Designing a standardised emergency nurse career pathway for use across rural, regional and metropolitan New South Wales, Australia: A consensus process.

BACKGROUND: Emergency nurses are the first clinicians to see patients in the ED; their practice is fundamental to patient safety. To reduce clinical variation and increase the safety and quality of emergency nursing care, we developed a standardised consensus-based emergency nurse career pathway for use across Australian rural, regional, and metropolitan New South Wales (NSW) emergency departments. METHODS: An analysis of career pathways from six health services, the College for Emergency Nursing Australasia, and NSW Ministry of Health was conducted. Using a consensus process, a 15-member expert panel developed the pathway and determined the education needs for pathway progression over six face-to-face meetings from May to August 2023. RESULTS: An eight-step pathway outlining nurse progression through models of care related to different ED clinical areas with a minimum 172 h protected face-to-face and 8 h online education is required to progress from novice to expert. Progression corresponds with increasing levels of complexity, decision making and clinical skills, aligned with Benner's novice to expert theory. CONCLUSION: A standardised career pathway with minimum 180 h would enable a consistent approach to emergency nursing training and enable nurses to work to their full scope of practice. This will facilitate transferability of emergency nursing skills across jurisdictions.

Applying Sydney Triage to Admission Risk Tool (START) to improve patient flow in emergency departments: a multicentre randomised, implementation study.

BACKGROUND: To determine the effectiveness of applying the Sydney Triage to Admission Risk Tool (START) in conjunction with senior early assessment in different Emergency Departments (EDs). METHODS: This multicentre implementation study, conducted in two metropolitan EDs, used a convenience sample of ED patients. Patients who were admitted, after presenting to both EDs, and were assessed using the existing senior ED clinician assessment, were included in the study. Patients in the intervention group were assessed with the assistance of START, while patients in the control group were assessed without the assistance of START. Outcomes measured were ED length of stay and proportion of patients correctly identified as an in-patient admission by START. RESULTS: A total of 773 patients were evaluated using the START tool at triage across both sites (Intervention group n = 355 and control group n = 418 patients). The proportion of patients meeting the 4-hour length of stay thresholds was similar between the intervention and control groups (30.1% vs. 28.2%; p = 0.62). The intervention group was associated with a reduced ED length of stay when compared to the control group (351 min, interquartile range (IQR) 221.0-565.0 min versus 383 min, IQR 229.25-580.0 min; p = 0.85). When stratified into admitted and discharged patients, similar results were seen. CONCLUSION: In this extension of the START model of care implementation study in two metropolitan EDs, START, when used in conjunction with senior early assessment was associated with some reduced ED length of stay.

Clinical characteristics and predictors for hospitalisation during the initial phases of the Delta variant COVID-19 outbreak in Sydney, Australia.

OBJECTIVES: The COVID-19 Delta variant of concern continues to pose significant challenges to health systems globally, with increased transmissibility and different patient populations affected. In Sydney, a virtual model of care was implemented in response to the COVID-19 pandemic and Special Health Accommodation (SHA) was made available for community patients with COVID-19 who could not isolate at home or needed health support. METHODS: This retrospective observational cohort study of all patients with COVID-19 Delta variant in SHA during the initial phases of the Delta variant outbreak in Sydney describes the demographic and clinical characteristics of patients with Delta variant COVID-19 and determines predictors of need for in-patient hospital admission. RESULTS: Data from 794 patients were analysed. One hundred and fifty-seven patients (19.8%) were transferred to ED. Of those, 125 were admitted to an in-patient unit (admission rate from ED 79.6%), and of these 30 (24%) went to ICU and seven were intubated. Two patients died within the follow-up period. Age >40 years, obesity, and presence of fever (temperature >37.5°C), hypoxia (oxygen saturation <95%), tachycardia or gastrointestinal symptoms on initial assessment in SHA were independent predictors of in-patient admission with an AUROC of 0.78 (95% confidence interval 0.73, 0.82). CONCLUSIONS: Initial symptoms and vital signs were just as predictive for short-term deterioration as age and pre-existing comorbidities and should be included in future risk prediction models for COVID-19. Based on this, we derive a proposed risk prediction score that incorporates these predictors with further validation required.

Does volume or occupancy influence emergency access block? A multivariate time series analysis from a single emergency department in Sydney, Australia during the COVID-19 pandemic.

OBJECTIVE: The study aims to determine whether ED presentation volume or hospital occupancy had a greater impact on ED performance before and during the COVID-19 health response at a tertiary referral hospital in Sydney, Australia. METHODS: Single centre time series analysis using routinely collected hospital and ED data from January 2019 to September 2020. The primary outcome was ED access block measured by emergency treatment performance (ETP; i.e. percentage of patients who were discharged or transferred to a ward from ED within 4 h of ED arrival time). Secondary outcomes were hospital occupancy, elective theatre cases and ambulance ramping. Multivariate time series analysis was performed using vector autoregression, to model effects of changes in various endogenous and correlated variables on ETP. RESULTS: There was an increase in ETP, drop in ED presentations and decrease in hospital occupancy between April and June 2020. Elective surgery and hospital occupancy had significant effects up to 2 days prior on ETP, while there were no significant effects of either ED or ambulance presentations on ETP. Hospital occupancy itself increased with ED presentations after 2-4 days and decreased with elective surgery after 1 day. Shocks (a one standard deviation increase) in hospital occupancy had a peak impact nearly two times greater compared to ED presentations (-1.43, 95% confidence interval -1.92, -0.93 vs -0.73, 95% confidence interval -1.21, -0.25). CONCLUSION: The main determinants of the reduction of ED overcrowding and access block during the pandemic were associated with reductions in hospital occupancy and elective surgery levels, and more research is required to assess more complex associations beyond the scope of this manuscript.

Evaluating an emergency department-based mental health liaison nurse service: A multi-site translational research project.

OBJECTIVE: We aimed to translate and evaluate a model of mental health liaison nursing (MHLN) care that was embedded within EDs. METHODS: The 12 month mixed-methods translational research study incorporated descriptive data on ED presentations, waiting times for MHLN intervention, time spent in ED and discharge arrangements across three EDs in New South Wales. The study involved an inner-city ED (where the model was first established) and two rural sites. Surveys were conducted on a subset of ED patients (n = 58), and emergency and psychiatry staff (n = 52). RESULTS: Triage category 3 presentations accounted for 49% of the MHLN team workload. Response times and ED length of stay varied between city and rural sites, with rural sites demonstrating prompt response times and reduced ED length of stay. The model was strongly endorsed by patients and staff, with 95% of staff and 85% of patients across the three sites recommending the model be implemented in other emergency settings. The need for adequate resources to maintain designated levels of staffing and sustain this model of care was highlighted. CONCLUSION: Findings from the present study indicate that a model of ED-based MHLN care developed in a metropolitan setting was successfully translated to two rural sites. However, the model needs to adhere to certain key principles, and be adequately resourced in order to be sustainable and improve outcomes for ED patients and access to community care.

Incidence and outcomes of aortic dissection for emergency departments in New South Wales, Australia 2017-2018: A data linkage study.

OBJECTIVE: The aims of the present study were to describe the age-specific incidence and 30-day mortality of aortic dissection patients presenting to the EDs in New South Wales (NSW). METHODS: This was a data linkage study involving emergency, inpatient and death registry administrative data from NSW. RESULTS: The present study found 273 instances of aortic dissection in NSW from July 2017 to July 2018. Calculated incidence was 3.47 per 100 000. Incidence increased exponentially with age. The 30-day mortality rate among this cohort was 35.53% (n = 97). Mortality was significantly associated with age and pre-existing comorbidity burden, but was not associated with gender, level of hospital or time of presentation. CONCLUSIONS: The present study found the incidence of aortic dissection within the NSW population to be 3.4 per 100 000. The incidence of aortic dissection in our population increased from 8.6 per 100 000 for people aged between 60 and 80 years to 32 per 100 000 for those aged over 80 years.

Predictors and in-hospital mortality associated with prolonged emergency department length of stay in New South Wales tertiary hospitals from 2017 to 2018.

OBJECTIVE: To determine specific patient, clinical and service factors associated with increased ED length of stay and investigate whether prolonged ED length of stay, as measured by emergency treatment performance (ETP) non-compliance, is an independent predictor of all cause 30-day mortality for patients presenting to, and admitted from ED. METHODS: This was a retrospective analysis of linked state-wide emergency, inpatient and death data from New South Wales. All patients who presented to a tertiary level public hospital (level 5 or 6) ED and admitted to an in-patient unit were included. Outcomes were the proportion of admitted patients who met ETP targets, and 30-day all-cause mortality. RESULTS: A total of 697 600 eligible cases were identified and analysed. The odds of meeting ETP benchmarks were 62% lower in those with complex or multiple medical comorbidities (odds ratio 0.38, 95% confidence interval 0.37-0.40, P < 0.001) compared with patients with no medical comorbidities. Admission under psychiatry, surgical and oncology service-related groups were associated with decreased ETP. The hazard ratio for 30-day all-cause mortality over time was 28% higher in those not meeting ETP benchmarks after adjusting for age, triage category, comorbidities, ICU and service-related group (hazard ratio 1.28, 95% confidence interval 1.26-1.30, P < 0.001). CONCLUSION: Patients with complex and multiple medical comorbidities, and those admitted under certain service-related groups such as psychiatry, surgery and oncology were found to have poorer ETP performance. Overall, failure to meet ETP was associated with increased mortality after adjusting for age, case-mix, comorbidities and acuity.

The Sydney triage to admission risk tool (START) to improve patient flow in an emergency department: a model of care implementation pilot study.

BACKGROUND: The Sydney Triage to Admission Risk Tool (START) is a validated clinical analytics tool designed to estimate the probability of in-patient admission based on Emergency Department triage characteristics. METHODS: This was a single centre pilot implementation study using a matched case control sample of patients assessed at ED triage. Patients in the intervention group were identified at triage by the START tool as likely requiring in-patient admission and briefly assessed by an ED Consultant. Bed management were notified of these patients and their likely admitting team based on senior early assessment. Matched controls were identified on the same day of presentation if they were admitted to the same in-patient teams as patients in the intervention group and same START score category. Outcomes were ED length of stay and proportion of patients correctly classified as an in-patient admission by the START tool. RESULTS: One hundred and thirteen patients were assessed using the START-based model of care. When compared with matched control patients, this intervention model of care was associated with a significant reduction in ED length of stay [301 min (IQR 225-397) versus 423 min (IQR 297-587) p < 0.001] and proportion of patients meeting 4 h length of stay thresholds increased from 24 to 45% (p < 0.001). CONCLUSION: In this small pilot implementation study, the START tool, when used in conjunction with senior early assessment was associated with a reduction in ED length of stay. Further controlled studies are now underway to further examine its utility across other ED settings.

Diagnoses, damned diagnoses and statistics: Dealing with disparate diagnostic coding systems within the New South Wales Emergency Department Data Collection.

OBJECTIVES: The aims of the present study were to describe the distribution of Systematised Nomenclature of Medicine - Clinical Terms (SNOMED-CT) codes used in the current New South Wales Emergency Department Data Collection (NSW EDDC) and classify duplicate and redundant terms into clinically meaningful sub-groups for future analyses. METHODS: This was an analysis of ED diagnosis codes using a large state-wide administrative ED dataset between 2015 and 2018. RESULTS: A total of 7.4 million (77%) of ED episode diagnoses were coded with SNOMED-CT. Of those coded with SNOMED-CT, 12 152 unique codes were identified. Around 1000 of the most frequently used codes accounted for 90% of the presentations coded with SNOMED-CT and 5000 codes accounted for 99.8% of these. Around 7000 codes were deemed to be redundant, and duplication in terms exists across all sub-groups. CONCLUSION: The use of SNOMED-CT in the NSW EDDC has resulted in substantial use of non-specific, duplicate and redundant codes, limiting the capacity of the NSW EDDC to be used for effective data analysis.

Triage, damned triage and statistics: Sorting out redundancy and duplication within an Emergency Department Presenting Problem Code Set to enhance research capacity.

BACKGROUND: Having a robust Emergency Department Presenting Problem Code Set (EDPPCS) is important for collecting and analysing data around Emergency Department (ED) activity, funding, bio-surveillance and research. This paper analyses the clinical utilisation of the current EDPPCS using two years worth of ED data collected as part of the larger state-wide Demand for Emergency Services Trends in Years 2010-2014 (DESTINY) project. This project proposes potential improvements in the current EDPPCS including a reduction in duplication and redundant clinical terms. METHODS: ED presenting problem fields were abstracted from the Emergency Department Data Collection (EDCC) Registry as entered by trained triage nurses. Frequencies of presenting problems were calculated and cross referenced with the EDPPCS. These were then categorised into clinically meaningful groups. RESULTS: There were 1,746,635million eligible ED presentations during January 2013 and December 2014 to 23 level 5 or 6 EDs. Of these, there were 64,849 unique presenting problem entries with 450 terms being used more than 100 times during the study period. Of those 450 terms, only 177 (39.3%) matched the current EDPPCS. CONCLUSION: Future iterations of the EDPPCS should be based on the evidence presented making it shorter, more comprehensive and systematic leading to improved triage performance, usefulness in research and bio-surveillance.

Feeling the HEAT: Using Hourly Emergency Activity Tracking to demonstrate a novel method of describing activity and patient flow.

OBJECTIVE: The objective of the present study is to demonstrate a novel method of mapping ED activity to analyse patterns presentations, occupancy and performance trends. METHODS: This was a retrospective, descriptive analysis of de-identified and linked ED presentations across NSW, Australia, over five calendar years, 2010-2014. It was undertaken as part of the Demand for Emergency Services Trend in Years 2010-2014 (DESTINY) study. The DESTINY project analysed 10.8 million presentations during 2010-2014. Hourly Emergency Activity Tracking (HEAT) maps were generated to visually represent and analyse the number of emergency arrivals to ED occupancy and proportion of patients leaving the ED within 4 h per hour of day across consecutive months of the year. RESULTS: HEAT maps provided a means of visually representing ED activity to demonstrate hour-to-hour trends in presentations, occupancy and performance between 2010 and 2014. This analysis has shown that the most marked increase in presentations per hour has occurred during the 10.00-14.00 hour period, associated with an improvement in ED performance during the same period. CONCLUSION: HEAT maps may be used to facilitate further analyses of ED demand, patterns of patient presentations and patient flow and future health system redesign.

Major trauma mortality in rural and metropolitan NSW, 2009-2014: a retrospective analysis of trauma registry data.

OBJECTIVE: To determine trends in crude and risk-adjusted mortality for major trauma patients injured in rural or metropolitan New South Wales, 2009-2014. DESIGN: A retrospective analysis of NSW statewide trauma registry data. PARTICIPANTS: Adult patients (aged 16 years or more) who presented with major trauma (Injury Severity Scores greater than 15) to a NSW hospital during 2009-2014. MAIN OUTCOME MEASURES: The main covariate of interest was geographic location of injury (metropolitan v rural/regional areas). Inpatient mortality was analysed by multivariable logistic regression. RESULTS: Data for 11 423 eligible patients were analysed. Inpatient mortality for those injured in metropolitan locations was 14.7% in 2009 and 16.1% in 2014 (P = 0.45). In rural locations, there was a statistically significant decline in in-hospital mortality over the study period, from 12.1% in 2009 to 8.7% in 2014 (P = 0.004). Risk-adjusted mortality for those injured in a rural location was lower in 2013 than during 2009, but remained stable for those injured in metropolitan locations. CONCLUSION: Crude and risk-adjusted mortality after major trauma have remained stable in those injured in metropolitan areas of NSW between 2009 and 2014. The apparent downward trend in mortality associated with severe trauma in rural/regional locations requires further analysis.

Demand for Emergency Services Trends in New South Wales Years 2010-2014 (DESTINY): Age and Clinical Factors Associated with Ambulance Transportation to Emergency Departments.

OBJECTIVES: The study aimed to analyze ambulance transportations to Emergency Departments (EDs) in New South Wales (NSW) and to identify temporal changes in demographics, acuity, and clinical diagnoses. METHODS: This was a retrospective analysis of a population based registry of ED presentations in New South Wales. The NSW Emergency Department data collection (EDCC) collects patient level data on presentations to designated EDs across NSW. Patients that presented to EDs by ambulance between January 2010 and December 2014 were included. Patients dead on arrival, transferred from another hospital, or planned ED presentations were excluded. RESULTS: A total of 10.8 million ED attendances were identified of which 2.6 million (23%) were transported to ED by ambulance. The crude rate of ambulance transportations to EDs across all ages increased by 3.0% per annum over the five years with the highest rate observed in those 85 years and over (620.5 presentations per 1,000 population). There was an increase in the proportion of category 1 and 2 (life-threatening or potentially life-threatening) cases from 18.1% to 24.0%. CONCLUSION: Demand for ambulance services appears to be driven by older patients presenting with higher acuity problems. Alternative models of acute care for elderly patients need to be planned and implemented to address these changes.

Statewide retrospective study of low acuity emergency presentations in New South Wales, Australia: who, what, where and why?

OBJECTIVE: The present study aims to use a statewide population-based registry to assess the prevalence of low acuity emergency department (ED) presentations, describe the trend in presentation rates and to determine whether they were associated with various presentation characteristics such as the type of hospital as well as clinical and demographic variables. DESIGN AND SETTING: This was a retrospective analysis of a population-based registry of ED presentations in New South Wales (NSW). Generalised estimating equations with log links were used to determine factors associated with low acuity presentations to account for repeat presentations and the possibility of clustering of outcomes. PARTICIPANTS: Patients were included in this analysis if they presented to an ED between January 2010 and December 2014. The outcomes of interest were low acuity presentation, defined as those who self-presented (were not transported by ambulance), were assigned a triage category of 4 or 5 (semiurgent or non-urgent) and discharged back to usual residence from ED. RESULTS: There were 10.7 million ED presentations analysed. Of these, 45% were classified as a low acuity presentation. There was no discernible increase in the rate of low acuity presentations across NSW between 2010 and 2014. The strongest predictors of low acuity ED presentation were age <40 years of age (OR 1.77); injury or musculoskeletal administrative and non-urgent procedures (OR 2.96); ear, nose and throat, eye or oral (OR 5.53); skin or allergy-type presenting problems (OR 2.84). CONCLUSIONS: Low acuity ED presentations comprise almost half of all ED presentations. Alternative emergency models of care may help meet the needs of these patients.

Trends and characteristics of short-term and frequent representations to emergency departments: A population-based study from New South Wales, Australia.

OBJECTIVE: The objective of this study is to describe the trends and characteristics of short-term and frequent representations to EDs in New South Wales, Australia. METHODS: This was a retrospective analysis of a linked population-based registry of ED representations in New South Wales, conducted as part of the Demand for Emergency Services in Years 2010-2014 project. Trend analysis of unplanned representations to ED within 3 days of discharge from ED, readmission to an in-patient unit within 30 days of index in-patient admission from ED and demographic data and trends for frequent and very frequent ED presenters is discussed. RESULTS: A total of 10 798 797 ED presentations were identified from 4 188 283 individual patients. Within 1 year, 48.9% of ED presentations had a previous presentation, and 4.9% had represented within 3 days of a previous presentation. The readmission rate within 30 days was 2.8%, the proportion of frequent (representing 5212 [0.1%] individual patients) and very frequent representations (representing 1186 [0.03%] individual patients) were 1.7% and 1.0%, respectively. The overall rate of representations within 3 days has decreased from 5.1% in 2010 to 4.7% in 2014 (P < 0.001). The rate of readmissions within 30 days has increased from 2.4% in 2010 to 3.1% in 2014 (P < 0.001). CONCLUSIONS: In this population-based study, short-term representations were highest in the infant patient population, in-patient readmission rates were highest in the elderly and very frequent representations to ED were characterised by middle-aged patients with mental health or drug and alcohol related presentations.

Understanding drivers of Demand for Emergency Service Trends in Years 2010-2014 in New South Wales: An initial overview of the DESTINY project.

OBJECTIVE: This study aims to describe the general characteristics and data definitions used in a population-based data set of ED presentations in New South Wales (NSW), used to form the basis of future-trend analyses. METHODS: Retrospective analysis of the Emergency Department Data Collection registry, which provided clinical and demographic information of ED presentations across all EDs in NSW between 2010 and 2014. Presenting problems and ED diagnoses were classified using broad clinical categories including injury/musculoskeletal, respiratory, cardiovascular, ear nose and throat, and mental health. Presentations were linked by patient to allow for analysis of representations, and population data were obtained from the Australian Bureau of Statistics. RESULTS: There were 11.8 million presentations that were analysed from 150 EDs (80.6% of all EDs). The rate of ED presentations was highest in those aged 85 years and older and appears to increase across all age groups between 2010 and 2014. The most common ED diagnosis categories were injury/musculoskeletal (27.5%) followed by abdominal/gastrointestinal (12.3%), respiratory (9%) and cardiovascular (8%). Both the Systematised Nomenclature of Medicine Clinical Terms (66%) and the International Classification of Diseases (24%) were used to code ED diagnoses. CONCLUSIONS: The elderly population had the highest rate of ED attendances. The use of diverse diagnosis classifications and source information systems may present problems with further analysis. Patterns and characteristics of ED presentations in NSW were broadly consistent with those reported in other states in Australia.