Responding to the ageing profile of emergency department patients

Background
Older people with acute superimposed on chronic health problems are becoming a core aspect of emergency department (ED) caseload. This project explored the ED experience from the perspective of older patients and their carers.

Method
A convenience sample of thirty participants was recruited across three participating EDs: tw o metropolitan and one regional. The project utilised two approaches to data collection: 1) an observation approach where a project officer observed participants from the time of ED presentation until discharge, or for up to six hours; and 2) a subsequent interview was conducted with the participant and their carer within a week of the ED presentation. Data from both sources were integrated, and independently thematically analysed by two members of the team.

Results
Thirty participants aged over 65 were recruited. Their average age was 77.1 (sd=6.7) years, 59% w ere female, and 74% were triage category 1- 3 (indicating moderate/high acuity). Participants spent on average 7 hours 47 minutes in the ED, with 50% discharged home, 43% admitted to general wards or MAPU, and 7% discharged to residential care/hospice. Key themes in the factors influencing the patient experience and examples of quality care were identified, along with opportunities to improve the capacity for EDs to be “older person friendly”, and “person-centred.” Challenges include improving the effectiveness of communication between staff and patients/carers (including issues around people from culturally and linguistically diverse backgrounds), availability of allied health professionals to assist with discharge planning, and a tendency for older people not to seek ED care until the health problem was severe. Patient exemplars highlight key themes.

Discussion and implications
Results of the project highlight positive aspects of emergency department care for older people and inform targets for improvement strategies. These can be used to drive ongoing improvements in care for older people presenting to EDs.

Small rural emergency departments are not simply cut-down large urban emergency departments

 It is important to understand how small rural emergency departments work. They are a significant fraction of a state’s medical system. Although they each see only a few thousand patients a year, as a group they are likely to treat more emergency patients than the largest city hospital. It is a myth that they only deal with minor ailments. 

An evidence-based practice approach to improving nursing care of acute stroke in an Australian emergency department

Aims. The aim of this study was to improve the emergency nursing care of acute stroke by enhancing the use of evidence regarding prevention of early complications.
Background. Preventing complications in the first 24–48 hours decreases stroke-related mortality. Many patients spend considerable part of the first 24 hours following stroke in the Emergency Department therefore emergency nurses play a key role in patient outcomes following stroke.
Design. A pre-test/post-test design was used and the study intervention was a guideline for Emergency Department nursing management of acute stroke.
Methods. The following outcomes were measured before and after guideline implementation: triage category, waiting time, Emergency Department length of stay, time to specialist assessment, assessment and monitoring of vital signs, temperature and blood glucose and venous-thromboembolism and pressure injury risk assessment and interventions.
Results. There was significant improvement in triage decisions (21Æ4% increase in triage category 2, p = 0Æ009; 15Æ6% decrease in triage category 4, p = 0Æ048). Frequency of assessments of respiratory rate (p = 0Æ009), heart rate (p = 0Æ022), blood pressure (p = 0Æ032) and oxygen saturation (p = 0Æ001) increased. In terms of risk management, documentation of pressure area
interventions increased by 28Æ8% (p = 0Æ006), documentation of nil orally status increased by 13Æ8% (ns), swallow assessment prior to oral intake increased by 41Æ3% (p = 0Æ003), speech pathology assessment in Emergency Department increased by 6Æ1% (ns) and there was 93Æ5 minute decrease in time to speech pathology assessment for admitted patients (ns).
Relevance to clinical practice. An evidence-based guideline can improve emergency nursing care of acute stroke and optimise patient outcomes following stroke. As the continuum of stroke care begins in the Emergency Department, detailed recommendations for evidence-based emergency nursing care should be included in all multidisciplinary guidelines for the management of acute stroke.

A systematic approach to writing and rating entrepreneurial business plans

This investigation is part of a series of studies in the field of venture capital deal screening. At issue is the use of theory-based standards for the systematic creation and assessment of entrepreneurial business plans. A synthesis of research-based principles contained in the literature culminated in the formal articulation and operationalization of 10 principles in the form of a questionnaire, titled the Entrepreneurial Business Plan Assessment Regime (EBRAR). The EBRAR can serve as a guide for both writing and rating entrepreneurial business plans. Discussion focuses on the utility of assessment, as well as future research directions.

Borderline personality disorder - an overview for emergency clinicians

The diagnosis of borderline personality disorder frequently underlies self-harm and suicidal presentations to the emergency department. Borderline pathology combined with high levels of comorbidity, stigma, and treatment uncertainty, increase the challenges of caring for someone with this diagnosis in an emergency setting. Attributes such as black-and-white thinking and splitting may compromise an already precarious situation. The maintenance of safety requires prioritisation and necessitates a practical and respectful approach, which avoids notions of attention-seeking behaviour. Clinical assessment should distinguish between self-harm and suicide attempts where possible and take into account acute on chronic risk. The emergency clinician will need to consider the degree of containment required in the emergency department and is encouraged to maintain transparency and honesty with the client regarding treatment decisions. If hospitalisation needs to be considered, clinicians should take into account immediate therapeutic benefit versus the counter-therapeutic risk of dependency and regression. Overall, it is reasonable for clinicians to aim for clients to return to their pre-crisis level of functioning, and beneficial for clinicians to approach this client group with therapeutic optimism.

Is the quality of entrepreneurial business plans related to the outcome of a new venture?

The evaluation of new ventures often involves two key aspects of entrepreneurial business plans: how best to write them and how best to rate (evaluate) them. Ultimately the performance of the venture should be the definitive criterion of quality. Surprisingly, the writing, rating and performance effects of entrepreneurial business plans (EBPs) comprise three related but under researched areas. This paper empirically tested principles for writing and rating entrepreneurial business plans to draw inferences on how to improve the private equity investment evaluation process. A simplified perspective of General Systems Theory guided our empirical investigation of the input and outcome of the VC investment decision. Our empirical investigation reveals that entrepreneurial business plans that comport with the writing principles from the literature improve a new venture’s likelihood of success.

Can the ABCD Score be dichotomised to identify high−risk patients with trainsient ischaemic attack in the emergency department?

Background: Recent evidence shows a substantial short-term risk of ischaemic stroke after transient ischaemic attack (TIA). Identification of patients with TIA with a high short-term risk of stroke is now possible through the use of the “ABCD Score”, which considers age, blood pressure, clinical features and duration of symptoms predictive of stroke.

Aim: To evaluate the ability of dichotomising the ABCD Score to predict stroke at 7 and 90 days in a population with TIA presenting to an emergency department.

Methods: A retrospective audit was conducted on all probable or definite TIAs presenting to the emergency department of a metropolitan hospital from July to December 2004. The ABCD Score was applied to 98 consecutive patients with TIA who were reviewed for subsequent strokes within 90 days. Patients obtaining an ABCD Score ≥5 were considered to be at high risk for stroke.

Results: Dichotomising the ABCD Score categorised 48 (49%) patients with TIA at high risk for stroke (ABCD Score ≥5). This high-risk group contained all four strokes that occurred within 7 days (sensitivity 100% (95% confidence interval (CI) 40% to 100%), specificity 53% (95% CI 43% to 63%), positive predictive value 8% (95% CI 3% to 21%) and negative predictive value 100% (95% CI 91% to 100%)), and six of seven occurring within 90 days (sensitivity 86% (95% CI 42% to 99%), specificity 54% (95% CI 43% to 64%), positive predictive value 12.5% (95% CI 5% to 26%) and negative predictive value 98% (95% CI 88% to 100%)). Removal of the “age” item from the ABCD Score halved the number of false-positive cases without changing its predictive value for stroke.

Conclusion: In this retrospective analysis, dichotomising the ABCD Score was overinclusive but highly predictive in identifying patients with TIA at a high short-term risk of stroke. Use of the ABCD Score in the emergency care of patients with TIA is simple, efficient and provides a unique opportunity to prevent stroke in this population of patients.