Is language a barrier for quality care in hospitals? A case series from an Emergency Department of a teaching hospital in Brisbane

Aim: The aim of this pilot study is to describe the use of an Emergency Department (ED) at a large metropolitan teaching hospital by patients who speak English or other languages at home. Methods: All data were retrieved from the Emergency Department Information System (EDIS) of this tertiary teaching hospital in Brisbane. Patients were divided into two groups based on the language spoken at home: patients who speak English only at home (SEO) and patients who do not speak English only or speak other language at home (NSEO). Modes of arrival, length of ED stay and the proportion of hospital admission were compared among the two groups of patients by using SPSS V18 software. Results: A total of 69,494 patients visited this hospital ED in 2009 with 67,727 (97.5%) being in the SEO group and 1,281 (1.80%) in the NSEO group. The proportion of ambulance utilisation in arrival mode was significantly higher among SEO 23,172 (34.2%) than NSEO 397 (31.0%), p <0.05. The NSEO patients had longer length of stay in the ED (M = 337.21, SD = 285.9) compared to SEO patients (M= 290.9, SD = 266.8), with 46.3 minutes (95%CI 62.1, 30.5, p <0.001) difference. The admission to the hospital among NSEO was 402 (31.9%) higher than SEO 17,652 (26.6%), p <0.001. Conclusion: The lower utilisation rates of ambulance services, longer length of ED stay and higher hospital admission rates in NSEO patients compared to SEO patients are consistent with other international studies and may be due to the language barriers.

Benchmarking clinical indicators of quality for Australian residential aged care facilities

To undertake exploratory benchmarking of a set of clinical indicators of quality care in residential care in Australia, data were collected from 107 residents within four medium-sized facilities (40–80 beds) in Brisbane, Australia. The proportion of residents in each sample facility with a particular clinical problem was compared with US Minimum Data Set quality indicator thresholds. Results demonstrated variability within and between clinical indicators, suggesting breadth of assessment using various clinical indicators of quality is an important factor when monitoring quality of care. More comprehensive and objective measures of quality of care would be of great assistance in determining and monitoring the effectiveness of residential aged care provision in Australia, particularly as demands for accountability by consumers and their families increase. What is known about the topic? The key to quality improvement is effective quality assessment, and one means of evaluating quality of care is through clinical outcomes. The Minimum Data Set quality indicators have been credited with improving quality in United States nursing homes. What does this paper add? The Clinical Care Indicators Tool was used to collect data on clinical outcomes, enabling comparison of data from a small Australian sample with American quality benchmarks to illustrate the utility of providing guidelines for interpretation. What are the implications for practitioners? Collecting and comparing clinical outcome data would enable practitioners to better understand the quality of care being provided and whether practices required review. The Clinical Care Indicator Tool could provide a comprehensive and systematic means of doing this, thus filling a gap in quality monitoring within Australian residential aged care.

The impact of nurse practitioner services on cost, quality of care, satisfaction and wait times in the emergency department: A systematic review

Aims To provide the best available evidence to determine the impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department for adult patients. Background The delivery of quality care in the emergency department is one of the most important service indicators in health delivery. Increasing service pressures in the emergency department have resulted in the adoption of service innovation models: the most common and rapidly expanding of these is emergency nurse practitioner services. The rapid uptake of emergency nurse practitioner service in Australia has outpaced the capacity to evaluate this service model in terms of outcomes related to safety and quality of patient care. Previous research is now outdated and not commensurate with the changing domain of delivering emergency care with nurse practitioner services. Data A comprehensive search of four electronic databases from 2006-­‐2013 was conducted to identify research evaluating nurse practitioner service impact in the emergency department. English language articles were sought using MEDLINE, CINAHL, Embase and Cochrane and included two previous systematic reviews completed five and seven years ago. Methods A three step approach was used. Following a comprehensive search, two reviewers assessed identified studies against the inclusion criteria. From the original 1013 studies, 14 papers were retained for critical appraisal on methodological quality by two independent reviewers and data extracted using standardised tools. Results Narrative synthesis was conducted to summarise and report the findings as insufficient data was available for meta-­‐analysis of results. This systematic review has shown that emergency nurse practitioner service has a positive impact on quality of care, patient satisfaction and waiting times. There was insufficient evidence to draw conclusions regarding impact on costs. Conclusion Synthesis of the available research attempts to provide an evidence base for emergency nurse practitioner service to guide healthcare leaders, policy makers and clinicians in reforming emergency department service provision. The findings suggest that further quality research is required for comparative measures of clinical and service effectiveness of emergency nurse practitioner service. In the context of increased health service demand and the need to provide timely and effective care to patients, such measures will assist in delivering quality patient care.

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.

The relationship between culture, attitude, social networks and quality of life in midlife Australian and Taiwanese citizens

Objectives: The objectives of this study were to specifically investigate the differences in culture, attitudes and social networks between Australian and Taiwanese men and women and identify the factors that predict midlife men and women’s quality of life in both countries. Methods: A stratified random sample strategy based on probability proportional sampling (PPS) was conducted to investigate 278 Australian and 398 Taiwanese midlife men and women’s quality of life. Multiple regression modelling and classification and regression trees (CARTs) were performed to examine the potential differences on culture, attitude, social networks, social demographic factors and religion/spirituality in midlife men and women’s quality of life in both Australia and Taiwan. Results: The results of this study suggest that culture involves multiple functions and interacts with attitudes, social networks and individual factors to influence a person’s quality of life. Significant relationships were found between the interaction between cultural circumstances and a person’s internal and external factors. The research found that good social support networks and a healthy optimistic disposition may significantly enhance midlife men and women’s quality of life. Conclusion: The study indicated that there is a significant relationship between culture, attitude, social networks and quality of life in midlife Australian and Taiwanese men and women. People who had higher levels of horizontal individualism and collectivism, positive attitudes and better social support had better psychological, social, physical and environmental health, while it emerged that vertical individualists with competitive characteristics would experience a lower quality of life. This study has highlighted areas where opportunities exist to further reflect upon contemporary social health policies for Australian and Taiwanese societies and also within the global perspective, in order to provide enhanced quality care for growing midlife populations.

Preferences of first-time expectant mothers for care of their child : 'I wouldn't leave them somewhere that made me feel insecure'

Australia has witnessed a continual increase in maternal employment over the past two decades, which places focus on both supply of childcare and a demand for high quality care. This study examined childcare preferences regarding the return to paid work of 124 Australian women who were expecting their first child. In contrast with most studies that have retrospective designs, the design of this study presents the perspectives of women prior to the birth of their first child-that is, before they have made a final decision about child care. This study found that the majority (78 per cent) of the women intended to re-commence work within the 12 months after the birth of their child. There were two factors that were the most salient features in their decision making-the quality of care and the personal satisfaction of engaging in paid work. The findings suggest that family friendly employment practices and access to secure, high-quality child care are key to women's secure participation in the paid workforce.

Evaluating patient presentations for care delivered by emergency nurse practitioners : a retrospective analysis of 12 months

Background The delivery of quality patient care in the emergency department (ED) is emerging as one of the most important service indicators to be measured in health services today. The emergency nurse practitioner role was implemented as a service innovation in a Emergency & Trauma Centre (ETC), Melbourne, Australia, in July 2004 .The primary aim of the role was intended to enhance healthcare services, improve the efficiency and timely delivery of high quality care to patients. Aim To conduct a retrospective study of patient presentations at the ETC to obtain a profile of the characteristics of patients managed by emergency nurse practitioners. Specifically the objectives of the study were to: 1) examine the demographics of the patient population 2) evaluate data on emergency department service indicators for this patient cohort Method All patients presenting to the ETC from January 01 2011 to December 31 2011 and managed by emergency nurse practitioners were included in the review. Data collection included baseline demographics, waiting times to be seen, length of stay, emergency department discharge diagnoses and referral patterns. Data were extracted and imported directly from the emergency department Patient Information System (Cerner log), for the specified time frame. Results A total of 5212 patients were reviewed in the study period. The median age of patients was 35 years and 61% of patients were male. The most common discharge diagnosis was open wounds to hand/wrist. Waiting times to be seen by the emergency nurse practitioner were 14 minutes and length of stay for patients with a discharge disposition of home were 122 minutes. Conclusions This study has provided information on patient baseline characteristics and performance on important service indicators for this patient sample that will inform further research to evaluate specific outcomes of the emergency nurse practitioner service.

A survey of the Queensland healthcare workforce : attitudes towards dementia care and training

Background Positive attitudes of healthcare staff towards people with dementia promote higher quality care, although little is known about important factors that underlie positive attitudes. Key aims of this project were to explore the relationships between staff attitudes towards dementia, self-confidence in caring for people with dementia, experience and dementia education and training. Method A brief online survey was developed and widely distributed to registered nurses and allied health professionals working in Queensland in 2012. Regression analyses were performed to identify important predictors of self-confidence in caring for people with dementia and positive attitudes towards people with dementia. Results Five hundred and twenty-four surveys were completed by respondents working in a range of care settings across Queensland. Respondents were predominantly female (94.1%), and most were registered nurses (60%), aged between 41 and 60 years (65.6%). Around 40% regularly worked with people with dementia and high levels of self-confidence in caring for this population and positive attitudes towards people with dementia were reported. The majority of respondents (67%) had participated in a dementia education/training activity in the past 12 months. More experience working with people with dementia predicted greater self-confidence while recent participation in a dementia education/training and higher self-confidence in caring for a person with dementia significantly predicted more positive attitudes towards people with dementia. Conclusion These results confirm the importance of self-confidence and dementia education in fostering positive attitudes and care practices towards people with dementia. Our results also indicate that the demand for ongoing dementia education is high amongst health care workers and it is recommended that regular dementia education/ training be provided and promoted for all healthcare personnel who work with people with dementia.

Parents’ perception about children’s academic stress and child care related issues

The present study intends to understand the parents' perception about children's academic stress and child care related issues. A group of 139 parents, 68 fathers and 71 mothers, participated in the study voluntarily and they were selected following convenience sampling technique. In order to achieve the objective of the study, a specially designed semi-structured questionnaire was used. Findings disclosed that about one-third of the fathers (29.4%) and one-tenth of the mothers (9.9%) frankly admitted that they could not provide quality care and guidance to their children and in this regard significant difference was observed between fathers and mothers (p<.05). More than four-fifth of the parents stated that they should be friendly with their children so that children feel comfortable to share their personal issues with them. More than one-fifth fathers (27.9%) and one-fourth mothers (16.9%) applied corporal punishment as they believed it is necessary to discipline them and/or for better academic performance.

Time to analgesia for care delivered by nurse practitioners in the emergency department: A retrospective chart audit

Objectives To evaluate quality of care delivered to patients presenting to the emergency department (ED) with pain and managed by emergency nurse practitioners by measuring: 1) Evaluate time to analgesia from initial presentation 2) Evaluate time from being seen to next analgesia 3) Pain score documentation Background The delivery of quality care in the emergency department (ED) is emerging as one of the most important service indicators being measured by health services. Emergency nurse practitioner services are designed to improve timely, quality care for patients. One of the goals of quality emergency care is the timely and effective delivery of analgesia for patients. Timely analgesia is an important indicator of ED service performance. Methods A retrospective explicit chart review of 128 consecutive patients with pain and managed by emergency nurse practitioners was conducted. Data collected included demographics, presenting complaint, pain scores, and time to first dose of analgesia. Patients were identified from the ED Patient Information System (Cerner log) and data were extracted from electronic medical records Results Pain scores were documented in 67 (52.3%; 95% CI: 43.3-61.2) patients. The median time to analgesia from presentation was 60.5 (IQR 30-87) minutes, with 34 (26.6%; 95% CI: 19.1-35.1) patients receiving analgesia within 30 minutes of presentation to hospital. There were 22 (17.2%; 95% CI: 11.1-24.9) patients who received analgesia prior to assessment by a nurse practitioner. Among patients that received analgesia after assessment by a nurse practitioner, the median time to analgesia after assessment was 25 (IQR 12-50) minutes, with 65 (61.3%; 95% CI: 51.4-70.6) patients receiving analgesia within 30 minutes of assessment. Conclusions The majority of patients assessed by nurse practitioners received analgesia within 30 minutes after assessment. However, opportunities for substantial improvement in such times along with documentation of pain scores were identified and will be targeted in future research.

The organisational context of nursing care in stroke units: A case study approach

Background Internationally the stroke unit is recognised as the evidence-based model for patient management, although clarity about the effective components of stroke units is lacking. Whilst skilled nursing care has been proposed as one component, the theoretical and empirical basis for stroke nursing is limited. We attempted to explore the organisational context of stroke unit nursing, to determine those features that staff perceived to be important in facilitating high quality care. Design A case study approach was used, that included interviews with nurses and members of the multidisciplinary teams in two Canadian acute stroke units. A total of 20 interviews were completed, transcribed and analysed thematically using the Framework Approach. Trustworthiness was established through the review of themes and their interpretation by members of the stroke units. Findings Nine themes that comprised an organisational context that supported the delivery of high quality nursing care in acute stroke units were identified, and provide a framework for organisational development. The study highlighted the importance of an overarching service model to guide the organisation of care and the development of specialist and advanced nursing roles. Whilst multidisciplinary working appears to be a key component of stroke unit nursing, various organisational challenges to its successful implementation were highlighted. In particular the consequence of differences in the therapeutic approach of nurses and therapy staff needs to be explored in greater depth. Successful teamwork appears to depend on opportunities for the development of relationships between team members as much as the use of formal communication systems and structures. A co-ordinated approach to education and training, clinical leadership, a commitment to research, and opportunities for role and practice development also appear to be key organisational features of stroke unit nursing. Recommendations for the development of stroke nursing leadership and future research into teamwork in stroke settings are made.

Advancing initiatives in care of cognitively impaired patients in acute care settings

In November 2014, the Australian Commission on Safety and Quality in Health Care (ACSQHC) released “A better way to care: Safe and high quality care for patients with cognitive impairment (dementia and delirium) in hospital”. http://www.safetyandquality.gov.au/our-work/cognitive-impairment. The handbook is available as three separate resources for the three audiences: clinicians, service managers and consumers. These resources are designed to inform and guide improved care for older patients with cognitive impairment (CI) (dementia, delirium) in acute care settings. In particular, the service managers resource recommends that organisations comprehensively prepare themselves so that they are alert to delirium and the risk it poses for patients, that they can recognise and respond to patients with CI, and that they are able to provide safe and high quality care tailored to individual patient’s needs. Service managers and clinicians should carefully consider the information provided in the resources and judiciously explore how best to modify and adapt everyday care practices where appropriate. It is important that clinical teams respond to the available information as the ACSQHC identifies that dementia and/or delirium is associated with adverse outcomes, including functional decline, increased risk of falls, and increased morbidity and mortality...

[Letter to the Editor] Telemonitoring in Patients with Heart Failure

To the Editor: Chaudhry et al. suggest that enhanced support in the use of a telephone-based interactive voice-response system for patients recently discharged after worsening heart failure does not improve outcomes. This finding is broadly consistent with previous systematic reviews of telephone support1 and contrasts with the substantial effect observed with home telemonitoring of vital signs in similar populations.1 The treatment of patients in the control group was excellent, but unrepresentative of usual clinical care and not inferior to the treatment of patients receiving enhanced support. Monitoring alone is unlikely to improve outcomes but may do so when it improves prescription of or adherence to lifesaving treatments. Given enough resources, traditional methods for delivering care may render an interactive voice-response system or a home telemonitoring system ineffective. Nonetheless, there may be more cost-efficient approaches to ensuring quality care.2 Informal post hoc addition of these data to our recent meta-analysis of telephone support1 does not substantially alter the point estimates for death from any cause or heart-failure−related hospitalizations, but it does nullify the small benefit in hospitalizations for any cause, which may not be reduced by a heart-failure−focused intervention.1 Original article: Telemonitoring in Patients with Heart Failure NEJM. December 9, 2010 | S.I. Chaudhry and Others