Acuity and severity of patients attending 28 Queensland hospitals emergency departments in 2008-09

Overcrowding of hospital Emergency Departments (EDs) in Australia is a complex issue of high public and professional prominence, resulted from a combination of increasing demands, increased complexity of care and Access Block. The aim of this study is to describe the distribution of the acuity and severity of current Queensland ED patients to better understand ED users...

Immigrants and the utilization of hospital emergency departments

BACKGROUND: Immigrants with language barriers are at high risk of having poor access to health care services. However, several studies have indicated that immigrants tend to use emergency departments (EDs) as their primary source of care at the expense of primary care. This may place an additional burden on already overcrowded EDs and lead to a low level of patient satisfaction with ED care. The study was to review if immigrants utilize ED care differently from host populations and to assess immigrants’ satisfaction with ED care. DATA SOURCES: Studies about immigrants' utilization of EDs in Australia and worldwide were reviewed. RESULTS: There are confl icting results in the literature about the pattern of ED care use among immigrants. Some studies have shown higher utilization by immigrants compared to host populations and others have shown lower utilization. Overall, immigrants use ED care heavily, make inappropriate visits to EDs, have a longer length of stay in EDs, and are less satisfi ed with ED care as compared to host populations. CONCLUSIONS: Immigrants might use ED care differently from host populations due to language and cultural barriers. There is sparse Australian literature regarding immigrants' access to health care including ED care. To ensure equity, further research is needed to inform policy when planning health care provision to immigrants. KEY WORDS: Emergency department; Health service; Immigrants; Language; Utilization

Appraisal of the quality of care of older people with cognitive impairment presenting to emergency departments

The medical records of 273 patients 75 years and older were reviewed to evaluate quality of emergency department (ED) care through the use of quality indicators. One hundred fifty records contained evidence of an attempt to carry out a cognitive assessment. Documented evidence of cognitive impairment (CI) was reported in 54 cases. Of these patients, 30 had no documented evidence of an acute change in cognitive function from baseline; of 26 patients discharged home with preexisting CI (i.e., no acute change from baseline), 15 had no documented evidence of previous consideration of this issue by a health care provider; and 12 of 21 discharged patients who screened positive for cognitive issues for the first time were not referred for outpatient evaluation. These findings suggest that the majority of older adults in the ED are not receiving a formal cognitive assessment, and more than half with CI do not receive quality of care according to the quality indicators for geriatric emergency care. Recommendations for improvement are discussed.

Language affects length of stay in emergency departments in Queensland public hospitals

BACKGROUND: A long length of stay (LOS) in the emergency department (ED) associated with overcrowding has been found to adversely affect the quality of ED care. The objective of this study is to determine whether patients who speak a language other than English at home have a longer LOS in EDs compared to those whose speak only English at home. METHODS: A secondary data analysis of a Queensland state-wide hospital EDs dataset (Emergency Department Information System) was conducted for the period, 1 January 2008 to 31 December 2010. RESULTS: The interpreter requirement was the highest among Vietnamese speakers (23.1%) followed by Chinese (19.8%) and Arabic speakers (18.7%). There were significant differences in the distributions of the departure statuses among the language groups (Chi-squared=3236.88, P<0.001). Compared with English speakers, the Beta coeffi cient for the LOS in the EDs measured in minutes was among Vietnamese, 26.3 (95%CI: 22.1–30.5); Arabic, 10.3 (95%CI: 7.3–13.2); Spanish, 9.4 (95%CI: 7.1–11.7); Chinese, 8.6 (95%CI: 2.6–14.6); Hindi, 4.0 (95%CI: 2.2–5.7); Italian, 3.5 (95%CI: 1.6–5.4); and German, 2.7 (95%CI: 1.0–4.4). The fi nal regression model explained 17% of the variability in LOS. CONCLUSION: There is a close relationship between the language spoken at home and the LOS at EDs, indicating that language could be an important predictor of prolonged LOS in EDs and improving language services might reduce LOS and ease overcrowding in EDs in Queensland's public hospitals.

Improving the measurement and surveillance of child abuse in Queensland emergency departments

There are no population studies of prevalence or incidence of child maltreatment in Australia. Child protection data gives some understanding but is restricted by system capacity and definitional issues across jurisdictions. Child protection data currently suggests that numbers of reports are increasing yearly, and the child protection system then becomes focussed on investigating all reports and diluting available resources for those children who are most in need of intervention. A public health response across multiple agencies enables responses to child safety across the entire population. All families are targeted at the primary level; examples include ensuring all parents know the dangers of shaking a baby or teaching children to say no if a situation makes them uncomfortable. The secondary level of prevention targets families with a number of risk factors, for example subsidised child care so children aren't left unsupervised after school when both parents have to be at work or home visiting for drug-addicted parents to ensure children are cared for. The tertiary response then becomes the responsibility of the child protection system and is reserved for those children where abuse and neglect are identified. This model requires that child safety is seen in a broader context than just the child protection system, and increasingly health professionals are being identified as an important component in the public health framework. If all injury is viewed as preventable and considered along a continuum of 'accidental' through to 'inflicted', it becomes possible to conceptualise child maltreatment in an injury context. Parental intent may not be to cause harm to the child, but by lack of insight or concern about risk, the potential for injury is high. The mechanisms for unintentional and intentional injury overlap and some suggest that by segregating child abuse (with the possible exception of sexual abuse) from unintentional injury, child abuse is excluded from the broader injury prevention initiative that is gaining momentum in the community. This research uses a public health perspective, specifically that of injury prevention, to consider the problem of child abuse. This study employed a mixed method design that incorporates secondary data analysis, data linkage and structured interviews of different professional groups. Datasets from the Queensland Injury Surveillance Unit (QISU) and The Department of Child Safety (DCS) were evaluated. Coded injury data was grouped according to intent of injury according to those with a code that indicated the ED presentation was due to child abuse, a code indicating that the injury was possibly due to abuse or, in the third group, the intent code indicated that the injury was unintentional and not due to abuse. Primary data collection from ED records was undertaken and information recoded to assess reliability and completeness. Emergency department data (QISU) was linked to Department of Child Safety Data to examine concordance and data quality. Factors influencing the collection and collation of these data were identified through structured interview methodology and analysed using qualitative methods. Secondary analysis of QISU data indicated that codes lacking specific information on the injury event were more likely to also have an intent code indicating abuse than those records where there was specific information on the injury event. Codes for abuse appeared in only 1.2% of the 84,765 records analysed. Unintentional injury was the most commonly coded intent (95.3%). In the group with a definite abuse code assigned at triage, 83% linked to a record with DCS and cases where documentation indicated police involvement were significantly more likely to be associated with a DCS record than those without such documentation. In those coded with an unintentional injury code, 22% linked to a DCS record with cases assigned an urgent triage category more likely to link than those with a triage category for resuscitation and children who presented to regional or remote hospitals more likely to link to a DCS record than those presenting to urban hospitals. Twenty-nine per cent of cases with a code indicating possible abuse linked to a DCS record. In documentation that indicated police involvement in the case, a code for unspecified activity when compared to cases with a code indicating involvement in a sporting activity and children less than 12 months of age compared to those in the 13-17 year old age group were all variables significantly associated with linkage to a DCS record. Only 13% of records contained documentation indicating that child abuse and neglect were considered in the diagnosis of the injury despite almost half of the sample having a code of abuse or possible abuse. Doctors and nurses were confident in their knowledge of the process of reporting child maltreatment but less confident about identifying child abuse and neglect and what should be reported. Many were concerned about implications of reporting, for the child and family and for themselves. A number were concerned about the implications of not reporting, mostly for the wellbeing of the child and a few in terms of their legal obligations as mandatory reporters. The outcomes of this research will help improve the knowledge of barriers to effective surveillance of child abuse in emergency departments. This will, in turn, ensure better identification and reporting practises; more reliable official statistical collections and the potential of flagging high-risk cases to ensure adequate departmental responses have been initiated.

Private hospital emergency departments in Australia : challenges and opportunities

BACKGROUND: Public hospital EDs in Australia have become increasingly congested because of increasing demand and access block. Six per cent of ED patients attend private hospital EDs whereas 45% of the population hold private health insurance. OBJECTIVES: This study describes the patients attending a small selection of four private hospital EDs in Queensland and Victoria, and tests the feasibility of a private ED database. METHODS: De-identified routinely collected patient data were provided by the four participating private hospital and amalgamated into a single data set. RESULT: The mean age of private ED patients was 52 years. Males outnumbered females in all age groups except > 80 years. Attendance was higher on weekends and Mondays, and between 08.00 and 20.00 h. There were 6.6% of the patients triaged as categories 1 and 2, and 60% were categories 4 or 5. There were 36.4% that required hospital admission. Also, 96% of the patients had some kind of insurance. Furthermore, 72% were self-referred and 12% were referred by private medical practitioners. Approximately 25% arrived by ambulance. There were 69% that completed their ED treatment within 4 h. CONCLUSION: This study is the first public description of patients attending private EDs in Australia. Private EDs have a significant role to play in acute medical care and in providing access to private hospitals which could alleviate pressure on public EDs. This study demonstrates the need for consolidated data based on a consistent data set and data dictionary to enable system-wide analysis, benchmarking and evaluation

Utilisation of hospital emergency departments among immigrants from refugee source-countries in Queensland

Despite the increasing number of immigrants, there is a limited body of literature describing the use of hospital emergency department (ED) care by immigrants in Australia. This study aims to describe how immigrants from refugee source countries (IRSC) utilise ED care, compared to immigrants from the main English speaking countries (MESC), immigrants from other countries (IOC) and the local population in Queensland. A retrospective analysis of a Queensland state-wide hospital ED dataset (ED Information System) from 1-1-2008 to 31-12-2010 was conducted. Our study showed that immigrants are not a homogenous group. We found that immigrants from IRSC are more likely to use interpreters (8.9%) in the ED compared to IOC. Furthermore, IRSC have a higher rate of ambulance use (odds ratio 1.2, 95% confidence interval (CI) 1.2–1.3), are less likely to be admitted to the hospital from the ED (odds ratio 0.7 (95% CI 0.7–0.8), and have a longer length of stay (LOS; mean differences 33.0, 95% CI 28.8–37.2), in minutes, in the ED compared to the Australian born population. Our findings highlight the need to develop policies and educational interventions to ensure the equitable use of health services among vulnerable immigrant populations.

Changes in health profiles of participants in an Australian police department’s Wellness program

Background: Little is known about the health effects of worksite wellness programs on police department staff. Objective: To examine 1-2 year changes in health profiles of participants in the Queensland Police Service’s wellness program. Methods: Participants underwent yearly physical assessments. Health profile data collected during assessments from 2008 to 2012 were included in the analysis. Data Analysis: Repeated-measures ANOVA was used for continuous outcome variables, related-samples Wilcoxon Signed Rank test for non-normally continuous variables, and McNemar’s test for binary variables. Results: Significant changes in physical measures included decreases in waist circumference and percent body fat, and increases in cardiorespiratory fitness and flexibility (p<0.01). Changes in serum cholesterol, haemoglobin, total cholesterol ratios, HDL, LDL and Triglyceride levels were also significant (p<0.01). Conclusion: Participants’ health profiles mostly improved between cycles although most changes were not clinically significant. As this evaluation used a single-group pre-test post-test design, it provides initial indications that wellness programs can benefit staff in police departments.

What is the evidence to guide best practice for the management of older people with cognitive impairment presenting to emergency departments? A systematic review

The aim of this study was to conduct a systematic literature review of research-based studies to identify practices designed to meet the specific care needs of older cognitively impaired patients in emergency departments (ED). A systematic literature review of studies was completed using PRIMSA methodology. The search criteria included articles from both emergency and acute care settings. A total of 944 articles were screened, and a total of 43 articles were identified as eligible. The review found a number of intervention studies to improve quality of care for older persons with cognitive impairment carried out or commenced in emergency settings, including interventions to improve cognitive impairment recognition (n = 9) and clinical approaches to reduce falls (n = 1) and both delirium incidence and prevalence (n = 2). Relevant studies carried out in acute care settings regarding cognitive impairment recognition (n = 4) and primary and secondary prevention of delirium (n = 18) and intervention studies that reduced the prescription of deliriogenic drugs (n = 1), reduced behavioral symptoms and discomfort (n = 7), and improved nutritional intake (n = 1) in hospitalized older persons with dementia were also identified. There is limited research available that reports interventions that improve the quality of care of older ED patients with cognitive impairment. Although this review found evidence obtained from the acute care setting, additional research is needed to identify whether these interventions are beneficial in fast-paced emergency settings.

Can SNOMED CT as implemented in New South Wales, Australia be used for road trauma injury surveillance in emergency departments?

The introduction of Systematized Nomenclature of Medicine - Clinical Terms (Snomed CT) for diagnosis coding in emergency departments (EDs) in New South Wales (NSW) has implications for injury surveillance abilities. This study aimed to assess the consequences of its introduction, as implemented as part of the ED information system in NSW, for identifying road trauma-related injuries in EDs. It involved a retrospective analysis of road trauma-related injuries identified in linked police, ED and mortality records during March 2007 to December 2009. Between 53.7% to 78.4% of all Snomed CT classifications in the principal provisional diagnosis field referred to the type of injury or symptom experienced by the individual. Of the road users identified by police, 3.2% of vehicle occupants, 6% of motorcyclists, 10.0% of pedal cyclists and 5.2% of pedestrians were identified using Snomed CT classifications in the principal provisional diagnosis field. The introduction of Snomed CT may provide flexible terminologies for clinicians. However, unless carefully implemented in information systems, its flexibility can lead to mismatches between the intention and actual use of defined data fields. Choices available in Snomed CT to indicate either symptoms, diagnoses, or injury mechanisms need to be controlled and these three concepts need to be retained in separate data fields to ensure a clear distinction between their classification in the ED.

The Implications of Activity Based Funding for Emergency Departments : A Comprehensive Literature Review

Executive Summary Emergency Departments (EDs) locally, nationally and internationally are becoming increasingly busy. Within this context, it can be challenging to deliver a health service that is safe, of high quality and cost-effective. Whilst various models are described within the literature that aim to measure ED ‘work’ or ‘activity’, they are often not linked to a measure of costs to provide such activity. It is important for hospital and ED managers to understand and apply this link so that optimal staffing and financial resourcing can be justifiably sought. This research is timely given that Australia has moved towards a national Activity Based Funding (ABF) model for ED activity. ABF is believed to increase transparency of care and fairness (i.e. equal work receives equal pay). ABF involves a person-, performance- or activity-based payment system, and thus a move away from historical “block payment” models that do not incentivise efficiency and quality. The aim of the Statewide Workforce and Activity-Based Funding Modelling Project in Queensland Emergency Departments (SWAMPED) is to identify and describe best practice Emergency Department (ED) workforce models within the current context of ED funding that operates under an ABF model. The study is comprised of five distinct phases. This monograph (Phase 1) comprises a systematic review of the literature that was completed in June 2013. The remaining phases include a detailed survey of Queensland hospital EDs’ resource levels, activity and operational models of care, development of new resource models, development of a user-friendly modelling interface for ED mangers, and production of a final report that identifies policy implications. The anticipated deliverable outcome of this research is the development of an ABF based Emergency Workforce Modelling Tool that will enable ED managers to profile both their workforce and operational models of care. Additionally, the tool will assist with the ability to more accurately inform adequate staffing numbers required in the future, inform planning of expected expenditures and be used for standardisation and benchmarking across similar EDs. Summary of the Findings Within the remit of this review of the literature, the main findings include: 1. EDs are becoming busier and more congested Rising demand, barriers to ED throughput and transitions of care all contribute to ED congestion. In addition requests by organisational managers and the community require continued broadening of the scope of services required of the ED and further increases in demand. As the population live longer with more lifestyle diseases their propensity to require ED care continues to grow. 2. Various models of care within EDs exist Models often vary to account for site specific characteritics to suit staffing profile, ED geographical location (e.g. metropolitan or rural site), and patient demographic profile (e.g. paediatrics, older persons, ethnicity). Existing and new models implemented within EDs often depend on the target outcome requiring change. Generally this is focussed on addressing issues at the input, throughput or output areas of the ED. Even with models targeting similar demographic or illness, the structure and process elements underpinning the model can vary, which can impact on outcomes and variance to the patient and carer experience between and within EDs. Major models of care to manage throughput inefficiencies include: A. Workforce Models of Care focus on the appropriate level of staffing for a given workload to provide prompt, timely and clinically effective patient care within an emergency care setting. The studies reviewed suggest that the early involvement of senior medical decision maker and/or specialised nursing roles such as Emergency Nurse Practitioners and Clinical Initiatives Nurse, primary contact or extended scope Allied Health Practitioners can facilitate patient flow and improve key indicators such as length of stay and reducing the number of those who did not wait to be seen amongst others. B. Operational Models of Care within EDs focus on mechanisms for streaming (e.g. fast-tracking) or otherwise grouping patient care based on acuity and complexity to assist with minimising any throughput inefficiencies. While studies support the positive impact of these models in general, it appears that they are most effective when they are adequately resourced. 3. Various methods of measuring ED activity exist Measuring ED activity requires careful consideration of models of care and staffing profile. Measuring activity requires the ability to account for factors including: patient census, acuity, LOS, intensity of intervention, department skill-mix plus an adjustment for non-patient care time. 4. Gaps in the literature Continued ED growth calls for new and innovative care delivery models that are safe, clinically effective and cost effective. New roles and stand-alone service delivery models are often evaluated in isolation without considering the global and economic impact on staffing profiles. Whilst various models of accounting for and measuring health care activity exist, costing studies and cost effectiveness studies are lacking for EDs making accurate and reliable assessments of care models difficult. There is a necessity to further understand, refine and account for measures of ED complexity that define a workload upon which resources and appropriate staffing determinations can be made into the future. There is also a need for continued monitoring and comprehensive evaluation of newly implemented workforce modelling tools. This research acknowledges those gaps and aims to: • Undertake a comprehensive and integrated whole of department workforce profiling exercise relative to resources in the context of ABF. • Inform workforce requirements based on traditional quantitative markers (e.g. volume and acuity) combined with qualitative elements of ED models of care; • Develop a comprehensive and validated workforce calculation tool that can be used to better inform or at least guide workforce requirements in a more transparent manner.

Use of hospital emergency departments by immigrants from non-English speaking backgrounds in Queensland

This study aimed to examine the use of hospital emergency departments and to investigate the level of satisfaction with the emergency department service among patients from a non-English-speaking background compared to those of patients from an English-speaking background in Queensland. The findings of this study might inform health professionals and policy planners to develop educational interventions and policies to ensure equitable use of emergency services among the populations.

Retrospective observational study of patients who present to Australian rural emergency departments with undifferentiated chest pain

Aim To identify the demographic and clinical characteristics of patients who present to Australian rural emergency departments with chest pain. Design Retrospective, observational study Setting Rural emergency departments (ED) in Queensland, Australia Participants 337 consecutive adult patients with undifferentiated chest pain that presented between 1st September 2013 and 30th November 2013. Main outcome measures Service indicators, discharge diagnoses and disposition Results Presentations for undifferentiated chest pain represented 3.5% of all patient presentations during the sampling period. The mean age of patients was 48 years and 54% were male. Overall, 92% of patients left the ED within the 4-hour NEAT target. The majority of presentations were related to cardiac concerns (39%), followed by non-cardiac chest pain (17%), musculoskeletal (15%) and respiratory (10%) conditions. More than half of these patients were discharged at the completion of the ED service (52.8%), 40.6% were admitted, 3.3% left at own risk, 2.4% did not wait and less than 1% of patients required transfer to another hospital directly from the ED. Conclusions This study has provided information on the characteristics and processes of care for patients presenting to Australian rural EDs with undifferentiated chest pain that will inform service planning and further research to evaluate the effectiveness of care for these patients.