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.

A randomised controlled trial evaluating outcomes of emergency nurse practitioner service

The emergency nurse practitioner role was developed as an innovative and cost effective approach to meet increasing patient demand for health care. This thesis is the first contemporary study to evaluate clinical outcomes of the role within a complex systems-intervention framework. Emergency nurse practitioner service effectiveness was demonstrated through superior performance in delivery of timely analgesia for emergency department patients. The results validate nurse practitioner service as being able to demonstrate comparable outcomes. This research provides a much-needed evidence base supporting nurse practitioner service and its role in the changing health system and the reform agenda for service innovation.

Evaluating emergency nurse practitioner service effectiveness on achieving timely analgesia: A pragmatic randomized controlled trial

Objectives The rapid uptake of nurse practitioner (NP) services in Australia has outpaced evaluation of this service model. A randomized controlled trial was conducted to compare the effectiveness of NP service versus standard medical care in the emergency department (ED) of a major referral hospital in Australia. Methods Patients presenting with pain were randomly assigned to receive either standard ED medical care or NP care. Primary investigators were blinded to treatment allocation for data analyses. The primary outcome measure was the proportion of patients receiving analgesia within 30 minutes from being seen by care group. Secondary outcome measures were time to analgesia from presentation and documentation of and changes in pain scores. Results There were 260 patients randomized; 128 received standard care (medical practitioner led), and 130 received NP care. Two patients needed to be excluded due to incomplete consent forms. The proportion of patients who received analgesia within 30 minutes from being seen was 49.2% (n = 64) in the NP group and 29.7% (n = 38) in the standard group, a difference of 19.5% (95% confidence interval [CI] = 7.9% to 31.2%; p = 0.001). Of 165 patients who received analgesia, 64 (84.2%) received analgesia within 30 minutes in the NP group compared to 38 (42.7%) in the standard care group, a difference in proportions of 41.5% (95% CI = 28.3% to 54.7%; p < 0.001). The mean (±SD) time from being seen to analgesia was 25.4 (±39.2) minutes for NP care and 43.0 (±35.5) minutes for standard care, a difference of 17.6 minutes (95% CI = 6.1 to 29.1 minutes; p = 0.003). There was a difference in the median change in pain score of 0.5 between care groups, but this was not statistically significant (p = 0.13). Conclusions Nurse practitioner service effectiveness was demonstrated through superior performance in achieving timely analgesia for ED patients.

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.

Factors influencing sustainability of health service innovation: Emergency nurse practitioner services

Introduction: Emergency department nurse practitioner services are one of the most frequently implemented service delivery models in Australian hospitals. This research examined factors influencing sustainability of this innovative service delivery model and offers some recommendations for future service integration. Background Many health service innovations have been implemented in an attempt to meet the growing demand for efficient, cost effective health care however, sustainability of many of these innovations has not been evaluated and is poorly understood. Aim The aim of the research was to identify factors that influence sustainability of emergency department nurse practitioner services and to operationalise a theoretical framework for evaluating innovation sustainability. Methodology The research used case study methodology. The case was emergency nurse practitioner services, and units of analysis were emergency department staff, emergency nurse practitioners and documents relating to nurse practitioner services. The data collection methods included, survey, one-on-one interviews, document analysis and telephone survey. Results This research shows that emergency nurse practitioner services partially comply with the factors of sustainability as described in the Sustainability of Innovation theoretical framework: Political, Organisational, Workforce, Financial and Innovation specific factors. Where services do not entirely meet the factors the existing benefits of the service may outweigh the barriers and other means of working around shortfalls are also implemented by staff to ensure patient safety. Conclusion The rapidly expanding emergency nurse practitioner service has been examined using case study methodology to find that certain factors may be threatening the sustainability of this health service innovation. Potentially an innovation may be sustained when only some factors are met in the short term, however, long term sustainability may be challenged if factors are not addressed and supported.

Hospital in the Nursing Home program reduces emergency department presentations and hospital admissions from residential aged care facilities in Queensland, Australia: A quasi-experimental study

Background There has been considerable publicity regarding population ageing and hospital emergency department (ED) overcrowding. Our study aims to investigate impact of one intervention piloted in Queensland Australia, the Hospital in the Nursing Home (HiNH) program, on reducing ED and hospital attendances from residential aged care facilities (RACFs). Methods A quasi-experimental study was conducted at an intervention hospital undertaking the program and a control hospital with normal practice. Routine Queensland health information system data were extracted for analysis. Results Significant reductions in the number of ED presentations per 1000 RACF beds (rate ratio (95 % CI): 0.78 (0.67–0.92); p = 0.002), number of hospital admissions per 1000 RACF beds (0.62 (0.50–0.76); p < 0.0001), and number of hospital admissions per 100 ED presentations (0.61 (0.43–0.85); p = 0.004) were noticed in the experimental hospital after the intervention; while there were no significant differences between intervention and control hospitals before the intervention. Pre-test and post-test comparison in the intervention hospital also presented significant decreases in ED presentation rate (0.75 (0.65–0.86); p < 0.0001) and hospital admission rate per RACF bed (0.66 (0.54–0.79); p < 0.0001), and a non-significant reduction in hospital admission rate per ED presentation (0.82 (0.61–1.11); p = 0.196). Conclusions Hospital in the Nursing Home program could be effective in reducing ED presentations and hospital admissions from RACF residents. Implementation of the program across a variety of settings is preferred to fully assess the ongoing benefits for patients and any possible cost-savings.

Factors influencing sustainability of health service innovation, emergency nurse practitioner service

Escalating health care delivery costs and consumer expectations have led to a range of health service and workforce innovations in the provision of high quality cost effective patient care. This research has operationalised a theoretical framework to examine factors that influence sustainability of health service innovations, in particular, emergency nurse practitioner service. The results of this research will inform health service policy and practice for future implementation of innovative workforce models and add to the understanding of factors that influence sustainability.

Change to costs and lengths of stay in the emergency department and the Brisbane protocol: An observational study

- Objective To compare health service cost and length of stay between a traditional and an accelerated diagnostic approach to assess acute coronary syndromes (ACS) among patients who presented to the emergency department (ED) of a large tertiary hospital in Australia. - Design, setting and participants This historically controlled study analysed data collected from two independent patient cohorts presenting to the ED with potential ACS. The first cohort of 938 patients was recruited in 2008–2010, and these patients were assessed using the traditional diagnostic approach detailed in the national guideline. The second cohort of 921 patients was recruited in 2011–2013 and was assessed with the accelerated diagnostic approach named the Brisbane protocol. The Brisbane protocol applied early serial troponin testing for patients at 0 and 2 h after presentation to ED, in comparison with 0 and 6 h testing in traditional assessment process. The Brisbane protocol also defined a low-risk group of patients in whom no objective testing was performed. A decision tree model was used to compare the expected cost and length of stay in hospital between two approaches. Probabilistic sensitivity analysis was used to account for model uncertainty. - Results Compared with the traditional diagnostic approach, the Brisbane protocol was associated with reduced expected cost of $1229 (95% CI −$1266 to $5122) and reduced expected length of stay of 26 h (95% CI −14 to 136 h). The Brisbane protocol allowed physicians to discharge a higher proportion of low-risk and intermediate-risk patients from ED within 4 h (72% vs 51%). Results from sensitivity analysis suggested the Brisbane protocol had a high chance of being cost-saving and time-saving. - Conclusions This study provides some evidence of cost savings from a decision to adopt the Brisbane protocol. Benefits would arise for the hospital and for patients and their families.

Lights and shades of mission work, or, Leaves from a worker's note book : being reminiscenses of seven years service at the capital, 1885-1892 / by B.H.W.

http://www.archive.org/details/lightsandshades00bhwuoft

Shaping the Future of Mental Health Policy and Legislation in Northern Ireland: The Impact of Service User and Professional Social Work Discourses

This paper explores the complex interrelationship between service user and professional social work discourses and provides a critical commentary on their respective contributions to the recent review of mental health policy and legislation in Northern Ireland. The analysis indicates that dominant trends in mental health care, as mediated through service structures and institutional identities, have tended to prioritize the more coercive aspects of the social work role and reinforce existing power inequalities with service users. It is argued that such developments underline the need for a ‘refocusing’ debate in mental health social work to consider how a more appropriate balance can be achieved between its participatory/empowering and regulatory/coercive functions. Whilst highlighting both congruence and dissonance between respective discourses, the paper concludes that opportunities exist within the current change process for service users and social workers to build closer alliances in working together to reconstruct practice, safeguard human rights and develop innovative alternatives to a traditional bio-medical model of treatment.