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

Managing intravenous medications in the non-hospital setting: An ethnographic investigation

Little published information exists about the issues involved in conducting complex intravenous medication therapy in patients' homes. An ethnographic study of a local hospital-in-the-home program in the Australian Capital Territory explored this phenomenon to identify those factors that had an impact on the use of medicine in the home environment. This article focuses on one of the three themes identified in the study-Clinical Practice. Within this theme, topics related to the organization and management of intravenous medications, geography and diversity of patient caseload, and communication in the practice setting are discussed. These findings have important implications for policy development and establishment of a research agenda for hospital-in-the-home services.

Hospital and home : strange bedfellows or new partners?

This paper addresses the hospital/community interface as an emerging context of health care practice. As a consequence of industry reforms health service managers are looking to the community space as a location for delivery of acute health care. This focus on the community is sharpened by the promise of cost savings and enhanced by the seemingly limitless potential of biomedical technology. The paper argues that the interface of hospital and community is a conceptual space where two different types of health services meet, bringing with them different cultural practices and expectations. The ‘hospital in the home’ programs that structure health care at this interface provide the delivery of acute nursing and medical care and the accoutrements of this care in the community, the neighbourhood, the home. Consequently, the home is becoming the new site for high technology ‘hospital’ care. This domestication of illness technology is contrasted with the notion of home as a place of sanctuary, familiarity and belonging.

Baby-friendly hospital accreditation, in-hospital care practices and breastfeeding : a population based survey

OBJECTIVES: To investigate the effect of Baby-Friendly Hospital Initiative (BFHI) accreditation and hospital care practices on breastfeeding rates at 1 and 4 months. METHODS: All women who birthed in Queensland, Australia, from February 1 to May 31, 2010, received a survey 4 months postpartum. Maternal, infant, and hospital characteristics; pregnancy and birth complications; and infant feeding outcomes were measured. RESULTS: Sample size was 6752 women. Breastfeeding initiation rates were high (96%) and similar in BFHI-accredited and nonaccredited hospitals. After adjustment for significant maternal, infant, clinical, and hospital variables, women who birthed in BFHI-accredited hospitals had significantly lower odds of breastfeeding at 1 month (adjusted odds ratio 0.72, 95% confidence interval 0.58–0.90) than those who birthed in non–BFHI-accredited hospitals. BFHI accreditation did not affect the odds of breastfeeding at 4 months or exclusive breastfeeding at 1 or 4 months. Four in-hospital practices (early skin-to-skin contact, attempted breastfeeding within the first hour, rooming-in, and no in-hospital supplementation) were experienced by 70% to 80% of mothers, with 50.3% experiencing all 4. Women who experienced all 4 hospital practices had higher odds of breastfeeding at 1 month (adjusted odds ratio 2.20, 95% confidence interval 1.78–2.71) and 4 months (adjusted odds ratio 2.93, 95% confidence interval 2.40–3.60) than women who experienced fewer than 4. CONCLUSIONS: When breastfeeding-initiation rates are high and evidence-based practices that support breastfeeding are common within the hospital environment, BFHI accreditation per se has little effect on both exclusive or any breastfeeding rates.C

Communicating in the pre-hospital emergency environment

Aim. To develop and evaluate the implementation of a communication board for paramedics to use with patients as an augmentative or alternative communication tool to address communication needs of patients in the pre-hospital setting. Method. A double-sided A4-size communication board was designed specifically for use in the pre-hospital setting by the Queensland Ambulance Service and Disability and Community Care Services. One side of the board contains expressive messages that could be used by both the patient and paramedic. The other side contains messages to support patients’ understanding and interaction tips for the paramedic. The communication board was made available in every ambulance and patient transport vehicle in the Brisbane Region. Results. A total of 878 paramedics completed a survey that gauged which patient groups they might use the communication board with. The two most common groups were patients from culturally and linguistically diverse backgrounds and children. Staff reported feeling confident in using the board, and 72% of interviewed paramedics agreed that the communication board was useful for aiding communication with patients. Feedback from paramedics suggests that the board is simple to use, reduces patient frustration and improves communication. Conclusion. These results suggest that a communication board can be applied in the pre-hospital setting to support communication success with patients. What is known about the topic? It is imperative that communication between patient and paramedic is clear and effective. Research has shown that communication boards have been effective with people with temporary or permanent communication difficulties. What does this paper add? This is the first paper outlining the development and use of a communication board by paramedics in the pre-hospital setting in Australia. The paper details the design of the communication board for the unique pre-hospital environment. The paper provides some preliminary data on the use of the communication board with certain patient groups and its effectiveness as an alternative communication tool. What are the implications for practitioners? The findings support the use of the tool as a viable option in supporting the communication between paramedics and a range of patients. It is not suggested that this communication board will meet the complete communication needs of any individual in this environment, but it is hoped that the board’s presence within the Queensland Ambulance Service may result in paramedics introducing the board on occasions where communication with a patient is challenging.

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.

Cost effectiveness of patient education for the prevention of falls in hospital : economic evaluation from a randomized controlled trial

Background Falls are one of the most frequently occurring adverse events that impact upon the recovery of older hospital inpatients. Falls can threaten both immediate and longer-term health and independence. There is need to identify cost-effective means for preventing falls in hospitals. Hospital-based falls prevention interventions tested in randomized trials have not yet been subjected to economic evaluation. Methods Incremental cost-effectiveness analysis was undertaken from the health service provider perspective, over the period of hospitalization (time horizon) using the Australian Dollar (A$) at 2008 values. Analyses were based on data from a randomized trial among n = 1,206 acute and rehabilitation inpatients. Decision tree modeling with three-way sensitivity analyses were conducted using burden of disease estimates developed from trial data and previous research. The intervention was a multimedia patient education program provided with trained health professional follow-up shown to reduce falls among cognitively intact hospital patients. Results The short-term cost to a health service of one cognitively intact patient being a faller could be as high as A$14,591 (2008). The education program cost A$526 (2008) to prevent one cognitively intact patient becoming a faller and A$294 (2008) to prevent one fall based on primary trial data. These estimates were unstable due to high variability in the hospital costs accrued by individual patients involved in the trial. There was a 52% probability the complete program was both more effective and less costly (from the health service perspective) than providing usual care alone. Decision tree modeling sensitivity analyses identified that when provided in real life contexts, the program would be both more effective in preventing falls among cognitively intact inpatients and cost saving where the proportion of these patients who would otherwise fall under usual care conditions is at least 4.0%. Conclusions This economic evaluation was designed to assist health care providers decide in what circumstances this intervention should be provided. If the proportion of cognitively intact patients falling on a ward under usual care conditions is 4% or greater, then provision of the complete program in addition to usual care will likely both prevent falls and reduce costs for a health service.

Designing a continuum of quality external cause of injury information in Queensland : from ambulance to hospital

This study is the first to employ an epidemiological framework to evaluate the ‘fit-for-purpose’ of ICD-10-AM external cause of injury codes, ambulance and hospital clinical documentation for injury surveillance. Importantly, this thesis develops an evidence-based platform to guide future improvements in routine data collections used to inform the design of effective injury prevention strategies. Quantification of the impact of ambulance clinical records on the overall information quality of Queensland hospital morbidity data collections for injury causal information is a unique and notable contribution of this study.

Princess Alexandra Hospital model of comprehensive geriatric assessment of cancer patients : methodological and logistical aspects

There is increasing momentum in cancer care to implement a two stage assessment process that accurately determines the ability of older patients to cope with, and benefit from, chemotherapy. The two-step approach aims to ensure that patients clearly fit for chemotherapy can be accurately identified and referred for treatment without undergoing a time- and resource-intensive comprehensive geriatric assessment (CGA). Ideally, this process removes the uncertainty of how to classify and then appropriately treat the older cancer patient. After trialling a two-stage screen and CGA process in the Division of Cancer Services at Princess Alexandra Hospital (PAH) in 2011-2012, we implemented a model of oncogeriatric care based on our findings. In this paper, we explore the methodological and practical aspects of implementing the PAH model and outline further work needed to refine the process in our treatment context.

A pre-post evaluation of an ambulatory nutrition support service for malnourished patients post hospital discharge: a pilot study

Introduction Malnutrition is common among hospitalised patients, with poor follow-up of nutrition support post-discharge. Published studies on the efficacy of ambulatory nutrition support (ANS) for malnourished patients post-discharge are scarce. The aims of this study were to evaluate the rate of dietetics follow-up of malnourished patients post-discharge, before (2008) and after (2010) implementation of a new ANS service, and to evaluate nutritional outcomes post-implementation. Materials and Methods Consecutive samples of 261 (2008) and 163 (2010) adult inpatients referred to dietetics and assessed as malnourished using Subjective Global Assessment (SGA) were enrolled. All subjects received inpatient nutrition intervention and dietetic outpatient clinic follow-up appointments. For the 2010 cohort, ANS was initiated to provide telephone follow-up and home visits for patients who failed to attend the outpatient clinic. Subjective Global Assessment, body weight, quality of life (EQ-5D VAS) and handgrip strength were measured at baseline and five months post-discharge. Paired t-test was used to compare pre- and post-intervention results. Results In 2008, only 15% of patients returned for follow-up with a dietitian within four months post-discharge. After implementation of ANS in 2010, the follow-up rate was 100%. Mean weight improved from 44.0 ± 8.5kg to 46.3 ± 9.6kg, EQ-5D VAS from 61.2 ± 19.8 to 71.6 ± 17.4 and handgrip strength from 15.1 ± 7.1 kg force to 17.5 ± 8.5 kg force; p<0.001 for all. Seventy-four percent of patients improved in SGA score. Conclusion Ambulatory nutrition support resulted in significant improvements in follow-up rate, nutritional status and quality of life of malnourished patients post-discharge.

Evaluation of an ambulatory nutrition support service for malnourished patients post hospital discharge

Introduction Malnutrition is common among hospitalised patients, with poor follow-up of nutrition support post-discharge. Published studies on the efficacy of ambulatory nutrition support (ANS) for malnourished patients post-discharge are scarce. The aims of this study were to evaluate the rate of dietetics follow-up of malnourished patients post-discharge, before (2008) and after (2010) implementation of a new ANS service, and to evaluate nutritional outcomes post-implementation. Materials and Methods Consecutive samples of 261 (2008) and 163 (2010) adult inpatients referred to dietetics and assessed as malnourished using Subjective Global Assessment (SGA) were enrolled. All subjects received inpatient nutrition intervention and dietetic outpatient clinic follow-up appointments. For the 2010 cohort, ANS was initiated to provide telephone follow-up and home visits for patients who failed to attend the outpatient clinic. Subjective Global Assessment, body weight, quality of life (EQ-5D VAS) and handgrip strength were measured at baseline and five months post-discharge. Paired t-test was used to compare pre- and post-intervention results. Results In 2008, only 15% of patients returned for follow-up with a dietitian within four months post-discharge. After implementation of ANS in 2010, the follow-up rate was 100%. Mean weight improved from 44.0 ± 8.5kg to 46.3 ± 9.6kg, EQ-5D VAS from 61.2 ± 19.8 to 71.6 ± 17.4 and handgrip strength from 15.1 ± 7.1 kg force to 17.5 ± 8.5 kg force; p<0.001 for all. Seventy-four percent of patients improved in SGA score. Conclusion Ambulatory nutrition support resulted in significant improvements in follow-up rate, nutritional status and quality of life of malnourished patients post-discharge.

Integrated Lean Six Sigma approach for patient flow improvement in hospital emergency department

Because of increased competition between healthcare providers, higher customer expectations, stringent checks on insurance payments and new government regulations, it has become vital for healthcare organisations to enhance the quality of the care they provide, to increase efficiency, and to improve the cost effectiveness of their services. Consequently, a number of quality management concepts and tools are employed in the healthcare domain to achieve the most efficient ways of using time, manpower, space and other resources. Emergency departments are designed to provide a high-quality medical service with immediate availability of resources to those in need of emergency care. The challenge of maintaining a smooth flow of patients in emergency departments is a global problem. This study attempts to improve the patient flow in emergency departments by considering Lean techniques and Six Sigma methodology in a comprehensive conceptual framework. The proposed research will develop a systematic approach through integration of Lean techniques with Six Sigma methodology to improve patient flow in emergency departments. The results reported in this paper are based on a standard questionnaire survey of 350 patients in the Emergency Department of Aseer Central Hospital in Saudi Arabia. The results of the study led us to determine the most significant variables affecting patient satisfaction with patient flow, including waiting time during patient treatment in the emergency department; effectiveness of the system when dealing with the patient’s complaints; and the layout of the emergency department. The proposed model will be developed within a performance evaluation metric based on these critical variables, to be evaluated in future work within fuzzy logic for continuous quality improvement.

Hospital separations in the Northern Territory for varicella-zoster virus related illnesses, 1993-1997

A varicella-zoster virus (VZV) vaccine is available overseas, and universal immunisation in childhood is recommended in the United States.1 Any decision to introduce the vaccine to Australia must be based on an assessment of potential benefits and harms. While there has been some assessment of VZV significance in populations in southern Australia,2 the impact on the NT population is not known. It is not a notifiable condition and information on morbidity and mortality is limited to a few data collections. These are hospital separation data, deaths registers, and in 1995 the inclusion of VZV congenital and neonatal complications in the Australian Paediatric Surveillance System. Hospital separation data were analysed to assess the importance of VZV as a cause of severe morbidity and mortality in the NT population.

Utilising hospital data to inform product safety prioritisation : the application of RAPEX severity rankings in ICD-coded burn data

Background The implementation of the Australian Consumer Law in 2011 highlighted the need for better use of injury data to improve the effectiveness and responsiveness of product safety (PS) initiatives. In the PS system, resources are allocated to different priority issues using risk assessment tools. The rapid exchange of information (RAPEX) tool to prioritise hazards, developed by the European Commission, is currently being adopted in Australia. Injury data is required as a basic input to the RAPEX tool in the risk assessment process. One of the challenges in utilising injury data in the PS system is the complexity of translating detailed clinical coded data into broad categories such as those used in the RAPEX tool. Aims This study aims to translate hospital burns data into a simplified format by mapping the International Statistical Classification of Disease and Related Health Problems (Tenth Revision) Australian Modification (ICD-10-AM) burn codes into RAPEX severity rankings, using these rankings to identify priority areas in childhood product-related burns data. Methods ICD-10-AM burn codes were mapped into four levels of severity using the RAPEX guide table by assigning rankings from 1-4, in order of increasing severity. RAPEX rankings were determined by the thickness and surface area of the burn (BSA) with information extracted from the fourth character of T20-T30 codes for burn thickness, and the fourth and fifth characters of T31 codes for the BSA. Following the mapping process, secondary data analysis of 2008-2010 Queensland Hospital Admitted Patient Data Collection (QHAPDC) paediatric data was conducted to identify priority areas in product-related burns. Results The application of RAPEX rankings in QHAPDC burn data showed approximately 70% of paediatric burns in Queensland hospitals were categorised under RAPEX levels 1 and 2, 25% under RAPEX 3 and 4, with the remaining 5% unclassifiable. In the PS system, prioritisations are made to issues categorised under RAPEX levels 3 and 4. Analysis of external cause codes within these levels showed that flammable materials (for children aged 10-15yo) and hot substances (for children aged <2yo) were the most frequently identified products. Discussion and conclusions The mapping of ICD-10-AM burn codes into RAPEX rankings showed a favourable degree of compatibility between both classification systems, suggesting that ICD-10-AM coded burn data can be simplified to more effectively support PS initiatives. Additionally, the secondary data analysis showed that only 25% of all admitted burn cases in Queensland were severe enough to trigger a PS response.