Desley Hegney, Elizabeth Buikstra, Chris Chamberlain, Judy March, Michelle McKay, Gail Cope, Tony Fallon
University of Queensland, University of Southern Queensland and Toowoomba Health Service, Toowoomba, Qld, Australia. email@example.com
AIM This study aimed to ascertain whether a model of risk screening carried out by an experienced community nurse was effective in decreasing re-presentations and readmissions and the length of stay of older people presenting to an Australian emergency department. OBJECTIVES The objectives of the study were to (i) identify all older people who presented to the emergency department of an Australian regional hospital;(ii) identify the proportion of re-presentations and readmissions within this cohort of patients; and (iii) risk-screen all older patients and provide referrals when necessary to community services. DESIGN The study involved the application of a risk screening tool to 2,139 men and women over 70 years of age from October 2002 to June 2003. Of these, 1,102 (51.5%) were admitted and 246 (11.5%) were re-presentations with the same illness. Patients presenting from Monday to Friday from 08:00 to 16:00 hours were risk-screened face to face in the emergency department. Outside of these hours, but within 72 hours of presentation, risk screening was carried out by telephone if the patient was discharged or within the ward if the patient had been admitted. RESULTS There was a 16% decrease in the re-presentation rate of people over 70 years of age to the emergency department. Additionally during this time there was a 5.5% decrease in the readmission rate (this decrease did not reach significance). There was a decrease in the average length of stay in hospital from 6.17 days per patient in October 2002 to 5.37 days per patient in June 2003. An unexpected finding was the decrease in re-presentations in people who represented to the emergency department three or more times per month (known as 'frequent flyers'). CONCLUSIONS Risk screening of older people in the emergency department by a specialist community nurse resulted in a decrease of re-presentations to the emergency department. There was some evidence of a decreased length of stay. It is suggested that the decrease in re-presentations was the result of increased referral and use of community services. It appears that the use of a specialist community nurse to undertake risk screening rather than the triage nurse may impact on service utilization. RELEVANCE TO CLINICAL PRACTICE It is apparent that older people presenting to the emergency department have complex care needs. Undertaking risk screening using an experienced community nurse to ascertain the correct level of community assistance required and ensuring speedy referral to appropriate community services has positive outcomes for both the hospital and the patient.
Roberto Forero, Kenneth M Hillman, Sally McCarthy, Daniel M Fatovich, Anthony P Joseph, Drew B Richardson
Simpson Centre for Health Services Research Affiliated with The Australian Institute of Health Innovation, University of New South Wales, Kensington, New South Wales.
Prospective and retrospective access block hospital intervention studies from 1998 to 2008 were reviewed to assess the evidence for interventions around access block and ED overcrowding, including over 220 documents reported in Medline and data extracted from The State of our Public Hospitals Reports. There is an estimated 20-30% increased mortality rate due to access block and ED overcrowding. The main causes are major increases in hospital admissions and ED presentations, with almost no increase in the capacity of hospitals to meet this demand. The rate of available beds in Australia reduced from 2.6 beds per 1000 (1998-1999) to 2.4 beds per 1000 (2002-2007) in 2002, and has remained steady at between 2.5-2.6 beds per 1000. In the same period, the number of ED visits increased over 77% from 3.8 million to 6.74 million. Similarly, the number of public hospital admissions increased at an average rate of 3.4% per year from 3.7 to 4.7 million. Compared with 1998-1999 rates, the number of available beds in 2006-2007 is thus similar (2.65 vs 2.6 beds per 1000), but the number of ED presentations has almost doubled. All patient groups are affected by access block. Access block interventions may temporarily reduce some of the symptoms of access block, but many measures are not sustainable. The root cause of the problem will remain unless hospital capacity is addressed in an integrated approach at both national and state levels.
Screening for risk of readmission of patients aged 65 years and above after discharge from the emergency department: predictive value of four instruments.
Center for Health Services and Nursing Research, Katholieke Universiteit Leuven, Kapucijnenvoer, Belgium. Philip.Moons@med.kuleuven.be
OBJECTIVES To compare the abilities of four different screening tools to predict return visits of older persons after they have been discharged from the emergency department (ED). METHODS We assessed 83 short-term (discharged within 24 h) patients (aged 65 years and above) who visited the ED of the University Hospitals Leuven, Belgium, from 15 October 2005 to 24 December 2005. The Identification of Seniors at Risk (ISAR), the Triage Risk Screening Tool (TRST), the eight-item questionnaire of Runciman, and the seven-item questionnaire of Rowland were administered at admission to screen the patients for risk factors of future ED readmission. By telephone follow-up 14, 30, and 90 days after discharge from the ED, we asked the patients (or their families) whether readmission had occurred since their initial discharge from the ED. RESULTS Readmission rates were 10%, 15.8%, and 32.5% after 14, 30, and 90 days, respectively. When using three or more positive answers as the cutoff scores, the Rowland questionnaire proved to be the most accurate predictive tool with a sensitivity of 88%, specificity of 72%, and negative predictive value of 98% at 14 days after discharge. Thirty days after discharge, the sensitivity was 73%, specificity was 75%, and negative predictive value was 92%. CONCLUSION Repeat visits in older persons admitted to an ED seemed to be most accurately predicted by using the Rowland questionnaire, with an acceptable number of false positives. This instrument can be easily integrated into the standard nursing assessment.
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Centre for Rural and Remote Area Health, University of Southern Queensland, Toowoomba, QLD, Australia. firstname.lastname@example.org
AIMS AND OBJECTIVES To support policy planning for health, the barriers to the use of health information and computer technology (ICT) by nurses in Australia were determined. BACKGROUND Australia, in line with many countries, aims to achieve a better quality of care and health outcomes through effective and innovative use of health information. Nurses form the largest component of the health workforce. Successful adoption of ICT by nurses will be a requirement for success. No national study has been undertaken to determine the barriers to adoption. DESIGN A self-administered postal survey was conducted. METHOD A questionnaire was distributed to 10,000 members of the Australian Nursing Federation. Twenty possible barriers to the use of health ICT uptake were offered and responses were given on a five point Likert scale. RESULTS Work demands, access to computers and lack of support were the principal barriers faced by nurses to their adoption of the technology in the workplace. Factors that were considered to present few barriers included age and lack of interest. While age was not considered by the respondents to be a barrier, their age was positively correlated with several barriers, including knowledge and confidence in the use of computers. CONCLUSIONS Results indicate that to use the information and computer technologies being brought into health care fully, barriers that prevent the principal users from embracing those technologies must be addressed. Factors such as the age of the nurse and their level of job must be considered when developing strategies to overcome barriers. RELEVANCE TO CLINICAL PRACTICE The findings of the present study provide essential information not only for national government and state health departments but also for local administrators and managers to enable clinical nurses to meet present and future job requirements.
Research Officer, University of Queensland School of Medicine, Centre for Rural and Remote Area Health, University of Southern Queensland, Toowoomba, Qld, Australia. email@example.com
AIMS The purpose of this paper is to present the findings of two qualitative studies which identified strategies used by breastfeeding women to assist them to continue breastfeeding. BACKGROUND While breastfeeding initiation rates are high in Australia, the majority of women wean before the recommended time. The identification of interventions which may increase breastfeeding duration is therefore a research priority. DESIGN The Against All Odds study used a case-controlled design to investigate the characteristics of women who continued to breastfeed in the face of extraordinary difficulties. Phase One of the I Think I Can study employed the Nominal Group Technique to investigate the views of subject matter experts regarding which psychological factors may influence the duration of breastfeeding. METHOD Against All Odds study participants (n = 40) undertook a one- to two-hour interview and the transcribed data were analysed using thematic analysis. Stratified purposeful sampling was employed in the I Think I Can study (n = 21), with participants assigned group membership according to their most recent breastfeeding experience. A fourth group was composed of experienced breastfeeding clinicians. The nominal group technique was used to generate group data and segments of the discussion were audiotaped and transcribed for thematic analysis. RESULTS Participants in both the studies raised strategies used to assist them in their efforts to cope with the challenges of breastfeeding and early motherhood. These strategies included increasing breastfeeding knowledge, staying relaxed and 'looking after yourself', the use of positive self-talk, challenging unhelpful beliefs, problem solving, goal setting and the practice of mindfulness. CONCLUSIONS Employment of these simple behavioural and cognitive strategies may assist women to cope with the pressures inherent in the experience of early mothering, thereby increasing the duration of breastfeeding. RELEVANCE TO CLINICAL PRACTICE These results may represent a 'tool box' of coping strategies which can be provided to women for use in the postnatal period.
Exploring the influence of psychological factors on breastfeeding duration, phase 1: perceptions of mothers and clinicians.
University of Queensland School of Medicine, Rural Clinical Division, Toowoomba, Qld, Australia. firstname.lastname@example.org
Breastfeeding duration rates in Australia are low, prompting a search for modifiable factors capable of increasing the duration of breastfeeding. In this study, participants were asked which psychological factors they believed influence breastfeeding duration. Participants included 3 groups of mothers who had breastfed for varied lengths of time (n = 17), and 1 group of breastfeeding clinicians (n = 4). The nominal group technique was employed, involving a structured group meeting progressing through several steps. Analyses included collation of individual and group responses, group comparisons, and a thematic analysis of group discussions. Forty-five psychological factors thought to influence the duration of breastfeeding were identified. Factors considered most important included the mother's priorities and mothering self-efficacy, faith in breast milk, adaptability, stress, and breastfeeding self-efficacy. In addition to informing the design of phase 2 of this study, these results add to our knowledge of this emerging research area.
The status of training and education in information and computer technology of Australian nurses: a national survey.
Centre for Rural and Remote Area Health, University of Southern Queensland, Toowoomba, Queensland, Australia. email@example.com
AIMS AND OBJECTIVES A study was undertaken of the current knowledge and future training requirements of nurses in information and computer technology to inform policy to meet national goals for health. BACKGROUND The role of the modern clinical nurse is intertwined with information and computer technology and adoption of such technology forms an important component of national strategies in health. The majority of nurses are expected to use information and computer technology during their work; however, the full extent of their knowledge and experience is unclear. DESIGN Self-administered postal survey. METHODS A 78-item questionnaire was distributed to 10,000 Australian Nursing Federation members to identify the nurses' use of information and computer technology. Eighteen items related to nurses' training and education in information and computer technology. RESULTS Response rate was 44%. Computers were used by 86.3% of respondents as part of their work-related activities. Between 4-17% of nurses had received training in each of 11 generic computer skills and software applications during their preregistration/pre-enrolment and between 12-30% as continuing professional education. Nurses who had received training believed that it was adequate to meet the needs of their job and was given at an appropriate time. Almost half of the respondents indicated that they required more training to better meet the information and computer technology requirements of their jobs and a quarter believed that their level of computer literacy was restricting their career development. Nurses considered that the vast majority of employers did not encourage information and computer technology training and, for those for whom training was available, workload was the major barrier to uptake. Nurses favoured introduction of a national competency standard in information and computer technology. CONCLUSIONS For the considerable benefits of information and computer technology to be incorporated fully into the health system, employers must pay more attention to the training and education of nurses who are the largest users of that technology. RELEVANCE TO CLINICAL PRACTICE Knowledge of the training and education needs of clinical nurses with respect to information and computer technology will provide a platform for the development of appropriate policies by government and by employers.
Centre for Rural and Remote Area Health, University of Southern Queensland, Toowoomba, Australia. firstname.lastname@example.org
AIMS AND OBJECTIVES Through comparison of two studies undertaken three years apart the opinions of nurses working in aged care facilities in Queensland were determined. Results will support policy planning for the Queensland Nurses Union. BACKGROUND An ageing population in Australia is placing increased demands on residential aged care facilities. In Queensland, the national situation is exacerbated by an influx of retirees from other states and territories. The ongoing problem of shortages of nurses in the workforce may be addressed by gaining further insight into the nurses' own views of their conditions and experiences. METHODS One thousand nurses working in public and privately owned residential aged care facilities were surveyed by postal questionnaire in 2004. Results were compared with data collected in an identical study in 2001. RESULTS Respondents offered their opinions on working hours and conditions, professional development and experiences in nursing. The predominately female aged care nursing workforce is ageing. Reported workplace violence has increased substantially since 2001. Some improvements are reported in staff numbers, skill mix and workplace policies. Nurses expressed very serious concerns about pay, workload, stress, physical and emotional demands and staff morale. CONCLUSION Working conditions for nurses in the residential aged care sector in Queensland must be addressed to retain the current nurses and to encourage new nurses to replace those that retire. RELEVANCE TO CLINICAL PRACTICE The findings of this study provide information not only for the Queensland Nurses Union but also policy makers and nurse managers both nationally and internationally on areas that need to be addressed to maintain the required workforce within the aged care sector.
Centre for Rural and Remote Area Health, University of Southern Queensland, University of Queensland, Toowoomba, Queensland, 4350, Australia.
Competencies by nurses in information technology (IT) are essential to health care in Australia yet data suggest deficiencies in access and use. A study commissioned by the Australian Government aimed to determine the extent of access and use and the barriers to the use of IT among nurses across Australia. A survey was distributed to 10,000 members of the Australian Nursing Federation with a 43% overall response rate. Fewer than 15% of nurses did not use computers as part of their work. The greatest use was for client records, patient pathology and radiology results and professional development. IT uptake in health is supported by nurses who are, however frustrated by limitations to access and software that is not fit for purpose. A lack of confidence in using IT was noted by many nurses. Fewer than 20% had received pre-registration training in any aspect of IT and only 30% post registration. In addition to training, high work load, numbers of computers and inadequate technical support were the major barriers to computer use.
Centre for Rural and Remote Area Health, USQ, Toowoomba, Queensland, Australia. email@example.com
INTRODUCTION The proliferation of professional palliative care services in recent years has increased access for people with palliative care needs; however, gaps in services continue to exist, particularly in rural and remote areas of Australia. In order to address one gap in rural health service delivery, the Support, Education, Assessment, and Monitoring (SEAM) Service for regional and rural people in Toowoomba, Queensland, Australia, was introduced. This new model of service delivery aimed to provide palliative services to patients and their families who live in the regional city of Toowoomba and its rural catchment area. It also aimed to facilitate education, support and networking among health-care professionals, particularly general practitioners and nurses employed in general practice (practice nurses). METHOD The evaluation involved twenty face-to-face interviews with a variety of health professionals who had contact with the SEAM service from June 2003 to June 2004. Qualitative data analysis of the transcribed interviews provided the basis for the evaluation. The emergent themes regarding the SEAM service included: satisfaction and benefit of the SEAM service; knowledge of and contact with the SEAM service; the SEAM role; and expansion of the role. RESULTS The data indicate that the majority of health professionals who had contact with the SEAM service were satisfied with the service and found it to be of benefit to them and their clients. Participants commented on the extensive networking and support work established by the SEAM nurse with other health service providers. Difficulties experienced with the SEAM service included poor utilisation by GPs and, therefore, clients in need of palliative support. This was predominately due to lack of knowledge of the service as well as limited understanding of the SEAM nurse role. CONCLUSION The SEAM service has resulted in increased links between health professionals providing palliative care to rural clients. The most successful strategy was the use of multidisciplinary case conferencing which not only built links among health professionals caring for individual clients, but also resulted in improved care for those clients. As a result of better integration and communication, palliative care services to rural people have been improved. However, with regard to the delivery of direct patient care, or in the support of GPs for the management of palliative care patients, it was apparent that the service did not meet its objectives. The lack of use by GPs and patients appears to be related to a lack of awareness of the existence of the service. A positive outcome of this poor utilisation is, however, that the model has allowed the identification of factors that work as barriers to GPs and client/family utilisation of rural palliative care services.
Attitudes to infant feeding decision-making--a mixed-methods study of Australian medical students and GP registrars.
Bond University. firstname.lastname@example.org
Breastfeeding is an important public health issue. While medical practitioners can have a significant impact on breastfeeding initiation and duration, there are few studies investigating their views regarding women's infant feeding decisions. This mixed-methods study employed qualitative (focus groups and interviews) and quantitative (questionnaire) data collection techniques to investigate the attitudes and views of Australian medical students and GP registrars about infant feeding decision-making. Three approaches to infant feeding decisions were evident:'the moral choice'(women were expected to breastfeed);'the free choice'(doctors should not influence a woman's decision); and 'the equal choice'(the outcome of the decision was unimportant). Participants were uncertain about differences between artificial-feeding and breastfeeding outcomes, and there was some concern that advising a mother to breastfeed may lead to maternal feelings of guilt and failure. These findings, the first in an Australian setting, provide a foundation on which to base further educational interventions for medical practitioners.
Centre for Rural and Remote Area Health, University of Southern Queensland, Toowoomba, Queensland, Australia. email@example.com
AIM This paper reports on a study examining the relationship between women's psychological characteristics and breastfeeding duration, after controlling for socio-demographic factors. BACKGROUND The literature suggests that psychological factors may influence breastfeeding behaviour, but studies are few. Existing evidence and the results of phase 1 of our study were used to construct a list of psychological factors, which were tested for their association with breastfeeding duration in the current design. METHOD Participants were postnatal inpatients in one of two regional hospitals between October and December 2005 and they completed the initial questionnaire within 14 days of giving birth (n = 375). Infant feeding method at 6 months and the timing of introduction of other food(s), where relevant, were ascertained by telephone interview. FINDINGS Forty-four per cent of the sample showed signs of postnatal distress in the 14 days following the birth. Breastfeeding duration was statistically significantly associated with psychological factors including dispositional optimism, breastfeeding self-efficacy, faith in breastmilk, breastfeeding expectations, anxiety, planned duration of breastfeeding and the time of the infant feeding decision. As a set, these psychological factors were more predictive of breastfeeding duration than was the set of socio-demographic characteristics. The duration of any breastfeeding was uniquely predicted by faith in breastmilk, planned breastfeeding duration and breastfeeding self-efficacy. CONCLUSION This increased knowledge of the factors influencing breastfeeding will assist in identifying women at risk of early weaning and in constructing programmes capable of increasing the length of time for which women breastfeed.
Against all odds: a retrospective case-controlled study of women who experienced extraordinary breastfeeding problems.
Research and Practice Development Centre, University of Queensland and Blue Care, Brisbane, Qld, Australia. firstname.lastname@example.org
AIMS The study investigated factors empowering women to continue breastfeeding despite experiencing extraordinary difficulties. The study documented the experiences and characteristics of women who continued to breastfeed (continuing cohort) and those who weaned (non-continuing cohort) despite extraordinary difficulties. DESIGN Retrospective case control. METHODS The study was undertaken in south-east Queensland, Australia in 2004. Forty women (20 in each cohort) were recruited over six months. Both quantitative (breastfeeding knowledge questionnaire) and qualitative (semi-structured interviews) data were collected. This paper describes the qualitative data. RESULTS Women from both cohorts expressed idealistic expectations about breastfeeding and experienced psychological distress due to their breastfeeding problems. Those who continued breastfeeding used coping strategies and exhibited personal qualities that assisted them to overcome the difficulties experienced. Women who continued to breastfeed were more likely to report relying on a health professional they could trust for support. This latter cohort were also more likely to report having peers with which they shared their experiences. Non-continuing women expressed feelings of guilt and inadequacy following weaning and were more likely to feel isolated. CONCLUSIONS This study has highlighted the methods women use to deal with breastfeeding problems. It has also revealed modificable factors that can improve breastfeeding duration. RELEVANCE TO CLINICAL PRACTICE The findings indicate that clinicians should:*Provide information which accurately reflects the breastfeeding experience;*Ensure systems are in place so that effective postnatal support for breastfeeding difficulties is available;*Consider screening to ascertain levels of psychological distress, sadness and disillusionment among breastfeeding women;*Design educational interventions with elements of cognitive skills, problem-solving and self-efficacy training to equip women with the skills to overcome any experienced difficulties.
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Feeling let down: An exploratory study of the experiences of older people who were readmitted to hospital following a recent discharge.
School of Nursing and Midwifery, University of Newcastle, Callaghan, NSW, Australia.
Abstract Background: Readmission of older people to hospital following a recent discharge may be an indicator of gaps in services either prior to or after discharge. Aims and objectives: To explore the experiences of older people who have been readmitted to hospital following recent discharge to their homes. Design: A qualitative descriptive study. Method: In-depth interviews were conducted with three older people who were discharged from a large tertiary referral hospital in NSW Australia and readmitted. Interviews were conducted within the hospital setting in a private room. An interview guide was used to explore the reasons for admission and readmission to hospital and experiences upon discharge to home. In particular the researchers were interested in the events that led to readmission. Data were analysed thematically. Results: Three main themes emerged including: being left out, being cared for and feeling let down. Conclusion: While this study was undertaken in only one hospital with only three older people the findings provide valuable insight into their experiences. Nurses need to be proactive in ensuring and promoting a person-centred approach to the care and treatment of older people.
Emerg Med J. 2012 Nov 8;: 23139096
Identifying older people at high risk of future falls: development and validation of a screening tool for use in emergency departments.
Anne Tiedemann, Catherine Sherrington, Teresa Orr, Jamie Hallen, Donna Lewis, Ann Kelly, Constance Vogler, Stephen R Lord, Jacqueline C T Close
Musculoskeletal Division, The George Institute for Global Health, Sydney, New South Wales, Australia.
BACKGROUND: Hospital emergency departments (EDs) treat a high proportion of older people, many as a direct consequence of falling. OBJECTIVE: To develop and externally validate a fall risk screening tool for use in hospital EDs and to compare the tool's predictive ability to existing screening tools. METHODS: This prospective cohort study involved two hospital EDs in Sydney, Australia. Potential participants were people aged 70+ years who presented to the ED after falling or with a history of 2+ falls in the previous year and were subsequently discharged. 219 people participated in the tool development study and 178 people participated in the external validation study. Study measures included number of fallers during the 6-month follow-up period, and physical status, medical history, fall history and community service use. RESULTS: 31% and 35% of participants fell in the development and external validation samples, respectively. The developed two-item screening tool included: 2+ falls in the past year (OR 4.18, 95% CI 2.61 to 6.68) and taking 6+ medications (OR 1.89, CI 1.18 to 3.04). The area under the receiver operating characteristic curve (AUC) was 0.70 (0.64-0.76). This represents significantly better predictive ability than the measure of 2+ previous falls alone (AUC 0.67, 0.62-0.72, p=0.02) and similar predictive ability to the FROP-Com (AUC 0.73, 0.67-0.79, p=0.25) and PROFET screens (AUC 0.70, 0.62-0.78, p=0.5). CONCLUSIONS: A simple, two-item screening tool demonstrated good external validity and accurately discriminated between fallers and non-fallers. This tool could identify high risk individuals who may benefit from onward referral or intervention after ED discharge.
When it comes to justifying staff in the emergency department, case management directors need to provide financial data, not anecdotal information to the hospital's finance department. Experts recommend the following: Track your facility's avoidable admissions and patients admitted in the wrong status and calculate how much reimbursement the hospital lost. Collect information on people treated for non-emergent conditions who didn't pay and what the hospital lost. Add up the number of frequent utilizers who use the emergency department to manage their chronic conditions and how many could have benefitted from a referral to community services.
Niels K Rathlev, Dan Obendorfer, Laura F White, Casey Rebholz, Brendan Magauran, Willie Baker, Andrew Ulrich, Linda Fisher, Jonathan Olshaker
Boston University Medical Center, Department of Emergency Medicine, Boston, Massachusetts.
INTRODUCTION The mean emergency department (ED) length of stay (LOS) is considered a measure of crowding. This paper measures the association between LOS and factors that potentially contribute to LOS measured over consecutive shifts in the ED: shift 1 (7:00 am to 3:00 pm), shift 2 (3:00 pm to 11:00 pm), and shift 3 (11:00 pm to 7:00 am). METHODS Setting: University, inner-city teaching hospital. Patients: 91,643 adult ED patients between October 12, 2005 and April 30, 2007. Design: For each shift, we measured the numbers of (1) ED nurses on duty,(2) discharges,(3) discharges on the previous shift,(4) resuscitation cases,(5) admissions,(6) intensive care unit (ICU) admissions, and (7) LOS on the previous shift. For each 24-hour period, we measured the (1) number of elective surgical admissions and (2) hospital occupancy. We used autoregressive integrated moving average time series analysis to retrospectively measure the association between LOS and the covariates. RESULTS For all 3 shifts, LOS in minutes increased by 1.08 (95% confidence interval 0.68, 1.50) for every additional 1% increase in hospital occupancy. For every additional admission from the ED, LOS in minutes increased by 3.88 (2.81, 4.95) on shift 1, 2.88 (1.54, 3.14) on shift 2, and 4.91 (2.29, 7.53) on shift 3. LOS in minutes increased 14.27 (2.01, 26.52) when 3 or more patients were admitted to the ICU on shift 1. The numbers of nurses, ED discharges on the previous shift, resuscitation cases, and elective surgical admissions were not associated with LOS on any shift. CONCLUSION Key factors associated with LOS include hospital occupancy and the number of hospital admissions that originate in the ED. This particularly applies to ED patients who are admitted to the ICU.
As district nurses, we are now experiencing extensive changes in the way community services are commissioned and run. Ideally, the result will be that patients living in the community will be better supported by having robust integrated services specifically designed to meet their needs. We are already seeing this with the emergence of 'admission avoidance' community teams specialising in supporting people through acute exacerbations of their health problems so that they do not have to go into hospital. Likewise, across the UK, specialist teams of community nurses are being commissioned locally to provide IV antibiotic therapy in people's homes and community clinics.
Service des urgences, Hôpital les Chanaux, Mâcon.
Context: Elderly patients represent an important and growing part of the emergency department activity. Purpose: To describe population aged of 75 and over admitted in an emergency department without programming and then compare patients addressed with a letter of referral or not. Methods: A prospective transversal study was carried out over one month in the emergency department of the hospital of Mâcon. It concerned all patients aged of 75 and over admitted at the emergency department. Results: The study concerned 459 passages of elders (17% of admissions during the period), among whom 40% were addressed with a letter of referral. Mean age was 83.4, with a sex-ratio of 0.6. The hospitalization rate is significantly higher among the letter addressed group: 84% vs 72%(p<0.01). The Emergency room reception of elderly people was evaluated as required for 70% of cases (essentially for medical reasons) and the family physician could have planed the hospitalization for 21% of cases. The mean duration stay was 8.6 days. The mortality at one month was 6%, without significant difference between the two groups. Readmission rate after 3 months was of 20% one more time at least during the period. Discussion: Elderly people passage through the emergency department tends to become the admission way to the hospital. An important part of these patients are addressed with a letter of referral, which does not modify the patient's orientation. Nevertheless, some could avoid emergency room passage. This report has to bring us to a reflexion about a work with the physicians to welcome in best these elders at hospital.
Contemp Nurse. 2012 Feb 10;: 22551270
Feeling let down: An exploratory study of the experiences of older people who were readmitted to hospital following a recent discharge.
University of Newcastle, School of Nursing and Midwifery Callaghan, New South Wales, Australia email@example.com.
Abstract Background: Readmission of older people to hospital following a recent discharge may be an indicator of gaps in services either prior to or after discharge. Aims and objectives: To explore the experiences of older people who have been readmitted to hospital following recent discharge to their homes. Design: A qualitative descriptive study Method: In-depth interviews were conducted with three older people who were discharged from a large tertiary referral hospital in NSW Australia and readmitted. Interviews were conducted within the hospital setting in a private room. An interview guide was used to explore the reasons for admission and readmission to hospital and experiences upon discharge to home. In particular the researchers were interested in the events that led to readmission. Data were analysed thematically Results: Three main themes emerged including: being left out, being cared for and feeling let down. Conclusion: While this study was undertaken in only one hospital with only three older people the findings provide valuable insight into their experiences. Nurses need to be proactive in ensuring and promoting a person centred approach to the care and treatment of older people.
Research Unit of Nursing, Institute of Clinical Research, University of Southern Denmark, Odense and Copenhagen University Hospital, Amager, Denmark. firstname.lastname@example.org
UNLABELLED Aim: To describe and test a model for structured nursing assessment and intervention to older people discharged from emergency department (ED). BACKGROUND Older people recently discharged from hospital are at high risk of readmission. This risk may increase when they are discharged straight home from an ED as time pressure requires staff to focus on the presenting problem although many have complex, unresolved, care needs. METHOD A prospective descriptive pilot study was conducted. Older people aged 70 and over and at risk of adverse health and functional outcome were included. Intervention: At discharge, and at 1 and 6 months follow-up, a brief standardised nursing assessment (ISAR 2) developed by McCusker et al. was carried out. The focus was on unresolved problems that required medical or nursing intervention, new or different home care services or comprehensive geriatric assessment. After assessment, the nurse made relevant referrals to the geriatric outpatient clinic, community health centre, general practitioner or made arrangements with next of kin. RESULTS One hundred and fifty people participated, mean age was 81.7. At discharge, they had a mean of 1.9 unresolved problems, after 1 month 0.8, and after 6 months 0.4. Older people receiving home care services increased from 79% at discharge to 89% at 1 month and 90% at 6 months follow-up. CONCLUSION ISAR 2 works well in a Danish ED setting and intercepts older peoples' problems. It seems that unresolved problems decrease when a nurse assesses and intervenes at discharge from ED, and at follow-up. However, a randomised controlled test should be carried out to confirm this. IMPLICATIONS FOR PRACTICE Nursing assessment and intervention should be implemented in the ED to reduce older peoples' unrevealed problems.
Emerg Nurse. 2012 Feb ;19 (9):12-6 22489362
At Leicester Royal Infirmary, the care of frail older people occupies a disproportionate amount of emergency department (ED) staff's time and resources. Too few ED staff are trained to deal with the complex comorbidities associated with older patients, 90 per cent of whom are therefore admitted to hospital. To take the pressure off the ED and reduce the number of avoidable admissions, the hospital has set up an emergency frailty unit to treat patients over the age of 70 who need not be admitted to hospital and to ensure they can receive community care as soon as possible. This article describes how the unit operates.
Neurologia. 2012 Feb 16;: 22341677
Unidad de Gestión Clínica de Neurología Intercentros, Hospital Juan Ramón Jiménez y Hospital Infanta Elena, Huelva, España.
INTRODUCTION: According to the Spanish Stroke Health Care Plan and the Spanish Health National Service Stroke Strategy, thrombolysis should only be performed in hospitals with Stroke Units. However, the Andalusian Stroke Health Care Plan includes, within the list of services of the Stroke Team, the need to have a neurologist present for the performing of thrombolysis in local hospitals. The objective of this study is to evaluate whether emergency doctors are able to achieve a reliable diagnosis of stroke in order to safely perform thrombolysis. METHODS: The diagnoses on hospital admission and discharge of all patients admitted for neurological reasons in 2006 in the community Hospital Infanta Elena (Huelva, Andalusia) were collected. The reliability of diagnosis performed by emergency doctors was analysed. RESULTS: A total of 655 patients were admitted to the hospital for neurological reasons, and 76% of them were diagnosed as strokes. The sensitivity of stroke diagnosis made by emergency doctors was very high (97%), but specificity and positive predictive value of that diagnosis was low (52% and 75%, respectively). CONCLUSIONS: To apply thrombolysis based of the diagnosis of a stroke by emergency doctors may subject a significant number of erroneously diagnosed patients to an unnecessary risk of brain haemorrhage. This risk makes performing thrombolysis in community hospitals ethically questionable in these circumstances. Although it is important to have thrombolytic treatment available to everyone, this treatment must be performed safely by neurologists Stroke Units.