‘Care in a chair’ – The impact of an overcrowded emergency department on the time to treatment and length of stay of self-presenting patients with abdominal pain

Objectives The aim in this study was to investigate the impact of overcrowding on the Australasian Triage Score’s (ATS) time to treatment target and the National Emergency Access Target (NEAT) for patients who self-present to the Emergency Department (ED) with abdominal pain. Background The causes and effects of ED overcrowding have been well described in the literature. It is a widespread phenomenon throughout the world and it can cause serious harm to patients and have a negative impact on access to emergency care. There is however, little research investigating the effect of overcrowding when patients self-present to the ED and experience a delay in being allocated a cubicle. Methods A retrospective analysis of 12-months of computerised records was carried out in order to determine if self-presenting patients with abdominal pain allocated a category 3 triage score who were required to ‘queue’ for a cubicle would meet ATS target and NEAT requirements. A multiple regression analysis was used to determine whether or not queuing for an ED cubicle, age and gender were predictors of meeting the ATS guidelines and NEAT requirements. Results Three hundred and five patients met the inclusion criteria and were included in the study. Of these 149 patients waited more than 15 min to be allocated a cubicle while 156 did not experience any delay. A multiple regression analysis revealed that gender and age were not predictive of meeting the ATS target and NEAT requirements, while delay in allocation to a cubicle was a significant predictor of not being assessed within 30 min and discharged within 4 h. Furthermore, 61.2% of patients allocated to the waiting room queue for any amount of time were admitted to the ward. Conclusion Queuing in the waiting room for an ED bed was a significant predictor of whether or not category three patients with abdominal pain had treatment commenced within 30 min of presentation and was associated with a longer total ED length of stay.

Emergency responses for clinical deterioration within and beyond 24 hours of emergency admission: Patient outcomes and ICU implications

Introduction: The National Emergency Access Target was implemented to ensure 90% of patients leave emergency departments (EDs) within 4h. The impact of time driven performance on the number of physiologically unstable ward-based patients is unknown. An increase in clinical deterioration episodes potentially leading to adverse events will have resource implications for intensive care units (ICUs).
Objectives: To compare the characteristics and outcomes of patients who required an emergency response for clinical deterioration (cardiac arrest team or rapid response system activation) within and beyond 24 h of emergency admission to general medical and surgical units.
Methods: A retrospective exploratory design was used. The study site was a 365 bed urban hospital in Melbourne. Emergency responses for clinical deterioration during 2012 were examined.
Results: Of 819 emergency responses for clinical deterioration, 587 patients were admitted via ED. The median time to first responsewas59h, 28.4% of patients required this <24 h after admission. One in eight patients required ICU admission. Comparison of patients requiring a response within and beyond 24h of admission showed no significant differences in age, gender, waiting times, ED length of stay or in-hospital mortality rates. Patients in whom first emergency response occurred <24h after admission were less likely to be admitted to ICU immediately following the emergency response (7.6% vs 13.9%, p-0.039), less likely to have recurrent emergency responses during their hospitalisation (9.7% vs 34.0%, p<0.001), and had shorter median hospital length of stay (7 vs 11 days, p<0.001).
Conclusions: Considerable ICU resources were utilised given one in eight patients required ICU admission following emergency response, and patients admitted via the ED constituted 55% of all rapid response system activations. Exploring potential antecedents to clinical deterioration in this cohort may assist in establishing risk management strategies to reduce utilisation of ICU resources.

The effect of transition to specialty practice programs on Australian emergency nurses' professional development, recruitment and retention

BACKGROUND: To date, emergency nursing Transition to Specialty Practice Program (TSPP) evaluations have been single-site observational studies. The aim of this paper was to examine the professional development, recruitment and retention outcomes of Australian emergency nursing TSPPs. METHODS: An explanatory sequential design was used. Data were collected via online surveys and interviews of emergency Nurse Unit Managers and Nurse Educators. Survey data from EDs with TSPPs and EDs without TSPPs were compared. Qualitative data were analysed using content analysis. RESULTS: Data were collected from 118 EDs, and 13 interviews. TSPPs were offered in 72.1% of EDs. EDs with TSPPs had higher proportions of nurses with postgraduate qualifications (Mdn 28.3% vs. 22.1%, p=0.45) and Clinical Specialists (Mdn 16.4% vs. 6.3%, p=0.04). The median proportion of currently rostered nurses with TSPP completion was 34.2% in EDs with TSPPs introduced in 2000-2005 indicating ED high levels of retention. CONCLUSION: Emergency nursing TSPPs have had a positive effect on nursing professional development, recruitment and retention. To ensure consistency in outcomes and optimise reliability of emergency nursing skills and knowledge, a national emergency nursing TSPP framework is needed.

Pharmacy access to the emergency contraceptive pill : a national survey of a random sample of Australian women

Background : The emergency contraceptive pill (ECP) has the potential to assist in reducing unintended pregnancy and abortion rates. Since its rescheduling to pharmacy availability without prescription in Australia in January 2004, there is little information about Australian women's knowledge, attitudes and use of the ECP. The aim of this study was to measure the knowledge about the ECP and sociodemographic patterns of and barriers to use of the ECP.

Study Design : A cross-sectional study, using a computer-assisted telephone interview (CATI) survey conducted with a national random sample of 632 Australian women aged 16–35 years.

Results : Most women had heard of the ECP (95%) and 26% had used it. The majority of women agreed with pharmacy availability of the ECP (72%); however, only 48% were aware that it was available from pharmacies without a prescription. About a third (32%) believed the ECP to be an abortion pill. The most common reason for not using the ECP was that women did not think they were at risk of getting pregnant (57%). Logistic regression showed that women aged 20–29 years (OR 2.58; CI: 1.29–5.19) and 30–35 years (OR 3.16; CI: 1.47–6.80) were more likely to have used the ECP than those aged 16–19 years. Women with poor knowledge of the ECP were significantly less likely to have used it than those with very good knowledge (OR 0.28; CI: 0.09–0.77). Those in a de facto relationship (OR 2.21; CI: 1.27–3.85), in a relationship but not living with the partner (OR 2.46; 95% CI 1.31–4.63) or single women (OR 2.40; CI: 1.33–4.34) were more likely to have used the ECP than married women.

Conclusions : Women in Australia have a high level of awareness of the ECP, but more information and education about how to use it and where to obtain it are still needed.

A realist case study of a regional hospital's response to improve emergency department access in the context of Australian healthcare reforms

Introduction: Major health-care reforms have extended across all Australian public hospitals in recent years. Improving emergency department (ED) access has been a focus of these reforms.

Objective: This study evaluates how the national reforms have led to improvement in ED access in a regional hospital in remote Australia.Methods: Assessing a complex scenario such as national reforms and the challenges faced by the regional hospital to implement these reforms requires in-depth analysis. A realist evaluation theory-based approach was employed, allowing investigation of what, how, why, and for whom change occurred. A case study mixed methods design was adopted within the realist framework to answer these questions about change.

Results and Conclusion: The study identified moderate improvement in ED access as a result of the reforms (investment in infrastructure and workforce and the introduction of ED targets). Clinical leadership and support from management were essential for the improvement. Without ongoing investment and clinical redesign activities, however, sustainability of the improvement may prove difficult.

Psychosocial risk factors for coronary heart disease: a consensus statement from the National Heart Foundation of Australia

In 2003, the National Heart Foundation of Australia published a position statement on psychosocial risk factors and coronary heart disease (CHD). This consensus statement provides an updated review of the literature on psychosocial stressors, including chronic stressors (in particular, work stress), acute individual stressors and acute population stressors, to guide health professionals based on current evidence. It complements a separate updated statement on depression and CHD.

Perceived chronic job strain and shift work are associated with a small absolute increased risk of developing CHD, but there is limited evidence regarding their effect on the prognosis of CHD. Evidence regarding a relationship between CHD and job (in)security, job satisfaction, working hours, effort-reward imbalance and job loss is inconclusive.

Expert consensus is that workplace programs aimed at weight loss, exercise and other standard cardiovascular risk factors may have positive outcomes for these risk factors, but no evidence is available regarding the effect of such programs on the development of CHD.

Social isolation after myocardial infarction (MI) is associated with an adverse prognosis. Expert consensus is that although measures to reduce social isolation are likely to produce positive psychosocial effects, it is unclear whether this would also improve CHD outcomes. Acute emotional stress may trigger MI or takotsubo ("stress") cardiomyopathy, but the absolute increase in transient risk from an individual stressor is low. Psychosocial stressors have an impact on CHD, but clinical significance and prevention require further study.

Awareness of the potential for increased cardiovascular risk among populations exposed to natural disasters and other conditions of extreme stress may be useful for emergency services response planning. Wider public access to defibrillators should be available where large populations gather, such as sporting venues and airports, and as part of the response to natural and other disasters.

Estimating the intensity of ward admission and its effect on emergency department access block

Emergency department access block is an urgent problem faced by many public hospitals today. When access block occurs, patients in need of acute care cannot access inpatient wards within an optimal time frame. A widely held belief is that access block is the end product of a long causal chain, which involves poor discharge planning, insufficient bed capacity, and inadequate admission intensity to the wards. This paper studies the last link of the causal chain-the effect of admission intensity on access block, using data from a metropolitan hospital in Australia. We applied several modern statistical methods to analyze the data. First, we modeled the admission events as a nonhomogeneous Poisson process and estimated time-varying admission intensity with penalized regression splines. Next, we established a functional linear model to investigate the effect of the time-varying admission intensity on emergency department access block. Finally, we used functional principal component analysis to explore the variation in the daily time-varying admission intensities. The analyses suggest that improving admission practice during off-peak hours may have most impact on reducing the number of ED access blocks.

Last drinks: a study of rural emergency department data collection to identify and target community alcohol-related violence

The present study summarises the methodology and findings of a pilot project designed to measure the sources and locations of alcohol-related harm by implementing anonymised 'last drinks' questions in the ED of a rural community.

In-reach nursing services improve older patient outcomes and access to emergency care

Aims: To identify the impact of in-reach services providing specialist nursing care on outcomes for older people presenting to the emergency department from residential aged care. Methods: Retrospective cohort study compared clinical outcomes of 2278 presentations from 2009 with 2051 presentations from 2011 before and after the implementation of in-reach services. Results: Median emergency department length of stay decreased by 24 minutes (7.0 vs 6.6 hours, P<0.001) and admission rates decreased by 23% (68 vs 45%, P<0.001). The proportion of people with repeat emergency department visits within six months decreased by 12% (27 vs 15%). The proportion of admitted patients who were discharged with an end of life palliative care plan increased by 13% (8 vs 21%, P=0.007). Conclusions: There was a significant reduction in the median length of stay, fewer hospital admissions and fewer repeat visits for people from residential aged care following implementation of in-reach services.

The National Perinatal Depression Initiative: An evaluation of access to general practitioners, psychologists and psychiatrists through the Medicare Benefits Schedule

OBJECTIVE: To evaluate the impact of the National Perinatal Depression Initiative on access to Medicare services for women at risk of perinatal mental illness. METHOD: Retrospective cohort study using difference-in-difference analytical methods to quantify the impact of the National Perinatal Depression Initiative policies on Medicare Benefits Schedule mental health usage by Australian women giving birth between 2006 and 2010. A random sample of women of reproductive age enrolled in Medicare who had not given birth where used as controls. The main outcome measures were the proportions of women giving birth each month who accessed a Medicare Benefits Schedule mental health items during the perinatal period (pregnancy through to the end of the first postnatal year) before and after the introduction of the National Perinatal Depression Initiative. RESULTS: The proportion of women giving birth who accessed at least one mental health item during the perinatal period increased from 88 to 141 per 1000 between 2007 and 2010. The difference-in-difference analysis showed that while there was an overall increase in Medicare Benefits Schedule mental health item access as a result of the National Perinatal Depression Initiative, this did not reach statistical significance. However, the National Perinatal Depression Initiative was found to significantly increase access in subpopulations of women, particularly those aged under 25 and over 34 years living in major cities. CONCLUSION: In the 2 years following its introduction, the National Perinatal Depression Initiative was found to have increased access to Medicare funded mental health services in particular groups of women. However, an overall increase across all groups did not reach statistical significance. Further studies are needed to assess the impact of the National Perinatal Depression Initiative on women during childbearing years, including access to tertiary care, the cost-effectiveness of the initiative, and mental health outcomes. It is recommended that new mental health policy initiatives incorporate a planned strategic approach to evaluation, which includes sufficient follow-up to assess the impact of public health strategies.

Cancer diagnosed in the emergency department of a regional health service

OBJECTIVE: Patients diagnosed with cancer in the Emergency Department (ED) have more advanced disease at diagnosis and poorer outcomes. High rates of initial presentation to ED suggest potential problems with access to care. The aim of this project was to interpret findings in regional/rural Victoria and explore implications for practice.

DESIGN: Cross-sectional study linking two independent data sets.

SETTING: Regional city of Geelong and surrounding rural areas in south-west Victoria.

PARTICIPANTS: All newly diagnosed cancer patients in 2009.

MAIN OUTCOME MEASURES: Number of cancer patients diagnosed in the ED.

RESULTS: One in five newly diagnosed cancer patients present to ED 6 months prior to cancer diagnosis. One in 10 is diagnosed as a result of their ED visit. Patients presenting to ED were older, more often men and from disadvantaged areas. Symptoms on presentation included chest complaints, bowel obstruction, abdominal pain, anaemia and generalised weakness. Cancer diagnosed in the ED is associated with advanced stage and shorter survival.

CONCLUSION: Reasons for presentation to ED would be multifactorial and include complex cases with coexisting symptoms making diagnosis difficult. The general public appear to have a low level of awareness of alternative primary care services or difficulty accessing such information. Some of the changes towards reducing the number of patients presenting to ED will include patient education.

Blood alcohol and injury in Bhutan: targeted surveillance in a national referral hospital emergency department

Bhutan is a low-middle-income country with poor roads, rapidly increasing motor vehicle use and heavy alcohol consumption. We estimated the proportion of emergency department patients presenting with injury who had positive blood alcohol. We sought to breathalyse and interview all adult patients (≥18 years) presenting with injury at the Jigme Dorji Wangchuck National Referral Hospital in the capital city Thimphu, from April to October 2015. Breath tests and interviews were conducted with 339 (91%) of 374 eligible adult patients. A third (34%) were alcohol-positive and 22% had blood alcohol concentrations >0.08 g/dL. The highest alcohol-positive fractions were for assault (71%), falls (31%) and traffic crashes (30%). Over a third (36%) of patients had a delay of >2 h between injury and breath test. The results underestimate blood alcohol concentrations at the time of injury so the true prevalence of pre-injury alcohol impairment is greater than our estimates suggest. Countermeasures are urgently needed, particularly roadside random breath testing and alcohol controls.

Protocol for ACCESS : a qualitative study exploring barriers and facilitators to accessing the emergency contraceptive pill from community pharmacies in Australia

INTRODUCTION: The rate of unplanned pregnancy in Australia remains high, which has contributed to Australia having one of the highest abortion rates of developed countries with an estimated 1 in 5 women having an abortion. The emergency contraceptive pill (ECP) offers a safe way of preventing unintended pregnancy after unprotected sex has occurred. While the ECP has been available over-the-counter in Australian pharmacies for over a decade, its use has not significantly increased. This paper presents a protocol for a qualitative study that aims to identify the barriers and facilitators to accessing the ECP from community pharmacies in Australia.

METHODS AND ANALYSIS: Data will be collected through one-on-one interviews that are semistructured and in-depth. Partnerships have been established with 2 pharmacy groups and 2 women's health organisations to aid with the recruitment of women and pharmacists for data collection purposes. Interview questions explore domains from the Theoretical Domains Framework in order to assess the factors aiding and/or hindering access to ECP from community pharmacies. Data collected will be analysed using deductive content analysis. The expected benefits of this study are that it will help develop evidence-based workforce interventions to strengthen the capacity and performance of community pharmacists as key ECP providers.

ETHICS AND DISSEMINATION: The findings will be disseminated to the research team and study partners, who will brainstorm ideas for interventions that would address barriers and facilitators to access identified from the interviews. Dissemination will also occur through presentations and peer-reviewed publications and the study participants will receive an executive summary of the findings. The study has been evaluated and approved by the Monash Human Research Ethics Committee.

Clinical decisions using the National Triage Scale: how important is postgraduate education?

Triage is the formal nursing assessment of all patients who present to an Emergency Department (ED). The National Triage Scale (NTS) is used in most Australian EDs. Triage decision making involves the allocation of every patient presenting to an ED to one of the five NTS categories. The NTS directly relates a triage category to illness or injury severity and need for emergency care. Triage nurses’ decisions not only have the potential to impact on the health outcomes of ED patients, they are also used, in part, to evaluate ED performance and allocate components of ED funding. This study was a correlational study that used survey methods. Triage decisions were classified as ‘expected triage’, ‘overtriage’ or ‘undertriage’ decisions. Participant’s qualifications were allocated to five categories: ‘nil’; ‘emergency nursing’; ‘critical care nursing’; ‘midwifery’; and ‘tertiary’ qualifications. There was no correlation between triage decisions and length of experience in emergency nursing or triage. ‘Expected triage’ decisions were more common when the predicted triage category was Category 3 (P< 0.001) and ‘overtriage’ decisions were less common when the predicted triage category was Category 2 (P< 0.0010). The frequency of ‘undertriage’ decisions decreased significantly when the predicted triage category was Category 3 (P< 0.001) or Category 4 (P< 0.001). There was no correlation between triage decisions and qualifications in the ‘nil’, ‘emergency nursing’ or ‘critical care nursing’ categories. A midwifery qualification demonstrated a positive correlation with ‘expected triage’ decisions (P = 0.048) and a negative correlation with ‘undertriage’ decisions (P = 0.012). There was also a positive correlation between a tertiary qualification and ‘expected triage’ decisions (P = 0.012).