Significance of the Microfluidic Flow Inside the Organ of Corti.

We study the vibration modes of a short section in the middle turn of the gerbil cochlea including both longitudinal and radial interstitial fluid spaces between the pillar cells (PC) and the sensory hair cells to determine the role of the interstitial fluid flow within the organ of corti (OoC). Three detailed finite element (FE) models of the cochlear short section (CSS) are studied. In model 1, the CSS is without fluids; model 2 includes the OoC fluid, but not the exterior scalae fluids; and model 3 is the CSS with both scalae and OoC fluids. We find that: (1) the fundamental mode shape of models 1 or 3 is similar to the classical basilar membrane (BM) bending mode that includes pivoting of the arch of corti, and hence determines the low frequency vibrational mode shape of the cochlea in the presence of the cochlear wave. (2) The fundamental mode shape of model 2 is characterized by a cross-sectional shape change similar to the passive response of the cochlea. This mode shape includes a tilting motion of the inner hair cell (IHC) region, a fluid motion within the tunnel of corti (ToC) in the radial direction and along the OoC, and a bulging motion of the reticular lamina (RL) above the outer hair cell (OHC). Each of these motions provides a plausible mode of excitation of the sensory hair cells. (3) The higher vibrational modes of model 1 are similar to the electrically evoked response within the OoC and suggests that the higher vibrational modes are responsible for the active response of the cochlea. We also observed that the fluid flow through the OoC interstitial space is significant, and the model comparison suggests that the OoC fluid contributes to the biphasic BM motion seen in electrical stimulation experiments. The effect of fluid viscosity on cilium deflection was assessed by performing a transient analysis to calculate the cilium shearing gain. The gain values are found to be within the range of experimentally measured values reported by Dallos et al. (1996, The Cochlea, Springer-Verlag, New York).

Impact of the Four-Hour Rule policy on emergency medical services delays in Australian EDs: a longitudinal cohort study.

INTRODUCTION: Delayed handover of emergency medical services (EMS) patients to EDs is a major issue with hospital crowding considered a primary cause. We explore the impact of the 4-hour rule (the Policy) in Australia, focusing on ambulance and ED delays. METHODS: EMS (ambulance), ED and hospital data of adult patients presenting to 14 EDs from 2002 to 2013 in three jurisdictions were linked. Interrupted time series 'Before-and-After' trend analysis was used for assessing the Policy's impact. Random effects meta-regression analysis was examined for associations between ambulance delays and Policy-associated ED intake, throughput and output changes. RESULTS: Before the Policy, the proportion of ED ambulances delayed increased between 1.1% and 1.7% per quarter across jurisdictions. After Policy introduction, Western Australia's increasing trend continued but Queensland decreased by 5.1% per quarter. In New South Wales, ambulance delay decreased 7.1% in the first quarter after Policy introduction. ED intake (triage delay) improved only in New South Wales and Queensland. Each 1% ambulance delay reduction was significantly associated with a 0.91% reduction in triage delay (p=0.014) but not ED length of stay ≤4 hours (p=0.307) or access-block/boarding (p=0.605) suggesting only partial improvement in ambulance delay overall. CONCLUSION: The Policy was associated with reduced ambulance delays over time in Queensland and only the immediate period in New South Wales. Associations may be due to local jurisdictional initiatives to improve ambulance performance. Strategies to alleviate ambulance delay may need to focus on the ED intake component. These should be re-examined with longer periods of post-Policy data.

Perceptions and experiences of emergency department staff during the implementation of the four-hour rule/national emergency access target policy in Australia: a qualitative social dynamic perspective.

BACKGROUND: The Four-Hour Rule or National Emergency Access Target policy (4HR/NEAT) was implemented by Australian State and Federal Governments between 2009 and 2014 to address increased demand, overcrowding and access block (boarding) in Emergency Departments (EDs). This qualitative study aimed to assess the impact of 4HR/NEAT on ED staff attitudes and perceptions. This article is part of a series of manuscripts reporting the results of this project. METHODS: The methodology has been published in this journal. As discussed in the methods paper, we interviewed 119 participants from 16 EDs across New South Wales (NSW), Queensland (QLD), Western Australia (WA) and the Australian Capital Territory (ACT), in 2015-2016. Interviews were recorded, transcribed, imported to NVivo 11 and analysed using content and thematic analysis. RESULTS: Three key themes emerged: Stress and morale, Intergroup dynamics, and Interaction with patients. These provided insight into the psycho-social dimensions and organisational structure of EDs at the individual, peer-to-peer, inter-departmental, and staff-patient levels. CONCLUSION: Findings provide information on the social interactions associated with the introduction of the 4HR/NEAT policy and the intended and unintended consequences of its implementation across Australia. These themes allowed us to develop several hypotheses about the driving forces behind the social impact of this policy on ED staff and will allow for development of interventions that are rooted in the rich context of the staff's experiences.

A model and experimental approach to the middle ear transfer function related to hearing in the humpback whale (Megaptera novaeangliae).

At present, there are no direct measures of hearing for any baleen whale (Mysticeti). The most viable alternative to in vivo approaches to simulate the audiogram is through modeling outer, middle, and inner ear functions based on the anatomy and material properties of each component. This paper describes a finite element model of the middle ear for the humpback whale (Megaptera novaeangliae) to calculate the middle ear transfer function (METF) to determine acoustic energy transmission to the cochlea. The model was developed based on high resolution computed tomography imaging and direct anatomical measurements of the middle ear components for this mysticete species. Mechanical properties for the middle ear tissues were determined from experimental measurements and published values. The METF for the humpback whale predicted a better frequency range between approximately 15 Hz and 3 kHz or between 200 Hz and 9 kHz based on two potential stimulation locations. Experimental measures of the ossicular chain, tympanic membrane, and tympanic bone velocities showed frequency response characteristics consistent with the model. The predicted best sensitivity hearing ranges match well with known vocalizations of this species.

Is it Appropriate for Patients to be Discharged at the Scene by Paramedics?

BACKGROUND: Outcomes of patients who are discharged at the scene by paramedics are not fully understood. OBJECTIVE: We aimed to describe the risk of re-presentation and/or death in prehospital patients discharged at the scene. METHODS: We conducted a retrospective cohort study using linked ambulance, emergency department (ED), and death data. We compared outcomes in patients who were discharged at the scene by paramedics with those who were transported to ED by paramedics and then discharged from ED between January 1 and December 31, 2013 in metropolitan Perth, Western Australia. Occurrences of subsequent ambulance requests, ED attendance, hospital admission and death were compared between those discharged at the scene and those discharged from ED. RESULTS: There were 47,330 patients during the study period, of whom 19,732 and 27,598 patients were discharged at the scene and from ED, respectively. Compared to those discharged from ED, those discharged at the scene were more likely to subsequently: request an ambulance (6.1% vs. 1.8%, adjusted odds ratio [adj OR] 3.4; 95% confidence interval [CI] 3.0-3.9), attend ED (4.6% vs. 1.4%, adj OR 3.3; 95% CI 2.8-3.8), be admitted to hospital (3.3% vs. 0.8%, adj OR 4.2; 95% CI 3.4-5.1). Those discharged at the scene tended towards an increased likelihood of death (0.2% vs. 0.1%, adj OR 1.8; 95% CI 0.99-3.2) within 24 hours of discharge compared to those discharged from ED. CONCLUSION: Patients attended by paramedics who were discharged at the scene had more subsequent events than those who were transported to and discharged from ED. Further consideration needs to be given to who is suitable to be discharged at the scene by paramedics.

Simulated masking of right whale sounds by shipping noise: incorporating a model of the auditory periphery.

Many species of large, mysticete whales are known to produce low-frequency communication sounds. These low-frequency sounds are susceptible to communication masking by shipping noise, which also tends to be low frequency in nature. The size of these species makes behavioral assessment of auditory capabilities in controlled, captive environments nearly impossible, and field-based playback experiments are expensive and necessarily limited in scope. Hence, it is desirable to produce a masking model for these species that can aid in determining the potential effects of shipping and other anthropogenic noises on these protected animals. The aim of this study was to build a model that combines a sophisticated representation of the auditory periphery with a spectrogram-based decision stage to predict masking levels. The output of this model can then be combined with a habitat-appropriate propagation model to calculate the potential effects of noise on communication range. For this study, the model was tested on three common North Atlantic right whale communication sounds, both to demonstrate the method and to probe how shipping noise affects the detection of sounds with varying spectral and temporal characteristics.

'I just need to find out if I had broken something or not.' A qualitative descriptive study into patient decisions to present to an Emergency Department with a simple fracture.

Background To investigate what factors contribute to a working age adult with a simple fracture seeking care in an Australian metropolitan Emergency Department (ED) Methods In this Qualitative Descriptive study, we interviewed ED patients with simple fractures including 5th metacarpal, 5th metatarsal, toe, radial head and clavicle fractures. Results We interviewed 30 patients aged 18-65. Two thirds of participants were aware they might have a minor injury. Many were well informed health consumers and convenience was the most important decision-making factor. Participants focussed on organising imaging, diagnosis and immobilisation. This sequence of care was often perceived as more complex and inefficient in primary care. ED was trusted and preferred to urgent primary care with an unknown doctor. Some patients defaulted to attending ED without considering alternatives due to poor health system knowledge or from escalating anxiety. Conclusions ED is safe, free and equipped to manage simple and complex injuries. Patients would attend primary care if comprehensive fracture management was easily accessible from a trusted clinician. To effectively divert simple fracture presentations from ED, primary care requires collocated imaging, imaging interpretation, orthopaedic expertise, and fracture management resources. Services need to operate 7 days a week and must have accessible 'urgent' appointments.

Climate and ecosystem linkages explain widespread declines in North American Atlantic salmon populations.

North American Atlantic salmon (Salmo salar) populations experienced substantial declines in the early 1990s, and many populations have persisted at low abundances in recent years. Abundance and productivity declined in a coherent manner across major regions of North America, and this coherence points toward a potential shift in marine survivorship, rather than local, river-specific factors. The major declines in Atlantic salmon populations occurred against a backdrop of physical and biological shifts in Northwest Atlantic ecosystems. Analyses of changes in climate, physical, and lower trophic level biological factors provide substantial evidence that climate conditions directly and indirectly influence the abundance and productivity of North American Atlantic salmon populations. A major decline in salmon abundance after 1990 was preceded by a series of changes across multiple levels of the ecosystem, and a subsequent population change in 1997, primarily related to salmon productivity, followed an unusually low NAO event. Pairwise correlations further demonstrate that climate and physical conditions are associated with changes in plankton communities and prey availability, which are ultimately linked to Atlantic salmon populations. Results suggest that poor trophic conditions, likely due to climate-driven environmental factors, and warmer ocean temperatures throughout their marine habitat area are constraining the productivity and recovery of North American Atlantic salmon populations.

Quantifying the proportion of general practice and low-acuity patients in the emergency department.

OBJECTIVE: To accurately estimate the proportion of patients presenting to the emergency department (ED) who may have been suitable to be seen in general practice. DESIGN: Using data sourced from the Emergency Department Information Systems for the calendar 2013s 2009 to 2011 at three major tertiary hospitals in Perth, Western Australia, we compared four methods for calculating general practice-type patients. These were the validated Sprivulis method, the widely used Australasian College for Emergency Medicine method, a discharge diagnosis method developed by the Tasmanian Department of Human and Health Services, and the Australian Institute of Health and Welfare (AIHW) method. MAIN OUTCOME MEASURE: General practice-type patient attendances to EDs, estimated using the four methods. RESULTS: All methods except the AIHW method showed that 10%-12% of patients attending tertiary EDs in Perth may have been suitable for general practice. These attendances comprised 3%-5% of total ED length of stay. The AIHW method produced different results (general practice-type patients accounted for about 25% of attendances, comprising 10%-11% of total ED length of stay). General practice-type patient attendances were not evenly distributed across the week, with proportionally more patients presenting during weekday daytime (08:00-17:00) and proportionally fewer overnight (00:00-08:00). This suggests that it is not a lack of general practitioners that drives patients to the ED, as weekday working hours are the time of greatest GP availability. CONCLUSION: The estimated proportion of general practice-type patients attending the EDs of Perth's major hospitals is 10%-12%, and this accounts for < 5% of the total ED length of stay. The AIHW methodology overestimates the actual proportion of general practice-type patient attendances.

Evidence-based paramedic models of care to reduce unnecessary emergency department attendance--feasibility and safety.

BACKGROUND: As demand for Emergency Department (ED) services continues to exceed increases explained by population growth, strategies to reduce ED presentations are being explored. The concept of ambulance paramedics providing an alternative model of care to the current default 'see and transport to ED' has intuitive appeal and has been implemented in several locations around the world. The premise is that for certain non-critically ill patients, the Extended Care Paramedic (ECP) can either 'see and treat' or 'see and refer' to another primary or community care practitioner, rather than transport to hospital. However, there has been little rigorous investigation of which types of patients can be safely identified and managed in the community, or the impact of ECPs on ED attendance. METHODS/DESIGN: St John Ambulance Western Australia paramedics will indicate on the electronic patient care record (e-PCR) of patients attended in the Perth metropolitan area if they consider them to be suitable to be managed in the community. 'Follow-up' will examine these patients using ED data to determine the patient's disposition from the ED. A clinical panel will then develop a protocol to identify those patients who can be safely managed in the community. Paramedics will then assess patients against the derived ECP protocols and identify those deemed suitable to 'see and treat' or 'see and refer'. The ED disposition (and other clinical outcomes) of these 'ECP protocol identified' patients will enable us to assess whether it would have been appropriate to manage these patients in the community. We will also 'track' re-presentations to EDs within seven days of the initial presentation. This is a 'virtual experiment' with no direct involvement of patients or changes in clinical practice. A systems modelling approach will be used to assess the likely impact on ED crowding. DISCUSSION: To date the efficacy, cost-effectiveness and safety of alternative community-based models of emergency care have not been rigorously investigated. This study will inform the development of ECP protocols through the identification of types of patient presentation that can be considered both safe and appropriate for paramedics to manage in the community.

A prediction of the minke whale (Balaenoptera acutorostrata) middle-ear transfer function.

The lack of baleen whale (Cetacea Mysticeti) audiograms impedes the assessment of the impacts of anthropogenic noise on these animals. Estimates of audiograms, which are difficult to obtain behaviorally or electrophysiologically for baleen whales, can be made by simulating the audiogram as a series of components representing the outer, middle, and inner ear (Rosowski, 1991; Ruggero and Temchin, 2002). The middle-ear portion of the system can be represented by the middle-ear transfer function (METF), a measure of the transmission of acoustic energy from the external ear to the cochlea. An anatomically accurate finite element model of the minke whale (Balaenoptera acutorostrata) middle ear was developed to predict the METF for a mysticete species. The elastic moduli of the auditory ossicles were measured by using nanoindentation. Other mechanical properties were estimated from experimental stiffness measurements or from published values. The METF predicted a best frequency range between approximately 30 Hz and 7.5 kHz or between 100 Hz and 25 kHz depending on stimulation location. Parametric analysis found that the most sensitive parameters are the elastic moduli of the glove finger and joints and the Rayleigh damping stiffness coefficient ß. The predicted hearing range matches well with the vocalization range.

Fracture liaison service utilising an emergency department information system to identify patients effectively reduce re-fracture rate is cost-effective and cost saving in Western Australia.

OBJECTIVES: To assess the benefits of the Emergency Department Information System (EDIS)-linked fracture liaison service (FLS). METHODS: Patients identified through EDIS were invited to attend an FLS at the intervention hospital, the Sir Charles Gairdner Hospital (SCGS-FLS). The intervention group was compared to usual care. Retrospective control (RC) at this hospital determined historical fracture risk (SCGH-RC). Prospective control (PC) was from a comparator, Fremantle Hospital (FH-PC). The main outcome measures were cost-effectiveness from a health system perspective and quality of life by EuroQOL (EQ-5D). Bottom-up cost of medical care, against the cost of managing recurrent fracture (weighted basket), was determined from the literature and 2013/14 Australian Refined Diagnosis Related Groups (AR-DRG) prices. Mean incremental cost-effectiveness ratios were simulated from 5000 bootstrap iterations. Cost-effectiveness acceptability curves were generated. RESULTS: The SCGH-FLS program reduced absolute re-fracture rates versus control cohorts (9.2-10.2%), producing an estimated cost saving of AUD$750,168-AUD$810,400 per 1000 patient-years in the first year. Between-groups QALYs differed with worse outcomes in both control groups (p < 0.001). The SCGH-FLS compared with SCGH-RC and FH-PC had a mean incremental cost of $8721 (95% CI -$1218, $35,044) and $8974 (95% CI -$26,701, $69,929), respectively, per 1% reduction in 12-month recurrent fracture risk. The SCGH-FLS compared with SCGH-RC and FH-PC had a mean incremental cost of $292 (95% CI -$3588, $3380) and -$261 (95% CI -$1521, $471) per EQ-5D QALY gained at 12 months respectively. With societal willingness to pay of $16,000, recurrent fracture is reduced by 1% in >80% of patients. CONCLUSIONS: This simple and easy model of identification and intervention demonstrated efficacy in reducing rates of recurrent fracture and was cost-effective and potentially cost saving.

The use of computed tomography in the management of injury in tertiary emergency departments in Western Australia: Evidence of overtesting?

BACKGROUND: This study investigated trends in computed tomography (CT) utilization across different triage categories of injury presentations to tertiary emergency departments (EDs) and associations with diagnostic yield measured by injury severity, hospitalization and length of stay (LOS), and mortality. METHODS: A total of 411,155 injury-related ED presentations extracted from linked records from Western Australia from 2004 to 2015 were included in the retrospective study. The use of CT scanning and diagnostic yield measured by rate of diagnosis with severe injury, hospitalizations and LOS, and mortality were captured annually for injury-related ED presentations. Multivariable regression models were used to calculate the annual adjusted rate of CT scanning for injury presentations and hospitalizations across triage categories, diagnosis with severe injury, LOS, and mortality. The significance of changes observed was compared among patients with CT imaging relative to those without CT. RESULTS: While the number of ED presentations with injury increased by 65% from 2004 to 2015, the use of CT scanning in these presentations increased by 176%. The largest increase in CT use was among ED presentations triaged as semi-/nonurgent (+256%). Injury presentations with CT, compared to those without, had a higher rate of diagnosis with moderate/severe injury and hospitalization but no difference in LOS and mortality. The probability/rate observed in the outcomes of interest had a greater decrease over time in those with CT scanning compared with those without CT scanning across triage categories. CONCLUSIONS: The reduction in diagnostic yield in terms of injury severity and hospitalization found in our study might indicate a shift toward overtesting using CT in ED for injury or a higher use of CT to assist in the management of injuries. This helps health care policymakers consider whether the current increase in CT use meets the desired levels of quality and efficient care.

Validation of a modified table to map the 1998 Abbreviated Injury Scale to the 2008 scale and the use of adjusted severities.

BACKGROUND: The Abbreviated Injury Scale 2008 (AIS 2008) is the most recent injury coding system. A mapping table from a previous AIS 98 to AIS 2008 is available. However, AIS 98 codes that are unmappable to AIS 2008 codes exist in this table. Furthermore, some AIS 98 codes can be mapped to multiple candidate AIS 2008 codes with different severities. We aimed to modify the original table to adjust the severities and to validate these changes. METHODS: We modified the original table by adding links from unmappable AIS 98 codes to AIS 2008 codes. We applied the original table and our modified table to AIS 98 codes for major trauma patients. We also assigned candidate codes with different severities the weighted averages of their severities as an adjusted severity. The proportion of cases whose injury severity scores (ISSs) were computable were compared. We also compared the agreement of the ISS and New ISS (NISS) between manually determined AIS 2008 codes (MAN) and mapped codes by using our table (MAP) with unadjusted or adjusted severities. RESULTS: All and 72.3% of cases had their ISSs computed by our modified table and the original table, respectively. The agreement between MAN and MAP with respect to the ISS and NISS was substantial (intraclass correlation coefficient = 0.939 for ISS and 0.943 for NISS). Using adjusted severities, the agreements of the ISS and NISS improved to 0.953 (p = 0.11) and 0.963 (p = 0.007), respectively. CONCLUSION: Our modified mapping table seems to allow more ISSs to be computed than the original table. Severity scores exhibited substantial agreement between MAN and MAP. The use of adjusted severities improved these agreements further.

Inner hair cell stereocilia displacement in response to focal stimulation of the basilar membrane in the ex vivo gerbil cochlea.

The inner hair cells in the mammalian cochlea transduce mechanical signals to electrical signals that provide input to the auditory nerve. The spatial-temporal displacement of the inner hair cell stereocilia (IHCsc) relative to basilar membrane (BM) displacement is central to characterizing the transduction process. This study specifically focuses on measuring displacement of the stereocilia hair bundles in the radial dimensions where they are most sensitive. To simplify the mechanical response of the cochlear partition, a mechanical probe was used to drive the BM. Optical imaging was used to measure radial displacement of the inner hair cell stereocilia local to the probe in ex vivo gerbil cochleae. The mechanical probe displaced the BM in the transverse direction using sinusoidal stimuli with frequencies ranging from 10 Hz to 42.5 kHz. IHCsc displacement measurements were made in the radial dimension as a function of their longitudinal location along the length of the BM. The results were used to quantify the frequency response, longitudinal space coupling, traveling wave velocity, and wavelength of the radial displacement of the stereocilia. The measurements were centered at two best frequency locations along the BM: Proximal to the round window (first turn), and in the second turn. At both locations, frequency tuning was seen that was consistent with published place maps. At both locations, traveling waves were observed simultaneously propagating basal and apical from the probe. The velocity of the traveling waves at the center frequency (CF) of the location was higher in the first turn than in the second. As the stimulus frequency increased and approached CF for a location, the traveling wavelength decreased. Differential motion of the BM and IHCsc was observed in the second turn as the stimulus frequency increased toward CF. The longitudinal coupling measured in this study was longer than observed in previous studies. In summary the results suggest that the shape of the wave patterns present on the BM are not sufficient to characterize the displacement of the IHCsc.

Review article: Emergency department crowding measures associations with quality of care: A systematic review.

ED crowding has been reported to reduce the quality of care. There are many proposed crowding metrics, but the metric most strongly associated with care quality remains unknown. The present study aims to determine the crowding metric with the strongest links with processes and outcomes of care linked to the Institute of Medicine quality domains. Systematic searches in healthcare databases were conducted using terms for 'crowding', 'metrics' and 'performance', supplemented by grey literature and citation searches. The level of evidence for each association was assessed using an explicit tool. The body of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. Evidence was synthesised using harvest plots. Titles and abstracts of 2052 studies were screened, 452 selected for full-text review and 183 included. Inter-observer agreement was moderate κ = 0.54 (95% confidence interval 0.50-0.59). Two thirds were from urban tertiary hospitals in North America (65%), Australasia (13%), Europe (12%) and Asia (8%). One third provided Level 3 or higher evidence. Metrics were based on occupancy (38%), time (31%), workload (19%) or combinations (9%). Data were synthesised from 25 607 375 patients, 2368 staff, 9089 hospitals and 101 177 sampling times. Almost all crowding metrics were patient-centred and reflect timeliness and efficiency. ED length of stay, boarding time and total occupancy had the strongest association with safety and effectiveness of care. ED length of stay was also associated with equity. The certainty of evidence for associations between crowding measures varied across domains of quality, from very low to moderate certainty.

An emergency department optimized protocol for qualitative research to investigate care seeking by patients with non-urgent conditions.

AIM: To describe a tailored qualitative research methodology for exploring the complex interaction of factors driving non-urgent care seeking in the emergency department. DESIGN: Qualitative descriptive design with a literature informed semi-structured interview and analysis structure. Triangulation with the State-Trait Anxiety Inventory allows expedited exploration of biopsychosocial factors. Consolidated criteria for reporting qualitative research requirements integrated. METHODS: With a short 10- to 15-min interview and a low-inference analysis process, this methodology offers a structured way to explore the "go to ED" decision, to understand the patient perspective on their healthcare needs and feed into the development of suitable local services that meet patient healthcare needs. RESULTS: This methodology offers a structured way for clinician-researchers to explore the factors that influence patients seeking care in the emergency departments for non-urgent conditions that are specific to their local health service environment. The described methodology is accessible to novice qualitative researchers and includes the semi-structured interview, coding and analysis frameworks.

Review article: Has the implementation of time-based targets for emergency department length of stay influenced the quality of care for patients? A systematic review of quantitative literature.

Time-based targets (TBTs) for ED stays were introduced to improve quality of care but criticised as having harmful unintended consequences. The aim of the review was to determine whether implementation of TBTs influenced quality of care. Structured searches in medical databases were undertaken (2000-2019). Studies describing a state, regional or national TBTs that reported processes or outcomes of care related to the target were included. Harvest plots were used to summarise the evidence. Thirty-three studies (n = 34 million) were included. In some settings, reductions in mortality were seen in ED, in hospital and at 30 days, while in other settings mortality was unchanged. Mortality reductions were seen in the face of increasing age and acuity of presentations, when short-stay admissions were excluded, and when pre-target temporal trends were accounted for. ED crowding, time to assessment and admission times reduced. Fewer patients left prior to completing their care and fewer patients re-presented to EDs. Short-stay admissions and re-admissions to wards within 30 days increased. There was conflicting evidence regarding hospital occupancy and ward medical emergency calls, while times to treatment for individual conditions did not change. The evidence for associations was mostly low certainty and confidence in the findings is accordingly low. Quality of care generally improved after targets were introduced and when compliance with targets was high. This depended on how targets were implemented at individual sites or within jurisdictions, with important implications for policy makers, health managers and clinicians.

Review article: Have emergency department time-based targets influenced patient care? A systematic review of qualitative literature.

Time-based targets for ED length of stay were introduced in England in 2000, followed by the rest of the UK, Canada, Ireland, New Zealand, and Australia after ED crowding was associated with poor quality of care and increased mortality. This systematic review evaluates qualitative literature to see if ED time-based targets have influenced patient care quality. We included 13 studies from four countries, incorporating 617 interviews. We conclude that time-based targets have impacted on the quality of emergency patient care, both positively and negatively. Successful implementation depends on whole hospital resourcing and engagement with targets.

When a health policy cuts both ways: Impact of the National Emergency Access Target policy on staff and emergency department performance.

OBJECTIVE: To explore the impact of the Four-Hour Rule/National Emergency Access Target (4HR/NEAT) on staff and ED performance. METHODS: A mixed-methods study design was used to link performance data from 16 participating hospitals with the experiences reported by 119 ED staff during policy implementation. Quantitative and qualitative measures were triangulated to identify the staff and organisational effects on hospital performance. An overall score was developed to categorise hospitals into: high, moderate and low performers, then compared with four qualitative themes: social factors, ED management, ED outcomes and 4HR/NEAT compliance. RESULTS: Key factors identified were stress and morale; intergroup dynamics; interaction with patients; resource management; education and training; financial incentives; impact on quality and safety; perceived improvements on access block and overcrowding. High performing hospitals reported increased stress and decreased morale, decreased staff-patient communication and staff shortages; significant changes in ED management and effective use of the whole-of-hospital approach. Moderate performing hospitals reported similar characteristics to a lesser degree, and the perception that 4HR/NEAT did not impact ED practice. Low performing hospitals also reported increased stress and low morale and a less effective whole-of-hospital approach. ED staff also reported a reduction in communication with patients. CONCLUSIONS: There was strong evidence of an association between high stress and low morale and the implementation of the 4HR/NEAT across all levels of performance. These adverse consequences of the 4HR/NEAT implementation indicate that a more nuanced approach to efficiency improvements is required. This would balance processes measured by 4HR/NEAT against a range of other clinical and organisational performance measures.