote patient throughput in the ED. CINAHL, Medline, PubMed, Scopus and Australian Government databases were searched for articles published between 1980 and 2014 using the key search terms ED flow/throughput, ED congestion, crowding, overcrowding, models of care, physician-assisted triage, medical assessment units, nurse practitioner, did not wait (DNW) and ED length of stay (LOS). Abstracts and articles not published in English and articles published before 1980 were excluded from the review. Quantitative and qualitative studies were considered for inclusion. The National Health Medical Research Council (NHMRC) Level of Evidence Hierarchy (2009) was applied to included studies. Twenty-one articles met criteria for review. The level of evidence assessed using the NHMRC guidelines of studies ranged from I to IV, with the majority falling into the Level II-2 (n = 6) and III-3 (n = 9) range. ED LOS was the outcome most often reported. Study quality was limited with few studies adjusting for confounding factors. Only one level I systematic review was included in this review. Advanced practice nursing roles, physician-assisted triage and medical assessment units are models of care that can positively impact ED throughput. They have been shown to decrease ED LOS and DNW rates. Confounding factors, such as site specific staffing requirements, patient acuity and rest-of-hospital processes, can also impact on patient throughput through the ED.
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Affiliation(s)
- Elizabeth Elder
- School of Nursing and Midwifery, Griffith Health, Gold Coast Campus, Griffith University, Brisbane, Queensland, Australia
| | - Amy Nb Johnston
- Department of Emergency Medicine and Griffith Health Institute, Gold Coast Hospital and Health Service and Griffith University, Gold Coast, Queensland, Australia
| | - Julia Crilly
- Department of Emergency Medicine and Griffith Health Institute, Gold Coast Hospital and Health Service and Griffith University, Gold Coast, Queensland, Australia
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Elder E, Johnston ANB, Crilly J. Improving emergency department throughput: An outcomes evaluation of two additional models of care. Int Emerg Nurs 2015. [PMID: 26208424 DOI: 10.1016/j.ienj.2015.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study was to explore the impact of incorporating a physician at triage (PAT) and the implementation of a medical assessment unit (MAU) on emergency department (ED) patient throughput. METHODS A retrospective comparative analysis of two additional models of care (standard care, T1; PAT, T2 and PATplusMAU, T3) was undertaken. Patient presentations to a large public teaching hospital in South-East Queensland between 10th January 2013 and 25th February 2013, and the same time period in 2012, were included. The impact of these care models on ED length of stay and other outcomes (time to be seen by a clinician, time from bed request to ward transfer, meeting 4 hour transit targets, admission rates and the proportion of patients who did not wait) were compared. RESULTS Compared to standard care, ED length of stay appeared to decrease with the introduction of both models, but was only significantly decreased after PATplusMAU was implemented (2013; T1, 186 min; T2, 181 min; T3, 175 min: T1 vs T3, P < 0.001). Outcomes that improved included: time to be seen by a clinician, proportion of patients who did not wait; increase in meeting 4-hour length of stay target for both admitted and not-admitted patients. CONCLUSION Placing a physician at triage and implementing a medical assessment unit were viable models of care that promoted patient flow and helped meet several time-sensitive health service targets.
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Affiliation(s)
- Elizabeth Elder
- School of Nursing & Midwifery, Griffith Health, Gold Coast Campus, Griffith University, QLD 4222, Australia.
| | - Amy N B Johnston
- Department of Emergency Medicine & Griffith Health Institute, Gold Coast Hospital and Health Service & Griffith University, Southport, QLD 4215, Australia
| | - Julia Crilly
- Department of Emergency Medicine & Griffith Health Institute, Gold Coast Hospital and Health Service & Griffith University, Southport, QLD 4215, Australia
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20
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Shetty AL, Shankar Raju SB, Hermiz A, Vaghasiya M, Vukasovic M. Age and admission times as predictive factors for failure of admissions to discharge-stream short-stay units. Emerg Med Australas 2014; 27:42-6. [PMID: 25406761 DOI: 10.1111/1742-6723.12329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Discharge-stream emergency short-stay units (ESSU) improve ED and hospital efficiency. Age of patients and time of hospital presentations have been shown to correlate with increasing complexity of care. We aim to determine whether an age and time cut-off could be derived to subsequently improve short-stay unit success rates. METHODS We conducted a retrospective audit on 6703 (5522 inclusions) patients admitted to our discharge-stream short-stay unit. Patients were classified as appropriate or inappropriate admissions, and deemed successful if discharged out of the unit within 24 h; and failures if they needed inpatient admission into the hospital. We calculated short-stay unit length of stay for patients in each of these groups. A 15% failure rate was deemed as acceptable key performance indicator (KPI) for our unit. RESULTS There were 197 out of 4621 (4.3%, 95% CI 3.7-4.9%) patients up to the age of 70 who failed admission to ESSU compared with 67 out of 901 (7.4%, 95% CI 5.9-9.3%, P < 0.01) of patients over the age of 70, reflecting an increased failure rate in geriatric population. When grouped according to times of admission to the ESSU (in-office 06.00-22.00 hours vs out-of-office 22.00-06.00 hours) no significant difference rates in discharge failure (4.7% vs 5.2%, P = 0.46) were noted. CONCLUSION Patients >70 years of age have higher rates of failure after admission to discharge-stream ESSU. Although in appropriately selected discharge-stream patients, no age group or time-band of presentation was associated with increased failure rate beyond the stipulated KPI.
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Affiliation(s)
- Amith L Shetty
- Emergency Department, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Emergency Medicine Research Unit, Sydney, New South Wales, Australia; NHMRC Centre for Research Excellence in Critical Infection, Westmead Millennium Institute for Medical Research, Sydney, New South Wales, Australia
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21
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Vaghasiya MR, Murphy M, O'Flynn D, Shetty A. The emergency department prediction of disposition (EPOD) study. ACTA ACUST UNITED AC 2014; 17:161-6. [PMID: 25112947 DOI: 10.1016/j.aenj.2014.07.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 07/07/2014] [Accepted: 07/08/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Emergency departments (ED) continue to evolve models of care and streaming as interventions to tackle the effects of access block and overcrowding. Tertiary ED may be able to design patient-flow based on predicted dispositions in the department. Segregating discharge-stream patients may help develop patient-flows within the department, which is less affected by availability of beds in a hospital. We aim to determine if triage nurses and ED doctors can predict disposition outcomes early in the patient journey and thus lead to successful streaming of patients in the ED. METHODS During this study, triage nurses and ED doctors anonymously predicted disposition outcomes for patients presenting to triage after their brief assessments. Patient disposition at the 24-h post ED presentation was considered as the actual outcome and compared against predicted outcomes. RESULTS Triage nurses were able to predict actual discharges of 445 patients out of 490 patients with a positive predictive value (PPV) of 90.8% (95% CI 87.8-93.2%). ED registrars were able to predict actual discharges of 85 patients out of 93 patients with PPV of 91.4% (95% CI 83.3-95.9%). ED consultants were able to predict actual discharges of 111 patients out of 118 patients with PPV 94.1% (95% CI 87.7-97.4%). PPVs for admission among ED consultants, ED registrars and Triage nurses were 59.7%, 54.4% and 48.5% respectively. CONCLUSIONS Triage nurses, ED consultants and ED registrars are able to predict a patient's discharge disposition at triage with high levels of confidence. Triage nurses, ED consultants, and ED registrars can predict patients who are likely to be admitted with equal ability. This data may be used to develop specific admission and discharge streams based on early decision-making in EDs by triage nurses, ED registrars or ED consultants.
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Affiliation(s)
- Milan R Vaghasiya
- Westmead Hospital Emergency Department, Corner of Darcy and Hawkesbury Roads, Westmead, Sydney, New South Wales 2145, Australia.
| | - Margaret Murphy
- Westmead Hospital Emergency Department, Corner of Darcy and Hawkesbury Roads, Westmead, Sydney, New South Wales 2145, Australia
| | - Daniel O'Flynn
- Westmead Hospital Emergency Department, Corner of Darcy and Hawkesbury Roads, Westmead, Sydney, New South Wales 2145, Australia
| | - Amith Shetty
- Westmead Hospital Emergency Department, Corner of Darcy and Hawkesbury Roads, Westmead, Sydney, New South Wales 2145, Australia
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Ulltang M, Vivanti AP, Murray E. Malnutrition prevalence in a medical assessment and planning unit and its association with hospital readmission. AUST HEALTH REV 2014; 37:636-41. [PMID: 24200115 DOI: 10.1071/ah13051] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 07/14/2013] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To investigate malnutrition prevalence on presentation to a Medical Assessment and Planning Unit (MAPU) in a setting designed to prevent hospital admission, the association of nutritional status with hospital readmission at 90 days, and agreement of nutritional risk between the Malnutrition Screening Tool (MST) and Subjective Global Assessment (SGA). METHODS Prospective longitudinal cohort study of consecutive patients admitted to MAPU during the first 6 weeks of operation. The main outcome measures were prevalence of malnutrition and hospital readmission at 90 days. Sensitivity and specificity of the MST was assessed against the criterion standard of SGA. RESULTS The mean participant age was 62 years (n = 153, s.d. 17.4 years) with 50% male (77/153, 95% CI 42-58%). According to the SGA, 17% (95% CI 8-26%) were assessed as malnourished on admission. The MST identified that 18% (95% CI 12-24%) were at nutritional risk, and participants screening positive for nutritional risk had significantly increased odds of hospital readmission at 90 days (OR 3.4, 95% CI, 1.3-9.1, P < 0.029). The MST was practical and successfully identified patients assessed as malnourished within the MAPU setting (sensitivity 73%, specificity 76%, negative predictive value 93%, positive predictive value 38%). CONCLUSIONS Malnutrition is a significant problem in a MAPU setting, and patients screened at nutritional risk are at significantly higher risk of hospital readmission within 90 days.
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Affiliation(s)
- Marte Ulltang
- Queensland University of Technology, Victoria Park Road, Kelvin Grove, Qld 4059, Australia
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Dinh MM, Bein KJ, Byrne CM, Gabbe B, Ivers R. Deriving a prediction rule for short stay admission in trauma patients admitted at a major trauma centre in Australia. Emerg Med J 2013; 31:263-7. [PMID: 23407379 DOI: 10.1136/emermed-2012-202222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The aim of this study was to derive and internally validate a prediction rule for short stay admissions (SSAs) in trauma patients admitted to a major trauma centre. METHODS A retrospective study of all trauma activation patients requiring inpatient admission at a single inner city major trauma centre in Australia between 2007 and 2011 was conducted. Logistic regression was used to derive a multivariable model for the outcome of SSA (length of stay ≤2 days excluding deaths or intensive care unit admission). Model discrimination was tested using area under receiver operator characteristic curve analyses and calibration was tested using the Hosmer-Lemeshow test statistic. Validation was performed by splitting the dataset into derivation and validation datasets and further tested using bootstrap cross validation. RESULTS A total of 2593 patients were studied and 30% were classified as SSAs. Important independent predictors of SSA were injury severity score ≤8 (OR 7.8; 95% CI 5.0 to 11.9), Glasgow coma score 14-15 (OR 3.2; 95% CI 1.8 to 5.4), no need for operative intervention (OR 2.2; 95% CI 1.6 to 3.2) and age < 65 years. (OR 1.7; 95% CI 1.2 to 2.6). The overall model had an area under receiver operator characteristic curve of 0.84 (95% CI 0.82 to 0.87) for the derivation dataset. After bootstrap cross validation the area under the curve of the final model was 0.83 (95% CI 0.81 to 0.84). CONCLUSIONS We report a prediction rule that could be used to establish admission criteria for a trauma short stay unit. Further studies are required to prospectively validate the prediction rule.
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Affiliation(s)
- Michael M Dinh
- Emergency Department, Royal Prince Alfred Hospital, , Sydney, New South Wales, Australia
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Ong BS, Van Nguyen H, Ilyas M, Boyatzis I, Ngian VJJ. Medical Assessment Units and the older patient: a retrospective case-control study. AUST HEALTH REV 2012; 36:331-5. [PMID: 22935127 DOI: 10.1071/ah11076] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 12/22/2011] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the effect of a Medical Assessment Unit (MAU) on older patients. METHODS Retrospective case-control study of patients 65 years and above admitted to the MAU (study group) and the general medical wards (control group) in Bankstown-Lidcombe Hospital from 1 October 2008 to 31 March 2009 with four most common Diagnosis-Related Groups (DRG) ('falls and gait disorder', 'chronic obstructive pulmonary disease (COPD)', 'other major respiratory diseases and 'cellulitis'). MAIN OUTCOME MEASURES Length of stay (LOS) in Emergency Department (ED) and in the hospital, mortality, readmissions within 1 month, and discharge destination. RESULTS Eighty-nine patients were studied; 47 in the MAU group and 42 in the non-MAU group. The MAU cohort was significantly older (84.1 ± 7.9 years v. 80.4 ± 7.8 years, respectively, P=0.03); and had shorter ED LOS (4.9 ± 3.0h v. 6.5 ± 2.8h, P=0.012). Overall hospital LOS did not differ except for patients with 'cellulitis', (5.7 ± 4.9 days for MAU cohort v. 14.8 ± 6.8 days for non-MAU cohort, P=0.022). There was no significant difference in mortality, readmission rate or discharge destination. Conclusions. The MAU can be an effective service model for older patients. More research is required to confirm this and to define the key elements that are essential for its effectiveness.
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Affiliation(s)
- Bin S Ong
- Medical Assessment Unit and Department of Aged Care, Bankstown-Lidcombe Hospital, Eldridge Road, NSW 2200, Australia.
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Realdi G, Giannini S, Fioretto P, Fabris F, Vettore G, Tosato F. Diagnostic pathways of the complex patients: rapid intensive observation in an Acute Medical Unit. Intern Emerg Med 2011; 6 Suppl 1:85-92. [PMID: 22009617 DOI: 10.1007/s11739-011-0681-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
The present-day patients have complex diseases that are responsible for the great increase of medical interventions, overcrowding in emergency departments and access to the wards, increased waiting times and length of stay, difficult discharge, increased readmission rate and finally increased mortality. By breaking the steps of the patients pathways it allows us to simplify the problems and to face the individual aspects of the complexity related to the management of patients in the hospital. One solution that has been growing in popularity is the rapid intensive observation of the patients in acute hospital setting within Internal Medicine wards. This model has been otherwise defined with different terminology, but the most widely used name is Acute Medical Unit (AMU). We describe the model of an AMU within an Internal Medicine department as proposed and adopted in Anglo-Saxon countries, the methods of clinical approach and the practical organisation of the units in close collaboration with the ED ward. Finally we report our experience at an Internal Medicine department in Padova and the initial results obtained during the first 4 months of the project. Our approach of intensive rapid observation of intermediate risk patients admitted from the ED led to a significant reduction in the duration of hospitalization, without increasing readmission rate after discharge and fatality rate. Factors significantly associated to a short hospital stay were a preserved function and a lower number of previous admissions to the hospital. Several gray zones in the realisation and management of the project were identified and the possible solutions are still matter of discussion and debate.
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Affiliation(s)
- Giuseppe Realdi
- Clinica Medica 1, Department of Medical and Surgical Sciences of University of Padova, Policlinico Universitario, Via Giustiniani 2, Padua, Italy.
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Jenkins PF, Thompson CH, Barton LL. Clinical deterioration in the condition of patients with acute medical illness in Australian hospitals: improving detection and response. Med J Aust 2011; 194:596-8. [PMID: 21644875 DOI: 10.5694/j.1326-5377.2011.tb03113.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Accepted: 02/22/2011] [Indexed: 11/17/2022]
Abstract
Medical Assessment Units (MAUs) provide an opportunity for multidisciplinary staff to manage recently admitted acutely unwell patients with complex medical illnesses. We propose concerted development of robust mechanisms for identifying and managing patients whose condition is unstable as they move through hospital departments. Track, trigger and response (TTR) systems (eg, medical emergency team calls and early warning scores) have been introduced to hospital practice, but evidence for their effectiveness is, so far, incomplete. The current variation in TTR systems within and between hospitals impairs intersite comparisons. A range of outcome measures, including risk of physiological deterioration, mortality and projected hospital length of stay, could be usefully investigated by future intersite collaborative research. More deliberate, systematic, evidence-based design of "response" in TTR systems may help in identifying patients who need early attention from skilled medical staff. We need more uniform TTR systems, more research on TTR systems and more multisite research; MAUs are ideally situated to address this important area.
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Jenkins PF, Thompson CH, MacDonald AB. What does the future hold for general medicine? Med J Aust 2011; 195:49-50. [DOI: 10.5694/j.1326-5377.2011.tb03192.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Accepted: 02/15/2011] [Indexed: 11/17/2022]
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