Methodological approaches to measuring the incidence of unplanned emergency department presentations by cancer patients receiving systemic anti-cancer therapy: a systematic review.

BACKGROUND: The need to mitigate the volume of unplanned emergency department (ED) presentations is a priority for health systems globally. Current evidence on the incidence and risk factors associated with unplanned ED presentations is unclear because of substantial heterogeneity in methods reporting on this issue. The aim of this review was to examine the methodological approaches to measure the incidence of unplanned ED presentations by patients receiving systemic anti-cancer therapy in order to determine the strength of evidence and to inform future research. METHODS: An electronic search of Medline, Embase, CINAHL, and Cochrane was undertaken. Papers published in English language between 2000 and 2019, and papers that included patients receiving systemic anti-cancer therapy as the denominator during the study period were included. Studies were eligible if they were analytical observational studies. Data relating to the methods used to measure the incidence of ED presentations by patients receiving systemic anti-cancer therapy were extracted and assessed for methodological rigor. Findings are reported in accordance with the Synthesis Without Meta-Analysis (SWiM) guideline. RESULTS: Twenty-one articles met the inclusion criteria: 20 cohort studies, and one cross-sectional study. Overall risk of bias was moderate. There was substantial methodological and clinical heterogeneity in the papers included. Methodological rigor varied based on the description of methods such as the period of observation, loss to follow-up, reason for ED presentation and statistical methods to control for time varying events and potential confounders. CONCLUSIONS: There is considerable diversity in the population and methods used in studies that measure the incidence of unplanned ED presentations by patients receiving systemic anti-cancer therapy. Recommendations to support the development of robust evidence include enrolling participants at diagnosis or initiation of treatment, providing adequate description of regular care to support patients who experience toxicities, reporting reasons for and characteristics of participants who are lost to follow-up throughout the study period, clearly defining the outcome including the observation and follow-up period, and reporting crude numbers of ED presentations and the number of at-risk days to account for variation in the length of treatment protocols.

Clinical effectiveness of a silicone foam dressing for the prevention of heel pressure ulcers in critically ill patients: Border II Trial.

OBJECTIVE: Critically ill patients are at high risk of developing pressure ulcers (PU), with the sacrum and heels being highly susceptible to pressure injuries. The objective of our study was to evaluate the clinical effectiveness of a new multi-layer, self-adhesive soft silicone foam heel dressing to prevent PU development in trauma and critically ill patients in the intensive care unit (ICU). METHOD: A cohort of critically ill patients were enrolled at the Royal Melbourne Hospital. Each patient had the multi-layer soft silicone foam dressing applied to each heel on admission to the emergency department. The dressings were retained with a tubular bandage for the duration of the patients' stay in the ICU. The skin under the dressings was examined daily and the dressings were replaced every three days. The comparator for our cohort study was the control group from the recently completed Border Trial. RESULTS: Of the 191 patients in the initial cohort, excluding deaths, loss to follow-up and transfers to another ward, 150 patients were included in the final analysis. There was no difference in key demographic or physiological variables between the cohorts, apart from a longer ICU length of stay for our current cohort. No PUs developed in any of our intervention cohort patients compared with 14 patients in the control cohort (n=152; p<0.001) who developed a total of 19 heel PUs. CONCLUSION: We conclude, based on our results, that the multi-layer soft silicone foam dressing under investigation was clinically effective in reducing ICU-acquired heel PUs. The findings also support previous research on the clinical effectiveness of multi-layer soft silicone foam dressings for PU prevention in the ICU.

Mental health-related risk factors for violence: using the evidence to guide mental health triage decision making.

Mental health clinicians working in emergency crisis assessment teams or mental health triage roles are required to make rapid and accurate risk assessments. The assessment of violence risk at triage is particularly pertinent to the early identification and prevention of patient violence, and to enhancing the safety of clinical staff and the general public. To date, the evidence base for mental health triage violence risk assessment has been minimal. This study aimed to address this evidence gap by identifying best available evidence for mental health-related risk factors for patient-initiated violence. We conducted a systematic review based on the National Health and Medical Research Council of Australia's methodology for systematic reviews. A total of 6847 studies were retrieved, of which 326 studies met the study inclusion criteria. Of these studies, 277 met inclusion criteria but failed the quality appraisal process, thus a total of 49 studies were included in the final review. The risk factors that achieved the highest evidence grading were predominantly related to dynamic clinical factors immediately observable in the patient's general appearance, behaviour and speech. These factors included hostility/anger, agitation, thought disturbance, positive symptoms of schizophrenia, suspiciousness and irritability.

Perceived differences in the management of mental health patients in remote and rural australia and strategies for improvement: findings from a national qualitative study of emergency clinicians.

Introduction. We aimed to describe perceptions of Australian emergency clinicians of differences in management of mental health patients in rural and remote Australia compared with metropolitan hospitals, and what could be improved. Methods. Descriptive exploratory study using semi-structured telephone interviews of doctors and nurses in Australian emergency departments (EDs), stratified to represent states and territories and rural or metropolitan location. Content analysis of responses developed themes and sub-themes. Results. Of 39 doctors and 32 nurses responding to email invitation, 20 doctors and 16 nurses were interviewed. Major themes were resources/environment, staff and patient issues. Clinicians noted lack of access in rural areas to psychiatric support services, especially alcohol and drug services, limited referral options, and a lack of knowledge, understanding and acceptance of mental health issues. The clinicians suggested resource, education and guideline improvements, wanting better access to mental health experts in rural areas, better support networks and visiting specialist coverage, and educational courses tailored to the needs of rural clinicians. Conclusion. Clinicians managing mental health patients in rural and remote Australian EDs lack resources, support services and referral capacity, and access to appropriate education and training. Improvements would better enable access to support and referral services, and educational opportunities.

A survey of psychiatrists' and registered nurses' levels of mental health literacy in a Chinese general hospital.

BACKGROUND: Mental health literacy (MHL) is the term used to describe people's knowledge and beliefs about mental disorders which aid in the recognition, management or the prevention of illness. Health professionals' levels of MHL will shape the therapeutic relationship in which they work in partnership with patients. Studies have been conducted in Australia and Singapore to determine levels of MHL among members of the general public and health professionals. To date, no such studies have been published in Chinese populations. AIM: The study aims to compare levels of MHL between registered nurses and psychiatrists in a Chinese general hospital. The paper reports participants' diagnosis and beliefs about interventions used to manage depression and schizophrenia. METHODS: A descriptive cross-sectional survey was undertaken among a group of psychiatrists and registered nurses in the psychiatric department of one large teaching hospital in China (n=70). Participants completed the survey by rating written vignettes related to depression and schizophrenia. RESULTS: The psychiatrists were highly accurate in correctly diagnosing both depression and schizophrenia; the registered nurses were less so for diagnosing depression. In terms of treatment options, the two groups reached a broad agreement on beliefs about the use of mental health interventions, but differed significantly in the use of some specific mental health interventions. CONCLUSIONS: This study provides preliminary information about levels of MHL among Chinese mental health professionals and describes their attitudes towards the helpfulness of interventions used to restore mental health and well-being. Future large-scale studies are required to identify factors that influence beliefs about the use of mental health interventions. The findings have implications for further education of registered nurses in the specialization of mental health nursing in China.

Homelessness: patterns of emergency department use and risk factors for re-presentation.

OBJECTIVES: To describe patterns of service use and to predict risk factors for re-presentation to a metropolitan emergency department (ED) among people who are homeless. METHODS: A retrospective cohort analysis was undertaken over a 24-month period from a principal referral hospital in Melbourne, Australia. All ED visits relating to people classified as homeless were included. A predictive model for risk of re-presentation was developed using logistic regression with random effects. Rates of re-presentation, defined as the total number of visits to the same ED within 28 days of discharge, were measured. RESULTS: The study period was 1 January 2003 to 31 December 2004. The re-presentation rate for homeless people was 47.8% (3199/6689) of ED visits and 45.5% (725/1595) of the patients. The final predictive model included risk factors, which incorporated both hospital and community service use. Those characteristics that resulted in significantly increased odds of re-presentation were leaving hospital at own risk (OR 1.31; 95% CI 1.10 to 1.56), treatment in another hospital (OR 1.45, 95% CI 1.23 to 1.72) and being in receipt of community-based case management (OR 1.31, 95% CI 1.11 to 1.54) or pension (OR 1.34, 95% CI 1.12 to 1.62). CONCLUSIONS: The predictive model identified nine risk factors of re-presentation to the ED for people who are homeless. Early identification of these factors among homeless people may alert clinicians to the complexity of issues influencing an individual ED visit. This information can be used at admission and discharge by ensuring that homeless people have access to services commensurate with their health needs. Improved linkage between community and hospital services must be underscored by the capacity to provide safe and secure housing.

Non-invasive mechanical ventilation in Australian emergency departments: a prospective observational cohort study.

OBJECTIVES: Data describing use of non-invasive ventilation (NIV) in the emergency department (ED) setting consist primarily of physician surveys. Our objective was to conduct a prospective study to document the characteristics of patients receiving NIV, interfaces, mode, and parameters used as well as NIV duration and decision-making responsibility. METHODS: We conducted a 2-month prospective observational study of adult patients who received NIV in 24 EDs. Patient characteristics, delivery methods, and decision-making responsibility were documented for each ED presentation. RESULTS: Data were recorded on 245 patients; 185 patients received non-invasive positive pressure ventilation (NIPPV) and 60 received continuous positive airway pressure (CPAP). Acute cardiogenic pulmonary oedema (ACPO) (80/245, 33%) and exacerbation of chronic obstructive pulmonary disease (COPD) (75/245, 31%) were the two most frequent indications for NIV. Compared to patients with respiratory failure from other aetiologies, those with ACPO were more likely to receive CPAP (28/80 [35%] versus 32/165 [19%] P=0.008). Initial NIV settings were selected by ED nurses for 118/245 (48%) patients, by ED physicians for 118/245 (48%) patients, and by ICU staff for 3/245 (1.5%) patients (not reported for 6 [2.5%] patients). The role of ED nurses in the selection of initial NIV settings was not influenced by ED location, patient type or triage category. CONCLUSIONS: Acute exacerbations of CPO and COPD were the most common indications for NIV. Clinicians demonstrated a preference for NIPPV for all patient aetiologies except ACPO. Responsibility for NIV management was shared by ED nurses and physicians.

Influence of task properties and subjectivity on consistency of triage: a simulation study.

AIM: This paper reports a study to determine nurses' levels of agreement using a standard 5-point triage scale and to explore the influence of task properties and subjectivity on decision-making consistency. BACKGROUND: Triage scales are used to define time-to-treatment in hospital emergency departments. Studies of the inter-rater reliability of these scales using paper-based simulation methods report varying levels of consistency. Understanding how various components of the decision task and individual perceptions of the case influence agreement is critical to the development of strategies to improve consistency of triage. METHOD: Simulations were constructed from naturalistic observation, cue types and frequencies were classified. Data collection was conducted in 2002, and the final response rate was 41 x 3%. Participants were asked to allocate an urgency code for 12 scenarios using the Australasian Triage Scale, and provide estimates of case complexity, levels of certainty and available information. Data were analysed descriptively, agreement between raters was calculated using kappa. The influence of task properties and participants' subjective estimates of case complexity, levels of certainty and available information on agreement were explored using a general linear model. FINDINGS: Agreement among raters varied from moderate to poor (kappa=0 x 18-0 x 64). Participants' subjective estimates of levels of available information were found to influence consistency of triage by statistically significant amounts (F 5 x 68;

Nursing skill mix and outcomes: a Singapore perspective.

AIM: To summarize key evidence on nursing skill mix in acute care hospitals and their limitations; and identify the gaps in current literature vis-à-vis Singapore's nursing workforce. BACKGROUND: Nursing skill mix has been theorized to be a factor influencing patient, nurse and organizational outcomes. While there is a growing body of literature explicating associations between nursing skill mix and positive outcomes, the evidence does not as yet provide firm directions in determining the best configuration. In addition, differences in nursing workforce characteristics also make it difficult to apply findings from one healthcare setting to another. CONCLUSIONS: In reviewing key evidence from the United States of America and Canada, this paper highlights three critical gaps in the nursing skill mix literature when examined in the context of Singapore's nursing workforce. Issues related to the interface between local and foreign nurses, the impact of speciality education, and the possible effects that work roles and distribution may have on quality of care need to be further examined. This knowledge should provide a robust evidence base with which to inform national policy on skill mix and maximize nursing resources in order to achieve optimal outcomes.

5-20: a model of minimum nurse-to-patient ratios in Victoria, Australia.

AIM: This study presents a critique of a new model of minimum nurse-to-patient ratio and considers its utility alongside established Patient Dependency Systems. BACKGROUND: Since 2001 legislation mandating minimum nurse-to-patient ratios has been enacted throughout large public hospitals in the state of Victoria, Australia. The Victorian model mandates minimum staffing of five nurses to 20 patients in acute medical and surgical wards. In conjunction with this approach, Patient Dependency Systems are employed to anticipate short-term resource needs. KEY ISSUES: Although this legislation has been successful in attracting nurses back into the public sector workforce, no published empirical evidence exists to support specific ratios. In addition, neither ratio nor Patient Dependency Systems approaches account for the critical influence of skill mix on hospital, employee, or patient outcomes. CONCLUSION: There is an urgent need for further research that specifically examines relationships between models of staffing, skill mix and quality outcomes.

Triage nurses' clinical decision making. An observational study of urgency assessment.

BACKGROUND: Researchers have described both the various decision tasks performed by triage nurses using self-report methods and identified time as a factor influencing the quality of triage decisions. However, little is known about the decision tasks performed by triage nurses when making acuity assessments, or the factors influencing triage duration in the real world. AIMS: The aims of this study were to: describe the data triage nurses collect from patients in order to allocate a triage priority using the Australasian Triage Scale (ATS); describe the duration of nurses' decision making for ATS categories 2-5; and to explore the impact of patient and nurse variables on the duration of the triage nurses' decision making in the clinical setting. DESIGN: A structured observational study was employed to address the research aims. Observational data was collected in one adult emergency department located in metropolitan Melbourne, Australia. A total of 26 triage nurses consented and were observed performing 404 occasions of triage. Data was collected by a single observer using a 20-item instrument that recorded the performance frequencies of a range of decision tasks and a number of observable patient, nurse and environmental variables. Additionally, the nurse-patient interaction was recorded as time in minutes. RESULTS: It was found that there was limited use of objective physiological data collected by the nurses' in order to decide patient acuity, and large variability in the duration of triage decisions observed. In addition, analysis of variance indicated strong evidence of a true difference between triage duration and a range of nurse, patient and environmental variables. CONCLUSION: These findings have implications for the development of practice standards and triage education. In particular, it is argued that practice standards should include routine measurement of physiological parameters in all but the collapsed or obviously unwell patient, where further delay may impede the delivery of time-critical intervention. Furthermore, the inclusion of arbitrary time frames for triage assessment in practice standards are not an appropriate method of evaluating triage decision making in the real world.

Australian triage nurses' decision-making and scope of practice.

A survey of 172 Australian triage nurses was undertaken to describe their scope of practice, educational background and to explore the self-reported influences perceived to impact on their decision-making. The survey results reveal variability in the educational requirements for nurses to triage. Indeed, over half of the nurses who participated in the study worked in emergency departments that provided no specified unit-based triage education. Additionally, substantial inter-respondent variations in nurses' self-reported participation in a range of decisions to expedite emergency care were identified. Analysis revealed significant associations between demographic characteristics of the triage service, levels of nurse' autonomy and the nurses' self-reported participation in a number of triage decisions. The findings of this study have implications for emergency nurse education and the development and evaluation of triage practice guidelines.

Why we do the things we do: applying clinical decision-making frameworks to triage practice.

This paper discusses major themes presented in the published literature concerning clinical decision making and links these to the practice of emergency department nurse triage. Themes discussed include: approaches to decision research in nursing and medicine; decision autonomy in nursing practice and clinical decision making under conditions of uncertainty. Some assumptions underpinning clinical decision-making frameworks are explored and the use of triage scales, algorithms and intuitive thought processes are discussed in terms of clinical practice. In addition, the strengths and limitations of each approach are outlined. It is argued that naturalistic research methods are necessary in order to describe the often uncertain and frequently chaotic environment in which triage decisions are made. This research must occur in order to evaluate and improve both the triage process and the outcomes of these decisions in practice.