Characteristics and outcomes of older frequent attenders to the Emergency Department

Ms Debra Berry1,3, Dr  Maryann Street1,2,3, Prof Julie Considine1,2,3

1Deakin University, School of Nursing & Midwifery, Geelong, Australia, 2Deakin University: Centre for Quality and Patient Safety, Geelong, Australia, 3Centre for Quality and Patient Safety, Eastern Health Partnership, Box Hill, Australia

Background: Older people are more likely to have repeat Emergency Department (ED) visits and experience adverse outcomes than younger adults.   However, the profile of older frequent ED attenders is under-reported. The aim of this study was to describe the characteristics and outcomes of older frequent ED attenders.

Methods: The study population were people aged ≥65 years, attending an Eastern Health ED in the 2013/2014 financial year. This retrospective cohort study used organisational data linkage at patient level to describe the characteristics and outcomes of frequent ED attenders (≥4 attendances/12-months) compared with non-frequent attenders (<4 attendances/12-months).

Results: In twelve months, 21,073 people aged ≥65 years attended the ED: 5.0% (n=1046) had ≥4 visits, accounting for 16.9% (n=5469) of ED presentations. Frequent ED attenders were more likely to be male (51.8% vs 45%, p<0.001), arrive by ambulance (62.2% vs 57.1%, p<0.001), arrive overnight (22.2% vs 19.8%, p<0.001) and be allocated to triage category 2 (20.4% vs 18.1%, p=0.01). The average ED stay was longer for frequent attenders (6.35 vs 5.88 hours; p<0.001). Frequent attenders had more frequent representations to ED within 48 hours (5.9% vs 2.6%, p<0.001) and readmissions to hospital within 30 days (20.8% vs 4.2%, p<0.001) of discharge.     The in-hospital mortality rate for older frequent ED attenders was double that of non-frequent attenders (3.2% vs 7.0%, p<0.001).

Conclusions: Older people who frequently attend an ED are more likely to arrive overnight, by ambulance and have high levels of clinical urgency suggesting limited opportunities for their problem to be resolved without ED care. Older frequent ED attenders had worse outcomes (increased in-hospital mortality, ED representations and hospital readmissions) than non-frequent ED attenders.

Implications: Alternative models of care that direct the patient to the specialist care they need rather than accessing specialist care via the ED warrant exploration


Biography:

Debra is a clinician of over thirty years nursing experience with greater than 21 years working in the specialty of Emergency Nursing. Her current roles are that of  Clinical Nurse Specialist in an outer Melbourne metropolitan ED and  Research Fellow in a clinical partnership between Eastern Health and Deakin University.

Influences on Emergency Department length of stay for older people

Prof. Julie Considine1, Ms Debra Berry2, Dr Anthony Cross3, Dr  Mohammadreza Mohebbi4, Dr Maryann  Street1

1Deakin University, School of Nursing and Midwifery and Centre for Quality and Patient Safety Research (QPS) /  QPS – Eastern Health Partnership , Geelong, Australia, 2Deakin University, School of Nursing and Midwifery /  QPS – Eastern Health Partnership , Geelong, Australia, 3Northern Health, Epping, Australia, 4Deakin University, Biostatistics Unit, Faculty of Health, Geelong, Australia

Background: Older people have longer emergency department length of stay (EDLOS) and higher hospital admission rates. Longer EDLOS is associated with increased length of hospital stay and in-hospital mortality. The aim of this study was to examine the influences on EDLOS for older people (≥65 years) and develop a predictive model for an EDLOS>4-hours.

Methods: This retrospective cohort study linked organisational data at the patient level. The study population were aged ≥65 years, attending one of three EDs at a major Australian health service during 2013/2014 financial year. A clinical prediction rule was developed and internally validated using multivariate logistic regression and evaluated using receiver operating characteristic (ROC) analysis.

Results: Of 33,926 ED attendances, 57.5% (n=19,517) had an EDLOS >4-hours. Factors associated with EDLOS >4-hours were prolonged time to medical assessment, ED overcrowding and access block, age >75 years, ED pathology testing or diagnostic imaging, ≥3 ED attendances resulting in hospital admissions, living in residential aged care, ED arrival overnight or by ambulance, triage category 3 or 4. The areas under ROC were 0.796 (derivation) and 0.80 (validation). The risk score assigned to each factor ranged from 2 to 68 points based on  coefficients. The clinical prediction rule stratified patients into five levels of risk.

Conclusions: Objective identification of older people at risk of EDLOS >4-hours early in their ED episode of care enables targeted approaches to streamline the patient journey, decrease EDLOS and optimise emergency care for older people.

Implications: Patient, clinical and organisational factors were strongly predictive of ED LOS for older individuals. Providing timely, safe and quality ED care for older patients has clear benefits for patients and their families, but will also improve ED and health service access for other patient groups.


Biography:

Julie is Deakin University’s Chair in Nursing at Eastern Heath in Melbourne. She has held clinical, education and research roles in emergency nursing over the last two decades and internationally recognised as a leader in research and education in emergency care. Julie has over 150 publications and has attracted over $5.2M in research and project funding. She is a Founding Fellow of the College of Emergency Nursing Australasia (CENA), Deputy Editor of the Australasian Emergency Nursing Journal, represents the College of Emergency Nursing Australasia on the Australian Resuscitation Council.

Refinement of an evidence informed care bundle for blunt chest injury

Ms Sarah Kourouche1, Professor  Kate Curtis1,2,3, Associate Professor Thomas Buckley1, Dr Belinda Munroe1,3

1University Of Sydney, Camperdown, Australia, 2The George Institute for Global Health,  Sydney, Australia, 3Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, Australia

Background: Blunt chest injuries, especially rib fractures, are associated with high rates of morbidity and mortality. In 2012, a Chest Injury Protocol (ChIP) was introduced at a Level 1 Trauma Centre in Australia. However, uptake of this protocol was poor (only 68%). One of the identified barriers to use of the protocol was a lack of information on what care to initiate for the patient. To address this gap, a review of the literature to enable inclusion of evidence-based treatment options in the protocol was conducted.

Objective: To determine the levels of evidence for blunt chest injury management and develop a blunt chest injury care bundle.

Methods: A literature review of primary research articles using MEDLINE, CINAHL, and Scopus from 1990 – April 2017 was conducted. Additional studies were identified by hand-searching bibliographies.

A two-step selection process was performed. All published and unpublished primary research studies were included according to the PICO: investigated human patients with blunt chest trauma in acute settings (P), Received any intervention for blunt chest injury (I), any comparator (C), and with any resulting outcomes (O).

A two-step data extraction process using pre-defined data fields, including study quality indicators. Each study was appraised using a quality assessment tool and scored for level of evidence.

Results: The search yielded a total of 1893 citations. Following duplicate removal, 1544 records were screened, and 215 full-text articles were reviewed.  Interventions identified in the literature included surgical rib fixation, incentive spirometry, multimodal analgesia, and epidural and paravertebral blocks. The level of evidence for interventions varied from weak to strong recommendations.

Conclusions: The review provided the supportive evidence to inform and develop the ChIP bundle.


Biography:

Sarah Kourouche has a keen interest in trauma; having worked in emergency and trauma for many years. She completed her Bachelor of Nursing in 2004; she has worked in St George Hospital since in the areas of orthopaedics, intensive care, operating theatres, emergency and trauma as a trauma case manager. She completed a Master’s degree in Emergency and Trauma Nursing through the University of Newcastle in 2010. She has been teaching at the Sydney Nursing School since 2013; teaching preregistration in both the Bachelor and Master’s programs. She is currently working towards a PhD through the University of Sydney investigating the implementation of a care bundle for patients with blunt chest injury.

Communication of graduate emergency nursing programs

Ms Tamsin Jones1,2, Professor Ramon  Shaban2,3, Professor  Debra Creedy3

1Monash University, School of Nursing and Midwifery, Frankston, Australia, 2Menzies Health institute Queensland, School of Nursing and Midwifery Griffith University, Meadowbrook, Logan, Australia, 3Infection Control Department, Cold Coast University Hospital, Gold Coast Hospital Health Service, , Southport, Australia

Background: Nurses who choose to work in emergency departments are often required to complete graduate education that informs the safe and competent care of patients. Currently there are no minimum standards for graduate emergency nursing programs. The websites of emergency nursing course providers are an important source for an environmental scan of key content and skills deemed to be necessary for ED practice.

Aims: The purpose of this study is to identify and analyse the publically available documents relating to course content, practice outcomes and assessment methods of Australian graduate-level emergency nursing education programs.

Methods: A document analysis framework will be applied to publicly available documents for each graduate program that offers emergency specialisation (n = 17). The analysis will focus on program philosophy/framework, course content and structure, graduate outcomes and assessment methods.

Results: The analysis is currently underway. Preliminary findings indicate variability in the publically available information provided by emergency nursing course providers. Differences are evident in the program outcomes, duration, content and approaches to assessment.

Conclusion: This is the first project of its kind to analyse Australian graduate emergency nursing programs. The results are the first in a program of work to determine minimum standards for graduate emergency nursing programs.

Key Words: Emergency nursing, postgraduate, graduate attributes, emergency education


Biography:

Tamsin is an experienced emergency nurse and is currently a PhD candidate at Griffith University. Tamsin’s PhD aims to develop minimum practice standards for the emergency nursing graduate.

Comparison of post graduate emergency nursing students and nurse educators formative and summative clinical appraisal assessments for patients requiring multi-system care

Ms Rachel Cross1, Dr Charne  Miller1, Dr Julia Morphet2,3

1La Trobe University, Melbourne, Australia, 2Nursing and Midwifery, Monash University , , , 3Monash Emergency Research Collaborative, Monash Health, ,

Background: Undertaking post graduate emergency nursing studies contributes to professional and personal advancement. Higher degree studies also strengthen the emergency nursing workforce and contribute to the provision of specialist patient care. Formative and summative assessments in post graduate study are important for student learning. These appraisals enable self-reflection and feedback which in turn influence and enhance student learning.

Aim: The study aim was to compare the formative and summative appraisal assessments between post graduate emergency nursing students and clinical nurse educators.

Method: A retrospective review of assessments completed by both post graduate student and educator in the final multi-system complex post graduate subject was undertaken. Data from both student and educator formative and summative assessments were extracted from university student records. Data for the two appraisal periods were compared using non-parametric tests in SPSS.

Results: Data on 52 emergency nursing students were extracted. Significant differences were detected between most students and educator ratings for both assessment appraisals. Areas where students provided the lowest rating of independence at the summative assessment included ‘critiquing research and considering translation’ (18.4%), analysing and interpreting assessment data accurately (24.5%), and provides effective and timely direction and supervision (29.2%). Educators concurred with these student ratings areas but also regarded ‘responding effectively to change’ and ‘delegates care approximately’ (both 66.7%) as requiring improvement. Students and educators agreed that students were performing independently on domains relating to legal, professional and ethical frameworks.

Conclusion: Post graduate emergency nursing study is important for the emergency nursing workforce. Examining student learning and educator assessment in this context enables a broader understanding of student learning and transition to emergency nursing specialty practice.


Biography:

Rachel Cross is a Lecturer for La Trobe University in Melbourne. Rachel’s professional career consists of clinical nursing positions in emergency departments both within Victoria and internationally in the United Kingdom. Rachel has also held Nursing Education positions. Alongside her current academic position Rachel also works as an emergency and trauma nurse in a large metropolitan hospital in Victoria. Rachel is also currently undertaking her PhD examining the transition of patient care from the emergency department to the ward with a specific focus on clinical deterioration and clinical handover.

Reducing the cost associated with care of elder patients in the ED: Impact of enhanced primary care in an aged care facility

Dr Marc Broadbent1, Dr  Alison Craswell1, Professor Marianne  Wallis1, Dr Elizabeth Marsden2, Ms. Andrea  Taylor2, Ms.  Kaye Coates3, Ms.  Colleen Johnston1

1University of the Sunshine Coast, Sippy Downs, Australia, 2Sunshine Coast Hospital and Health Service, Sunshine Coast, Australia, 3Sundale, Sunshine Coast, Australia

Background: Frail, older people are at increased risk of complications when they require transfer for acute care from their residence, particularly for those in residential aged care facilities (RACF). Interventions that improve health outcomes and reduce potentially avoidable transfer to emergency departments (ED) are integral to managing an ageing population. The care coordination through emergency departments, residential aged care and primary health collaboration (CEDRiC) project coordinates care of the older person between:

  1. A Nurse Practitioner Candidate (NPC) in one RACF providing primary care facility aiming to reduce unnecessary transfer to hospital with onset of acute illness, and
  2. Advanced Practice Clinical Nurses in the local ED providing a Geriatric Emergency Department Intervention (GEDI).

This presentation describes the economic impact on the ED, of the NPC intervention and explores the structures and processes that enhance care in the ED.

Design & Methods: Quasi- experimental, with an embedded qualitative component. Data collected included: i) patient level costing and covariate data from the ED information system and hospital databases, ii) semi structured interviews. Multivariate modelling of quantitative data and themes from the qualitative data pertaining to structures and processes from the intervention, will be presented.

Results: Older people who received NPC care in the RACF incurred less cost to the ED compared to other RACF residents and other people aged 70 years and over. These costs savings related to reductions in ED length of stay. GEDI staff reported enhanced communication and streamlining of care of older people from the RACF when NPC involved.

Conclusion: A NPC providing early intervention for older people in a RACF reduces the demand on EDs, time spent with older patients and saves money, thus freeing resources. GEDI nurses report the goals of transfer are more clear facilitating targeted interventions, expediting care and improving turnaround.


Biography:

Marc Broadbent commenced working as an academic in 2005 following a career in critical care and emergency nursing. He has experience in coronary care, cardiothoracic, trauma and general intensive care, with his main area of expertise being in trauma and emergency nursing. He has worked as a clinical nurse specialist, nurse educator and nurse manager in emergency departments within Australia and overseas.

Marc has published and presented both nationally and internationally in the area of emergency mental health triage. The management of vulnerable populations in the ED, particularly those with a mental illness, is his research focus. Marc’s work has been cited as the best available evidence for the triage of clients with mental illness in the Australian National Emergency Triage Training Kit. Marc is a member of the Australian College of Mental Health Nurses, a Fellow of the Australian College of Nursing and Associate Editor – Mental Health for the Australasian Emergency Nursing Journal. Marc is currently an expert member of the Mental Health Advisory Group of the Australian Commission on Safety and Quality in Health Care and is contributing to the development of national standards of mental health care.

Improving the quality of care of elderly patients in the ED: Geriatric Emergency Department intervention

Mrs Andrea Taylor1,2, Dr Elizabeth Marsden1,2, Dr Marc Broadbent2, Dr  Alison Craswell2, Professor Marianne Wallis2, Mrs  Colleen Johnston2

1Sunshine Coast Hospital and Health Service, Queensland Health, Birtinya, Australia, 2University of the Sunshine Coast, Sippy Downs, Australia

Emergency departments (ED) are experiencing an increase in the volume of elderly persons, resulting in significant challenges. Interventions within the ED targeting this vulnerable cohort are essential to improve health outcomes and reduce overall associated cost. The Geriatric Emergency Department Intervention (GEDI) is an innovative model of care, provided in a consultant capacity, focussing on early assessment of older patients to support to clinical and disposition decision making. Consequently, inappropriate and unnecessary hospital admissions are potentially avoided and early discharge is facilitated. GEDI nurses communicate with and provide support to primary and secondary healthcare sectors and residential aged care facilities.

This research used a quasi-experimental pre-post design and an embedded qualitative component to describe the structures, processes and outcomes of GEDI. Primary outcomes included disposition, length of stay in ED and hospital (if admitted) and all-cause mortality.  We used a survival analysis to jointly model length of stay and disposition, with discharge outcomes as competing risks. Health economic analysis utilised generalised linear modelling for cost outcomes.

When compared with pre-intervention, GEDI significantly reduced the risk of longer length of stay in the ED (HR = 1.29; CI 95%: 1.06 to 1.58) and increased the likelihood of discharge (HR = 1.27; CI 95%: 1.19 to 1.36) for people 70 years of age and over. We observed a cost reduction in both ED presentations ($35 [95% CI: $21, $49]) and hospital admissions ($1,469 [95% CI: $1,105, $1,834]) for the full-GEDI compared to the pre-GEDI period. The ED staff reported high levels of satisfaction with GEDI.

The GEDI model of care, embedded in the ED and focused on the vulnerable elderly population, improves patient care, reduces costs and supports ED staff management and workflow.


Biography:

Andrea Taylor is a Clinical Nurse Consultant who leads the Geriatric Emergency Department Intervention (GEDI) team of nurses at the Sunshine Coast University Hospital and Nambour General Hospital emergency departments, Queensland.  Andrea has 20 years’ experience in the care of older persons both in the acute, community and ED settings. She has been central to the development of the GEDI model of care using a combination of her expertise, research and collaboration in all aspects including recruitment, training, policy and model development.

She is a co-investigator for the CEDRiC research project, funded by a Department of Social Services, Aged Care Service Improvement and Healthy Ageing Grant totaling $1.15M. In addition, she is the principal investigator for a local research project to investigate the predictive validity of the interRAI ED Screener in the local population.  She is also currently working for the Clinical Excellence Division of Queensland Health to develop a toolkit to enable emergency departments in the state of Queensland to implement GEDI.  In her downtime, Andrea is a PhD candidate with a focus on Comprehensive Geriatric Assessment in the emergency department setting, a wife and mother of 3.

Presenting patterns and pharmacological treatment of migraine in the ED

Mr James Hughes1, Dr Emily Shao2, Dr Rob Eley3

1Princess Alexandra Hospital, Brisbane, Australia, 2Royal Brisbane and Womens Hospital, Brisbane, Australia, 3Facility of Medicine, University of Queensland, Brisbane, Australia

BACKGROUND: Migraine is a common neurological condition that frequently presents to the emergency department (ED). Many medications are available to treat migraine. This study aims to characterize the demographics of patients who present to a large metropolitan ED with migraine and to identify the medications used in treating this condition.

METHODS: This study is a retrospective database interrogation of clinical records, used to

collect quantitative data on patient demographics and medication prescriptions in the ED.

RESULTS: A total of 2 228 patients were identified as being treated for migraine over a 10-

Year period. The proportion of the ED population presenting with migraine steadily increased in this time. Females (71%) more commonly presented to the ED with migraine than males. The migraine population was significantly younger (M=37.05, SD=13.23) than the whole ED population (M=46.17, SD=20.50) (P<0.001). A variety of medications were used in the treatment of migraine in the ED. Simple analgesics such as paracetamol and ibuprofen, anti-emetics and IV fluids with phenothiazine additives were commonly used. Over 20% of patients received oral or parental opiates (42 of 194 initial medication prescriptions, and 64 of 292 as required medication prescriptions). Triptans were very rarely used.

CONCLUSION: Migraine is an increasingly common presentation to the ED. People presenting to the ED with migraine are more likely to be younger and female than the general ED population. Peak presentations for migraines occurred in January and February. The medications that are prescribed in the ED for migraine is varied and are not always in line with current evidence for the treatment of migraine. The excessive reliance on opiates and lack of the use of triptans denotes a significant variation from published guidelines.


Biography:

Mr Hughes has worked in some of the busiest emergency departments in Queensland. He currently is a Clinical Nurse Consultant at the Princess Alexandra Hospital in Brisbane and is completing his PhD in factors that influence pain care in the emergency department.

Emergency nurses knowledge and understanding of their role in recognising patients with sepsis: A clinical review

CN Amanda Harley1, Dr Amy Johnston2, Professor Julia Crilly2, Dr Debbie Massey3, Professor Gerben Keijzers1, Dr Kerina Denny1

1Gold Coast University Hospital, Southport Gold Coast, Australia, 2Menzies Health Institute Queensland Griffith University  and Gold Coast University Hospital, Southport Gold Coast, Australia, 3University of Sunshine Coast, Sippy Downs Sunshine Coast, Australia

Sepsis remains a significant cause of morbidity and mortality for patients who present to emergency departments (EDs); accounting for more than 500,000 ED visits per year. Early identification of sepsis is important, so that appropriate treatment regimens can be instigated in a time critical fashion. Existing guidelines focus on the treatment of sepsis once identified, but do not specify the role of nurses.

This study will use an exploratory case study research design to address current gaps in our understanding of the complex, poorly understood phenomena of ED nurse recognition of and response to patients with sepsis. This qualitative component of a wider mixed-methods study will draw on semi-structured interviews undertaken with ~20 ED nurses from a single health service who have cared for a patient with sepsis. Interviews will explore their perceptions and practices around recognising and responding to patients with sepsis, their awareness of/and familiarity with validated sepsis recognition tools and the barriers and benefits they identify from implementing such tools. Nurse understanding of evidence based practice will be reviewed in relation to the quick Sepsis Related Organ Failure Assessment (qSOFA) and Systemic Inflammatory Response Syndrome (SIRS) criteria.  Themes derived from the interview transcripts will be developed using an inductive approach. To limit risks of errors, and to ensure dependability, transferability, confirmability and credibility, clear analysis guidelines will be used.

Improvements in the care of the patient with sepsis is of local, national and international importance reflected by the emerging literature demanding the use of best evidence and guidelines. As part of a multi-disciplinary team, nurses have a vital role in the recognition and response to sepsis. The knowledge and insights gained from this study can be used to inform local and state-wide ED policies, and enrich educational packages that will improve quality of patient care and outcomes.


Biography:

Amanda Harley is an experienced Clinical Nurse based at Gold Coast University Hospital Emergency Department. She is a passionate advocate for nurse involvement in development and implementation of evidence-based guidelines for recognition and management of patients with sepsis. Her academic qualifications inclusive of a Masters of Emergency Nursing and Graduate Diploma in Education, coupled with her current shared research, university teaching, and clinical roles, are helping her achieve these aims.

Amy Johnston is a conjoint research fellow in Emergency Care, based between Gold Coast Health and Menzies Health Institute Queensland. She is a widely published and cited academic and registered nurse with experience in a range of research techniques.

An exploration of the barriers and enablers to meaningful engagement with multidisciplinary simulation education among doctors and nurses in the Emergency Department

Miss Samantha Hoole1

1Royal Darwin Hospital, Nightcliff, Australia

This research was designed to identify barriers and enablers to meaningful engagement with multidisciplinary simulation based education in a tertiary teaching hospital emergency department.

Simulation based education is gaining traction in the health care arena with the wealth of evidence to prove its benefit developing rapidly. There is now proven benefit for skill acquisition, communication, knowledge development, recognition and management of clinical deterioration all of which translates into improved patient safety and health care outcomes. This evidence is international and across disciplines and healthcare sectors.

The inception of this research came when medical and nursing staff expressed distaste and dissatisfaction with the multidisciplinary simulation based education that made up a core part of the weekly registrar teaching program. Evidence of work avoidance or late arrivals became apparent as staff used this as a tool to avoid participation. Poor engagement by participants led to poor performance in the simulation which in turn seemed to drive a lack of willingness to further participate. Individuals stated they were unable to “suspend their disbelief” or engage in the moment. This poor engagement and performance even when displayed by a single individual significantly impacted the progression and development of simulation scenarios and impeded the learning of others. Research was undertaken to try and identify what barriers and enablers exist to engagement with simulation based education. The outcome of such research would enable educators and organisations to create a more relevant, relatable and meaningful learning opportunity for medical and nursing staff in the emergency department.

In order to investigate this, a two phase exploratory, mixed methods study was constructed. This used a validated survey to investigate experiences and attitudes towards simulation based education followed by semi-structured, face to face interview.

This study is still ongoing with the results anticipated to be completed by 2018.


Biography:

Sam is an Acting Clinical Nurse Educator in Royal Darwin Hospital Emergency Department where her focus is on staff development and progression through each clinical area.

Sam has always been passionate about the education and development of nurses in the emergency department and changing the culture to one of support and “can-do”. Education is part of the role of every nurse, by embracing our roles as teachers and advocates we can make take meaningful steps in the direction of positive workplace culture, staff satisfaction and patient safety is by empowering nurses through meaningful education.

Sam is currently undertaking research which looks into attitudes towards simulation based education with the primary focus on the barriers and enablers to meaningful engagement.

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