Australasian Emergency Care最新文献

Accessing care in the Emergency Department is often fraught with stress and heightened emotions due to illness or injury, and the complexity of navigating an often busy and overwhelming healthcare setting. For people who identify as trans (binary and non-binary), accessing Emergency Department care is often associated with additional stress or avoided due to fears of discrimination, or previous negative experiences (1). The aim of this integrative review was to identify and review the literature relating to the experiences of trans (binary and non-binary) people accessing Emergency Department care, to guide practice and future research. A structured search process was used to identify 11 articles published between January 2013 and November 2023. These articles were appraised using the mixed methods appraisal tool (MMAT) (2) and included in this review. Utilising the methodology outlined by Whittemore & Knafl (3), a constant comparison analytic approach identified five key themes; 1. emergency department context; 2. interactions with staff and language; 3. health professional knowledge; 4. advocacy; and 5. disclosing trans status. This review identified a perceived lack of competence for healthcare providers to deliver gender affirming healthcare in the Emergency Department due to perceptions of inadequate healthcare provider knowledge, and structural barriers founded on cisgender processes.

Introduction

Existence of Advance Care Planning (ACP) documents including contact details of Medical Treatment Decision Makers (MTDM), are essential patient care records that support Emergency Department (ED) clinicians in implementing treatment concordant with patients’ expressed wishes. Based upon previous findings, we conducted a statewide study to evaluate the performance of Victorian public hospital emergency departments on reporting of availability of records for ACP.

Method

The study is a quantitative retrospective observational comparative design based upon ED tier levels as defined by the Australasian College for Emergency Medicine (ACEM) for the calendar year 2021.

Results

Of 1.8 million total Victorian ED attendances, 15,222 patients had an ACP alert status recorded. Of these, 7296 were aged ≥ 65 years (study group). Of the thirty-one public EDs that submitted data, 65 % were accredited and assigned a level of service tier. The presence of ACP alerts positively correlated to location, tier level, age and gender (MANOVA wilk’s; p < 0.001, value=.981, F = (12, 15,300), partial ƞ² = .006, observed power = 1.0 = 95.919).

Conclusion

The identified rate of ACP reporting is low. Strategies to improve the result include synchronising ACP (generated at different points) electronically, staff education, training and further validation of the data at the sending and receiving agencies.

Purpose

To explore paramedics’ experiences and perspectives about attending and managing older adults who had fallen.

Procedures

This qualitative, exploratory study used a purposive sample of paramedics in Western Australia. Participants had at least one year of clinical experience. Semi-structured interviews were undertaken. Data were analysed via an inductive thematic approach.

Findings

Fourteen paramedics were interviewed (Median age: 38 years, n = 5 females). The main theme identified that experiences were positive when attending patients with high-acuity medical problems or injuries following falls because binary decision-making (transport vs non-transport) was appropriate. Themes highlighted that decision-making for low-acuity falls attendances was a complex balance between 1) patient context, 2) risk management, 3) paramedic reactions, and 4) the lack of alternate referral pathways available. Experiences could be stressful and frustrating when attending falls call-outs for older adults with no injuries or medical problems. Participants concurred that when transport to hospital was not required there were no available, alternative pathways to refer onwards for appropriate health or social care.

Conclusion

Attending low-acuity call-outs for falls was often frustrating and required complex decision-making, with gaps in services identified. Further exploration of alternative referral pathways for health care for pre-hospital management of adults who fall is required.

Background

Rural Australians with acute myocardial infarction (AMI) face higher mortality rates due to limited access to specialised cardiac services. Paramedic-administered prehospital thrombolysis (PHT) has emerged as an alternative to primary percutaneous intervention (pPCI) for patients facing barriers or delays to cardiac care. There is variability in PHT practices among Australian ambulance services, lacking standardised definitions and outcome measures. The aim of this scoping review was to identify quality indicators and influencing factors associated with outcomes for patients receiving PHT.

Methods

A systematic search of literature in SCOPUS and Academic Search Complete, CINAHL and Health Source: Nursing/Academic Edition databases via EBSCO (Health) was conducted following the Joanna Briggs Institute methodology. Peer-reviewed studies from the past decade were screened using search criteria relevant to prehospital thrombolysis and quality indicators. Data extraction was performed and themed using five domains from the Utstein-style template commonly known for standardised prehospital cardiac arrest reporting.

Results

After removing duplicates, the search yielded 3596 articles with 28 empirical studies meeting inclusion criteria for the review. These were primarily retrospective cohort studies performed in Australia, Canada and the United States. The scoping review identified 24 clinical quality indicators and factors related to Emergency Medical Service (EMS) systems, AMI recognition and ambulance dispatch, patient variables, PHT processes and patient outcomes. These findings correlate to the Donabedian structure-process-outcome quality of care model and have utility to inform future PHT reporting guidelines for jurisdictional ambulance services.

Conclusions

Given the variability in prehospital practice across Australian ambulance services, standardised reporting on quality indicators for PHT is needed. The Utstein-style template used to report data on pre-hospital cardiac arrest, trauma and airway management could be used for quality improvement in PHT. This review presents 24 quality indicators representing system, recognition and response, patient, process, and outcomes related to PHT. These results could be used to inform a future Delphi study and Utstein-like reporting guideline for prehospital thrombolysis.

Background

This study aimed to assess the efficacy of a screening questionnaire, based on historical criteria, in distinguishing between seizures and syncope in patients experiencing their first episode of transient loss of consciousness (TLOC) in a neurology emergency department.

Methods

A prospective cohort of 159 patients with initial TLOC episodes underwent clinical observation and answered a nine-question screening questionnaire. The questionnaire's predictive ability was compared to final diagnoses determined through detailed neurology, electrophysiology, and cardiology assessments during a minimum 12-month follow-up. Logistic regression (LR) analysis was performed with final diagnosis as the outcome variable. The calibration and discrimination of the models were assessed.

Results

revealed that the screening score accurately classified 72.33% of patients. Among those with positive screening scores, 65 (67.71%) had seizures compared to 31 (32.29%) with syncope. Introducing a novel risk-scoring model incorporating age and gender, in addition to the screening score, significantly improved performance achieving an accurate classification rate of 81.48%. Among patients with a positive prediction, 63 (80.77%) had seizure, whereas 15 (19.23%) had syncope.

Conclusions

Employing a structured questionnaire based on common historical criteria is a valuable tool for distinguishing between seizure and syncope in the dynamic setting of the emergency department.

Background

Many education interventions in emergency nursing are aimed at changing nurse behaviours. This scoping review describes and synthesises the published research education interventions and emergency nurses’ clinical practice behaviours.

Methods

Arksey and O’Malley’s methodological framework guided this review, which is reported according to Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). CINAHL, MEDLINE complete, ERIC, and Psycinfo were searched on 3 August 2023. Two pairs of researchers independently conducted all screening. Synthesis was guided by the Behaviour Change Wheel and Bloom’s Taxonomy of Educational Objectives.

Results

Twenty-five studies were included. Educational interventions had largely positive effects on emergency nurses’ clinical practice behaviours. Ten different interventions were identified, the most common was education sessions (n = 24). Seven studies reported underpinning theoretical frameworks. Of the essential elements of behaviour change, seven interventions addressed capability, four addressed motivation and one addressed opportunity. Mapping against Bloom’s taxonomy, thirteen studies addressed analysis, eleven studies addressed synthesis and two studies addressed evaluation.

Conclusion

Few studies addressed elements of behaviour change theory or targeted cognitive domains. Future studies should focus on controlled designs, and more rigorous reporting of the education intervention(s) tested, and theoretical underpinning for intervention(s) selected.

Background

Following a national multicentre study, two emergency department (ED) screening tools were developed to determine risk of medication-related problems; one for use at ED presentation and another at ED discharge to the community. This study aimed to determine the inter-rater reliability amongst ED health professionals when applying these screening tools to a series of case scenarios.

Methods

A prospective, cross-sectional study was undertaken in the ED of a major metropolitan hospital. Twelve case scenarios were developed following ED observation of a range of patients, which were incorporated into a questionnaire and distributed to 50 health professionals. Inter-rater reliabilities of each explanatory variable of the screening tools and overall assessment were calculated using Fleiss’ multi-rater kappa.

Results

The questionnaire was completed by 15 doctors, 19 nurses and 16 pharmacists. Fleiss’ kappa showed an overall inter-rater reliability for the ED presentation tool of 0.83 (95% CI 0.83–0.84), indicating near perfect agreement. Fleiss’ kappa for the ED discharge tool was 0.83 (95% CI 0.83–0.85), which also showed near perfect agreement.

Conclusions

The screening tools produced favourable inter-rater reliability amongst ED health professionals. These results have important implications for ensuring consistency of ED decision-making in screening patients at risk of developing medication-related problems.

Background

Patients who frequently present to Emergency Department (ED) experience complex health and social needs. While research has examined interventions that aim to decrease frequent ED attendances, there is a need to understand the types of interventions provided to patients by hospital clinicians during presentations.

Methods

Using qualitative content analysis, 82 management plans were evaluated to understand the scope and type of interventions provided by clinicians for patients frequently presenting to the ED at the Royal Melbourne Hospital, Australia.

Results

Patients often presented to the ED due to mental and psychological distress, substance use and physical health concerns alongside psychosocial vulnerabilities. The goals of care documented in plans focussed on management of health issues, aggression within the ED, and coordinating care with community services. Recommended interventions addressed presenting needs with multi-disciplinary approach to respond to distress and aggression. Finally, the plans provided insight into service coordination dynamics between the ED and community-based health and social care services.

Conclusions

The plans recommended interventions that sought to provide holistic care for patients in collaboration with relevant community-based services. The findings suggest that clinicians in the ED can provide appropriate and meaningful care for patients who experience frequent presentations.

Background

Virtual emergency services have been proposed as an alternative service model to conventional in-person emergency department attendance.

Methods

Twenty participants were interviewed: 10 emergency medicine physicians, 4 health care consumers, and 6 other health care professionals. Conventional content analysis was performed on the interview transcriptions to identify perceived strengths and weaknesses of the VED, and barriers and facilitators to scaling-up the VED.

Results

VEDs are perceived as a convenient approach to provide and receive emergency care while ensuring safety and quality of care, however some patients may still need to attend the ED in person for physical assessments. There is currently a lack of evidence, guidelines, and resources to support their implementation. Most of the potential and existing barriers and facilitators for scaling-up the VED were related to their effectiveness, reach and adoption. Broader public health contextual factors were viewed as barriers, while potential actions to address resources and costs could be facilitators.

Conclusions

VEDs were viewed as a convenient service model to provide care, can not replace all in-person visits. Current policies and guidelines are insufficient for wider implementation. Most of the barriers and facilitators for its scaling-up were related to VED effectiveness and delivery.