The Fifth International Survey of Critical Care Nursing Organizations: Implications for Policy.

PURPOSE: To examine the activities, concerns, and expectations of critical care nurses and professional critical care nursing organizations worldwide. DESIGN: A descriptive survey methodology was used. This study is the fifth worldwide quadrennial review of its type to monitor variations in critical care nursing needs and provide robust evidence to inform policy related to critical care nursing practice. METHODS: The fifth World Federation of Critical Care Nurses international survey of critical care nursing organizations was emailed to potential participants from countries with critical care nursing organizations or known critical care nurse leaders. Data were collected online. Responses were entered into SPSS version 23 software (IBM Corp., Armonk, NY, USA) and analyzed by geographical region and national wealth group. FINDINGS: Eighty-two national representative respondents participated in the survey, of whom two thirds (n = 56, 68%) had an established critical care nursing organization in their country. The five most important issues identified were working conditions, teamwork, staffing levels, the need for formal practice guidelines and competencies, and wages. The top five critical care nursing organization services that were considered to be of most importance were professional representation, as well as provision of workshops and education forums, national conferences, practice standards and guidelines, and local conferences. The most important contributions expected from the World Federation of Critical Care Nurses were standards for clinical practice and professional practice, international conferences, professional representation, and study and education grants. CONCLUSIONS: The results highlight priority areas for critical care nursing and reinforce the need to address factors that can inform critical care nursing policy and practice. Results of this survey should be incorporated into strategic action plans at the national and international levels. CLINICAL RELEVANCE: Nursing leaders, policymakers, and other interested stakeholders should consider these findings when planning critical care workforce requirements. Interested parties should work collaboratively to inform recommendations for further policy and action.

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.

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.

Evaluation of the impact of implementation of a Medical Assessment and Planning Unit on length of stay.

OBJECTIVE: The Medical Assessment and Planning Unit (MAPU) model provides a multidisciplinary and 'front end loading' approach to acute medical care. The objective of this study was to evaluate the impact of a 10-bed MAPU in Royal Melbourne Hospital (RMH) on hospital length of stay. METHODS: A pre-post study design was used. Cases were defined as all general medical patients admitted to the RMH between 1 August 2003 and 31 January 2004. MAPU patients were defined as general medical patients who had been discharged from RMH MAPU unit as part of their RMH inpatient admission. Historical controls were defined as all general medical patients admitted to the RMH between 1 August 2002 and 31 January 2003. RESULTS: There was a reduction in median length of stay that did not reach statistical significance. During the study period, median emergency department length of stay for MAPU patients was 10.3 h compared with 13.2 h for non-MAPU patients who were admitted directly to general wards. CONCLUSIONS: The reductions in length of stay are likely to be of clinical significance at the emergency department (ED) level. The MAPU model also contributes to providing care appropriate care for older admitted patients.