Mortality and readmission differences associated with after-hours hospital admission: A population-based cohort study in Queensland Australia.

Background and Aims: Policy makers and health system managers are seeking evidence on the risks involved for patients associated with after-hours care. This study of approximately 1 million patients who were admitted to the 25 largest public hospitals in Queensland Australia sought to quantify mortality and readmission differences associated with after-hours hospital admission. Methods: Logistic regression was used to assess whether there were any differences in mortality and readmissions based on the time inpatients were admitted to hospital (after-hours versus within hours). Patient and staffing data, including the variation in physician and nursing staff numbers and seniority were included as explicit predictors within patient outcome models. Results: After adjusting for case-mix confounding, statistically significant higher mortality was observed for patients admitted on weekends via the hospital's emergency department compared to within hours. This finding of elevated mortality risk after-hours held true in sensitivity analyses which explored broader definitions of after-hours care: an "Extended" definition comprising a weekend extending into Friday night and early Monday morning; and a "Twilight" definition comprising weekends and weeknights.There were no significant differences in 30-day readmissions for emergency or elective patients admitted after-hours. Increased mortality risks for elective patients was found to be an evening/weekend effect rather than a day-of-week effect. Workforce metrics that played a role in observed outcome differences within hours/after-hours were more a time of day rather than day of week effect, i.e. staffing impacts differ more between day and night than the weekday versus weekend. Conclusion: Patients admitted after-hours have significantly higher mortality than patients admitted within hours. This study confirms an association between mortality differences and the time patients were admitted to hospital, and identifies characteristics of patients and staffing that affect those outcomes.

An Applicant's Residency Program Region May Influence Where They Complete Fellowship.

The primary goal of this study was to determine if an applicant's geographic region of residency was associated with where they matched for fellowship. San Francisco Match (SF Match) provided results regarding applicant data and match results from 2014-2018 for orthopaedic subspecialties except hand and shoulder and elbow. Residency programs were divided into five regions: (Northeast [NE], Southeast [SE], Midwest [MW], Southwest [SW] and West [W]). The MW region had the fewest number of fellowship positions per applicant (0.62), the W region had the most (1.7). Applicants from each region were significantly (p < 0.0001) more likely to complete fellowship in the same region where they completed residency, and there were significant (p < 0.05) differences between regions for specific subspecialties. There are imbalances in terms of the number of applicants and specific fellowship spots available in each region. This imbalance seems important considering the strong associations found between the region in which an applicant completes residency and fellowship. Level of Evidence: Level 3. (Journal of Surgical Orthopaedic Advances 30(1):030-035, 2021).

After-hours emergency department care: Does time or day of arrival affect survival?

OBJECTIVE: To determine whether after-hours presentation to EDs is associated with differences in 7-day and 30-day mortality. The influence of patient case-mix and workforce staffing differences are also explored. METHODS: We conducted a retrospective observational study of 3.7 million ED episodes across 30 public hospitals in Queensland, Australia during May 2013-September 2015 using routinely collected hospital data linked to hospital staffing data and the death registry. Episodes were categorised as within/after-hours using time of presentation. Staffing was derived from payroll records and explored by defining 11 staffing ratios. RESULTS: Weekend presentation was slightly more associated (7-day mortality odds ratio 1.05, 95% confidence interval [CI] 1.01-1.10) or no more associated (30-day mortality odds ratio 1.01, 95% CI 0.98-1.03) with death than weekday presentation. When weeknights are included in the 'after-hours' period, odds ratios are smaller, so that after-hours presentation is no more associated (7-day mortality odds ratio 1.03, 95% CI 0.99-1.08) or less associated (30-day mortality odds ratio 0.95, 95% CI 0.93-0.97) with death. No significant after-hours patient case-mix differences were observed between weekday and weekend presentations for 7-day mortality. In other combinations of outcome and after-hours definition, some differences (especially measures relating to severity of presenting condition) were found. Staffing ratios were not strongly associated with any within/after-hours differences in ED mortality. CONCLUSIONS: After-hours presentation on the weekend to an ED is associated with higher 7-day mortality even after controlling for case-mix.

Trends in opioid prescribing in Australia: a systematic review.

Objective This review systematically identified studies that estimated the prevalence of prescription opioid use in Australia, assessed the prevalence estimates for bias and identified areas for future research. Methods Literature published after 2000 containing a potentially representative estimate of prescription opioid use in adults, in the community setting, in Australia was included in this review. Studies that solely assessed opioid replacement, illicit opioid usage or acute hospital in-patient use were excluded. Databases searched included PubMed, EMBASE, Web of Science and the grey literature. Results The search identified 2253 peer-reviewed publications, with 34 requiring full-text review. Of these, 20 were included in the final qualitative analysis, in addition to four publications from the grey literature. Most studies included analysed prescription claims data for medicines dispensed via Australia's national medicines subsidy scheme (the Pharmaceutical Benefits Scheme). Although data sources were good quality, all prevalence estimates were at least at moderate risk of bias, predominantly due to incompleteness of data or potential confounding. Included publications demonstrated a significant rise in opioid use up to 2017 (including a 15-fold increase in prescriptions dispensed over the 20 years to 2015), predominantly driven by a sharp rise in oxycodone use. Although opioid prescription numbers continue to escalate, usage, as measured by oral morphine equivalent per capita, may have plateaued since 2014. Codeine remains the most prevalently obtained opioid, followed by oxycodone and tramadol. There was a substantial delay (median 30 months; interquartile range 20-37 months) to publication of opioid usage data from time of availability. Conclusions Australia has experienced a marked increase in opioid prescribing since the 1990s. Current published literature is restricted to incomplete, delayed and historical data, limiting the ability of clinicians and policy makers to intervene appropriately. What is known about the topic? Opioid prescriptions in Australia have continued to increase since the 1990s and may be mirroring the epidemic being seen in the US. What does this paper add? This paper systematically identifies all publications that have examined the prevalence of prescription opioid use in Australia since 2000, and only identified prevalence estimates that were at moderate or high risk of bias, and found significant delays to publication of these estimates. What are the implications for practitioners? Because published literature on the prevalence of prescription opioid consumption is restricted to incomplete, delayed and historical data, the ability of clinicians and policy makers to appropriately intervene to curb prescription opioid use is limited. A national policy of real-time monitoring and reporting of opioid prescribing may support improvements in practice.

How the Reputation of Orthopaedic Residency Programs Is Associated with Orthopaedic Fellowship Match Results.

BACKGROUND: The primary goal of the present study was to determine if applicants from higher-ranking U.S. orthopaedic surgery residency programs match at a more desired position on their fellowship match-rank list compared with those applicants from lower-ranked residency programs. METHODS: San Francisco Match provided results regarding applicant data and match results from 2014 to 2018 for all orthopaedic subspecialties except the hand and the shoulder and elbow. Unmatched applicants and international medical graduates were excluded. Residency programs were divided into 5 tiers (with tier 1 being the highest-ranked residency programs and tier 5 being the lowest-ranked programs) on the basis of 2018 Doximity rankings of orthopaedic residency programs. Statistical analysis consisted of descriptive statistics, chi-square tests, and analysis of variance. RESULTS: Two thousand eight hundred and eleven applicants met inclusion criteria. Applicants from residency programs in tiers 1 and 2 applied to significantly fewer programs than those from tiers 3, 4, or 5 (p < 0.0001). Applicants from each tier were significantly more likely to attain interviews than applicants from all tiers below them (p < 0.01). Applicants from tier-1 residency programs matched at a significantly higher position on their rank list (p < 0.001) and were more desirably ranked by fellowship programs (p = 0.003) compared with all other tiers. CONCLUSIONS: Applicants from the highest-ranking residency programs apply to fewer programs, interview at a greater percentage of these programs, and are more likely to match to 1 of their top-ranking programs than applicants from lower-ranking programs. However, the association of the applicant match position with the program ranking appears to be most pronounced when it comes to fellowships selecting which applicants to interview. These findings may help future applicants when determining which programs to apply to during the match.

Controlled substance prescribing and education in orthopedic residencies: A program director survey.

BACKGROUND: Opioid misuse is currently plaguing the US. Efforts to reduce this include opioid prescribing education (OPE). Orthopaedic residents often prescribe opioids but, their education is unknown. METHODS: A survey was sent to orthoapedic residency program directors (PDs) regarding their program's controlled substance (CS) policies and knowledge of local CS regulations. RESULTS: There were 60 (36.8%) completed surveys. 54 (90.0%) programs allow resident outpatient opioid prescribing. Nine (16.7%) programs require individual DEA registration and 7 (13.0%) were unsure about DEA registrations. State laws regarding PDMP utilization and OPE for fully licensed physicians were correctly answered by 52 (86.7%) and 43 (71.6%), respectively. 27 (45.0%) programs had a mandatory OPE. Six (10.0%) PDs were unsure about a mandatory OPE. 16 (48.5%) programs that did not confirm an OPE were considering adding one. CONCLUSIONS: The majority of programs permit residents outpatient opioid prescribing; less than half provide mandatory OPE. Several PDs were unaware local CS prescribing regulations and education. This study demonstrates opportunities to improve OPE among orthopaedic residencies and PDs' knowledge regarding CS regulations.

Affecting emergency department oxycodone discharge prescribing: An educational intervention.

OBJECTIVE: To describe the impact of an educational intervention for ED prescribers on discharge oxycodone prescribing both for the number of oxycodone prescriptions per 1000 discharged patients, and the number of tablets per prescription. Secondary outcomes included the quality of general practitioner communication. METHODS: An interrupted time series assessment was conducted in the ED of a tertiary referral hospital to establish the pre-intervention, peri-intervention and post-intervention prescribing profile of ED medical practitioners. Prescriber numbers were used to obtain drug data for all oxycodone-containing prescriptions from the Queensland Health Medicines Regulation and Quality Unit database. The intervention included education sessions, a staff information email, posters within the ED, and a patient brochure. It was conducted with relevant nurses, pharmacists and prescribing doctors. RESULTS: In the pre-intervention period, 656/17 371 (38 per 1000) discharged patients were prescribed oxycodone, compared to 180/5938 (30 per 1000) during the intervention, and 602/20 505 (29 per 1000) post-intervention. This equated to a decrease of 8 per 1000 (95% CI 5-12 per 1000) and a 22% (95% CI 13-31%) relative prescribing reduction. The mean total number of tablets of oxycodone per prescription decreased from 16.7 (SD 16.5) pre-intervention, to 12.7 (SD 6.0) peri-intervention, to 10.7 (SD 5.2) post-intervention. After the intervention, there was an increase in discharge communications to general practitioners by 15.4% (95% CI 9.7-21.1%). CONCLUSIONS: An ED prescriber-targeted intervention reduced overall prescribing of oxycodone and improved communication at discharge. The prescribing intervention is one strategy that may be used by ED medical staff to improve patient safety and opioid stewardship in Australia.

Review article: Best practice management of neck pain in the emergency department (part 6 of the musculoskeletal injuries rapid review series).

Neck pain and whiplash injuries are a common presentation to the ED, and a frequent cause of disability globally. This rapid review investigated best practice for the assessment and management of musculoskeletal neck pain in the ED. PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites, were searched in 2017. Primary studies, systematic reviews and guidelines were considered for inclusion. English-language articles published in the past 12 years addressing acute neck pain assessment, management or prognosis in the ED were included. Data extraction was conducted, followed by quality appraisal to rate levels of evidence where possible. The search revealed 2080 articles, of which 51 were included (n = 22 primary articles, n = 13 systematic reviews and n = 16 guidelines). Consistent evidence was found to support the use of 'red flags' to screen for serious pathologies, judicious use of imaging through clinical decision rule application and promotion of functional exercise coupled with advice and reassurance. Clinicians may also consider applying risk-stratification methods, such as using a clinical prediction rule, to guide patient discharge and referral plans; however, the evidence is still emerging in this population. This rapid review provides clinicians managing neck pain in the ED a summary of the best available evidence to enhance quality of care and optimise patient outcomes.

Understanding ED performance after the implementation of activity-based funding.

OBJECTIVE: The aim of this study was to describe emergency department (ED) activities and staffing after the introduction of activity-based funding (ABF) to highlight the challenges of new funding arrangements and their implementation. METHODS: A retrospective study of public hospital EDs in Queensland, Australia, was undertaken for 2013-2014. The ED and hospital characteristics are described to evaluate the alignment between activity and resourcing levels and their impact on performance. RESULTS: Twenty EDs participated (74% response rate). Weighted activity units (WAUs) and nursing staff varied based on hospital type and size. Larger hospital EDs had on average 9076 WAUs and 13 full time equivalent (FTE) nursing staff per 1000 WAUs; smaller EDs had on average 4587 WAUs and 10.3 FTE nursing staff per 1000 WAUs. Medical staff was relatively consistent (8.1-8.7 FTE per 1000 WAUs). The proportion of patients admitted, discharged, or transferred within 4 hours ranged from 73% to 79%. The ED medical and nursing staffing numbers did not correlate with the 4-hour performance. CONCLUSION: Substantial variation exists across Queensland EDs when resourcing service delivery in an activity-based funding environment. Historical inequity persists in the staffing profiles for regional and outer metropolitan departments. The lack of association between resourcing and performance metrics provides opportunity for further investigation of efficient models of care.

The ED-inpatient dashboard: Uniting emergency and inpatient clinicians to improve the efficiency and quality of care for patients requiring emergency admission to hospital.

Patients who require emergency admission to hospital require complex care that can be fragmented, occurring in the ED, across the ED-inpatient interface (EDii) and subsequently, in their destination inpatient ward. Our hospital had poor process efficiency with slow transit times for patients requiring emergency care. ED clinicians alone were able to improve the processes and length of stay for the patients discharged directly from the ED. However, improving the efficiency of care for patients requiring emergency admission to true inpatient wards required collaboration with reluctant inpatient clinicians. The inpatient teams were uninterested in improving time-based measures of care in isolation, but they were motivated by improving patient outcomes. We developed a dashboard showing process measures such as 4 h rule compliance rate coupled with clinically important outcome measures such as inpatient mortality. The EDii dashboard helped unite both ED and inpatient teams in clinical redesign to improve both efficiencies of care and patient outcomes.

The National Emergency Access Target (NEAT) and the 4-hour rule: time to review the target.

OBJECTIVE: We explored the relationship between the National Emergency Access Target (NEAT) compliance rate, defined as the proportion of patients admitted or discharged from emergency departments (EDs) within 4 hours of presentation, and the risk-adjusted in-hospital mortality of patients admitted to hospital acutely from EDs. DESIGN, SETTING AND PARTICIPANTS: Retrospective observational study of all de-identified episodes of care involving patients who presented acutely to the EDs of 59 Australian hospitals between 1 July 2010 and 30 June 2014. MAIN OUTCOME MEASURE: The relationship between the risk-adjusted mortality of inpatients admitted acutely from EDs (the emergency hospital standardised mortality ratio [eHSMR]: the ratio of the numbers of observed to expected deaths) and NEAT compliance rates for all presenting patients (total NEAT) and admitted patients (admitted NEAT). RESULTS: ED and inpatient data were aggregated for 12.5 million ED episodes of care and 11.6 million inpatient episodes of care. A highly significant (P < 0.001) linear, inverse relationship between eHSMR and each of total and admitted NEAT compliance rates was found; eHSMR declined to a nadir of 73 as total and admitted NEAT compliance rates rose to about 83% and 65% respectively. Sensitivity analyses found no confounding by the inclusion of palliative care and/or short-stay patients. CONCLUSION: As NEAT compliance rates increased, in-hospital mortality of emergency admissions declined, although this direct inverse relationship is lost once total and admitted NEAT compliance rates exceed certain levels. This inverse association between NEAT compliance rates and in-hospital mortality should be considered when formulating targets for access to emergency care.

The Ethical Imperative to Move to a Seven-Day Care Model.

Whilst the nature of human illness is not determined by time of day or day of week, we currently structure health service delivery around a five-day delivery model. At least one country is endeavouring to develop a systems-based approach to planning a transition from five- to seven-day healthcare delivery models, and some services are independently instituting program reorganization to achieve these ends as research, amongst other things, highlights increased mortality and morbidity for weekend and after-hours admissions to hospitals. In this article, we argue that this issue does not merely raise instrumental concerns but also opens up a normative ethical dimension, recognizing that clinical ethical dilemmas are impacted on and created by systems of care. Using health policy ethics, we critically examine whether our health services, as currently structured, are at odds with ethical obligations for patient care and broader collective goals associated with the provision of publicly funded health services. We conclude by arguing that a critical health policy ethics perspective applying relevant ethical values and principles needs to be included when considering whether and how to transition from five-day to seven-day models for health delivery.

Report on the 4-h rule and National Emergency Access Target (NEAT) in Australia: time to review.

Objective The aim of the present study was to provide a summary of a systematic review of literature reporting benefits and limitations of implementing National Emergency Access Target (NEAT), a target stipulating that a certain proportion of patients presenting to hospital emergency departments are admitted or discharged within 4h of presentation. Methods A systematic review of published literature using specific search terms, snowballing techniques applied to retrieved references and Google searches was performed. Results are presented as a narrative synthesis given the heterogeneity of included studies. Results Benefits of a time-based target for emergency care are improved timeliness of emergency care and reduced in-hospital mortality for emergency admissions to hospital. Limitations centre on using a process measure (time) alone devoid of any monitoring of patient outcomes, the threshold nature of a time target and the fact that currently NEAT combines the measurement of clinical management of two very different patient cohorts seeking emergency care: less acute patients discharged home and more acute patients admitted to hospital. Conclusions Time-based access targets for emergency presentations are associated with significant improvements in in-hospital mortality for emergency admissions. However, other patient-important outcomes are deserving of attention, choice of targets needs to be validated by empirical evidence of patient benefit and single targets need to be partitioned into separate targets pertaining to admitted and discharged patients. What is known about the topic? Time targets for emergency care originated in the UK. The introduction of NEAT in Australia has been controversial. NEAT directs that a certain proportion of patients will be admitted or discharged from an emergency department (ED) within 4h. Recent dissolution of the Australian National Partnership Agreement (which provided hospitals with financial incentives for achieving NEAT compliance) has prompted a re-examination of the 4-h rule, the evidence underpinning its introduction and its benefits and risks to patients What does this paper add? This paper is executive summary of key findings from a systematic literature review on the benefits and limitations of NEAT (the 4-h rule) commissioned by the Queensland Clinical Senate to inform future policy and targets. What are the implications for practitioners? There is evidence that a time-based target has been associated with a reduction in in-hospital mortality for emergency admissions to Australian hospitals. Concerns remain regarding a time-based target alone being used to drive redesign efforts at improving access to emergency care. A time-based target should be coupled with close monitoring of patient outcomes of emergency care. Target thresholds need to be evidence based and separate targets should be reported for admitted, discharged and all patients presenting to the ED.

Review article: Emergency department models of care in the context of care quality and cost: a systematic review.

To identify current ED models of care and their impact on care quality, care effectiveness, and cost. A systematic search of key health databases (Medline, CINAHL, Cochrane, EMbase) was conducted to identify literature on ED models of care. Additionally, a focused review of the contents of 11 international and national emergency medicine, nursing and health economic journals (published between 2010 and 2013) was undertaken with snowball identification of references of the most recent and relevant papers. Articles published between 1998 and 2013 in the English language were included for initial review by three of the authors. Studies in underdeveloped countries and not addressing the objectives of the present study were excluded. Relevant details were extracted from the retrieved literature, and analysed for relevance and impact. The literature was synthesised around the study's main themes. Models described within the literature mainly focused on addressing issues at the input, throughput or output stages of ED care delivery. Models often varied to account for site specific characteristics (e.g. onsite inpatient units) or to suit staffing profiles (e.g. extended scope physiotherapist), ED geographical location (e.g. metropolitan or rural site), and patient demographic profile (e.g. paediatrics, older persons, ethnicity). Only a few studies conducted cost-effectiveness analysis of service models. Although various models of delivering emergency healthcare exist, further research is required in order to make accurate and reliable assessments of their safety, clinical effectiveness and cost-effectiveness.

Funding emergency care: Australian style.

The ongoing challenge for ED leaders is to remain abreast of system-wide changes that impact on the day-to-day management of their departments. Changes to the funding model creates another layer of complexity and this introductory paper serves as the beginning of a discussion about the way in which EDs are funded and how this can and will impact on business decisions, models of care and resource allocation within Australian EDs. Furthermore it is evident that any funding model today will mature and change with time, and moves are afoot to refine and contextualise ED funding over the medium term. This perspective seeks to provide a basis of understanding for our current and future funding arrangements in Australian EDs.