Self-reported cognitive function in a large international cohort of people with multiple sclerosis: associations with lifestyle and other factors.

BACKGROUND AND PURPOSE: We aimed to estimate the prevalence of perceived cognitive impairment (PCI) and explore its associations with lifestyle and disease characteristics in a large international cohort of people with multiple sclerosis (MS). METHODS: This study was a cross-sectional analysis. Participants rated their cognitive function over the preceding 4 weeks using four questions in a subscale within the Multiple Sclerosis Quality of Life questionnaire (MSQOL-54). These questions assessed perceived concentration, attention and memory by the patient and family/friends. Four definitions of PCI were derived, ranging from lowest to highest specificity. Associations with PCI were assessed by log-binomial regression. RESULTS: The prevalence of PCI in our sample ranged from 41.0% (95% confidence interval, 39.0-43.0) using the least-specific definition to 11.6% (95% confidence interval, 10.3-12.9) using the most specific definition. A number of factors were associated with PCI, increasing in magnitude as the definition specificity increased, including positive associations for smoking and body mass index, whereas physical activity, dietary quality and use of vitamin D/omega-3 supplements were inversely associated with PCI. CONCLUSIONS: Our study reports associations between healthy lifestyle behaviours and PCI in people with MS. Although reverse causality is a potential explanation for our findings, previous studies have shown comparable associations with healthy lifestyle and MS onset and progression. Subject to external validation, these results suggest benefits realized from a healthy lifestyle in people with MS.

The cost-effectiveness of hospital-based telephone coaching for people with type 2 diabetes: a 10 year modelling analysis.

BACKGROUND: Type 2 diabetes (T2DM) is a burdensome condition for individuals to live with and an increasingly costly condition for health services to treat. Cost-effective treatment strategies are required to delay the onset and slow the progression of diabetes related complications. The Diabetes Telephone Coaching Study (DTCS) demonstrated that telephone coaching is an intervention that may improve the risk factor status and diabetes management practices of people with T2DM. Measuring the cost effectiveness of this intervention is important to inform funding decisions that may facilitate the translation of this research into clinical practice. The purpose of this study is to assess the cost-effectiveness of telephone coaching, compared to usual diabetes care, in participants with poorly controlled T2DM. METHODS: A cost utility analysis was undertaken using the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model to extrapolate outcomes collected at 6 months in the DTCS over a 10 year time horizon. The intervention's impact on life expectancy, quality-adjusted life expectancy (QALE) and costs was estimated. Costs were reported from a health system perspective. A 5 % discount rate was applied to all future costs and effects. One-way sensitivity analyses were conducted to reflect uncertainty surrounding key input parameters. RESULTS: The intervention dominated the control condition in the base-case analysis, contributing to cost savings of $3327 per participant, along with non-significant improvements in QALE (0.2 QALE) and life expectancy (0.3 years). CONCLUSIONS: The cost of delivering the telephone coaching intervention continuously, for 10 years, was fully recovered through cost savings and a trend towards net health benefits. Findings of cost savings and net health benefits are rare and should prove attractive to decision makers who will determine whether this intervention is implemented into clinical practice. TRIAL REGISTRATION: ACTRN12609000075280.

Factors relating to consent for organ donation: prospective data on potential organ donors.

BACKGROUND: Obtaining family consent to organ donation is a significant obstacle to improving further Australian deceased organ donation rates. Currently, neither the consent rates for donors eligible to donate after circulatory death, nor factors that influence decision to decline or consent to donation in general are known in Australia. METHODS: This study at four university teaching hospitals in Melbourne, Victoria, examined consecutive patients where organ donation was discussed with the family RESULTS: A total of 123 cases were identified; the family consent rate was 52.8%, and 34.1% proceeded to donation. Consent to donation was related to potential donor factors such as country of birth, cultural background in Australia, a non-religious or Christian background and registration on the Australian Organ Donor Register. Family-related factors included being English speaking and having knowledge of the deceased's wishes about organ donation. Family of donation after circulatory death-eligible donors were less likely to consent to donation than the family of donation after brain death-eligible donors, although not reaching statistical significance. Among consented potential donors, those eligible for donation after brain death and with a shorter length of stay were more likely to proceed to donating organs for transplantation. CONCLUSION: Despite a small sample size, these findings describe current consent and donation rates and associated factors and may assist in improving conversations about organ donation.

Ideal care and the realities of practice: interdisciplinary relationships in the management of advanced cancer patients in Australian emergency departments.

PURPOSE: Over the course of their illness, a person with cancer is likely to see a number of different healthcare professionals, including those in the emergency department (ED). There is limited research examining the interaction and communication between the involved healthcare professionals when such a patient presents to the ED. This study aimed to explore the views and experiences of interdisciplinary interactions of healthcare professionals caring for patients with advanced cancer who present to the ED. METHODS: Focus groups and semistructured interviews were conducted with clinical staff working in ED, oncology and community and hospital-based palliative care services. Interviews and focus groups were recorded and transcribed verbatim. Thematic analysis was undertaken by three researchers independently. These themes were then discussed by the wider team and consensus reached on themes and subthemes. RESULTS: Eighty-three healthcare professionals participated in focus groups, and 11 were interviewed. The over-arching theme to emerge was one of a conflict between ideal care and the realities of practice, particularly arising where clinicians from different services were required to work together to provide care. This idea was further understood through a series of subthemes including communication, decision-making and understanding of other services. CONCLUSIONS: Participants articulated agreed upon ideals of optimal care for advanced cancer patients across all three services, however there was frequently discord between these ideals and the actual care provided. Service demands and the day-to-day stressors of practice appeared to influence people's actions and engender conflict.

Effect of hospital-based telephone coaching on glycaemic control and adherence to management guidelines in type 2 diabetes, a randomised controlled trial.

BACKGROUND: Failure to achieve treatment targets is common among people with type 2 diabetes. Cost-effective treatments are required to delay the onset and slow the progression of diabetes-related complications. AIMS: This study aimed to measure the effect of a 6-month telephone coaching intervention on glycaemic control, risk factor status and adherence to diabetes management practices at the intervention's conclusion (6 months) and at 12 months. METHOD: This randomised controlled trial recruited 94 adults with type 2 diabetes and an HbA1C > 7% from the Diabetes Clinic of St Vincent's Hospital Melbourne. People who were non-English speaking, cognitively impaired, severely hearing impaired or without telephone access were excluded. Participants were randomised to receive usual care plus 6 months of telephone coaching focusing on achieving treatment targets and complication screening, or usual care only. The primary outcome was HbA1C at 6 months; secondary outcomes included other physiological and monitoring measures. RESULTS: Significant interaction effects were observed between group and time at 6 months, demonstrating improvement in HbA1C, fasting glucose, diastolic blood pressure and physical activity. The intervention's effect on these parameters was not sustained at 12 months. Intervention group participants also improved compliance with foot examinations and pneumococcal vaccination by 6 months and retinal screening by 12 months. CONCLUSIONS: Telephone coaching improved glycaemic control and adherence to complication screening in people with type 2 diabetes, for the duration of its delivery, but these effects were not maintained on withdrawal of the intervention. Strategies that assist patients to sustain these benefits are required.

Care of the dying cancer patient in the emergency department: findings from a National survey of Australian emergency department clinicians.

BACKGROUND: Patients with cancer are presenting to emergency departments (ED) for end-of-life care with increasing frequency. Little is known about this experience for patients and ED clinicians in Australia. AIMS: To assess the barriers and enablers regarding end-of-life care for cancer patients as perceived by Australian ED clinicians. METHODS: There were 4501 Australian ED clinicians invited through their professional colleges to complete an online survey, using multiple-choice and free-text responses. RESULTS: A total of 681 ED clinicians responded, most (84.2%) felt comfortable providing care to the dying and found it to be rewarding (70.9%). Although 83.8% found caring for the dying a reasonable demand on their role as clinician, 83.8% also agreed that the ED is not the right place to die. Respondents demonstrated a wide range of views regarding caring for this patient group in ED through free-text responses. In addition, 64.5% reported that futile treatment is frequently provided in the ED; the main reasons reported were that limitations of care were not clearly documented, or discussed with the patient or their family. Almost all (94.6%) agreed that advance care plans assist in caring for dying patients in the ED. CONCLUSIONS: Our findings provide important new insights into a growing area of care for ED. Barriers and enablers to optimal care of the dying patient in ED were identified, and especially the reported high occurrence of futile care, likely a result of these barriers, is detrimental to both optimal patient care and allocation of valuable healthcare resources.

Hospitalisation of high-care residents of aged care facilities: are goals of care discussed?

BACKGROUND: Residents of residential aged care facilities (RACF) are commonly hospitalised towards the end of life. Determining the hospitalisation experiences, including the discussion of goals of treatment, is essential to best plan care including planning for end-of-life care for this population. AIM: To document hospital presentation characteristics, course, outcomes and care planning for high-care residents of RACF. METHODS: A retrospective review of medical records was conducted for all high-care residents aged >64 years presenting to a metropolitan hospital over a 6-month period. RESULTS: One hundred and eighty-six high-care residents of RACF presented to hospital 228 times. Transfer paperwork documented resuscitation status for 49 (21%) presentations, and a medical enduring power of attorney or advanced care plan for 85 (37%). Patients had high rates of comorbidities (average Charlson comorbidity index score = 3), polypharmacy (93%), impaired mobility (89%), impaired cognition (81%) and incontinence (76%). Resuscitation status was documented in 50 (55%) and family discussion in 38 (42%) of 91 admissions exceeding 48 h. Documented family discussion was significantly associated with complications or new events occurring during admission (odds ratio 1.56, 95% confidence interval 1.07-2.26). CONCLUSION: There were low rates of documentation of resuscitation status or family discussion for this highly vulnerable population. Neither hospitals nor community providers appear to take responsibility for future care planning. Acute hospitals could play a greater role in care planning because discussion around course of illness and goals of treatment may enhance patient management, satisfaction and reduce hospitalisations.

Donation after cardiac death: are Australian emergency clinicians supportive?

To improve organ donation processes and outcomes, many Australian hospitals have introduced donation after cardiac death (DCD) following the 2010 publication of the National Protocol for DCD. As emergency clinicians play a significant role in identifying potential DCD donors, it is critical to assess their support and knowledge. Although many support DCD, most are unaware of the protocol or procedures regarding DCD. Education is needed and desired by many emergency clinicians.

The feasibility of an online educational lifestyle program for people with multiple sclerosis: A qualitative analysis of participant semi-structured interviews.

Objective: To explore the feasibility of a randomised controlled trial of a multiple sclerosis online course (MSOC) via qualitative analysis of participant semi-structured interviews. Methods: The MSOC was developed in two arms: intervention arm which contained evidence-based lifestyle modification recommendations, and standard-care arm which delivered information from MS websites reflecting standard advice. Participants were recruited via online advertisements, completed a baseline questionnaire, and randomised. Seven modules were delivered over six weeks. Course completers were invited to participate in semi-structured interviews. Within a qualitative paradigm, interviews were analysed using reflexive thematic analysis. Results: Fourteen of the 17 course completers were interviewed: 86% (12/14) female; mean age 50 years; residing in Australia, New Zealand, and the USA, predominantly had relapsing-remitting MS, mean time from diagnosis 9.5 years, and patient-determined disease steps disability assessment distributed evenly across all three categories. Four themes were identified: 1) "Hearing our stories" (hope for the future, feeling represented, exploring the journey of others with MS, learning from diversity, and wanting to connect with others); 2) "Taking the plunge" (not wanting to be first, feelings of nervousness or reluctance and feeling confronted); 3) "The accessibility and safety of being online" (ease of access, going at your own pace, making it work and not letting others down); and 4) "unpacking the course" (ease of navigation, visuals, understandability, and length and timing). Conclusion: Participants felt represented, found the course accessible and content was easy to understand. These experiences provide important insights and considerations for this digital health intervention.

A multiple sclerosis lifestyle behavior online course: Qualitative analysis of participants' motivations, expectations and experiences.

Background: Modification of lifestyle-related risk factors for multiple sclerosis (MS) has been associated with improved health outcomes when compared with standard medical management alone. Based on an existing lifestyle modification program offered as a residential workshop, the MS Online Course (MSOC) was developed to translate the workshop into an online intervention. We performed a pilot randomized controlled trial (RCT), to assess the feasibility concepts of accessibility, learnability and desirability through quantitative and qualitative analyzes. In the present study, we performed additional qualitative analyzes to explore participants' motivations, expectations, and experiences of the MSOC. This study aims to complement prior feasibility analyzes and inform recruitment strategies and course content redevelopment so that its effectiveness may be assessed by examining behavior change and health outcomes in a future larger RCT. Methods: Participants were recruited via online advertisements and randomized to either: the standard care course, containing material sourced from public facing MS websites; or the intervention course, based on an evidence-based lifestyle modification program for people with MS. Course completers were invited to participate in semi-structured interviews. Within a qualitative paradigm, reflexive thematic analysis of interviews was undertaken. Results: Of 31 eligible participants, 17 completed the MSOC and 14 agreed to be interviewed. Four themes were identified in this analysis: (1) "Wanting to help others" (helping through volunteering, contributing to knowledge base, spreading the word; (2) "Seeking knowledge" (confirmation of existing knowledge; obtaining new knowledge, relevant, credible information); (3) "Doing what I can to help myself" (understanding lifestyle modification, changing my lifestyle, remaining well); and (4) "Changing attitudes" (finding positivity, feeling more confident and in control). Conclusions: Participants were motivated to help others through research, help themselves by improving knowledge and to find ways to better manage their MS. Expectations included obtaining credible, reliable information, to substantiate existing knowledge, and to further understand lifestyle modification. Participants' experiences included confirmation of and obtaining new knowledge, and early implementation of modified lifestyle behaviors. These insights surrounding participants' motivations, expectations and experiences will assist in recruitment strategies, course redevelopment and outcome measures for the future RCT to examine the effectiveness of the MSOC.

Validation of the Full Outline of Unresponsiveness (FOUR) Scale for conscious state in the emergency department: comparison against the Glasgow Coma Scale.

OBJECTIVES: To determine (a) the inter-rater reliability of pairs of emergency doctors' and/or nurses' ratings of the Glasgow Coma Scale (GCS) and the Full Outline of Unresponsiveness (FOUR) Scale in emergency department (ED) patients, (b) the concurrent validity of the FOUR Scale using the GCS as the reference scale and (c) doctors' and nurses' knowledge and attitudes towards the GCS and FOUR Scale. METHODS: A prospective observational study was conducted using staff participants' ratings for a convenience sample of ED patients requiring quantification of conscious state. Participating doctors and nurses attended a formal training session on the correct use of the GCS and FOUR Scale. Pairs of clinicians then independently completed the GCS and FOUR Scale on patients within 5 min of each other. RESULTS: 140 clinicians were recruited and trained in the use of the GCS and FOUR Scale. A total of 217 observations were performed on 203 patients presenting to the ED with various conditions. The inter-rater reliability for the FOUR Scale was greater than that of the GCS (FOUR: к = 0.76, p < 0.01; GCS: к = 0.59, p < 0.01). The reliability for both the GCS and the FOUR Scale was poorest within doctor-nurse pairs. CONCLUSION: The FOUR Scale showed greater reliability than the GCS in ED patients using ED clinicians as raters. A larger study of ED patients is warranted to determine the predictive validity of the FOUR Scale and to further examine the reliability of the scale in various patient populations.

Characteristics of mHealth app use in an international sample of people with multiple sclerosis.

The management of multiple sclerosis (MS) has progressed significantly with the emergence of mHealth technologies. Uptake of mHealth apps amongst people with MS, and clinical and demographic characteristics of mHealth adopters is unknown outside North America. Participants of the HOLISM study were queried about their mHealth apps use. We summarize mHealth app usage, and clinical and demographic characteristics of mHealth app adopters using descriptive statistics. Overall, 3.1% of respondents reported using an mHealth app, most of whom were located in Australasia and North America. This study provides insight regarding mHealth app usage within a large international cohort of people with MS.

Mastery is associated with greater physical and mental health-related quality of life in two international cohorts of people with multiple sclerosis.

BACKGROUND: Mastery is the sense of being in control of one's life and improvement in mastery may help to enhance quality of life. Little research has explored mastery in people with multiple sclerosis (MS), including its association with quality of life. OBJECTIVE: To explore the association between mastery and health-related quality of life (HRQOL) in people with MS. METHOD: Two cross-sectional cohorts of adults with MS (n = 1401 and n = 573), recruited through convenience sampling, completed an online survey which measured mastery using the Pearlin Mastery Scale, physical and mental HRQOL via physical and mental health composite scores of MSQOL-54, along with other covariates, including demographics, clinical characteristics and lifestyle factors. Linear regression assessed associations between mastery and physical HRQOL adjusting for age, sex, education, disability and depression, and between mastery and mental HRQOL adjusting for age, sex, education, disability and clinically significant fatigue. RESULTS: Greater mastery score was associated with higher physical and mental HRQOL in both cohorts, such that a one-point increase in the PMS was associated with an increase of 2.9 (95% Confidence Interval (CI): 2.6, 3.1) and 2.8 points (95% CI: 2.4, 3.2) in the means of physical HRQOL score in the first and second cohorts respectively, and a 2.9-point (95% CI: 2.7, 3.1) and 3.1-point (95% CI: 2.7, 3.4) increase in the means of mental HRQOL score. A dose-dependent relationship was demonstrated between a quartile categorical mastery variable and both physical and mental HRQOL in both cohorts. Mastery was associated with all subscores of both physical and mental HRQOL. CONCLUSIONS: Greater mastery is associated with better physical and mental quality of life. Efforts to improve the sense of self control and agency of people with MS may have benefits for their quality of life, even despite clinical features of the illness.

Skills, expertise and role of Australian emergency clinicians in caring for people with advanced cancer.

OBJECTIVES: To explore the views of Australian emergency department (ED) clinicians about their skills, role and expertise in caring for people with advanced cancer. METHODS: A cross-sectional electronic survey of doctors and nurses working in Australian EDs was undertaken. Comparisons were made by demographics and whether respondents had received palliative care education. RESULTS: The sample comprised 444 doctors (response rate 13.5%), the majority Fellows (emergency medicine specialists) of the Australasian College for Emergency Medicine, and 237 nurses, from all states, territories and regions (metropolitan and regional). A minority (n=123, 20.6%) felt that the ED was not an appropriate place for patients with advanced cancer to present for acute care, while almost two-thirds (n=397, 64.8%) found caring for such patients rewarding, particularly nurses and those who had received palliative care education; very few (n=40, 6.5%) reported feeling uncomfortable talking to the families of dying patients. A minority (n=129, 21.0%) felt that it was not appropriate for junior medical staff to assess these patients, nurses much more than doctors (42.9% vs 8.5%, p<0.001). Over half (n=338, 55.1%) felt sufficiently skilled in managing pain for people with advanced cancer, with Fellows, more experienced doctors, and those who had received palliative care education more likely to feel skilled. CONCLUSIONS: ED clinicians in Australia, particularly those who have received palliative care education, feel comfortable and adequately skilled in managing people with advanced cancer presenting to EDs, and most find it rewarding. The importance of palliative care education to emergency clinicians' training should be recognised.

Potential donor families' experiences of organ and tissue donation-related communication, processes and outcome.

We aimed to describe the experiences of families of potential organ and tissue donors eligible for donation after circulatory death or brain death. Forty-nine family members of potential donors from four Melbourne hospitals were interviewed to assess their experiences of communication, processes and the outcomes of donation. Interviews were recorded, transcribed verbatim and analysed thematically. Families expressed a range of perspectives on themes of communication, hospital processes and care, the processes of consent and donation and reflected on decisions and outcomes. They expressed satisfaction overall with communication when receiving bad news, discussing death and donation. Honest and frank communication and being kept up-to-date and prepared for potential outcomes were important aspects for families, especially those of post circulatory death donors. Participants reported high levels of trust in healthcare professionals and satisfaction with the level of care received. Many donor families indicated the process was lengthy and stressful, but not significantly enough to adversely affect their satisfaction with the outcome. Both the decision itself and knowing others' lives had been saved provided them with consolation. No consenting families, and only some non-consenting families, regretted their decisions. Many expressed they would benefit from a follow-up opportunity to ask questions and clarify possible misunderstandings. Overall, while experiences varied, Australian families valued frank communication, trusted health professionals, were satisfied with the care their family member received and with donation processes, despite some apparent difficulties. Family satisfaction, infrequently assessed, is an important outcome and these findings may assist education for Australian organ donation professionals.

Understanding Australian families' organ donation decisions.

Numbers of deceased organ donors in Australia have increased, but rates of consent to donation remain at around 60%. Increasing family consent is a key target for the Australian Organ and Tissue Authority. Reasons for donation decisions have been reported in the international literature, but little is known of reasons for Australian families' decisions. Potential organ donors in four Melbourne hospitals were identified and 49 participants from 40 families (23 consenting and 17 non-consenting) were interviewed to understand reasons for consent decisions. Themes for consent to organ donation included that: donation was consistent with the deceased's explicit wishes or known values, the desire to help others or self-including themes of altruism, pragmatism, preventing others from being in the same position, consolation received from donation and aspects of the donation conversation and care that led families to believe donation was right for them. Themes for non-consent included: lack of knowledge of wishes; social, cultural and religious beliefs; factors related to the donation process and family exhaustion; and conversation factors where negative events influenced decisions. While reasons for consent were similar to those described in international literature, reasons for non-consent differed in that there was little emphasis on lack of trust of the medical profession, concerns regarding level of care provided to the potential donor, preserving the deceased's body, fears of body invasion or organ allocation fairness.

Suicide risk assessment in Australian emergency departments: assessing clinicians' disposition decisions.

Objective. To determine (1) the uniformity of disposition decisions made by clinicians working in Australian emergency departments (EDs) using vignettes describing patients presenting with deliberate self-harm or suicide risk; (2) factors associated with these decisions; (3) factors associated with confidence in these decisions. Methodology. We validated and distributed by email an online survey tool to Australian emergency clinicians via their colleges. Participants were presented with five vignettes and asked to rate the level of risk and protective factors for suicide, the patient's disposition (admit/discharge/review), factors influencing this decision, their confidence in the decision, and factors that would have improved their confidence. Results. Percentages of participants choosing the modal disposition decision for each scenario ranged from 58.6% (136/232) to 92.4% (220/238), demonstrating uniformity in clinicians' disposition decisions. Predictors of disposition were consistently level of risk factors perceived and, infrequently, clinician factors including age and years experience. Confidence in disposition decisions was high across scenarios. Clinicians reported patient, clinician, contextual and decision support factors relevant to an Australian emergency context affected their disposition decisions and confidence in decisions. Conclusion. Emergency clinicians are uniform and confident in their disposition decisions for patient vignettes where there is risk of suicide or self harm.

Prevalence of and risk factors for peripheral arterial disease in older adults in an Australian emergency department.

The aim of the paper is to estimate the prevalence of symptomatic and asymptomatic peripheral arterial disease (PAD) in emergency department (ED) patients aged 50 years or more and to identify associated clinical and demographic factors. A prospective cross-sectional study was conducted at a single ED. The main outcome was estimated prevalence of PAD (ankle brachial index <0.9 in either leg). Demographic and clinical history data were collected. The San Diego Claudication Questionnaire (SDCQ), the Intermittent Claudication Questionnaire (ICQ) and the Kessler Psychological Distress Scale (K10) were also administered. Participants with a positive diagnosis of PAD were referred for further management and followed up by telephone. A total of 329 ED patients aged >50 years were screened. PAD prevalence was 10.3% (95% Cl 7.5-14.1%). The prevalence of symptomatic and asymptomatic PAD was 6.4% (95% CI 4.2-9.6%) and 3.9% (95% Cl 2.3-6.7%), respectively. PAD prevalence increased significantly with age rising to 25.7% (95% Cl 17.0-36.7) among those 180 years. Multivariate analyses revealed that being aged 180 years (odds ratio [OR] 5.97,95% CI 2.74-13.02), having a history of angina (OR 3.034, 95% CI 1.35-6.80) and being a former smoker (2.77, 95% CI 1.23-6.22) were the strongest predictors of PAD. In conclusion, targeted screening for PAD among the older ED population identifies ED patients with PAD.

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.