Frequency and nature of medical emergency team afferent limb failure in patients with documented vital sign abnormalities: A retrospective point prevalence study.

BACKGROUND: Medical emergency team (MET) afferent limb failure is the presence of MET triggers and the absence of a documented MET call. OBJECTIVES: The aim of this study was to measure and understand the frequency and nature of MET afferent limb failure in patients with documented vital sign abnormalities in an Australian major teaching hospital. METHODS: A retrospective point prevalence study was conducted at a 600-bed teaching hospital in Melbourne, Australia. Data were collected for all adult inpatients (aged ≥18 years) on 13 wards (three general medicine, three surgical, and seven specialist wards) during a randomly selected 24-h period. Data were extracted from the electronic medical record. RESULTS: There were 357 patients included in the study, with a median age of 72 y. Of the 9716 vital sign measures extracted, 0.9% fulfilled patient-specific MET activation criteria. There were 93 MET triggers documented in 36 patients: 25 patients experienced MET afferent limb failure. The major issues related to MET afferent limb failure were MET trigger modification processes, resolution of vital sign abnormalities, alternative escalation of care, and limitations of medical treatment orders without specific modifications to MET triggers. CONCLUSIONS: Mandating MET activation for one aberrant vital sign at a single point in time warrants further assessment: lack of timely vital sign resolution may be a more appropriate trigger for MET calls and should be formally tested in future research. The frequency and effectiveness of alternative escalation pathways and local management of patients with MET triggers also warrant further investigation.

Recognizing and responding to clinical deterioration in adult patients in isolation precautions for infection control: a retrospective cohort study.

BACKGROUND: Patient isolation is widely used as a strategy for prevention and control of infection but may have unintended consequences for patients. Early recognition and response to acute deterioration is an essential component of safe, quality patient care and has not been explored for patients in isolation. OBJECTIVE: The primary aims of this study were to (i) describe the timing, frequency and nature of clinical deterioration during hospital admission for patients with isolation precautions for infection control and (ii) compare the characteristics of patients who did and did not deteriorate during their initial period of isolation precautions for infection control. METHODS: This retrospective cohort study was conducted across three sites of a large Australian health service. The study sample were adult patients (≥18 years) admitted into isolation precautions within 24 h of admission from 1 July 2019 to 31 December 2019. RESULTS: There were 634 patients who fulfilled the study inclusion criteria. One in eight patients experienced at least one episode of clinical deterioration during their time in isolation with most episodes of deterioration occurring within the first 2 days of admission. Timely Medical Emergency Team calls occurred in almost half the episodes of deterioration; however, the same proportion (47.2%) of deterioration episodes resulted in no Medical Emergency Team activation (afferent limb failure). In the 24 h preceding each episode of clinical deterioration (n = 180), 81.6% (n = 147) of episodes were preceded by vital signs fulfilling pre-Medical Emergency Team criteria. Patients who deteriorated during isolation for infection control were older (median age 74.0 vs 71.0 years, P = 0.042); more likely to live in a residential care facility (21.0% vs 7.2%, P = 0.006); had a longer initial period of isolation (4.0 vs 2.9 days, P = < 000.1) and hospital length-of-stay (median 4.9 vs 3.2 days, P = < 0.001) and were more likely to die in hospital (12.3% vs 4.3%, P < 0.001). CONCLUSION: Patients in isolation precautions experienced high Medical Emergency Team afferent limb failure and most fulfilled pre-Medical Emergency Team criteria in the 24 h preceding episodes of deterioration. Timely recognition and response to clinical deterioration continue to be essential in providing safe, quality patient care regardless of the hospital-care environment.

Enhancing active patient participation in nursing handover: A mixed methods study.

AIMS AND OBJECTIVES: To explore: i) the frequency and nature of patient participation in nursing handover and ii) patients' and nurses' perceived strategies to enhance patient involvement in nursing handover. BACKGROUND: Patient participation in nursing handover is important for patient-centred care, shared decision-making, patient safety and a positive healthcare experience DESIGN: A multi-site prospective study using a mixed methods design. METHODS: Between September and December 2019, nursing handovers were observed on ten randomly selected wards, followed by semi-structured interviews with patients (n = 33), and nurses (n = 20) from the observed handovers. Data were analysed using descriptive statistics for structured observations and thematic analysis of interviews, and triangulated to develop a greater understanding of patient participation in nursing handover. This study is reported using the Good Reporting of Mixed Methods Study guidelines. RESULTS: The median patient age was 77 years and 47% (n = 55) patients were female. Of the 117 handovers, 76.9% (n = 90) were conducted in the patient's presence. Patients were active participants in 33.3% (n = 30) and passive participants in 46.7% (n = 42) of handovers; in 20% of handovers (n = 18), the patient had no input at all. Active participation was more likely in women (vs. men), surgical patients (vs. medical patients) and when nurses displayed engagement behaviours (eye contact, opportunity to ask questions, explanations). Three major themes were identified from the interviews: 'Being Involved', 'Layers of Influence' and 'Information Exchange'. CONCLUSIONS: The main finding was that patient participation in handover was low and strongly influenced by a complex interplay of factors including patient and nurse preferences and perceptions. RELEVANCE TO CLINICAL PRACTICE: Handover is an essential tool in the provision of safe patient care. Patients were able to actively participate in nursing handover when they understood the purpose and timing of handover and had rapport with nurses.

Team-based learning in nursing education: A scoping review.

AIMS AND OBJECTIVES: To explore the use and student outcomes of Team-Based Learning in nursing education. BACKGROUND: Team-Based Learning is a highly structured, evidence-based, student-centred learning strategy that enhances student engagement and facilitates deep learning in a variety of disciplines including nursing. However, the breadth of Team-Based Learning application in nursing education and relevant outcomes are not currently well understood. DESIGN: A scoping review of international, peer-reviewed research studies was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. METHODS: The following databases were searched on 7 May 2020: Cumulative Index of Nursing and Allied Health Literature, MEDLINE Complete, PsycINFO and Education Resources Information Center. Search terms related to nursing, education and Team-Based Learning. Original research studies, published in English, and reporting on student outcomes from Team-Based Learning in nursing education programmes were included. RESULTS: Of the 1081 potentially relevant citations, 41 studies from undergraduate (n = 29), postgraduate (n = 4) and hospital (n = 8) settings were included. The most commonly reported student outcomes were knowledge or academic performance (n = 21); student experience, satisfaction or perceptions of Team-Based Learning (n = 20); student engagement with behaviours or attitudes towards Team-Based Learning (n = 12); and effect of Team-Based Learning on teamwork, team performance or collective efficacy (n = 6). Only three studies reported clinical outcomes. CONCLUSIONS: Over the last decade, there has been a growing body of knowledge related to the use of Team-Based Learning in nursing education. The major gaps identified in this scoping review were the lack of randomised controlled trials and the dearth of studies of Team-Based Learning in postgraduate and hospital contexts. RELEVANCE TO CLINICAL PRACTICE: This scoping review provides a comprehensive understanding of the use and student outcomes of Team-Based Learning in nursing education and highlights the breadth of application of Team-Based Learning and variability in the outcomes reported.

Clinical deterioration and hospital-acquired complications in adult patients with isolation precautions for infection control: A systematic review.

AIM: To review and synthesize literature examining clinical deterioration and hospital-acquired complications in adult patients with isolation precautions for infection control. BACKGROUND: Isolation precautions are a common infection prevention and control strategy which may have impact on safety and quality of care. DESIGN: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines guided this systematic review, which was registered with PROSPERO [CRD42019131573]. DATA SOURCES: A search of Medline, Embase, and Cumulative Index to Nursing and Allied Health Literature was conducted for studies published in English up to 5 April 2019. REVIEW METHODS: Risk of bias was determined using Critical Appraisal Skills Program tools. Quality appraisal was performed using the Grades of Recommendation, Assessment, Development, and Evaluation approach. The primary outcomes of interest were clinical deterioration events and hospital-acquired complications. In-hospital death and hospital length of stay were secondary outcomes. Data were synthesized using a narrative approach. RESULTS: The search yielded 785 citations after removal of duplicates, of which, six studies were relevant. Certainty of evidence for outcomes of interest was low to very low. CONCLUSION: There is no strong evidence that adult medical and surgical ward patients in isolation precautions for infection control are more or less likely to experience clinical deterioration or hospital-acquired complications. IMPACT: What problem did the study address? Are patients in isolation precautions more likely to experience clinical deterioration or hospital-acquired complications than non-isolated patients? What were the main findings? There is no strong evidence that clinical deterioration and hospital-acquired complications are more likely to occur to patients in isolation precautions for infection control. This research is of relevance to acute care nurses.

Anti-D from alloimmunization versus RhIG: detective work in the blood bank and transfusion medicine services.

BACKGROUND: The blood bank and transfusion medicine services (BBTMS) engages with electronic health records (EHRs), clinicians, and outside hospitals (OHs) to obtain comprehensive patient history to optimize care. Detection of anti-D in a pregnant patient underscores this work. Differentiating passive anti-D due to RhIG administration versus alloanti-D affects clinical decision making. The objectives of this study were to identify the required steps, barriers, and outcomes of anti-D investigations in obstetric patients. STUDY DESIGN AND METHODS: This retrospective case series reviewed nine pregnant patients over 24 months, for whom anti-D was identified with no reported RhIG history. Six steps were performed to ascertain anti-D history: 1) review the on-site EHR; 2) contact the on-site obstetrician, 3) review history from the automatic health information exchange (HIE) with OHs using the same EHR platform, 4) request information from OHs with a shared EHR platform and without automatic HIE, 5) contact the OH BBTMS, and 6) communicate with the outside ambulatory practice (OAP). RESULTS: The investigations revealed that eight of nine patients received RhIG before their presentation. Five patients received RhIG at an OH's emergency department and three at an OAP. One patient's history remained unknown after initial investigations; however, a subsequent sample unveiled a confounding alloantibody. CONCLUSION: In the absence of a national HIE, continuity of care suffers through omission of critical information. Strategies to avoid confusing passive anti-D and alloanti-D include expanding HIE capabilities and use of patient identification cards with critical BBTMS information to include RhIG administration dates.

Factors associated with unplanned readmissions within 1 day of acute care discharge: a retrospective cohort study.

BACKGROUND: Unplanned hospital readmissions are a quality and safety indicator. In Australian, 8% to 11.1% of unplanned readmissions occur ≤1 day of acute care discharge. The aim of this study was to explore the reasons for unplanned hospital readmissions ≤1 day of acute care discharge, and determine what proportion of such unplanned hospital readmissions were potentially preventable. METHODS: A retrospective exploratory cohort design was used to conduct this two phase study. In Phase 1, organisational data from 170 readmissions ≤1 day and 1358 readmissions between 2 and 28 days were compared using the Cochran-Mantel-Haenszel test. Binary logistic regression was used to examine factors associated with unplanned readmission ≤1 day. In Phase 2, a medical record audit of 162 Phase 1 readmissions ≤1 day was conducted and descriptive statistics used to summarise the study data. Index discharges occurred between 1 August and 31 December 2015. RESULTS: In Phase 1, unplanned readmissions ≤1 day were more likely in paediatric patients (< 0.001); index discharges on weekends (p = 0.006), from short stay unit (SSU) (p < 0.001) or against health professional advice (p = 0.010); or when the readmission was for a Diagnosis Related Group (p < 0.001). The significant predictors of unplanned readmission ≤1 day were index discharge against advice or from SSU, and 1-5 hospital admissions in the 6 months preceding index admission. In Phase 2, 88.3% readmissions were unpreventable and 11.7% were preventable. The median patient age was 57 years and comorbidities were uncommon (3.1%). Most patients (94.4%) lived at home and with others (78.9%). Friday was the most common day of index discharge (17.3%) and Saturday was the most common day of unplanned readmission (19.1%). The majority (94.4%) of readmissions were via the emergency department: 58.5% were for a like diagnosis and pain was the most common reason for readmission. CONCLUSIONS: Advanced age, significant comorbidities and social isolation did not feature in patients with an unplanned readmission ≤1 day. One quarter of patients were discharged on a Friday or weekend, one quarter of readmissions occurred on a weekend, and pain was the most common reason for readmission raising issues about access to services and weekend discharge planning.

Frequent use of emergency departments by older people: a comparative cohort study of characteristics and outcomes.

OBJECTIVE: To characterise older people who frequently use emergency departments (EDs) and compare patient outcomes with older non-frequent ED attenders. DESIGN: Retrospective comparative cohort study. Logistic regression modelling of patient characteristics and health service usage, comparing older frequent ED attenders (≥4 ED attendances in 12 months) to non-frequent ED attenders. SETTING: Three Australian public hospital EDs, with a total of 143 327 emergency attendances in the 12 months. PARTICIPANTS: People aged ≥65 years attending the ED in financial year 2013/2014. MAIN OUTCOME MEASURES: The primary outcome was frequent ED use; secondary outcomes were ED length of stay, discharge destination from ED, hospital length of stay, re-presentation within 48 h, hospital readmission within 30 days and in-hospital mortality. RESULTS: Five percent of older people were frequent attenders (n = 1046/21 073), accounting for 16.9% (n = 5469/32 282) of all attendances by older people. Frequent ED attenders were more likely to be male, aged 75-84 years, arrive by ambulance and have a diagnosis relating to chronic illness. Frequent attenders stayed 0.4 h longer in ED (P < 0.001), were more likely to be admitted to hospital (69.2% vs 67.2%; P = 0.004), and had a 1 day longer hospital stay (P < 0.001). In-hospital mortality for older frequent ED attenders was double that of non-frequent attenders (7.0% vs 3.2%, P < 0.001) over 12 months. CONCLUSIONS: Older frequent ED attenders had more chronic disease and care needs requiring hospital admission than non-frequent attenders. A new approach to care planning and coordination is recommended, to optimise the patient journey and improve outcomes.

Detection of synchronous primary lung adenocarcinomas with genomic sequencing.

In the setting of synchronous pulmonary carcinomas, distinguishing between a monoclonal process with intrapulmonary metastasis and two independent tumors has significant therapeutic and prognostic implications. We describe two cases in which molecular profiling was used to characterize synchronous, primary pulmonary tumors and guide clinical management. In both cases, the patients underwent surgical resection without adjuvant chemotherapy or radiation and remain free of disease.

Vital signs as predictors for aggression in hospital patients (VAPA).

AIMS AND OBJECTIVES: To examine and describe the relationship between physiological status and violent and aggressive behaviours in hospital patients. BACKGROUND: The majority of adverse events are preceded by physiological abnormalities; whether physiological deterioration is a predictor of violent or aggressive behaviours remains unknown. DESIGN: Prospective case-control study. METHODS: Prospective audit of 999 patients from two major health services in Melbourne, Australia. There were 333 cases who required an emergency response for aggressive or violent behaviour (Code Grey) in the emergency department, medical or surgical units, or inpatient mental health unit between January-June 2015. Two control patients who did not have a Code Grey were randomly selected from the same unit and same day that the Code Grey occurred for the case patient. RESULTS: Patient locations were 54·4% medical or surgical units, 23·7% emergency department and 21·9% mental health units. Code Grey patients had less documentation of physiological assessment and were more likely to have respiratory rate, heart rate and conscious state abnormalities in the 12 hours preceding Code Grey. After adjusting for confounders, the risk of Code Grey was highest for patients with confusion. CONCLUSION: Patients experiencing behavioural disturbance had lower standards of patient assessment, greater incidence of physiological abnormalities and more inpatient deaths. Early recognition of, and response to, patient and physiological predictors of Code Grey should be a strategy to prevent behavioural escalation to the point of Code Grey. RELEVANCE TO CLINICAL PRACTICE: Strategies are needed to improve physiological assessment of patients with behavioural disturbance while ensuring staff safety. There are patient and physiological factors associated with increased risk of Code Grey that may be used to prevent behavioural escalation to the point of an emergency response.

Development, implementation and evaluation of an interprofessional graduate program for nursing-paramedicine double-degree graduates.

Over the past decade, several Australian universities have offered a double degree in nursing and paramedicine. Mainstream employment models that facilitate integrated graduate practice in both nursing and paramedicine are currently lacking. The aim of the present study was to detail the development of the Interprofessional Graduate Program (IPG), the industrial and professional issues that required solutions, outcomes from the first pilot IPG group and future directions. The IPG was an 18-month program during which participants rotated between graduate nursing experience in emergency nursing at Northern Health, Melbourne, Australia and graduate paramedic experience with Ambulance Victoria. The first IPG with 10 participants ran from January 2011 to August 2012. A survey completed by nine of the 10 participants in March 2014 showed that all nine participants nominated Ambulance Victoria as their main employer and five participants were working casual shifts in nursing. Alternative graduate programs that span two health disciplines are feasible but hampered by rigid industrial relations structures and professional ideologies. Despite a 'purpose built' graduate program that spanned two disciplines, traditional organisational structures still hamper double-degree graduates using all of skills to full capacity, and force the selection of one dominant profession.

Nurses' experiences of using falls alarms in subacute care: A qualitative study.

Bed and chair alarms have been included in many multifaceted falls prevention interventions. None of the randomised trials of falls alarms as sole interventions have showed significant effect on falls or falls with injury. Further, use of bed and chair alarms did not change patients' fear of falling, length of hospital stay, functional status, discharge destination or health related quality of life. The aim of this study was to explore nurses' experiences of using bed and chair alarms. A qualitative descriptive study using semi-structured interviews with a purposive sample of 12 nurses was conducted on a 32-bed Geriatric Evaluation and Management ward in Melbourne, Australia. Participants were interviewed between 27 January and 12 March 2021.Transcribed audio-recordings of interviews were analysed using inductive thematic analysis. NVIVO 12.6 was used to manage the study data. Three major themes and four subthemes were constructed from the data: i) negative impacts of falls alarms (subthemes: noisy technology, imperfect technology), ii) juggling the safety-risk conflict, and iii) negotiating falls alarm use (subthemes: nurse decision making and falls alarm overuse). Nurses' experience of using falls alarms was predominantly negative and there was tension between falls alarms having limited impact on patient safety and risks associated with their use. Nurses described a need to support nurse decision making related to falls alarms use in practice and policy, and a desire to be empowered to manage falls risk in other ways.

An evaluation of interventions to improve outcomes for hospitalized patients in isolation: A systematic review.

BACKGROUND: Isolation is effective in preventing transmission of infectious disease. However, it has been shown to have negative effects including increased anxiety and poor physical outcomes. OBJECTIVES: To summarize the effects of interventions to improve safety and outcomes for patients in isolation DESIGN: Systematic review (PROSPERO protocol registration - CRD42020222779). SETTING: Acute hospital PARTICIPANTS: Intervention studies including patients in preventative or protective isolation in a single room. METHODS: MEDLINE, Global Health, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Excerpta Medica database were searched from 1996-October 2020. Two independent reviewers screened references and assessed risk of bias. One reviewer extracted data and was checked by another. Main outcomes were Quality of Life and mortality. RESULTS: We identified 16,698 references and included 6 studies with different study designs. Average age ranged from 4-71 years. Samples sizes were small (range 10-49 participants) apart from one non-randomized controlled trial including >600 participants. Interventions were music therapy (n = 3), psychological counseling (n = 2) and exercise training (n = 1). One study reporting on Quality of Life and found no change after exercise. None of the studies reported on mortality. Due to heterogeneous results no meta-analyses were performed. CONCLUSIONS: There is a lack of high-quality evidence for effective comprehensive interventions to manage adverse effects associated with isolation. Future studies should investigate the effect of multi-component interventions using rigorous methods to improve outcomes for hospitalized isolated patients.

Impact of emergency department length of stay on anxiety and comfort in older people.

INTRODUCTION: Older people are frequent emergency department (ED) users, a vulnerable population and often have long stays in the ED. The aim of this study was to determine whether ED length of stay (LOS) had an impact on older people's (aged ≥65 years) anxiety, comfort and adverse events. METHODS: This prospective observational study was conducted in Melbourne, Australia. Patients (n = 301) from three EDs were classified by ED LOS: ≤4-hours (n = 89), 4-8 h (n = 136) and >8-hours (n = 76). Current state and trait anxiety and comfort were measured in ED. Adverse event data were collected from medical records. LOS groups were compared using Chi-Square and Kruskal-Wallis test. RESULTS: There was no significant difference in Trait Anxiety Scores. Patients with ED LOS ≤ 4-hours had lower median State Anxiety Scores (p = 0.003), were less likely to require ward admission (p < 0.001), and more likely to require short stay unit admission (p < 0.001). There were no significant differences between groups in comfort or adverse events during ED care or hospitalisation (for admitted patients). CONCLUSION: The impact of ED LOS on the anxiety of older ED users appears limited. There was no association identified between ED LOS and comfort during ED care or adverse events during ED care or hospitalisation.

Specific Elements of Team-Based Learning Used in Nursing Education: A Scoping Review.

BACKGROUND: Team-based learning (TBL) is an evidence-based, highly structured teaching strategy. PURPOSE: The purpose of this review was to explore the specific TBL structure and process design elements reported in nursing education studies. METHODS: A scoping review was undertaken according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Databases were searched on February 15, 2021, using search terms related to nursing, education, and TBL. RESULTS: Of 226 potentially relevant citations, 45 studies were included. The specific TBL design elements reported were team size (n = 41), team formation (n = 24), readiness assurance process (n = 45), immediate feedback (n = 42), activity sequencing (n = 42), 4S application design (n = 13), incentive structure(s) (n = 22), and peer evaluation (n = 13). CONCLUSIONS: There was variability in the reporting of TBL design elements. Preclass preparation and individual and team Readiness Assurance Tests were well reported. Application exercise design and approach to peer evaluation were gaps in the included studies.

Dural Convexity Chondroma Mimicking Meningioma in a Young Female.

Intracranial meningeal convexity chondroma is a rare benign lesion hypothesized to stem from remnant chondrocyte precursors of embryonic origin. This lesion often masquerades as meningioma given the similar dural-based attachment and pattern of calcification. We describe the case of a 26-year-old female with incidentally discovered convexity meningeal chondroma, originally presumed to be a meningioma. In this case, we share our diagnostic and operative intervention and outcome and discuss the unique pathologic findings in this lesion that differentiate it from similar appearing lesions. To the authors' knowledge, there are fewer than 20 cases of convexity meningeal chondroma in the literature; thus, we also provide a brief review of the literature regarding this rare pathology.

Understanding the patient experience of early unplanned hospital readmission following acute care discharge: a qualitative descriptive study.

OBJECTIVES: To understand from a patient and carer perspective: (1) what features of the discharge process could be improved to avoid early unplanned hospital readmission (within 72 hours of acute care discharge) and (2) what elements of discharge planning could have enhanced the discharge experience. DESIGN: A qualitative descriptive design was used. Study data were collected using semi-structured interviews that were transcribed verbatim and analysed using inductive thematic analysis. Data related to participant characteristic were collected by medical record audit and summarised using descriptive statistics. SETTING: Three acute care hospitals from one health service in Australia. PARTICIPANTS: Patients who had an early unplanned hospital readmission and/or their carers, if present during the interviews and willing to participate, with patient permission. FINDINGS: Thirty interviews were conducted (23 patients only; 6 patient and carer dyads; 1 carer only). Five themes were constructed: 'experiences of care', 'hearing and being heard', 'what's wrong with me', 'not just about me' and 'all about going home'. There was considerable variability in patients' and carers' experiences of hospital care, discharge processes and early unplanned hospital readmission. Features of the discharge process that could be improved to potentially avoid early unplanned hospital readmission were better communication, optimal clinical care including ensuring readiness for discharge and shared decision-making regarding discharge timing and goals on returning home. The discharge experience could have been enhanced by improved communication between patients (and carers) and the healthcare team, not rushing the discharge process and a more coordinated approach to patient transport home from hospital. CONCLUSIONS: The study findings highlight the complexities of the discharge process and the importance of effective communication, shared decision-making and carer engagement in optimising hospital discharge and reducing early unplanned hospital readmissions.

Neurocysticercosis Presenting as an Isolated Suprasellar Lesion.

BACKGROUND: Although extraparenchymal neurocysticercosis (NCC) is well established, presentation in the suprasellar space is rare. When presenting in the suprasellar space, the imaging characteristics may mimic more common lesions including craniopharyngioma and Rathke cleft cyst depending on the life cycle of the parasite. Although antiparasitic medical therapy may be effective for viable NCC, it is not routinely employed for calcified NCC. CASE DESCRIPTION: This report presents a 39-year-old male patient who presented with profound visual decline secondary to a partially calcified suprasellar NCC. Suprasellar NCC was presumed based on specific radiologic findings, which are discussed. Medical therapy was not offered because of the proximity to the optic chiasm and the partial calcification of the lesion leading to the presumption that the mass was nonviable. The patient underwent successful endoscopic endonasal resection of the suprasellar NCC and experienced significant improvement in vision. Despite the calcification, pathological evaluation revealed that a portion remained viable. CONCLUSIONS: Regardless of the life cycle stage, endonasal resection offers a minimally invasive approach for suprasellar NCC; treatment can be tailored to the patient's presentation and stage of infection.

Case study: obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a major health problem that often goes undiagnosed. A case study is utilized to illustrate recognition, diagnosis, and treatment of individuals with OSA. Prevalence, risk factors, and health and safety issues also are discussed.

Influences on emergency department length of stay for older people.

OBJECTIVE: The aim of this study was to examine the influences on emergency department (ED) length of stay (LOS) for older people and develop a predictive model for an ED LOS more than 4 h. METHODS: This retrospective cohort study used organizational data linkage at the patient level from a major Australian health service. The study population was aged 65 years or older, attending an ED during the 2013/2014 financial year. We developed and internally validated a clinical prediction rule. Discriminatory performance of the model was evaluated by receiver operating characteristic (ROC) curve analysis. An integer-based risk score was developed using multivariate logistic regression. The risk score was evaluated using ROC analysis. RESULTS: There were 33 926 ED attendances: 57.5% (n=19 517) had an ED LOS more than 4 h. The area under ROC for age, usual accommodation, triage category, arrival by ambulance, arrival overnight, imaging, laboratory investigations, overcrowding, time to be seen by doctor, ED visits with admission and access block relating to ED LOS more than 4 h was 0.796, indicating good performance. In the validation set, area under ROC was 0.80, P-value was 0.36 and prediction mean square error was 0.18, indicating good calibration. The risk score value attributed to each risk factor ranged from 2 to 68 points. The clinical prediction rule stratified patients into five levels of risk on the basis of the total risk score. CONCLUSION: Objective identification of older people at intermediate and high risk of an ED LOS more than 4 h early in ED care enables targeted approaches to streamline the patient journey, decrease ED LOS and optimize emergency care for older people.