From little things, big things grow: An exploratory analysis of the national cost of peripheral intravenous catheter insertion in Australian adult emergency care.

OBJECTIVE: To estimate the total economic impact of peripheral intravenous catheter (PIVC) or cannula insertion and use in adult Australian EDs, including those cannulas that remain unused for therapeutic purposes. METHODS: Searches on Australian government websites were conducted to find rates of insertion, complications and cost of cannula; following this, gaps in national data sets were filled with MEDLINE and PubMed searches to estimate the total cost of cannula use in Australian EDs. Once the data were collected, totals were combined to establish an estimated cost for the listed categories. RESULTS: The estimated cost of cannulation in Australia may be up to A$594 million per year, including the cost of insertion (equipment and staff), cost of complications such as Staphylococcus aureus bacteraemia and phlebitis, and patient-centred costs (lost patient productivity, infiltration, occlusion and dislodgement). Approximately A$305.9 million is attributed to unused cannulas and approximately 11 790 days of clinician time is spent annually inserting cannula that remains idle. CONCLUSION: The figures developed in the present study represent an important educational opportunity to encourage thoughtful consideration of all interventions, no matter how small. ED cannula insertion represents a large economic and health cost to Australia's health system, many of which remain unused. There are no national data sets that record complications associated with PIVCs and we highlight the urgent need for improved data.

Examining the translational success of an initiative to accelerate the assessment of chest pain for patients in an Australian emergency department: a pre-post study.

BACKGROUND: The Improved assessment of chest pain trial (IMPACT) protocol is an accelerated strategy for the risk stratification and management of patients presenting to the emergency department (ED) with chest pain. This study sought to describe the adoption, sustainability and health services implications of implementing the IMPACT protocol. METHODS: This was a study of adult patients in a large Australian tertiary hospital who had serial troponin testing commenced within the ED. Data from two periods were utilized; the pre-implementation period (8th April 2012 to 5th April 2014) and the post-implementation period (6th April 2014 to 2nd April 2016). The primary outcome was the proportion of patients undergoing accelerated care. Secondary endpoints were ED assessment time, hospital length of stay, and costs. Data were compared in the pre- and post-implementation periods. RESULTS: The proportion of patients receiving accelerated care increased from 3% in the pre- to 34% in the post-intervention period. This increase occurred rapidly after implementation of IMPACT and was sustained over a 2-year period. For patients with troponin concentrations <99th percentile, the mean ED assessment time reduced from 12.3 h in the pre- to 10.1 h in the post-implementation period. Mean hospital length of stay was similar in the pre- and post-implementation periods (82.4 and 80.9 h). The average cost of chest pain assessment reduced from $3520 pre implementation to $3204 post implementation; a $316 reduction per patient. CONCLUSIONS: The IMPACT protocol was rapidly adopted and utilised after implementation into standard care. The initial increase in the proportion of patients undergoing accelerated assessment, followed by a plateau towards the end of the study period indicate adoption and sustainability of the IMPACT protocol over a two-year period. Modest reductions in length of stay and cost were seen after implementation. Given the large number of patients investigated for chest pain, such reductions may have substantial impact on the overall healthcare system.

Facilitators and barriers for emergency department clinicians using a rapid chest pain assessment protocol: qualitative interview research.

BACKGROUND: Guideline-based processes for the assessment of chest pain are lengthy and resource intensive. The IMProved Assessment of Chest Pain Trial (IMPACT) protocol was introduced in one Australian hospital Emergency Department (ED) to more efficiently risk stratify patients. The theoretical domains framework is a useful approach to assist in identifying barriers and facilitators to the implementation of new guidelines in clinical practice. The aim of this study was to understand clinicians' perceptions of facilitators and barriers to the use of the IMPACT protocol. METHODS: Guided by the theoretical domains framework, semi-structured interviews with nine ED clinical staff (medical and nursing) were undertaken in 2016. Content analysis was conducted independently by two researchers to identify those theoretical domains that facilitated or hindered protocol use. RESULTS: Domains most often reported as fundamental to the use of the IMPACT protocol included 'social/professional role and identity', 'environmental context and resources' and 'social influences'. These factors seemingly influenced professional confidence, with participants noting 'goals' that included standardisation of practice, enhanced patient safety, and reduced need for unnecessary testing. The domain 'environmental context and resources' also contained the most noted barrier - the need to inform new members of staff regarding protocol use. Opportunities to overcome this barrier included modelling of protocol use by staff at all levels and education - both formal and informal. CONCLUSIONS: A range of domains were identified by ED staff as influencing their chest pain management behaviour. Fundamental to its use were champions/leaders that were trusted and accessible, as well as social influences (other staff within ED and other specialty areas) that enabled and supported protocol use. Research investigating the implementation and perceived use of the protocol at other sites, of varied geographical locations, is warranted.

Engaging African Americans in Research: The Recruiter's Perspective.

Purpose: To examine barriers recruiters encounter when enrolling African American study participants, identify motivating factors to increase research participation, and provide recommendations to facilitate successful minority recruitment. Background: Recruiters are often the first point of contact between the research study and potential African American participants. While challenges in enrolling African Americans into clinical and epidemiologic research has been reported in numerous studies the non-physician recruiter's role as a determinant of overall participation rates has received minimal attention. Methods: We conducted four 90-minute teleconference focus groups with 18 recruiters experienced in enrolling African Americans for clinical and epidemiologic studies at five academic/medical institutions. Participants represented diverse racial and ethnic backgrounds and were asked to reflect on barriers preventing African Americans from participating in research studies, factors that motivated participation, and recommendations to increase participation of African Americans in research. Multi-coder and thematic data analysis was implemented using the Braun and Clarke method. Results: Prominent concerns in recruitment of African Americans in research include fear and mistrust and inflexible research protocols. The participants suggest that improved recruitment could be achieved through cross-cultural and skillset building training opportunities for recruiters, greater community engagement among researchers, and better engagement with clinic staff and research teams.

Improved Assessment of Chest pain Trial (IMPACT): assessing patients with possible acute coronary syndromes.

OBJECTIVE: To examine the safety and efficacy of the Improved Assessment of Chest pain Trial (IMPACT) protocol, a strategy for accelerated assessment of patients presenting to emergency departments (EDs) with chest pain. DESIGN, SETTING AND PARTICIPANTS: IMPACT was an intervention trial at a single tertiary referral hospital (Royal Brisbane and Women's Hospital) during February 2011 - March 2014. 1366 prospectively recruited patients presenting to the ED with symptoms of suspected acute coronary syndrome (ACS) were stratified into groups at low, intermediate or high risk of an ACS. INTERVENTION: High risk patients were treated according to NHFA/CSANZ guidelines. Low and intermediate risk patients underwent troponin testing (sensitive assay) 0 and 2 hours after presentation. Intermediate risk patients underwent objective testing after the second troponin test; low risk patients were discharged without further objective testing. MAIN OUTCOME MEASURES: The primary outcome was an ACS within 30 days of presentation. Secondary outcomes were ED and hospital lengths of stay (LOS). RESULTS: The IMPACT protocol stratified 244 (17.9%) patients to low risk, 789 (57.7%) to intermediate risk, and 333 (24.4%) to high risk categories. The overall 30-day ACS rate was 6.6%, but there were no ACS events in the low risk group, and 14 (1.8%) in the intermediate risk group. The median hospital LOS was 5.1 hours (IQR, 4.2-5.6 h) for low risk and 7.7 hours (IQR, 6.1-21 h) for intermediate risk patients. CONCLUSIONS: The IMPACT protocol safely and efficiently allowed a large proportion of patients presenting to EDs with chest pain to undergo accelerated assessment for risk of an ACS. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12611000206921.

Cost and outcomes of assessing patients with chest pain in an Australian emergency department.

OBJECTIVES: We sought to characterise the demographics, length of admission, final diagnoses, long-term outcome and costs associated with the population who presented to an Australian emergency department (ED) with symptoms of possible acute coronary syndrome (ACS). DESIGN, SETTING AND PARTICIPANTS: Prospectively collected data on ED patients presenting with suspected ACS between November 2008 and February 2011 was used, including data on presentation and at 30 days after presentation. Information on patient disposition, length of stay and costs incurred was extracted from hospital administration records. MAIN OUTCOME MEASURES: Primary outcomes were mean and median cost and length of hospital stay. Secondary outcomes were diagnosis of ACS, other cardiovascular conditions or non-cardiovascular conditions within 30 days of presentation. RESULTS: An ACS was diagnosed in 103 (11.1%) of the 926 patients recruited. 193 patients (20.8%) were diagnosed with other cardiovascular-related conditions and 622 patients (67.2%) had non-cardiac-related chest pain. ACS events occurred in 0 and 11 (1.9%) of the low-risk and intermediate-risk groups, respectively. Ninety-two (28.0%) of the 329 high-risk patients had an ACS event. Patients with a proven ACS, high-grade atrioventricular block, pulmonary embolism and other respiratory conditions had the longest length of stay. The mean cost was highest in the ACS group ($13 509; 95% CI, $11 794-$15 223) followed by other cardiovascular conditions ($7283; 95% CI, $6152-$8415) and non-cardiovascular conditions ($3331; 95% CI, $2976-$3685). CONCLUSIONS: Most ED patients with symptoms of possible ACS do not have a cardiac cause for their presentation. The current guideline-based process of assessment is lengthy, costly and consumes significant resources. Investigation of strategies to shorten this process or reduce the need for objective cardiac testing in patients at intermediate risk according to the National Heart Foundation and Cardiac Society of Australia and New Zealand guideline is required.