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Williamson M, Barton A, Edwards D, Morrisby C, Jacques A, Harper KJ. Improving care for older patients visiting emergency departments. Are they receiving falls prevention guideline care? Australas Emerg Care 2023; 26:84-89. [PMID: 35995675 DOI: 10.1016/j.auec.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/27/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND The primary objective was to examine whether the Emergency Department (ED) treatment of older adults who fall in Australia is concordant with falls prevention and management clinical guideline care recommendations. METHODS A retrospective medical records audit was completed for patients 65years and older, who attended the ED with a fall and were discharged home. An audit tool was developed from local, national, and international falls clinical guidelines. RESULTS One thousand and twenty-seven patients presented following a fall throughout 2020. One hundred and seven patient medical records were audited. Assessment of cognition (94%), medication review (76%) and use of a falls risk screen (76%) were commonly completed. Under half of the patients had a documented gait evaluation (40%) and review of vision (18%). Concordance with guideline care was more likely for older patients (p = 0.042), with higher levels of comorbidity (p = 0.013), who required care assistance (p = 0.008) and received treatment from a multidisciplinary team (p < 0.001) in an observation ward (p < 0.001). CONCLUSIONS Older patients with increased comorbidities and higher care needs had more falls guideline care recommendations documented. This was likely to occur when patients were moved to the observation ward where more comprehensive care by a multidisciplinary team could occur.
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Affiliation(s)
- Melinda Williamson
- Occupational Therapy Department, Sir Charles Gairdner Hospital, Australia.
| | - Annette Barton
- Occupational Therapy Department, Sir Charles Gairdner Hospital, Australia
| | - Deborah Edwards
- Occupational Therapy Department, Sir Charles Gairdner Hospital, Australia
| | | | - Angela Jacques
- Institute for Health Research, The University of Notre Dame Australia, Australia
| | - Kristie J Harper
- Occupational Therapy Department, Sir Charles Gairdner Hospital, Australia; Curtin University, School of Allied Health, Australia
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2
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Lines LM. Games People Play: Lessons on Performance Measure Gaming from New Zealand Comment on "Gaming New Zealand's Emergency Department Target: How and Why Did It Vary Over Time and Between Organisations?". Int J Health Policy Manag 2021; 10:225-227. [PMID: 32610791 PMCID: PMC8167274 DOI: 10.34172/ijhpm.2020.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 03/05/2020] [Indexed: 11/18/2022] Open
Abstract
For decades, observers have noted that gaming of performance measurement appears to be both endemic and endlessly creative. A recent study by Tenbensel and colleagues provides a detailed look at gaming of a health system performance measure—emergency department (ED) wait times—within four hospitals in New Zealand. Combined, these four hospitals handled more than 25% of the ED visits in the country each year. Tenbensel and colleagues examine whether the New Zealand ED wait time target was set appropriately and whether we can trust any performance measure statistics that are not independently verified or audited. Their thoughtprovoking examination is relevant to anyone working in quality improvement and provides a valuable set of tools for detecting gaming in performance measurement.
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Affiliation(s)
- Lisa M Lines
- Center for Advanced Methods Development, RTI International, Durham, NC, USA.,Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Oberlin M, Andrès E, Behr M, Kepka S, Le Borgne P, Bilbault P. [Emergency overcrowding and hospital organization: Causes and solutions]. Rev Med Interne 2020; 41:693-699. [PMID: 32861534 DOI: 10.1016/j.revmed.2020.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 04/14/2020] [Accepted: 05/05/2020] [Indexed: 10/23/2022]
Abstract
Emergency Department (ED) overcrowding is a silent killer. Thus, several studies in different countries have described an increase in mortality, a decrease in the quality of care and prolonged hospital stays associated with ED overcrowding. Causes are multiple: input and in particular lack of access to lab test and imaging for general practitioners, throughput and unnecessary or time-consuming tasks, and output, in particular the availability of hospital beds for unscheduled patients. The main cause of overcrowding is waiting time for available beds in hospital wards, also known as boarding. Solutions to resolve the boarding problem are mostly organisational and require the cooperation of all department and administrative levels through efficient bed management. Elderly and polypathological patients wait longer time in ED. Internal Medicine, is the ideal specialty for these complex patients who require time for observation and evaluation. A strong partnership between the ED and the internal medicine department could help to reduce ED overcrowding by improving care pathways.
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Affiliation(s)
- M Oberlin
- Structure d'urgences, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France.
| | - E Andrès
- Service de Médecine Interne, Diabète et Maladies métaboliques, Hôpitaux Universitaires de Strasbourg, Clinique Médicale B - HUS, 1 porte de l'Hôpital, 67000 Strasbourg, France; Unité INSERM EA 3072 « Mitochondrie, Stress oxydant et Protection musculaire », Faculté de Médecine - Université de Strasbourg, 4 rue Kirschleger, 67085 Strasbourg, France
| | - M Behr
- Structure d'urgences, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France
| | - S Kepka
- Structure d'urgences, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France
| | - P Le Borgne
- Structure d'urgences, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France; Unité INSERM UMR 1260, Regenerative NanoMedicine (RNM), Fédération de Médecine Translationnelle (FMTS), Faculté de Médeine - Université de Strasbourg, 4 rue Kirschleger, 67085 Strasbourg, France
| | - P Bilbault
- Structure d'urgences, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France; Unité INSERM UMR 1260, Regenerative NanoMedicine (RNM), Fédération de Médecine Translationnelle (FMTS), Faculté de Médeine - Université de Strasbourg, 4 rue Kirschleger, 67085 Strasbourg, France
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Affiliation(s)
- Adrian A Boyle
- Emergency Department, Addenbrooke's Hospital Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Katherine Henderson
- Emergency Department, Guys & St Thomas' NHS Foundation Trust, London, UK.,Royal College of Emergency Medicine, London, UK
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Tenbensel T, Jones P, Chalmers LM, Ameratunga S, Carswell P. Gaming New Zealand's Emergency Department Target: How and Why Did It Vary Over Time and Between Organisations? Int J Health Policy Manag 2020; 9:152-162. [PMID: 32331495 PMCID: PMC7182144 DOI: 10.15171/ijhpm.2019.98] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 10/18/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Gaming is a potentially dysfunctional consequence of performance measurement and management systems in the health sector and more generally. In 2009, the New Zealand government initiated a Shorter Stays in Emergency Department (SSED) target in which 95% of patients would be admitted, discharged or transferred from an emergency department (ED) within 6 hours. The implementation of similar targets in England led to well-documented practices of gaming. Our research into ED target implementation sought to answer how and why gaming varies over time and between organisations. METHODS We developed a mixed-methods approach. Four organisation case study sites were selected. ED lengths of stay (ED LOS) were collected over a 6-year period (2007-2012) from all sites and indicators of target gaming were developed. Two rounds of surveys with managers and clinicians were conducted. Interviews (n=68) were conducted with clinicians and managers in EDs and the wider hospital in two phases across all sites. The interview data was used to develop explanations of the patterns of variation across time and across sites detected in the ED LOS data. RESULTS Our research established that gaming behaviour - in the form of 'clock-stopping' and decanting patients to short-stay units (SSUs) or observation beds to avoid target breaches - was common across all 4 case study sites. The opportunity to game was due to the absence of independent verification of ED LOS data. Gaming increased significantly over time (2009-2012) as the means to game became more available, usually through the addition or expansion of short-stay facilities attached to EDs. Gaming varied between sites, but those with the highest levels of gaming differed substantially in terms of organisational dynamics and motives. In each case, however, high levels of gaming could be attributed to the strategies of senior management more than to the individual motivations of frontline staff. CONCLUSION Gaming of New Zealand's ED target increased after the real benefits (in terms of process improvement) of the target were achieved. Gaming of ED targets could be minimised by eliminating opportunities to game through independent verification, or by monitoring and limiting the means and motivations to game.
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Affiliation(s)
- Tim Tenbensel
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Peter Jones
- Auckland District Health Board Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | | | - Shanthi Ameratunga
- School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Peter Carswell
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Prang KH, Canaway R, Bismark M, Dunt D, Kelaher M. The impact of Australian healthcare reforms on emergency department time-based process outcomes: An interrupted time series study. PLoS One 2018; 13:e0209043. [PMID: 30540856 PMCID: PMC6291126 DOI: 10.1371/journal.pone.0209043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/27/2018] [Indexed: 12/01/2022] Open
Abstract
Background In 2011, the Australian government introduced national healthcare reforms aimed at increasing the timeliness and quality of hospital care. The healthcare reforms included, but were not limited to, emergency department (ED) time-based targets, financial incentives, and public performance reporting of hospital data. We sought to evaluate the impact of the national healthcare reforms on ED time-based process outcomes. Methods A quasi-experimental study of ED presentations from 2006 to 2016 in the state of Victoria, Australia. Uncontrolled, interrupted time-series analyses were used to evaluate, by hospital peer groups, the effect of national healthcare reforms on: patient wait times for treatment; treatment within recommended time; and patient departure within four hours of arrival in ED. Results There were small improvements in ED time-based process outcomes following the introduction of the national healthcare reforms. These occurred in most hospital peer groups immediately and over the longer term, across the various triage categories. The largest improvements occurred in small hospitals and smallest improvements in medium sized hospitals. ED time-based targets, now abolished by the Australian government, were not achieved in any hospital peer groups. Conclusions Our findings suggest that national healthcare reforms had the potential to prompt fundamental changes in ED processes leading to significant improvements in ED performances across most hospital peer groups but were generally unable to reach the ED targets imposed nationally. ED performances also varied by hospital peer groups. Attention to ED time-based process outcomes within hospital peer groups may provide insights into hospital practices that could improve the quality and efficiency of ED care.
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Affiliation(s)
- Khic-Houy Prang
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rachel Canaway
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marie Bismark
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - David Dunt
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Margaret Kelaher
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- * E-mail:
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Higginson I, Boyle A. What should we do about crowding in emergency departments? Br J Hosp Med (Lond) 2018; 79:500-503. [DOI: 10.12968/hmed.2018.79.9.500] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ian Higginson
- College Registrar, Royal College of Emergency Medicine, London EC4A 1DT
| | - Adrian Boyle
- Chair, Quality in Emergency Care Committee, Royal College of Emergency Medicine, London
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Van Der Linden MC, Van Loon M, Feenstra NSF, Van Der Linden N. Assessing bottlenecks in Emergency Department flow of patients with abdominal pain. Int Emerg Nurs 2018; 40:1-5. [PMID: 29636284 DOI: 10.1016/j.ienj.2018.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/14/2018] [Accepted: 03/22/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Abdominal pain has a wide range of possible causes, which may lead to difficulties in diagnosing and lengthy Emergency Department (ED) stays. In this study, bottlenecks in ED processes of patients with abdominal pain were identified. METHODS Time-points of patients who presented to a Dutch ED with abdominal pain were observed and documented. The institutional review board approved the study. RESULTS In total, 3015 min of patient time were observed in 54 patients. Median length of stay (LOS) was 218 min for admitted patients, and 168 min for discharged patients. For 65 patients (27.4%), LOS exceeded 4 h. Delays were found during the diagnostic process, when multiple physicians were needed in order to make a decision, and during departure. CONCLUSIONS Our study concerning individual patients' time-points provides important insight into delays in the patient journey of patients with abdominal pain. Flow improvement can be achieved by focusing on these bottlenecks, for example by minimizing diagnostic delays and by simultaneous specialists' consultations for patients who need more than one physician. The optimization of ED flow for patients with abdominal pain depends on coordinated efforts between ED staff, medical specialists, radiology and laboratory staff, staff from inpatient units, and hospital supporting services.
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Affiliation(s)
| | - Merel Van Loon
- Emergency Department, Haaglanden Medical Center, PO Box 432, 2501 CK The Hague, The Netherlands.
| | - Nienke S F Feenstra
- Erasmus University, Rotterdam, Burgemeester Oudlaan 50, 3062 PA Rotterdam, The Netherlands.
| | - Naomi Van Der Linden
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, PO Box 123, Broadway, Sydney, NSW 2007, Australia.
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Tenbensel T, Chalmers L, Jones P, Appleton-Dyer S, Walton L, Ameratunga S. New Zealand's emergency department target - did it reduce ED length of stay, and if so, how and when? BMC Health Serv Res 2017; 17:678. [PMID: 28950856 PMCID: PMC5615466 DOI: 10.1186/s12913-017-2617-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 09/13/2017] [Indexed: 11/10/2022] Open
Abstract
Background In 2009, the New Zealand government introduced a hospital emergency department (ED) target – 95% of patients seen, treated or discharged within 6 h - in order to alleviate crowding in public hospital EDs. While these targets were largely met by 2012, research suggests that such targets can be met without corresponding overall reductions in ED length-of-stay (LOS). Our research explores whether the NZ ED time target actually reduced ED LOS, and if so, how and when. Methods We adopted a mixed-methods approach with integration of data sources. After selecting four hospitals as case study sites, we collected all ED utilisation data for the period 2006 to 2012. ED LOS data was derived in two forms-reported ED LOS, and total ED LOS - which included time spent in short-stay units. This data was used to identify changes in the length of ED stay, and describe the timing of these changes to these indicators. Sixty-eight semi-structured interviews and two surveys of hospital clinicians and managers were conducted between 2011 and 2013. This data was then explored to identify factors that could account for ED LOS changes and their timing. Results Reported ED LOS reduced in all sites after the introduction of the target, and continued to reduce in 2011 and 2012. However, total ED LOS only decreased from 2008 to 2010, and did not reduce further in any hospital. Increased use of short-stay units largely accounted for these differences. Interview and survey data showed changes to improve patient flow were introduced in the early implementation period, whereas increased ED resources, better information systems to monitor target performance, and leadership and social marketing strategies mainly took throughout 2011 and 2012 when total ED LOS was not reducing. Conclusions While the ED target clearly stimulated improvements in patient flow, our analysis also questions the value of ED targets as a long term approach. Increased use of short-stay units suggests that the target became less effective in ‘standing for’ improved timeliness of hospital care in response to increasing acute demand. As such, the overall challenges in managing demand for acute and urgent care in New Zealand hospitals remain. Electronic supplementary material The online version of this article (10.1186/s12913-017-2617-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tim Tenbensel
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, 92019, Auckland, 1142, New Zealand.
| | - Linda Chalmers
- Nursing Development Unit, Auckland City Hospital, Private Bag 92024, Auckland, 1142, New Zealand
| | - Peter Jones
- Adult Emergency Department, Auckland City Hospital, Private Bag 92024, Auckland, 1142, New Zealand
| | - Sarah Appleton-Dyer
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, 92019, Auckland, 1142, New Zealand
| | - Lisa Walton
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, 92019, Auckland, 1142, New Zealand
| | - Shanthi Ameratunga
- Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, 92019, Auckland, 1142, New Zealand
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Pope I, Burn H, Ismail SA, Harris T, McCoy D. A qualitative study exploring the factors influencing admission to hospital from the emergency department. BMJ Open 2017; 7:e011543. [PMID: 28851767 PMCID: PMC5577896 DOI: 10.1136/bmjopen-2016-011543] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The number of emergency admissions to hospital in England and Wales has risen sharply in recent years and is a matter of concern to clinicians, policy makers and patients alike. However, the factors that influence this decision are poorly understood. We aimed to ascertain how non-clinical factors can affect hospital admission rates. METHOD We conducted semistructured interviews with 21 participants from three acute hospital trusts. Participants included 11 emergency department (ED) doctors, 3 ED nurses, 3 managers and 4 inpatient doctors. A range of seniority was represented among these roles. Interview questions were developed from key themes identified in a theoretical framework developed by the authors to explain admission decision-making. Interviews were recorded, transcribed and analysed by two independent researchers using framework analysis. FINDINGS Departmental factors such as busyness, time of day and levels of senior support were identified as non-clinical influences on a decision to admit rather than discharge patients. The 4-hour waiting time target, while overall seen as positive, was described as influencing decisions around patient admission, independent of clinical need. Factors external to the hospital such as a patient's social support and community follow-up were universally considered powerful influences on admission. Lastly, the culture within the ED was described as having a strong influence (either negatively or positively) on the decision to admit patients. CONCLUSION Multiple factors were identified which go some way to explaining marked variation in admission rates observed between different EDs. Many of these factors require further inquiry through quantitative research in order to understand their influence further.
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Affiliation(s)
- Ian Pope
- Emergency Department, Royal London Hospital, London, UK
| | - Helen Burn
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Sharif A Ismail
- Barts Health NHS Trust and Queen Mary University of London, London, UK
| | - Tim Harris
- Emergency Department, Royal London Hospital, London, UK
| | - David McCoy
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
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