The epidemiology of dying within 48 hours of presentation to emergency departments: a retrospective cohort study of older people across Australia and New Zealand.

BACKGROUND: Emergency department (ED) clinicians are more frequently providing care, including end-of-life care, to older people. OBJECTIVES: To estimate the need for ED end-of-life care for people aged ≥65 years, describe characteristics of those dying within 48 hours of ED presentation and compare those dying in ED with those dying elsewhere. METHODS: We conducted a retrospective cohort study analysing data from 177 hospitals in Australia and New Zealand. Data on older people presenting to ED from January to December 2018, and those who died within 48 hours of ED presentation, were analysed using simple descriptive statistics and univariate logistic regression. RESULTS: From participating hospitals in Australia or New Zealand, 10,921 deaths in older people occurred. The 48-hour mortality rate was 6.43 per 1,000 ED presentations (95% confidence interval: 6.31-6.56). Just over a quarter (n = 3,067, 28.1%) died in ED. About one-quarter of the cohort (n = 2,887, 26.4%) was triaged into less urgent triage categories. Factors with an increased risk of dying in ED included age 65-74 years, ambulance arrival, most urgent triage categories, principal diagnosis of circulatory system disorder, and not identifying as an Aboriginal or Torres Strait Islander person. Of the 7,677 older people admitted, half (n = 3,836, 50.0%) had an encounter for palliative care prior to, or during, this presentation. CONCLUSIONS: Our findings provide insight into the challenges of recognising the dying older patient and differentiating those appropriate for end-of-life care. We support recommendations for national advanced care planning registers and suggest a review of triage systems with an older person-focused lens.

Factors predictive of hospital admission for children via emergency departments in Australia and Sweden: an observational cross-sectional study.

BACKGROUND: Identifying factors predictive of hospital admission can be useful to prospectively inform bed management and patient flow strategies and decrease emergency department (ED) crowding. It is largely unknown if admission rate or factors predictive of admission vary based on the population to which the ED served (i.e., children only, or both adults and children). This study aimed to describe the profile and identify factors predictive of hospital admission for children who presented to four EDs in Australia and one ED in Sweden. METHODS: A multi-site observational cross-sectional study using routinely collected data pertaining to ED presentations made by children < 18 years of age between July 1, 2011 and October 31, 2012. Univariate and multivariate analysis were undertaken to determine factors predictive of hospital admission. RESULTS: Of the 151,647 ED presentations made during the study period, 22% resulted in hospital admission. Admission rate varied by site; the children's EDs in Australia had higher admission rates (South Australia: 26%, Queensland: 23%) than the mixed (adult and children's) EDs (South Australia: 13%, Queensland: 17%, Sweden: 18%). Factors most predictive of hospital admission for children, after controlling for triage category, included hospital type (children's only) adjusted odds ratio (aOR):2.3 (95%CI: 2.2-2.4), arrival by ambulance aOR:2.8 (95%CI: 2.7-2.9), referral from primary health aOR:1.5 (95%CI: 1.4-1.6) and presentation with a respiratory or gastrointestinal condition (aOR:2.6, 95%CI: 2.5-2.8 and aOR:1.5, 95%CI: 1.4-1.6, respectively). Predictors were similar when each site was considered separately. CONCLUSIONS: Although the characteristics of children varied by site, factors predictive of hospital admission were mostly similar. The awareness of these factors predicting the need for hospital admission can support the development of clinical pathways.

Clinicians' experiences of caring for people brought in by police to the emergency department: A qualitative interpretive study.

AIM: To explore nurses' and doctors' experiences of providing care to people brought in by police (BIBP) to the emergency department (ED). DESIGN: A qualitative interpretive study using in-depth individual interviews. METHODS: Semi-structured interviews were conducted with nurses and doctors who worked in various EDs in one Australian state and were involved in the care of people BIBP. Interviews were undertaken between May and October 2022 and focused on the structures (i.e., what), processes (i.e., how) and outcomes of care for people BIBP. Data were analysed using deductive and then inductive content analysis. RESULTS: Nine nurses and eight doctors were interviewed. Structures described by participants included human structures (staff) and organizational structures (areas for assessment, involuntary assessment orders, investigations, chemical/physical restraints). For processes, participants described practices including risk/mental health assessments, legal considerations, and increased/decreased levels of care compared to other presentations. Communication processes were largely between police and health care staff. Service outcomes pertained to discharge location (custody, community, hospital admission) and length of stay. CONCLUSION: The current care delivery for people BIBP to the ED is unique and complex, often occurring in high traffic, resource-intensive areas. There is a need to strengthen structures and processes, to improve service outcomes. IMPLICATIONS FOR THE PROFESSION: Understanding the care requirements for people brought into ED by police enables the delivery of targeted care alongside appropriate resource allocation. IMPACT: This study provides a comprehensive understanding of the health care requirements for people BIBP to EDs. Interventions delivered in the ED to support health care delivery for people BIBP and foster clinician and police relationships are required to optimize patient and health service outcomes. REPORTING METHOD: This study adheres to the COREQ checklist (Table S1) of the EQUATOR guidelines. PATIENT OR PUBLIC CONTRIBUTION: This study focused on ED staff experiences.

Emergency department presentations during the COVID-19 pandemic in Queensland (to June 2021): interrupted time series analysis.

OBJECTIVES: To assess emergency department (ED) presentation numbers in Queensland during the coronavirus disease 2019 (COVID-19) pandemic to mid-2021, a period of relatively low COVID-19 case numbers. DESIGN: Interrupted time series analysis. SETTING: All 105 Queensland public hospital EDs. MAIN OUTCOME MEASURES: Numbers of ED presentations during the COVID-19 lockdown period (11 March 2020 - 30 June 2020) and the period of easing restrictions (1 July 2020 - 30 June 2021), compared with pre-pandemic period (1 January 2018 - 10 March 2020), overall (daily numbers) and by Australasian Triage Scale (ATS; daily numbers) and selected diagnostic categories (cardiac, respiratory, mental health, injury-related conditions) and conditions (stroke, sepsis) (weekly numbers). RESULTS: During the lockdown period, the mean number of ED presentations was 19.4% lower (95% confidence interval, -20.9% to -17.9%) than during the pre-pandemic period (predicted mean number: 5935; actual number: 4786 presentations). The magnitudes of the decline and the time to return to predicted levels varied by ATS category and diagnostic group; changes in presentation numbers were least marked for ATS 1 and 2 (most urgent) presentations, and for presentations with cardiac conditions or stroke. Numbers remained below predicted levels during the 12-month post-lockdown period for ATS 5 (least urgent) presentations and presentations with mental health problems, respiratory conditions, or sepsis. CONCLUSIONS: The COVID-19 pandemic and related public restrictions were associated with profound changes in health care use. Pandemic plans should include advice about continuing to seek care for serious health conditions and health emergencies, and support alternative sources of care for less urgent health care needs.

Patient and public involvement in emergency care research: a scoping review of the literature.

BACKGROUND: Establishing the benefits of patient and public involvement (PPI) in emergency care research is important to improve the quality and relevance of research. Little is known about the extent of PPI in emergency care research, its methodological and reporting quality. This scoping review aimed to establish the extent of PPI in emergency care research, identify PPI strategies and processes and assess the quality of reporting on PPI in emergency care research. METHODS: Keyword searches of five databases (OVID MEDLINE, Elsevier EMBASE, EBSCO CINAHL, PsychInfo, Cochrane Central Register of Controlled trials); hand searches of 12 specialist journals and citation searches of the included journal articles were performed. A patient representative contributed to research design and co-authored this review. RESULTS: A total of 28 studies reporting PPI from the USA, Canada, UK, Australia and Ghana were included. The quality of reporting was variable, with only seven studies satisfying all Guidance for Reporting Involvement of Patients and the Public short form reporting criteria. None of the included studies adequately described all the key aspects of reporting the impact of PPI. CONCLUSION: Relatively few emergency care studies comprehensively describe PPI. Opportunity exists to improve the consistency and quality of reporting of PPI in emergency care research. Further research is required to better understand the specific challenges for implementing PPI in emergency care research, and to determine whether emergency care researchers have adequate resources, education and funding to undertake and report involvement.

Profile and Outcomes of Emergency Department Mental Health Patient Presentations Based on Arrival Mode: A State-Wide Retrospective Cohort Study.

INTRODUCTION: People arriving to the emergency department with mental health problems experience varying and sometimes inferior outcomes compared with people without mental health problems, yet little is known about whether or how their arrival mode is associated with these outcomes. This study describes and compares demographics, clinical characteristics, and patient and health service outcomes of adult mental health emergency department patient presentations, based on arrival mode: brought in by ambulance, privately arranged transport, and brought in by police. METHODS: Using a retrospective observational study design with state-wide administrative data from Queensland, Australia, mental health presentations from January 1, 2012, to December 31, 2017, were analyzed using descriptive and inferential analyses. RESULTS: Of the 446,815 presentations, 51.8% were brought in by ambulance, 37.2% arrived via privately arranged transport, and 11.0% were brought in by police. Compared with other arrival modes, presentations brought in by ambulance were more likely to be older and female and have more urgent triage categories and a longer length of stay. Presentations arriving by privately arranged transport were more likely than other arrival modes to present during the day, be assigned a less urgent triage category, be seen within their recommended triage time, have a shorter length of stay in the emergency department, have higher rates of discharge, and have waited longer to be seen by a clinician. Presentations brought in by police were more likely than other arrival modes to be younger and male and experience a shorter time to be seen by a clinician. DISCUSSION: Discrepancies between arrival modes indicates a need for further investigation to support inter- and intra-agency mental health care interventions.

'I knew I'd be taken care of': Exploring patient experiences in the Emergency Department.

AIMS: To explore adult Emergency Department patient experiences to inform the development of a new Emergency Department patient-reported experience measure. DESIGN: Descriptive, exploratory qualitative study using semi-structured individual interviews with adult Emergency Department patients. METHODOLOGY: Participants were recruited across two Emergency Departments in Southeast Queensland, Australia during September and October 2020. Purposive sampling based on maximum variation was used. Participants were recruited during their Emergency Department presentation and interviewed in 2-weeks via telephone. Inductive thematic analysis followed the approach proposed by Braun and Clarke (2012). RESULTS: Thirty participants were interviewed, and four themes were inductively identified: Caring relationships between patients and Emergency Department care providers; Being in the Emergency Department environment; Variations in waiting for care; and Having a companion in the Emergency Department. Caring relationships between patients and Emergency Department care providers included being treated like a person and being cared for, being informed about and included in care, and feeling confident in care providers. Being in the Emergency Department environment included being around other patients, feeling comfortable and having privacy. Variations in waiting for care included expecting a longer wait, waiting throughout the Emergency Department journey and receiving timely care. Having a companion in the Emergency Department included not feeling alone, and observing care providers engage with companions. CONCLUSION: Patient experiences in the Emergency Department are multifaceted, and themes are not mutually exclusive. These findings demonstrate consistency with the core experiential themes identified in the international literature. IMPACT: Strategies to improve patient engagement in shared decision-making, and communication between patients and care providers about wait times will be critical to optimizing Emergency Department patient experiences, and person-centred practice. These findings holistically conceptualize patient experiences in the Emergency Department which is the first step to developing a new Emergency Department patient-reported experience measure.

Establishing the content validity of a new emergency department patient-reported experience measure (ED PREM): a Delphi study.

BACKGROUND: Patient-reported experience measures aim to capture the patient's perspective of what happened during a care encounter and how it happened. However, due to a lack of guidance to support patient-reported experience measure development and reporting, the content validity of many instruments is unclear and ambiguous. Thus, the aim of this study was to establish the content validity of a newly developed Emergency Department Patient-Reported Experience Measure (ED PREM). METHODS: ED PREM items were developed based on the findings of a systematic mixed studies review, and qualitative interviews with Emergency Department patients that occurred during September and October, 2020. Individuals who participated in the qualitative interviews were approached again during August 2021 to participate in the ED PREM content validation study. The preliminary ED PREM comprised 37 items. A two-round modified, online Delphi study was undertaken where patient participants were asked to rate the clarity, relevance, and importance of ED PREM items on a 4-point content validity index scale. Each round lasted for two-weeks, with 1 week in between for analysis. Consensus was a priori defined as item-level content validity index scores of ≥0.80. A scale-level content validity index score was also calculated. RESULTS: Fifteen patients participated in both rounds of the online Delphi study. At the completion of the study, two items were dropped and 13 were revised, resulting in a 35-item ED PREM. The scale-level content validity index score for the final 35-item instrument was 0.95. CONCLUSIONS: The newly developed ED PREM demonstrates good content validity and aligns strongly with the concept of Emergency Department patient experience as described in the literature. The ED PREM will next be administered in a larger study to establish its' construct validity and reliability. There is an imperative for clear guidance on PREM content validation methodologies. Thus, this study may inform the efforts of other researchers undertaking PREM content validation.

Compression Socks Reduce Running-Induced Intestinal Damage.

ABSTRACT: Zadow, EK, Edwards, KH, Kitic, CM, Fell, JW, Adams, MJ, Singh, I, Kundur, A, Johnstone, ANB, Crilly, J, Bulmer, AC, Halson, SL, and, and Wu, SSX. Compression socks reduce running-induced intestinal damage. J Strength Cond Res 36(9): 2461-2464, 2022-Exercise is associated with a reduction in splanchnic blood flow that leads to the disruption of intestinal epithelium integrity, contributing to exercise-induced gastrointestinal syndrome. Strategies that promote intestinal blood flow during exercise may reduce intestinal damage, which may be advantageous for subsequent recovery and performance. This study aimed to explore if exercise-associated intestinal damage was influenced by wearing compression garments, which may improve central blood flow. Subjects were randomly allocated to wear compression socks ( n = 23) or no compression socks (control, n = 23) during a marathon race. Blood samples were collected 24 hours before and immediately after marathon and analyzed for intestinal fatty acid-binding protein (I-FABP) concentration as a marker of intestinal damage. The magnitude of increase in postmarathon plasma I-FABP concentration was significantly greater in control group (107%; 95% confidence interval [CI], 72-428%) when compared with runners wearing compression socks (38%; 95% CI, 20-120%; p = 0.046; d = 0.59). Wearing compression socks during a marathon run reduced exercise-associated intestinal damage. Compression socks may prove an effective strategy to minimize the intestinal damage component of exercise-induced gastrointestinal syndrome.

Disaster preparedness: A concept analysis and its application to the intensive care unit.

OBJECTIVES: The aim of the study is to understand the concept of disaster preparedness in relation to the intensive care unit through the review and critique of the peer-reviewed literature. REVIEW METHOD USED: Rodgers' method of evolutionary concept analysis was used in the study. DATA SOURCES: Healthcare databases included in the review were Cumulative Index to Nursing and Allied Health Literature, Public MEDLINE, Scopus, and ProQuest. REVIEW METHODS: Electronic data bases were searched using terms such as "intensive care unit" OR "critical care" AND prep∗ OR readiness OR plan∗ AND disaster∗ OR "mass casualty incidents" OR "natural disaster" OR "disaster planning" NOT paed∗ OR ped∗ OR neonat∗. Peer-reviewed articles published in English between January 2000 and April 2020 that focused on intensive care unit disaster preparedness or included intensive care unit disaster preparedness as part of a facility-wide strategy were included in the analysis. RESULTS: Eighteen articles were included in the concept analysis. Fourteen different terms were used to describe disaster preparedness in intensive care. Space, physical resources, and human resources were attributes that relied on each other and were required in sufficient quantities to generate an adequate response to patient surges from disasters. When one attribute is extended beyond normal operational capacities, the effectiveness and capacity of the other attributes will likely be limited. CONCLUSION: This concept analysis has shown the varied language used when referring to disaster preparedness relating to the intensive care unit within the research literature. Attributes including space, physical resources, and human resources were all found to be integral to a disaster response. Future research into what is required of these attributes to generate an all-hazards approach in disaster preparedness in intensive care units will contribute to optimising standards of care.

A systematic mixed studies review of patient experiences in the ED.

BACKGROUND: Understanding patient experiences is crucial to evaluating care quality in EDs. However, while previous reviews describe the determinants of ED patient experiences (ie, factors that influence patient experiences), few have described actual patient experiences. The aim of this systematic mixed studies review was to describe patient experiences in the ED from the patient's perspective. METHODS: Embase, Medline, ProQuest Nursing and Allied Health, the Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library electronic databases were searched, with publication dates limited between 1 January 2001 and 16 September 2019. Studies describing adult patient experiences in the ED were included. Studies describing patient satisfaction, proxy-reported experiences or child/adolescent experiences were excluded. The quality of included studies was appraised using the Mixed Methods Appraisal Tool (2018 version). An inductive, convergent qualitative synthesis of the extracted data was undertaken following Thomas and Harden's (2008) methods. RESULTS: Fifty-four studies were included and of those, only five (9%) studies included a standardised definition of patient experience. Two inter-related themes emerged: Relationships between ED patients and care providers; and Spending time in the ED environment. The first theme included four subthemes regarding respect, communication, caring behaviours and optimising patient confidence. A key finding related to the potential for power imbalances between patients and their care providers. The second theme included two subthemes regarding physical aspects of the ED environment and patients' waiting experience. Patients attributed more importance to the waiting experience itself rather than the duration they had to wait. CONCLUSIONS: Patients in the ED have unique and complex experiences. Greater research is needed to understand the relational and environmental factors that contribute to power imbalances between patients and care providers, how to support more positive waiting experiences, and developing a standardised definition of patient experience in the ED. PROSPERO REGISTRATION NUMBER: CRD42020150154.

Identifying 'at-risk' critically ill patients who present to the emergency department and require intensive care unit admission: A retrospective observational cohort study.

BACKGROUND: Emergency department (ED) triage is the process of prioritising patients by medical urgency. Delays in intensive care unit (ICU) admission can adversely affect patients. OBJECTIVES: This study aimed to identify characteristics associated with ICU admission for patients triaged as Australasian Triage Scale (ATS) 3 but subsequently admitted to the ICU within 24 h of triage. METHODS: This retrospective, observational cohort study was conducted in a public teaching hospital in Queensland, Australia. Patients older than 18 y triaged with an ATS 3 and admitted to the ICU within 24 h of triage or admitted to the ward between January 1, 2012, and December 31, 2012, were included. The demographic and clinical profiles of ICU admissions vs. all other ward admissions for patients triaged an ATS of 3 were compared. Multivariable regression analysis compared characteristics of patients triaged with an ATS of 3 who did and did not require ICU transfer. Descriptive data are reported as n (%) and median and interquartile range (IQR). Regression analysis is reported as adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs). RESULTS: Of the 27 454 adult ED presentations triaged with an ATS of 3, 22.4% (n = 6138) required hospital admission, comprising 5302 individuals, 2.1% of whom (n = 110) were admitted to the ICU within 24 h of triage. Age- and sex-adjusted predictors of ICU admission for patients triaged with an ATS of 3 included infectious (aOR: 3.7; 95% CI: 2.0-6.9), neurological (aOR: 2.8; 95% CI: 1.6-5.0), and gastrointestinal disorders (aOR: 2.2; 95% CI 1.2-3.5); arriving by ambulance; arriving after hours; or arriving on weekends. Regardless of diagnosis or sex, persons older than 80 y were less likely to be admitted to the ICU (aOR: 0.4; 95% CI: 0.2-0.8). CONCLUSIONS: Patients triaged as ATS 3 presenting on weekends or after hours, and those with infectious, gastrointestinal, or neurological conditions warrant careful attention as these factors were associated with higher odds of ICU admission. Ongoing staff education regarding triage and signs of deterioration are important to prevent avoidable outcomes.

Predictors of a long length of stay in the emergency department for older people.

BACKGROUND: Dedicated geriatric models of care are becoming more prevalent due to the complexity of, and increase in, acute healthcare presentations for older patients. For older people, a long stay in the emergency department (ED) may reflect the complexity of their presentation, or deficiencies in systems that manage these complexities. AIMS: To identify predictors of a long ED length of stay (LLoS) for patients ≥65 years old. METHODS: Linked hospital information systems data from a large, public Australian ED were analysed in this retrospective cohort study. LLoS was defined as the 75th percentile (617 min). Multivariate regression identified LLoS predictors for admissions and discharges separately. RESULTS: Of 16 791 ED presentations made by older people, 4192 experienced a LLoS; 55% were admitted. Increasing age was associated with an increasing ED LoS. Factors most predictive of LLoS for both admitted and discharged patients included: investigations (both pathology and imaging), less urgent Australasian triage scale categories and after-hours arrival. Ambulance arrival did not increase the risk of a LLoS for patients eventually admitted, but conferred nearly a twofold increased risk for a LLoS for discharged older persons (adjusted odds ratios = 1.9; 95% confidence interval 1.5-2.4). CONCLUSIONS: This study assists clinicians and decision-makers to identify reasons why older persons have a LLoS, whether admitted or discharged. Interventions to streamline care for older patients arriving after-hours and who require imaging and pathology are required. LoS targets should consider age distribution. The use of ED LoS as a quality of care indicator should be assessed for admissions and discharges, separately.

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.

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.

Key occupational stressors in the ED: an international comparison.

BACKGROUND: The ED Stressor Scale outlines 15 stressors that are of importance for ED staff. Limited research has identified how commonly such stressors occur, or whether such factors are perceived with similar importance across different hospitals. This study sought to examine the frequency or perceived severity of these 15 stressors using a multicentre cohort of emergency clinicians (nurses and physicians) in EDs in two countries (Australia and Sweden). METHOD: This was a cross-sectional survey of staff working in eight hospitals in Australia and Sweden. Data were collected between July 2016 and June 2017 (depending on local site approvals) via a printed survey incorporating the 15-item ED stressor scale. The median stress score for each item and the frequency of experiencing each event was reported. RESULTS: Events causing most distress include heavy workload, death or sexual abuse of a child, inability to provide optimum care and workplace violence. Stressors reported most frequently include dealing with high acuity patients, heavy workload and crowding. Violence, workload, inability to provide optimal care, poor professional relations, poor professional development and dealing with high-acuity patients were reported more commonly by Australian staff. Swedish respondents reported more frequent exposure to mass casualty incidents, crisis management and administrative concerns. CONCLUSIONS: Workload, inability to provide optimal care, workplace violence and death or sexual abuse of a child were consistently reported as the most distressing events across sites. The frequency with which these occurred differed in Australia and Sweden, likely due to differences in the healthcare systems.

Immunisation status of children presenting to the emergency department: Linkage of a longitudinal birth cohort with national immunisation data.

AIM: To describe the relationship between emergency department (ED) diagnosis of infectious disease and immunisation status in children ≤5 years. We also aimed to demonstrate feasibility of proof-of-concept linkage between disparate databases. METHODS: Data from a cohort of 3404 children born in Southeast Queensland/Far North New South Wales between 2006 and 2011 were linked to Australian Childhood Immunisation Registry data and Emergency Department Information System data for presentations between 2006 and 2014. Immunisation status was assigned using the 2009 National Immunisation Program schedule. RESULTS: Of 1490 children (79% of those consented) with data on immunisation status, 87.2 and 84.6% were fully immunised by 12 and 24 months, respectively. Adding partially immunised children increased this to 93.2 and 91.4% at 12 and 24 months, respectively. Nearly two-thirds of all children made at least one ED presentation. Children presenting to ED with an infectious disease did not differ in immunisation status compared to children with other (non-infectious disease type) presentations but were younger, more likely to live with other children and had a longer ED stay and higher admission rate. Respiratory syncytial virus (RSV) was more frequently diagnosed in unimmunised children. CONCLUSIONS: In an existing birth cohort, immunisation rates were lower than the national average. RSV was more prevalent in unimmunised children presenting to ED, but immunisation status was not significantly associated with other infectious disease presentations. Linkage between national immunisation data and Australian ED data is feasible and has the potential to identify previously unrecognised factors related to child immunisation status and health-care utilisation.

Staff's Perception of the Intensive Care Outreach Nurse Role: A Multisite Cross-sectional Study.

BACKGROUND: Rapid Response Systems are emerging internationally to provide a patient-focused approach to prevent potentially avoidable deaths and serious adverse events. LOCAL PROBLEM: This study focused on ward nurses in the United Arab Emirates (UAE) government hospitals who were perceived to lack the confidence and knowledge to detect and/or respond to deteriorating patients. METHOD: A cross-sectional study design was used to evaluate the Intensive Care Outreach Nurse (ICON) role from the perspectives of the ICONs, their managers/educators, and ward-based physicians and nurses. ICONs are intensive care experienced nurses with additional education in the role of rapid responder to the deteriorating patient. INTERVENTIONS: An ICON role was implemented across 4 hospitals to respond to and support clinicians in the recognition and management of the deteriorating patient on general inpatient wards. RESULTS: ICON skills perceived as most beneficial by respondents included staff education, respiratory therapy, medication administration, and intravenous access. CONCLUSIONS: The ICON role is able to support recognition and management of the deteriorating patients.

Emergency health service contact and reincarceration after release from prison: A prospective cohort study.

BACKGROUND: Adults released from prison often have complex health needs. They are at high risk of poor health outcomes and reincarceration, with health service use unlikely to be planned. AIMS/HYPOTHESES: To determine the incidence of emergency health service (EHS) use, ambulance attendance and/or emergency department presentation, among 1,181 adults released from Australian prisons. We hypothesised that EHS contact would be associated with increased reincarceration risk. METHODS: Baseline surveys were conducted within 6 weeks before release. Postrelease EHS contacts and reincarceration were identified through prospective data linkage. For each participant, EHS contacts within a 24-hour period were combined to make an episode. We used Cox proportional hazards regression to examine the relationship between EHS episodes and reincarceration, controlling for covariates. RESULTS: More than half (53.3%) of participants had at least one EHS contact over a median of 25.6-month follow-up. In adjusted analyses, compared to those with no EHS contacts, the hazard of reincarceration was greater for participants who had one to three EHS episodes (hazard ratio [HR] = 1.84; 95% confidence interval [CI] [1.48, 2.29]) or four or more (HR = 2.35; 95% CI [1.67, 3.29]). CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Emergency department attendance by people with a history of imprisonment may be indicative of wider decompensation. Improved management of such patients may improve health outcomes and have collateral benefits for reducing reincarceration.