Practices and knowledge levels of prehospital doctors in traumatic brain injury management in Hubei, China

This thesis is a cross-sectional questionnaire survey of pre-hospital doctors' knowledge and practice of managing traumatic brain injury in two major cities of Hubei province, China. This study provides evidence for future research on improving the quality of pre-hospital management in China.

Emergency department models of care in the context of care quality and cost: A systematic review

To identify current ED models of care and their impact on care quality, care effectiveness, and cost. A systematic search of key health databases (Medline, CINAHL, Cochrane, EMbase) was conducted to identify literature on ED models of care. Additionally, a focused review of the contents of 11 international and national emergency medicine, nursing and health economic journals (published between 2010 and 2013) was undertaken with snowball identification of references of the most recent and relevant papers. Articles published between 1998 and 2013 in the English language were included for initial review by three of the authors. Studies in underdeveloped countries and not addressing the objectives of the present study were excluded. Relevant details were extracted from the retrieved literature, and analysed for relevance and impact. The literature was synthesised around the study's main themes. Models described within the literature mainly focused on addressing issues at the input, throughput or output stages of ED care delivery. Models often varied to account for site specific characteristics (e.g. onsite inpatient units) or to suit staffing profiles (e.g. extended scope physiotherapist), ED geographical location (e.g. metropolitan or rural site), and patient demographic profile (e.g. paediatrics, older persons, ethnicity). Only a few studies conducted cost-effectiveness analysis of service models. Although various models of delivering emergency healthcare exist, further research is required in order to make accurate and reliable assessments of their safety, clinical effectiveness and cost-effectiveness.

Discovering future disaster management capability needs using scenario planning

In recent years disaster risk reduction efforts have focused on disturbances ranging from climate variability, seismic hazards, geo-political instability and public and animal health crises. These factors combined with uncertainty derived from inter-dependencies within and across systems of critical infrastructure create significant problems of governance for the private and public sector alike. The potential for rapid spread of impacts, geographically and virtually, can render a comprehensive understanding of disaster response and recovery needs and risk mitigation issues beyond the grasp of competent authority. Because of such cascading effects communities and governments at local and state-levels are unlikely to face single incidents but rather series of systemic impacts: often appearing concurrently. A further point to note is that both natural and technological hazards can act directly on socio-technical systems as well as being propagated by them: as network events. Such events have been categorised as ‘outside of the box,’ ‘too fast,’ and ‘too strange’ (Lagadec, 2004). Emergent complexities in linked systems can make disaster effects difficult to anticipate and recovery efforts difficult to plan for. Beyond the uncertainties of real world disasters, that might be called familiar or even regular, can we safely assume that the generic capability we use now will suit future disaster contexts? This paper presents initial scoping of research funded by the Bushfire and Natural Hazards Cooperative Research Centre seeking to define future capability needs of disaster management organisations. It explores challenges to anticipating the needs of representative agencies and groups active in before, during and after phases of emergency and disaster situations using capability deficit assessments and scenario assessment.

Emergency pre-hospital disaster response training. What's the state of play?

Study/Objective This study examines the current state of disaster response education for Australian paramedics from a national and international perspective and identifies both potential gaps in content and challenges to the sustainability of knowledge acquired through occasional training. Background As demands for domestic and international disaster response increase, experience in the field has begun to challenge traditional assumptions that response to mass casualty events requires little specialist training. The need for a “streamlined process of safe medical team deployment into disaster regions”1 is generally accepted and, in Australia, the emergence of national humanitarian aid training has begun to respond to this gap. However, calls for a national framework for disaster health education2 haven’t received much traction. Methods A critical analysis of the peer reviewed and grey literature on the core components/competencies and training methods required to prepare Australian paramedics to contribute to effective health disaster response has been conducted. Research from the past 10 years has been examined along with federal and state policy with regard to paramedic disaster education. Results The literature shows that education and training for disaster response is variable and that an evidence based study specifically designed to outline sets of core competencies for Australian health care professionals has never been undertaken. While such competencies in disaster response have been developed for the American paradigm it is suggested that disaster response within the Australian context is somewhat different to that of the US, and therefore a gap in the current knowledge base exists. Conclusion Further research is needed to develop core competencies specific to Australian paramedics in order to standardise teaching in the area of health disaster management. Until this occurs the task of evaluating or creating disaster curricula that adequately prepares and maintains paramedics for an effective all hazards disaster response is seen as largely unattainable.

Structural quality indicators to support quality of care for older people with cognitive impairment in emergency departments

Objectives The purpose of this study was to identify the structural quality of care domains and to establish a set of structural quality indicators (SQIs) for the assessment of care of older people with cognitive impairment in emergency departments (EDs). Methods A structured approach to SQI development was undertaken including: 1) a comprehensive search of peer-reviewed and gray literature focusing on identification of evidence-based interventions targeting structure of care of older patients with cognitive impairment and existing SQIs; 2) a consultative process engaging experts in the care of older people and epidemiologic methods (i.e., advisory panel) leading to development of a draft set of SQIs; 3) field testing of drafted SQIs in eight EDs, leading to refinement of the SQI set, and; 4) an independent voting process among the panelists for SQI inclusion in a final set, using preestablished inclusion and exclusion criteria. Results At the conclusion of the process, five SQIs targeting the management of older ED patients with cognitive impairment were developed: 1) the ED has a policy outlining the management of older people with cognitive impairment during the ED episode of care; 2) the ED has a policy outlining issues relevant to carers of older people with cognitive impairment, encompassing the need to include the (family) carer in the ED episode of care; 3) the ED has a policy outlining the assessment and management of behavioral symptoms, with specific reference to older people with cognitive impairment; 4) the ED has a policy outlining delirium prevention strategies, including the assessment of patients' delirium risk factors, and; 5) the ED has a policy outlining pain assessment and management for older people with cognitive impairment. Conclusions This article presents a set of SQIs for the evaluation of performance in caring for older people with cognitive impairment in EDs.

General practice coordinated chronic disease management to reduce avoidable hospital admission

Chronic disease accounts for about 80 per cent of the total disease burden in Australia, and its management accounts for 70 per cent of all current health expenditure.1 Effective prevention and management of chronic disease requires a coordinated approach between primary health care, acute care services, and the patients.2 However, what is not clear is whether improvements in primary healthcare management can have a clear benefit in the cost of care of patients with chronic disease. We recently completed a pilot study in rural Western Australia to ascertain the feasibility of a coordinated general practice-based approach to managing chronic respiratory and cardiovascular conditions, and to determine the direct cost savings to the public insurer through reduction in avoidable hospital admission. The aim of this correspondence is to share our preliminary findings and encourage debate on how such a project may be scaled up or adapted to other primary healthcare settings.

Public use and perceptions of emergency departments: A population survey

Objectives To inform demand management strategies aimed at reducing congestion in EDs by: (i) identifying public use of EDs, decision-making and reasons; and (ii) measuring acceptance of alternative care models. Methods A cross-sectional telephone survey of a random sample of Queensland population aged 18 years or older residing in a dwelling unit in Queensland that could be contacted on a land-based telephone service was conducted. One person per household was selected according to a predetermined algorithm to ensure sex and regional balance were interviewed. The main outcome measures were: ED use, attitudes towards ED staff and services, and alternative models of care. Results The final sample included a total of 1256 respondents (response rate = 40.3%). Twenty-one per cent attended EDs in the preceding 12 months. The decision to attend was made by patients (51%), health and medical professionals (31%), and others (18%). The main reasons included perceived severity of the illness (47%), unavailability of alternative services (26%) and better care (11%). Most respondents agreed with more flexible care models of service delivery including incentives for general practitioners (90%), private health insurance coverage for ED use (89%), and enhanced roles for paramedics and nurses. Conclusions Main reason for attending ED is perceived severity of illness, followed by lack of alternative care. The majority of both consumers and the public are in favour of more flexible care models. However, further research is necessary to detail those alternatives and to test and validate their effectiveness.

Projecting excess emergency department visits and associated costs in Brisbane, Australia, under population growth and climate change scenarios

The direct and indirect health effects of increasingly warmer temperatures are likely to further burden the already overcrowded hospital emergency departments (EDs). Using current trends and estimates in conjunction with future population growth and climate change scenarios, we show that the increased number of hot days in the future can have a considerable impact on EDs, adding to their workload and costs. The excess number of visits in 2030 is projected to range between 98–336 and 42–127 for younger and older groups, respectively. The excess costs in 2012–13 prices are estimated to range between AU$51,000–184,000 (0–64) and AU$27,000–84,000 (65+). By 2060, these estimates will increase to 229–2300 and 145–1188 at a cost of between AU$120,000–1,200,000 and AU$96,000–786,000 for the respective age groups. Improvements in climate change mitigation and adaptation measures are likely to generate synergistic health co-benefits and reduce the impact on frontline health services.

A dynamic real time scheduling methodology for the emergency department

This project constructs a scheduling solution for the Emergency Department. The schedules are generated in real-time to adapt to new patient arrivals and changing conditions. An integrated scheduling formulation assigns patients to beds and treatment tasks to resources. The schedule efficiency is assessed using waiting time and total care time experienced by patients. The solution algorithm incorporates dispatch rules, meta-heuristics and a new extended disjunctive graph formulation which provide high quality solutions in a fast time-frame for real time decision support. This algorithm can be implemented in an electronic patient management system to improve patient flow in the Emergency Department.

Why do Queenslanders seek care in emergency departments? A population study

Objective This study aims to identify the main reasons for which first time and multiple users seek medical care through Queensland emergency departments (ED). Methods A cross-sectional survey was conducted at eight public EDs among presenting patients (n = 911). The questions measured the socio-demographic characteristics of patients, their beliefs and attitudes towards EDs services, and perceptions of health status. Bivariate and binary logistic regression analyses were performed to examine the differences between first time and multiple users of EDs. Results First time and multiple users accounted for 55.5% and 44.5%, respectively. Multiple users themselves believed to be sicker, have poorer health status, and additional and/or chronic health conditions. Multiple users more strongly believed that their condition required treatment at an ED and perceived their condition as being very serious. Multiple users reported weekly household incomes below $600, and half of the multiple users were not working as compared to 35% first time users. Multivariate analysis showed that multiple use was significantly associated with the existence of additional health problems, having chronic condition, lower self-efficacy, and need for ED treatment. Conclusions Patients who sought care for multiple times at EDs more often than first time users suffered from additional and chronic conditions. Their opinion of an ED as the most suitable place to address their current health problem was stronger than first time users. Any proposed demand management strategies need to address these beliefs together with the reasoning of patients to provide effective and appropriate care outside or within ED services.

Implementation of a chest pain management service improves patient care and reduces length of stay

Objective Chest pain is one of the most common complaints in patients presenting to an emergency department. Delays in management due to a lack of readily available objective tests to risk stratify patients with possible acute coronary syndromes can lead to an unnecessarily lengthy admission placing pressure on hospital beds or inappropriate discharge. The need for a co-ordinated system of clinical management based on enhanced communication between departments, timely and appropriate triage, clinical investigation, diagnosis, and treatment was identified. Methods An evidence-based Chest Pain Management Service and clinical pathway were developed and implemented, including the introduction of after-hours exercise stress testing. Results Between November 2005 and March 2013, 5662 patients were managed according to a Chest Pain Management pathway resulting in a reduction of 5181 admission nights by more timely identification of patients at low risk who could then be discharged. In addition, 1360 days were avoided in high-risk patients who received earlier diagnosis and treatment. Conclusions The creation of a Chest Pain Management pathway and the extended exercise stress testing service resulted in earlier discharge for low-risk patients; and timely treatment for patients with positive and equivocal exercise stress test results. This service demonstrated a significant saving in overnight admissions.

Doctor’s knowledge and practices of traumatic brain injury management in Chinese prehospital settings

Objectives: The incidence and mortality of traumatic brain injury (TBI) has increased rapidly in the last decade in China. Appropriate ambulance service can reduce case-fatality rates of TBI significantly. This study aimed to explore the factors (age, gender, education level, clinical experience, professional title, organization, specialty before prehospital care, and training frequency) that could influence prehospital doctors’ knowledge level and practices in TBI management in China, Hubei Province. Methods: A cross-sectional questionnaire survey was conducted in two cities in Hubei Province. The self-administered questionnaire consisted of demographic information and questions about prehospital TBI management. Independent samples t-test and one-way ANOVA were used to analyze group differences in the average scores in terms of demographic character. General linear regression was used to explore associated factors in prehospital TBI management. Results: A total of 56 questionnaires were handed out and 52 (93%) were returned. Participants received the lowest scores in TBI treatment (0.64; SD=0.08) and the highest scores in TBI assessment (0.80; SD=0.14). According to the regression model, the education level was associated positively with the score of TBI identification (P=.019); participants who worked in the emergency department (ED; P=.011) or formerly practiced internal medicine (P=.009) tended to get lower scores in TBI assessment; participants’ scores in TBI treatment were associated positively with the training frequency (P=.011); and no statistically significant associated factor was found in the overall TBI management. Conclusion: This study described the current situation of prehospital TBI management. The prehospital doctors’ knowledge level and practices in TBI management were quantified and the influential factors hidden underneath were explored. The results indicated that an appropriate continuing medical education (CME) program enables improvement of the quality of ambulance service in China.

Disaster management in Nepal: Media engagement in the Post-2015 Framework for Disaster Risk Reduction

Nepal, as a consequence of its geographical location and changing climate, faces frequent threats of natural disasters. According to the World Bank’s 2005 Natural Disasters Hotspots Report, Nepal is ranked the 11th most vulnerable country to earthquake and 30th to flood risk. Geo-Hazards International (2011) has classified Kathmandu as one of the world’s most vulnerable cities to earthquakes. In the last four decades more than 32,000 people in Nepal have lost their lives and annual monetary loss is estimated at more than 15 million (US) dollars. This review identifies gaps in knowledge, and progress towards implementation of the Post Hyogo Framework of Action. Nepal has identified priority areas: community resilience, sustainable development and climate change induced disaster risk reduction. However, one gap between policy and action lies in the ability of Nepal to act effectively in accordance with an appropriate framework for media activities. Supporting media agencies include the Press Council, Federation of Nepalese Journalists, Nepal Television, Radio Nepal and Telecommunications Authority and community based organizations. The challenge lies in further strengthening traditional and new media to undertake systematic work supported by government bodies and the National Risk Reduction Consortium (NRRC). Within this context, the ideal role for media is one that is proactive where journalists pay attention to a range of appropriate angles or frames when preparing and disseminating information. It is important to develop policy for effective information collection, sharing and dissemination in collaboration with Telecommunication, Media and Journalists. The aim of this paper is to describe the developments in disaster management in Nepal and their implications for media management. This study provides lessons for government, community and the media to help improve the framing of disaster messages. Significantly, the research highlights the prominence that should be given to flood, landslides, lightning and earthquakes.

Qualitative study of patients' choice between public and private hospital emergency departments

Objective The aim of this study was to gather patients' perceptions regarding their choice between public and private hospital EDs for those who hold private health insurance. The findings of this study will contribute to knowledge regarding patients' decision-making processes and therefore may contribute to the development of evidence based public policies. Methods An in-depth semi-structured guide was used to interview participants at public and private hospital EDs. Questions sought to identify the issues that were considered by the participants to decide to attend that hospital ED, previous ED experience, expectations of ED services and perceived benefits and barriers to accessing services. Interviews were audio recorded, transcribed verbatim and analysed using content and thematic approaches. Results Four core themes emerged: prior good experience with the hospital, perceived quality of care, perceived waiting times and perceived costs that may explain patients' choice. Patients' choice between public and private EDs can be explained by the interaction of these core themes. The principal issues appear to be concern for gap payments at private hospital ED and waiting times at public hospital ED. Conclusions Patients who choose to attend public EDs appear to value financial concern over waiting time; those who choose to attend private EDs appear to value waiting time ahead of financial concerns.