Push or pull? Digital notification platform implementation reduces dysglycaemia.

Pushing selected information to clinicians, as opposed to the traditional method of clinicians pulling information from an electronic medical record, has the potential to improve care. A digital notification platform was designed by clinicians and implemented in a tertiary hospital to flag dysglycaemia. There were 112 patients included in the study, and the post-implementation group demonstrated lower rates of dysglycaemia (2.5% vs 1.1%, P = 0.038). These findings raise considerations for information delivery methods for multiple domains in contemporary healthcare.

Use of a capacity audit tool in a mental health setting.

OBJECTIVE: This paper reports on a pilot applying the capacity audit tool (CAT) in a mental health environment and what the tool reveals regarding mental health in-patient capacity issues. METHODS: The CAT was modified to create an electronic mental health-relevant tool to audit acute in-patient capacity. This tool was then piloted across nine bedded units, within a single Local Health Network, covering a total of 153 mental health beds. RESULTS: The application of the mental health CAT resulted in 100% compliance in completion. The findings revealed that 16% (25 beds) of the 153 beds surveyed were occupied by patients who did not need to occupy the bed or the bed was vacant. Of these 25 beds, 10 had patients awaiting transfer to another facility or service, nine were empty and six were occupied by patients ready for discharge but for whom there were delays. CONCLUSION: The CAT was successfully applied to the mental health setting and identified a set of opportunities to improve processes and practices to reduce the identified delays or barriers in order to improve patient flow.

Using capacity alert calls to reduce overcrowding in a major public hospital.

OBJECTIVE: To investigate the efficacy of capacity alert calls in reducing acute hospital overcrowding through addressing rising occupancy, high patient throughput and increased access block. METHODS: Retrospective analysis of 24 months of in-patient, emergency department, and capacity alert call log data from a large metropolitan public hospital in Australia. The analysis explored statistical differences in patient flow parameters between capacity alert call days and other days including a control case set of days with statistically similar levels of occupancy. RESULTS: The study identified a significant (P<0.05) reduction in occupancy, patient throughput and access block on capacity alert call days. Capacity alert call days reversed rising occupancy trends, with 6 out of 7 flow parameters reporting significant improvement (P<0.05) over the 48 h following the call. Only 3 of these 7 flow parameters were significantly improved 48 h after control case days, confirming value in the alert mechanism and that the results are not a regression toward the mean phenomenon. CONCLUSIONS Escalation processes that alert and engage the whole hospital in tackling overcrowding can successfully deliver sustained improvements in occupancy, patient throughput and access block. The findings support and validate the use of capacity alert escalation calls to manage overcrowding, but suggest the need to improve the consistency of trigger mechanisms and the efficiency of the processes initiated by the capacity alert call.

Translational artificial intelligence-led optimization and realization of estimated discharge with a supportive weekend interprofessional flow team (TAILORED-SWIFT).

Weekend discharges occur less frequently than discharges on weekdays, contributing to hospital congestion. Artificial intelligence algorithms have previously been derived to predict which patients are nearing discharge based upon ward round notes. In this implementation study, such an artificial intelligence algorithm was coupled with a multidisciplinary discharge facilitation team on weekend shifts. This approach was implemented in a tertiary hospital, and then compared to a historical cohort from the same time the previous year. There were 3990 patients included in the study. There was a significant increase in the proportion of inpatients who received weekend discharges in the intervention group compared to the control group (median 18%, IQR 18-20%, vs median 14%, IQR 12% to 17%, P = 0.031). There was a corresponding higher absolute number of weekend discharges during the intervention period compared to the control period (P = 0.025). The studied intervention was associated with an increase in weekend discharges and economic analyses support this approach as being cost-effective. Further studies are required to examine the generalizability of this approach to other centers.

What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing.

AIM: To identify the common, core elements of patient-centred care in the health policy, medical and nursing literature. BACKGROUND: Healthcare reform is being driven by the rhetoric around patient-centred care yet no common definition exists and few integrated reviews undertaken. DESIGN: Narrative review and synthesis. DATA SOURCES: Key seminal texts and papers from patient organizations, policy documents, and medical and nursing studies which looked at patient-centred care in the acute care setting. Search sources included Medline, CINHAL, SCOPUS, and primary policy documents and texts covering the period from 1990-March 2010. REVIEW METHODS: A narrative review and synthesis was undertaken including empirical, descriptive, and discursive papers. Initially, generic search terms were used to capture relevant literature; the selection process was narrowed to seminal texts (Stage 1 of the review) and papers from three key areas (in Stage 2). RESULTS: In total, 60 papers were included in the review and synthesis. Seven were from health policy, 22 from medicine, and 31 from nursing literature. Few common definitions were found across the literature. Three core themes, however, were identified: patient participation and involvement, the relationship between the patient and the healthcare professional, and the context where care is delivered. CONCLUSION: Three core themes describing patient-centred care have emerged from the health policy, medical, and nursing literature. This may indicate a common conceptual source. Different professional groups tend to focus on or emphasize different elements within the themes. This may affect the success of implementing patient-centred care in practice.

The ebbs and flows of changing acute bed capacity delays.

OBJECTIVE: This case study provides a summary of changes in acute hospital bed delays that have occurred over a 4-year period as identified through a Capacity Audit process. BACKGROUND: Royal Adelaide Hospital (RAH) designed a Capacity Audit process and tool that provides a systematic method to evaluate factors limiting access to inpatient bed capacity. The aim of the audit is to improve understanding of bed capacity by identifying key causes of delay for hospital inpatients and quantify the most frequent causes of blocked bed capacity. This can then be used to underpin targeted improvement work. The Capacity Audit has been undertaken at the RAH over three cycles. METHOD: The Capacity Audit involves a survey of every open and staffed bed, identifying how the bed is being used: for acute care or treatment, if there was a delay to the patient for discharge, or if the bed was unavailable. The first and second cycle of the audit (2007-2008) involved a twice-daily survey over a 2-week period and the third audit cycle in 2010 occurred once daily for 1 week. RESULTS: On average, 620 beds were surveyed daily with an audit compliance rate ranging from 85-97%. This process has revealed almost 75% of beds are used positively for care. Of the remaining 25% of hidden capacity identified, non-clinical discharge delays account for 10% of total beds surveyed. Waiting for post-acute beds has consistently remained the main cause of acute bed delay. CONCLUSION: The Capacity Audit process and tool has been used to track progress, trends and change resulting from service improvement efforts, and to provide the evidence to commence strategies to reduce the hidden capacity issues. This case study has shown that whilst overall bed stock usage for positive care has not changed significantly there are various ebbs and flows over time in relation to the reasons for bed delays.

Understanding the drivers on medical workloads: an analysis of spectators at the Australian Football League.

OBJECTIVE: The present study was designed to further understand the psychosocial drivers of crowds impacting on the demand for healthcare. This involved analysing different spectator crowds for medical usage at mass gatherings; more specifically, did different football team spectators (of the Australian Football League) generate different medical usage rates. METHODS: In total, 317 games were analysed from 10 venues over 2 years. Data were analysed by the ANOVA and Pearson correlation tests. RESULTS; Spectators who supported different football teams generated statistically significant differences in patient presentation rates (PPR) (F15, 618=1.998, P=0.014). The present study confirmed previous findings that there is a positive correlation between the crowd size and PPR at mass gatherings but found a negative correlation between density and PPR (r = -0.206, n=317, P<0.0005). CONCLUSIONS: The present study has attempted to scientifically explore psychosocial elements of crowd behaviour as a driver of demand for emergency medical care. In measuring demand for emergency medical services there is a need to develop a more sophisticated understanding of a variety of drivers in addition to traditional metrics such as temperature, crowd size and other physical elements. In this study we saw that spectators who supported different football teams generated statistically significant differences in PPR. What is known about this topic? Understanding the drivers of emergency medical care is most important in the mass gathering setting. There has been minimal analysis of psychological 'crowd' variables. What does this paper add? This study explores the psychosocial impact of supporting a different team on the PPR of spectators at Australian Football League matches. The value of collecting and analysing these types of data sets is to support more balanced planning, better decision support and knowledge management, and more effective emergency medical demand management. What are the implications for practitioners? This information further expands the body of evidence being created to understand the drivers of emergency medical demand and usage. In addition, it supports the planning and management of emergency medical and health-related requirements by increasing our understanding of the effect of elements of 'crowd' that impact on medical usage and emergency healthcare.

Does hospital occupancy impact discharge rates?

OBJECTIVE: To understand what impact hospital inpatient occupancy levels have on patient throughput by analysing one hospital's occupancy levels and the rate of patient discharge. METHODS: A four-stage model was fit to hospital admission and separation data and used to analyse the per-capita separation rate according to the patient load and the impact of hospital over-census actions. RESULTS: Per-capita separation rates are significantly higher on days when the hospital declares an over-census due to emergency department crowding. Per-capita separation rates are also higher or lower on days with 8-10% higher or lower patient loads, respectively, but the response is not nearly as strong as the response to an over-census declaration, and is limited to patients with an elapsed stay of 10 days or more. Within the medical division there is an increase in per-capita separation rates on over-census days, but no significant difference in per-capita release rates for different patient loads. Within the surgical division there is no significant difference in per-capita separation rates on over-census days compared with other days, but the patient load does make a significant difference. CONCLUSION: Staff do discharge a greater proportion of long-stay patients when the hospital is experiencing high demand and a lower proportion when occupancy is low, but the reasons driving those changes remains unclear.

Patients' views of patient-centred care: a phenomenological case study in one surgical unit.

AIMS: To report a study of patients' views of patient-centred care. The study aimed to explore patients' understanding and conceptualization of patient-centred care and link it to existing literature on the topic. BACKGROUND: Patient-centred care currently lacks a widely accepted definition, with much of the literature based on definitions formulated by health professionals and researchers. DESIGN: Qualitative research study grounded in phenomenology. METHODS: Interpersonal interviews were conducted with ten participants who were patients in a surgical ward in a large metropolitan hospital in South Australia in 2010. RESULTS/FINDINGS: Participants were unfamiliar with the concept of patient-centred care, but despite this, were able to describe what the term meant to them and what they wanted from their care. Patients equated the type and quality of care they received with the staff that provided it and themes of connectedness, involvement and attentiveness were prevalent in their descriptions of what they wanted from their care. CONCLUSION: Ensuring that patients have a voice in the definition and conceptualization of patient-centred care is essential and further and regular consultation with patients about their needs and priorities will ensure an integrated approach to patient-centred care.

Hospital design features that optimise pandemic response.

The COVID-19 pandemic has changed forever how we plan, respond to, and deliver health care. The lived experience of hospital infrastructure design to support a pandemic is currently not well described in the literature. Much of what is known covers generic elements of hospital design and/or assumptions about in-built disaster design features. The Central Adelaide Local Health Network became a key stakeholder in South Australia's response when the Royal Adelaide Hospital (RAH) became the designated receiving hospital for the state. Preparation for a pandemic commenced back in 2007 when a new build for the RAH was announced. Several disaster response infrastructure design features were incorporated into the RAH design specifications to provide a resilient facility that could respond to any type of disaster event while continuing to provide core clinical services. Key pandemic design elements included patient room design, pandemic air handling capability, and a 7-step scalability function. We describe these key elements based on real-time experience along with the key lessons learnt as the pandemic response evolved with the aim of guiding future hospital building design to not only support the more frequent time-limited disasters but, more specifically, a pandemic response. The RAH capitalised on its key design features to support its pandemic response and contributed to the overall success of South Australia's pandemic response.

Campaign Disaster Response - What Makes It Different.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has seen health systems adapt and change in response to local and international experiences. This study describes the experiences and learnings by the Central Adelaide Local Health Network (CALHN) in managing a campaign style, novel public health disaster response. METHODS: Disaster preparedness has focused on acute impact, mass casualty incidents. In early 2020, CALHNs largest hospital the Royal Adelaide Hospital (RAH) was appointed as the state primary COVID-19 adult receiving hospital. Between the period of February 1, 2020, when the first COVID-19 positive patient was admitted, through to December 31, 2020, the RAH had admitted 146 inpatients with COVID-19, 118 admitted to our hospital in the home service, 18 patients admitted to Intensive Care, and 4 patients died while inpatients. During this time CALHN has sustained an active (physical and virtual) Network Incident Command Centre (NICC) supported by a Network Incident Management Team (NIMT). RESULTS: This study describes our key lessons learnt in relation to the management of a campaign style disaster response including the importance of disaster preparedness, fatigue management, and communication. Also described, were the challenges of operating in a command model and the role of exercising and education and an overview of our operating rhythm, how we built capability, and lessons management. CONCLUSIONS: Undertaking a longer duration disaster response, relating to the COVID-19 pandemic has shown that, although traditional disaster principles still are important, there are many nuances that need to be considered to retain a proportionate response. Our key lessons have revolved around the key tenants of disaster management, communication, capability, and governance.

Working together to improve the care of older people: a new framework for collaboration.

AIM: This paper is a report of a study identifying the care issues experienced by older people in the acute setting that could be improved through a collaborative approach to action. BACKGROUND: Actively involving consumers in the governance of healthcare organizations is viewed positively, although there is less agreement on how to do this. Co-operative inquiry is a useful approach to involve consumers and clinicians in structured dialogue about understanding and changing care, whereas traditional quality improvement methodologies are often singular in their dimensions of change. METHOD: Using a co-operative inquiry approach, five workshops were facilitated over a 4-month period in 2008 with four volunteer older people, four clinicians and three facilitators (n=11). All participants were actively involved in generating ideas and actions using a range of facilitation techniques and data collection methods. FINDINGS: There was increased awareness, understanding and acceptance of clinicians' and consumers' experiences and expectations of care. The complexity behind changing so-called simple care (providing warm drinks, appetizing food), which were the key concerns for consumers, relied on the active management and broader transformation of the system, including teamwork, communication processes and organizational and individual values and beliefs. CONCLUSION: Consumers and clinicians put different emphasis on perspectives related to improving care of older people in the acute hospital setting. The disconnect between what consumers viewed as 'simple' organizational behaviours to change and what the clinicians viewed as complex, led to a recognition that the approach to organizational change needs to be reconceptualized.

Assessing the psychosocial elements of crowds at mass gatherings.

INTRODUCTION: The environmental aspects of mass gatherings that can affect the health and safety of the crowd have been well described. Although it has been recognized that the nature of the crowd will directly impact the health and safety of the crowd, the majority of research focuses on crowd behavior in a negative context such as violence or conflict. Within the mass gathering literature, there is no agreement on what crowd behavior, crowd mood and crowd type actually mean. At the same time, these elements have a number of applications, including event management and mass gathering medicine. These questions are worthy of exploration. METHODS: This paper will report on a pilot project undertaken to evaluate how effective current crowd assessment tools are in understanding the psychosocial domain of a mass gathering event. RESULTS: The pilot project highlighted the need for a more consistent descriptive data set that focuses on crowd behavior. CONCLUSIONS: The descriptive data collected in this study provide a beginning insight into the science of understanding crowds at a mass gathering event. This pilot has commenced a process of quantifying the psychosocial nature of an event. To maximize the value of this work, future research is required to understand the interplay among the three domains of mass gatherings (physical, environmental and psychological), along with the effects of each element within the domains on safety and health outcomes for participants at mass gatherings.

Clinical nursing leaders', team members' and service managers' experiences of implementing evidence at a local level.

AIM: To describe the experiences of 14 clinical nursing leaders introducing a knowledge translation (KT) project into one metropolitan acute care hospital in South Australia. The study also explored team members' and service managers' experiences. BACKGROUND: KT strategies assume that local (nursing) clinical leaders have the capacity and capability to champion innovation combining positional leadership roles (ward leader) with a project lead role. There is limited evidence to support these assumptions. METHOD: Semi-structured interviews of clinical nursing leaders and managers were undertaken at month 4 and 12 of the project. Data were also collected from the interdisciplinary team members (n = 28). RESULTS: Clinical nursing leaders identified risks and anxieties associated with taking on an additional leadership role, whereas managers acknowledged the multiple pressures on the system and the need for local level innovation. Team members generally reported positive experiences. CONCLUSIONS: With support, clinical nursing leaders can effectively embrace KT project leadership roles that complement their positional leadership roles. Clinical nursing leaders' experiences differed from nursing and medical managers' experiences. IMPLICATIONS FOR NURSING MANAGEMENT: Managers need to be more attuned to the personal risks local leaders experience, providing support for leaders to experiment and innovate. Managers need to integrate local priorities with broader system wide agendas.

The role of the nurse sedationist.

AIM AND OBJECTIVES: This paper aims to provide a quality improvement review to identify the benefits and level of satisfaction for the role of the nurse sedationists. BACKGROUND: Traditionally procedural sedation was only administered by an anaesthetist or dentist and it was not until the early 1990s that nurses in America commenced administering procedural sedation. A literature review on the role of the nurse sedationist undertaken identified no documented evidence of such a role in Australia. The role of the nurse sedationist was pursued as a strategy to meet the increased demand for anaesthetic services, manage the shortage of anaesthetists and address concerns associated with the administration of procedural sedation by healthcare workers untrained in this area. METHOD: Evaluation of the role of the nurse sedationist was essential to ensure that the role met both the needs of the organisation, patients and key stakeholders. Due to the variety of stakeholders and associated expectations a variety of evaluation methods were used. RESULTS: Results indicate that the introduction of the nurse sedationist role has been recognised as value adding through increases in patient safety, a more collaborative approach to patient care, improved work environments for all staff groups and strengthened multi disciplinary relationships. Patients also indicate a very high level of patient satisfaction with the service. CONCLUSION: The role of nurse sedationist has been successfully introduced in an Australian acute public hospital. The introduction of the role has assisted to address an increased demand for anaesthetic services and to address patient safety concerns. RELEVANCE TO CLINICAL PRACTICE: Recent years have seen an expansion of advanced practice nursing roles throughout Australia. This expansion of roles has resulted in an increase in nursing expertise, high quality patient outcomes and an improved multidisciplinary approach to healthcare. The role of the nurse sedationist has been a result of expansion in this area.

Chain of survival at mass gatherings: a case series of resuscitation events.

BACKGROUND: At a large public event, or mass gathering, various factors influence patient presentations that brings challenges to patient care. The chain of survival has been investigated in the prehospital setting. However, this has not explicitly included the mass-gathering environment. OBJECTIVE: This study sought to determine the facilitators and barriers to the chain of survival at mass gatherings. METHODS: This case-series research was exploratory and descriptive, using the analysis of personal experiences of resuscitation. Participants were members of St John Ambulance Australia who had participated actively in a resuscitation event in 2007. Telephone interviews were used as a means of data collection. Participant narrative was recorded electronically, transcribed verbatim, and analyzed thematically using a well established human science approach. RESULTS: The thematic analysis revealed five main themes and a number of sub-themes. Four of the main themes were aligned easily with the four chain of survival links. The remaining main theme outlined a new link in the chain of survival of specific importance to mass gatherings, 'early planning'. Additionally, a number of sub-themes were identified, which exemplified various facilitators and barriers to the chain of survival in this environment. CONCLUSIONS: This research highlights various barriers and facilitators to the chain of survival in the mass-gathering environment. Additionally, the unique "early planning" link in the chain of survival as described in this research highlights the importance of a preparatory phase for responders at mass gatherings.

Out-of-hospital cardiac arrest-review of demographics in South Australia to inform decisions about the provision of automatic external defibrillators within the community.

INTRODUCTION: Sudden, out-of-hospital cardiac arrest (OHCA) has an annual incidence of approximately 50 per 100,000 population. Public access defibrillation is seen as one of the key strategies in the chain-of-survival for OHCA. Positioning of these devices is important for the maximization of public health outcomes. The literature strongly advocates widespread public access to automated external defibrillatiors (AEDs). The most efficient placement of AEDs within individual communities remains unclear. METHODS: A retrospective case review of OHCAs attended by the South Australia Ambulance Service in metropolitan and rural South Australia over a 30-month period was performed. Data were analyzed using Utstein-type indicators. Detailed demographics, summative data, and clinical data were recorded. RESULTS: A total of 1,305 cases of cardiac arrest were reviewed. The annual rate of OHCA was 35 per 100,000 population. Of the cases, the mean value for the ages was 66.3 years, 517 (39.6%) were transported to hospital, 761 (58.3%) were judged by the paramedic to be cardiac, and 838 (64.2%) were witnessed. Bystander cardiopulmonary resuscitation (CPR) was performed in 495 (37.9%) of cases. The rhythm on arrival was ventricular fibrillation (VF) or ventricular tachycardia (VT) in 419 (32.1%) cases, and 315 (24.1%) of all arrests had return of spontaneous circulation (ROSC) before or on arrival at the hospital. For cardiac arrest cases that were witnessed by the ambulance service (n=121), the incidence of ROSC was 47.1%. During the 30-month period, there only was one location that recorded more than one cardiac arrest. No other location recorded recurrent episodes. CONCLUSIONS: This study did not identify any specific location that would justify defibrillator placement over any other location without an existing defibrillator. The impact of bystander CPR and the relatively low rate of bystander CPR in this study points to an area of need. The relative potential impact of increasing bystander CPR rates versus investing in defibrillators in the community is worthy of further consideration.

Capacity Audit Tool: identifying inpatient delays to maximise service improvement.

OBJECTIVE: This case study describes the development of a process and tool, the 'Capacity Audit', to quantify key inpatient delays in an acute care tertiary hospital setting. METHOD: The Capacity Audit Tool is an adaption of an existing Wasted Capacity Audit Tool supported by a systematic process to assess and quantify the status of patients in a cohort of inpatient beds. This paper reports on the application of the tool for all inpatient beds in an acute tertiary hospital assessed twice a day for a 15-day period. RESULTS: In total, 820 surveys were completed. This represents 9126 beds assessed in the morning shift and 9261 in the afternoon shift over the 15-day period. The simplicity of the Capacity Audit Tool and the process to collect data resulted in a 95% compliance rate. The audit revealed that 76% of beds audited were being used appropriately for acute care. The top three delays were patients awaiting a post-acute care, the bed being empty and awaiting a patient to be allocated, and patients awaiting discharge transport. CONCLUSIONS: The Capacity Audit Tool facilitates a high level of compliance, providing a comprehensive understanding of the use of hospital bed stock and bed capacity. In addition, the process reveals key inpatient delays to target critical improvement strategies.

Piloting a mass gathering conceptual framework at an Adelaide schoolies festival.

UNLABELLED: During the summer months in Australia, school leavers celebrate their end of school life at schoolies festivals around the nation. These events are typically described as a mass gathering as they are an organised event taking place within a defined space, attended by a large number of people. A project was undertaken to analyse the usefulness of Arbon's (2004) conceptual model of mass gatherings in order to develop a process to better understand the Adelaide Schoolies Festival. METHOD: Arbon's conceptual framework describes the inter-relationship between the psychosocial, environmental and bio-medical domains of a mass gathering. Each domain has set characteristics which help to understand the impact on the mass gathering event. The characteristics within three domains were collected using field work and bio-medical data to examine the relationship between injury and illness rates. RESULTS: Using the conceptual framework to evaluate this schoolies event helped create an understanding of the physiology, environment and behaviour contributing to patient presentations. Results showed that the schoolies crowd was active and energetic, and the main crowd behaviour observed was dancing and socialising with friends. The environmental domain was characterised by a grassy outdoor venue that was bounded and dry. Due to the overall health of the crowd, activities undertaken and the supportive environment, the majority of injuries to schoolies were minor (68%). However, twenty-four percent of schoolies who presented with alcohol related illness were found to have consumed alcohol at risky levels; half of this cohort was transported to hospital. CONCLUSION: The conceptual framework successfully guided a higher level of examination of the mass gathering event. In particular, the framework facilitated a greater understanding of the inter-relationships of the various characteristics of a mass gathering event, in this case the Adelaide Schoolies Festival.