Involuntary Patient Assessment in Australia: A Mental Health or Public Health Response?

Involuntary assessment relates to detaining and transporting a person at risk of harming themselves or others, and without their consent, to hospital for examination and treatment. State and Territory statutory authorities generally allow police, paramedics and/or health practitioners to initiate involuntary assessment. Because of the stigma attached to mental illness, and to protect people from harming themselves or others in broader circumstances than mental illness alone, the Queensland government changed involuntary assessment powers. Instead of mental health legislation governing involuntary assessment in Queensland, this is now a public health function. Despite the best intentions, the public health legislation does not address some of the practical challenges of involuntary assessment for health practitioners. This article explores the evolution of involuntary assessment powers in Australia and considers the impacts of it becoming a public health power in Queensland.

Diabetic ketoacidosis presentations in a low socio-economic area: are services suitable?

BACKGROUND: Diabetic ketoacidosis causes a significant number of hospitalisations worldwide, with rates tending to increase with remoteness and socioeconomic disadvantage. Our study aimed to explore healthcare professionals' perceptions of factors affecting presentation of people with type 1 diabetes in a low socioeconomic area of Queensland, Australia. METHODS: This was a qualitative study. Individual semi-structured face-to-face or telephone interviews were completed with patients with type 1 diabetes who had presented in diabetic ketoacidosis, and healthcare professionals who have experience in related care. Data were analysed using Gibbs's framework of thematic analysis. RESULTS: Four patients with type 1 diabetes and 18 healthcare professionals were interviewed. Restricted access was identified as a factor contributing to diabetic ketoacidosis and delayed presentation, with ketone testing supplies, continuous glucose monitoring technology and transport considered barriers. Many of these factors were arguably preventable. Opportunities to improve the care available to patients with type 1 diabetes were detailed, with particularly strong support for dedicated out of hours telephone help lines for adults with type 1 diabetes. CONCLUSIONS: Gaps in support for patient self-care to avoid diabetic ketoacidosis presentations and prevent late presentation of diabetic ketoacidosis revealed by this study require service reconfiguration to support care delivery. Until change is made, people with type 1 diabetes will continue to make both avoidable and delayed, acutely unwell, presentations to Emergency Departments.

The development of a modified comprehensive geriatric assessment for use in the emergency department using a RAND/UCLA appropriateness method.

BACKGROUND: The universal screening and comprehensive assessment of older persons presenting to the emergency department is considered useful, yet is difficult to embed. A number of assessment instruments exist however they are not widely used and there is a lack of agreement between clinicians as to which tools are best suited to the emergency department. The aim of this study was to develop a modified comprehensive geriatric assessment using consensus methodology for use by the multidisciplinary team in the emergency department. METHOD: The modified comprehensive geriatric assessment was formulated using the RAND/UCLA appropriateness methodology incorporating consensus opinion from an expert group of clinicians and the best scientific evidence available. A series of pre and post survey and expert group meetings were held with expert multidisciplinary clinicians. Emphasis was placed on a pragmatic approach to the development of a document which reflected consensus opinion. RESULTS: Between nine and 15 expert group members participated in the stages of the process. A tiered approach incorporating different aspects of screening and/or assessments was considered optimal to reflect the stages of decision-making in the emergency department process. CONCLUSION: A unique approach to the screening and assessment of the frail older person was developed using consensus methodology to develop a modified comprehensive geriatric assessment for use in the emergency department. Associated actions and interventions are an important next step, with pilot site testing.

The Geriatric Emergency Department Intervention model of care: a pragmatic trial.

BACKGROUND: To evaluate a Geriatric Emergency Department Intervention (GEDI) model of service delivery for adults aged 70 years and older. METHODS: A pragmatic trial of the GEDI model using a pre-post design. GEDI is a nurse-led, physician-championed, Emergency Department (ED) intervention; developed to improve the care of frail older adults in the ED. The nurses had gerontology experience and education and provided targeted geriatric assessment and streamlining of care. The final format included 2.4 full time equivalent nurses working 7 days from 0700 h to 1730 h (1530 h at weekends). There were three implementations periods: pre-implementation (2012); a developmental phase from January 2013 to August 2015; and full implementation from September 2015 to August 2016. The outcomes measured were disposition (discharged home, admitted or died); ED length of stay; hospital length of stay; all cause in-hospital mortality within 28 days; time to ED re-presentation up to 28 days post-discharge; in-hospital costs. The setting was a tertiary hospital ED, with 385 beds, in Queensland, Australia. Approximately 53,000 patients presented to the ED annually with 20% aged 70 years and older. All patients over the age 70 who presented to the ED between January 2012 and August 2016 (n = 44,983) were included in the trial. RESULTS: Older persons who presented to the ED when the GEDI team were working had increased likelihoods of discharge (Hazard ratio (HR) = 1.19; 95% CI: 1.13-1.24) and reduced ED length of stay (HR = 1.42; 95% CI: 1.33-1.52) compared with those who presented when GEDI were not working. There was no increase in the risk of mortality (HR = 1.01; 95% CI = 0.23-4.43) or risk of same cause re-presentation to 28 days (HR = 1.21; 95% CI: 0.99-1.49). The GEDI service resulted in average cost savings per ED presentation of $35 [95% CI, $21, $49] and savings of $1469 [95% CI, $1105, $1834] per hospital admission. CONCLUSIONS: Implementation of a nurse-led physician-championed model of ED care, focused on frail older adults, reduced ED length of stay, hospital admission and if admitted, hospital length of stay and cost, without increasing mortality or same cause re-presentation. These increases were sustained over time and after the initial implementation team had changed roles. TRIAL REGISTRATION: Australian Clinical Trials Registration Number ACTRN12615001157561 - retrospectively registered on 29/10/2015. Data were retrieved via retrospective access to clinical information systems. First data access was on 1/7/2015.

Nurse-led multidisciplinary initiatives to improve outcomes and reduce hospital admissions for older adults: The Care coordination through Emergency Department, Residential Aged Care and Primary Health Collaboration project.

OBJECTIVES: This article describes the Care coordination through Emergency Department, Residential Aged Care and Primary Health Collaboration (CEDRiC) project. METHODS: CEDRiC is designed to improve the health outcomes for older people with an acute illness. It attempts this via enhanced primary care in residential aged care facilities, focused and streamlined care in the emergency department and enhanced intersectoral communication and referral. RESULTS: Implementing this approach has the potential to decrease inappropriate hospital admissions while improving care for older people in residential aged care and community settings. CONCLUSION: This article discusses an innovative way of caring for older adults in an ageing population utilising the existing evidence. A formal evaluation is currently underway.

The use of functional and cognitive assessment in the emergency department to inform decision making: A scoping review.

BACKGROUND: The use of functional and/or cognitive assessment in the emergency department (ED) to inform decision making in the complex older adult is considered important, yet not routinely administered. METHOD: Electronic databases were searched to identify eligible published research studies: older adults >65 years; the administration of a functional and/or cognition assessment instrument whilst the older adult is in any part of the ED; interventions resulting from the administration of the instrument; and a measured outcome post ED visit. A revised scoping review methodology was applied to chart study data and to identify key differences. RESULTS: Ten research studies were identified that met the criteria for review. There are a variety of assessments, aimed at different age groups, for several purposes and used at different times in the ED journey. Assessments are not being used in conjunction with routine medical assessment early in the ED patient journey. CONCLUSION: This scoping review identified no consistent suite of tools being administered in the ED to influence the disposition decision with measurable outcomes. Further research is required to identify a suite of assessment instruments suitable for use in the ED setting aimed at improving disposition decision making in the complex elderly person.

A structure, process and outcome evaluation of the Geriatric Emergency Department Intervention model of care: a study protocol.

BACKGROUND: Emergency departments are chaotic environments in which complex, frail older persons living in the community and residential aged care facilities are sometimes subjected to prolonged emergency department lengths of stay, excessive tests and iatrogenic complications. Given the ageing population, the importance of providing appropriate, quality health care in the emergency department for this cohort is paramount. One possible solution, a nurse-led, physician-championed, emergency department gerontological intervention team, which provides frontload assessment, early collateral communication and appropriate discharge planning, has been developed. The aim of this Geriatric Emergency Department Intervention is to maximise the quality of care for this vulnerable cohort in a cost effective manner. METHODS: The Geriatric Emergency Department Intervention research project consists of three interrelated studies within a program evaluation design. The research comprises of a structure, process and outcome framework to ascertain the overall utility of such a program. The first study is a pre-post comparison of the Geriatric Emergency Department Intervention in the emergency department, comparing the patient-level outcomes before and after service introduction using a quasi-experimental design with historical controls. The second study is a descriptive qualitative study of the structures and processes required for the operation of the Geriatric Emergency Department Intervention and clinician and patient satisfaction with service models. The third study is an economic evaluation of the Geriatric Emergency Department Intervention model of care. DISCUSSION: There is a paucity of evidence in the literature to support the implementation of nurse-led teams in emergency departments designed to target frail older persons living in the community and residential aged care facilities. This is despite the high economic and patient morbidity and mortality experienced in these vulnerable cohorts. This research project will provide guidance related to the optimal structures and processes required to implement the model of care and the associated cost related outcomes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registration Number is 12615001157561 . Date of registration 29 October 2015.

Review of triage reform: the case for national consensus on a single triage scale for clients with a mental illness in Australian emergency departments.

AIMS AND OBJECTIVES: The aim of this paper is to examine the use of mental health triage scales in Australian emergency departments (EDs) and to explore the use of the Australasian Triage Scale (ATS) with existing mental health triage scales. BACKGROUND: Since the introduction of mainstreaming and deinstitutionalisation in Australian mental health care, the number of clients presenting to Australian EDs has been increasing. It has become apparent that the lack of mental health descriptors in existing triage scales diminishes the ability of ED triage staff to accurately assess clients with a mental illness. In response to this, specialised mental health triage scales have been developed and introduced into practice. Concurrently, mental health descriptors have been incorporated into the ATS used across Australian EDs. DESIGN: A review of English language literature was conducted. METHOD: The data bases Proquest, Synergy and CINAHL were searched using the key words 'emergency department', 'triage', 'mental health' and again using the term 'emergency mental health triage'. RESULTS: There is a paucity of literature surrounding the use of mental health triage scales in Australian EDs; 18 articles were found to be directly relevant to the subject matter. CONCLUSION: Currently clients with a mental illness presenting to the ED may be triaged against one of four mental health triage scales. Research has shown that the mental health descriptors in the ATS are not as reliable as a specialised mental health triage scale. RELEVANCE TO CLINICAL PRACTICE: This has implications for clinical practice on two levels. First, it affects the initial triage assessment in the ED and the ability for mental health clinicians to respond in a timely manner and this will have an impact on clinical outcomes. Second, the use of the mental health triage criteria in the ATS may misrepresent ED workloads and affect data pertaining to ED performance.

Public support for anti-smoking legislation varies with smoking status.

OBJECTIVE: Rural Australians have higher rates of smoking than their urban counterparts, contributing to poorer health outcomes. In 2004, the Queensland Government introduced legislation to reduce the impact of environmental tobacco smoke on the community. The aims of the study were to describe smoking behaviours and associations between smoking behaviour and agreement with current anti-smoking laws. PARTICIPANTS: A total of 1208 people over the age of 18 years and living in rural, remote and very remote central Queensland participated in this telephone survey. RESULTS: About 22% (n = 130) of female and 21% of male (n = 125) participants identified themselves as smokers. No difference existed between the mean age of smokers (47.3 years) and non-smokers (47.1 years). While there is high level of support for smoking restrictions in public places (75%), attitudes vary with smoking status. Smokers were less likely than smokers to agree that the legislation would create a healthier environment, reduce exposure to passive smoking or agree that 'it is right to ban smoking in public places'. Smokers were significantly more likely to agree that the legislation had gone too far. CONCLUSION: The gradual implementation of the anti-smoking legislation is changing social beliefs on what are acceptable smoking practices. It is likely that the legislation within Queensland and the subsequent forced changes in social conditions for smokers will continue to reduce the number of people smoking and reduce exposure to environmental tobacco smoke.