Patient outcome quality indicators for older persons in acute care: original development data using interRAI AC-CGA.

BACKGROUND: A range of strategies are available that can improve the outcomes of older persons particularly in relation to basic activities of daily living during and after an acute care (AC) episode. This paper outlines the original development of outcome-oriented quality indicators (QIs) in relation to common geriatric syndromes and function for the care of the frail aged hospitalized in acute general medical wards. METHODS: Design QIs were developed using evidence from literature, expert opinion, field study data and a formal voting process. A systematic literature review of literature identified existing QIs (there were no outcome QIs) and evidence of interventions that improve older persons' outcomes in AC. Preliminary indicators were developed by two expert panels following consideration of the evidence. After analysis of the data from field testing (indicator prevalence, variability across sites), panel meetings refined the QIs prior to a formal voting process. SETTING: Data was collected in nine Australian general medical wards. PARTICIPANTS: Patients aged 70 years and over, consented within 24 h of admission to the AC ward. MEASUREMENTS: The interRAI Acute Care - Comprehensive Geriatric Assessment (interRAI AC-CGA) was administered at admission and discharge; a daily risk assessment in hospital; 28-day phone follow-up and chart audit. RESULTS: Ten outcome QIs were established which focused on common geriatric syndromes and function for the care of the frail aged hospitalized in acute general medical wards. CONCLUSION: Ten outcome QIs were developed. These QIs can be used to identify areas where specific action will lead to improvements in the quality of care delivered to older persons in hospital.

The implementation and impacts of the Comprehensive Care Standard in Australian acute care hospitals: a survey study.

BACKGROUND: Comprehensive care (CC) is becoming a widely acknowledged standard for modern healthcare as it has the potential to improve health service delivery impacting both patient-centred care and clinical outcomes. In 2019, the Australian Commission on Safety and Quality in Health Care mandated the implementation of the Comprehensive Care Standard (CCS). However, little is known about the implementation and impacts of the CCS in acute care hospitals. Our study aimed to explore care professionals' self-reported knowledge, experiences, and perceptions about the implementation and impacts of the CCS in Australian acute care hospitals. METHODS: An online survey using a cross-sectional design that included Australian doctors, nurses, and allied health professionals in acute care hospitals was distributed through our research team and organisation, healthcare organisations, and clinical networks using various methods, including websites, newsletters, emails, and social media platforms. The survey items covered self-reported knowledge of the CCS and confidence in performing CC, experiences in consumer involvement and CC plans, and perceptions of organisational support and impacts of CCS on patient care and health outcomes. Quantitative data were analysed using Rstudio, and qualitative data were analysed thematically using Nvivo. RESULTS: 864 responses were received and 649 were deemed valid responses. On average, care professionals self-reported a moderate level of knowledge of the CCS (median = 3/5) and a high level of confidence in performing CC (median = 4/5), but they self-reported receiving only a moderate level of organisational support (median = 3/5). Only 4% (n = 17) of respondents believed that all patients in their unit had CCS-compliant care plans, which was attributed to lack of knowledge, motivation, teamwork, and resources, documentation issues, system and process limitations, and environment-specific challenges. Most participants believed the CCS introduction improved many aspects of patient care and health outcomes, but also raised healthcare costs. CONCLUSION: Care professionals are confident in performing CC but need more organisational support. Further education and training, resources, multidisciplinary collaboration, and systems and processes that support CC are needed to improve the implementation of the CCS. Perceived increased costs may hinder the sustainability of the CCS. Future research is needed to examine the cost-effectiveness of the implementation of the CCS.

Factors associated with teletrauma utilization in rural areas: a review of the literature.

INTRODUCTION: Trauma patients residing in rural areas face increased challenges to accessing timely and appropriate health services as a result of large geographic distances and limited resource availability. Virtual trauma supports, coined 'teletrauma', are one solution offered to address gaps in rural trauma care. Teletrauma represents a new and innovative solution to addressing health system gaps and optimizing patient care within rural settings. Here, the authors synthesize the empirical evidence on teletrauma research. METHODS: A review of literature, with no date limiters, was guided by Arksey and O'Malley's (2005) scoping review methodology. The aim of the review was to provide an overview of the current landscape of teletrauma research while identifying factors associated with utilization. RESULTS: Following a systematic search of key health databases, 1484 articles were initially identified, of which 28 met the inclusion criteria and were included for final analysis. From the review of the literature, the benefits of teletrauma for rural and remote areas were well-recognized. Several factors were found to be significantly associated with teletrauma utilization, including younger patient age, penetrating injury, and higher injury or illness severity. Lack of access to resources and clinician characteristics were also identified as reasons that sites adopted teletrauma services. CONCLUSION: By identifying factors associated with teletrauma utilization, teletrauma programs may be used more judiciously and effectively in rural areas as a means of enhancing access to definitive trauma care in rural areas. Gaps in current knowledge were also identified, along with recommendations for future research.

A systematic scoping review of change management practices used for telemedicine service implementations.

BACKGROUND: Telemedicine improves access to health care services enabling remote care diagnosis and treatment of patients at a distance. However, the implementation of telemedicine services often pose challenges stemming from the lack of attention to change management (CM). Health care practitioners and researchers agree that successful telemedicine services require significant organizational and practice change. Despite recognizing the importance of the "people-side" of implementation, research on what constitutes best practice CM strategies for telemedicine implementations remains fragmented, offering little cohesive insight into the specific practices involved in the change process. We conducted a systematic scoping review of the literature to examine what and how CM practices have been applied to telemedicine service implementation, spanning a variety of health care areas and countries. METHODS: Three bibliographic databases (CINAHL, PubMed, and ISI Web of Science) and four specialist telehealth journals were searched. To keep the review manageable and relevant to contemporary telemedicine technologies and contexts, the search was limited to articles published from 2008 to 2019. Forty-eight articles were selected for inclusion. RESULTS: From the 48 articles, 16 CM practices were identified relating to either strategic or operational aspects of telemedicine implementations. We identify the key CM practices that are recognized in the broader CM literature as essential for successful and sustained change but are not commonly reported in telemedicine implementation studies. We draw on the CM literature to provide a comprehensive process-based, researched-informed, organizing framework to guide future telemedicine service implementations and research. CONCLUSIONS: Our findings suggest that the slow rate of adoption of telemedicine may be due to a piecemeal approach to the change process, and a lack of understanding of how to plan, manage and reinforce change when implementing telemedicine services.

Process quality indicators for musculoskeletal injuries in the emergency department.

OBJECTIVES: Measuring quality of care for musculoskeletal injuries presenting to the ED is important given their prevalence, variations in care, the associated morbidity and financial impacts and pressure to achieve time-based performance measures. Process quality indicators (QIs) provide a quantitative method to measure the actions taken during healthcare delivery. This study aimed to develop a set of process QIs to measure the quality of care for musculoskeletal injuries in the ED. METHODS: A multiphase mixed-methods study was undertaken from 2015 to 2018, commencing with a systematic review to identify existing musculoskeletal QIs. This review, along with current evidence regarding musculoskeletal injury management in the ED, informed an expert panel who developed a preliminary set of process QIs. The preliminary set was field tested at eight EDs in Queensland, Australia, to determine the validity, reliability, feasibility and usefulness of each QI. Prospective observational data collection and retrospective chart audits were used to score the process QIs. These results were presented to the expert panel who determined a final QI set. RESULTS: A total of 633 patients were recruited and 36 process QIs included in the final set. The QIs covered important domains of pain assessment and management, history taking and physical examination, appropriateness and timeliness of imaging, fracture management, mobility, patient information and discharge considerations including safety and referrals. The best performing QIs included the use of opioid sparing analgesics and avoiding prescription of 'just in case' opioids at discharge. The poorest performing QIs included the completion of spinal red flag questioning and referrals for fragility fractures. CONCLUSION: An evidence and best practice-based set of QIs has been developed to allow EDs to assess and quantify the quality of care for musculoskeletal presentations. This will allow EDs to compare and benchmark, leading to the optimisation of care for patients.

Developing quality indicators for the care of patients with musculoskeletal injuries in the Emergency Department: study protocol.

BACKGROUND: Musculoskeletal injuries are a common presentation to the Emergency Department (ED). The quality of care provided is important to the patients, clinicians, organisations and purchasers of care. In the context of the increasing burden of musculoskeletal disease, quality of care needs to occur despite financial impacts, variations in care, and pressure to reach time-based performance measures. This study aims to develop a suite of evidence-based quality indicators (QI) which will provide a measure of the quality of care for patients with musculoskeletal injuries in the ED. METHODS: This study will utilise a multi-phase mixed methods protocol, commencing with a systematic review of the literature to identify and critically appraise existing QIs for musculoskeletal injuries in the ED. The study will then build on the gaps identified in the review to develop a suite of preliminary QIs, in accordance with established research methodology under the governance of an expert panel. The developed QI set will then be field-tested for feasibility and validity in selected EDs. After field-testing, the suite will be refined in consultation with the expert panel and finalised using a formal voting process. DISCUSSION: The assessment of performance against QIs provides a quantitative measure for the quality of care provided to patients, to identify and target quality improvement activities. The QIs developed through this study will be evidence-based and balanced across the areas of structures, processes and outcomes. The rigorous methodology used to develop and test the QIs will result in QIs that are meaningful, valid, feasible to collect and efficiently measurable, amenable to improvement, and selected by experts in the emergency medicine field. The final QI suite will have applications across EDs that affords comparison, benchmarking and optimisation of emergency care for patients.

The Development of a Telemedicine Planning Framework Based on Needs Assessment.

Providing equitable access to healthcare services in rural and remote communities is an ongoing challenge that faces most governments. By increasing access to specialty expertise, telemedicine may be a potential solution to this problem. Regardless of its potential, many telemedicine initiatives do not progress beyond the research phase, and are not implemented into mainstream practice. One reason may be that some telemedicine services are developed without the appropriate planning to ascertain community needs and clinical requirements. The aim of this paper is to report the development of a planning framework for telemedicine services based on needs assessment. The presented framework is based on the key processes in needs assessment, Penchansky and Thomas's dimensions of access, and Bradshaw's types of need. This proposed planning framework consists of two phases. Phase one comprises data collection and needs assessment, and includes assessment of availability and expressed needs; accessibility; perception and affordability. Phase two involves prioritising the demand for health services, balanced against the known limitations of supply, and the implementation of an appropriate telemedicine service that reflects and meets the needs of the community. Using a structured framework for the planning of telemedicine services, based on need assessment, may help with the identification and prioritisation of community health needs.

Trends and predicted trends in presentations of older people to Australian emergency departments: effects of demand growth, population aging and climate change.

Objectives The aim of the present study was to describe trends in and age and gender distributions of presentations of older people to Australian emergency departments (EDs) from July 2006 to June 2011, and to develop ED utilisation projections to 2050. Methods A retrospective analysis of data collected in the National Non-admitted Patient Emergency Department Care Database was undertaken to assess trends in ED presentations. Three standard Australian Bureau of Statistics population growth models, with and without adjustment for current trends in ED presentation growth and effects of climate change, were examined with projections of ED presentations across three age groups (0-64, 65-84 and ≥85 years) to 2050. Results From 2006-07 to 2010-11, ED presentations increased by 12.63%, whereas the Australian population over this time increased by only 7.26%. Rates of presentation per head of population were greatest among those aged ≥85 years. Projections of ED presentations to 2050 revealed that overall ED presentations are forecast to increase markedly, with the rate of increase being most marked for older people. Conclusion Growth in Australian ED presentations from 2006-07 to 2010-11 was greater than that expected from population growth alone. The predicted changes in demand for ED care will only be able to be optimally managed if Australian health policy, ED funding instruments and ED models of care are adjusted to take into account the specific care and resource needs of older people. What is known about the topic? Rapid population aging is anticipated over coming decades. International studies and specific local-level Australian studies have demonstrated significant growth in ED presentations. There have been no prior national-level Australian studies of ED presentation trends by age group. What does this paper add? The present study examined national ED presentation trends from July 2006 to June 2011, with specific emphasis on trends in presentation by age group. ED presentation growth was found to exceed population growth in all age groups. The rate of ED presentations per head of population was highest among those aged ≥85 years. ED utilisation projections to 2050, using standard Australian Bureau of Statistics population modelling, with and without adjustment for current ED growth, were developed. The projections demonstrated linear growth in ED presentation for those aged 0-84 years, with growth in ED presentations of the ≥85 year age group demonstrating marked acceleration after 2030. What are the implications for practitioners? Growth in ED presentations exceeding population growth suggests that current models of acute health care delivery require review to ensure that optimal care is delivered in the most fiscally efficient manner. Trends in presentation of older people emphasise the imperative for ED workforce planning and education in care of this complex patient cohort, and the requirement to review funding models to incentivise investment in ED avoidance and substitutive care models targeting older people.

The Mental Health of Older Persons After Human-Induced Disasters: A Systematic Review and Meta-Analysis of Epidemiological Data.

BACKGROUND: Older people are increasingly "in harm's way" following human-induced disasters (HIDs). There is debate in the literature as to the relative impact of disasters on their psychological health compared with other age groups. Natural disasters and HIDs are thought to affect survivors differentially, and this may extend to older adults as a group. In the absence of existing systematic reviews, we aimed to synthesize the available evidence and conduct meta-analyses of the effects of HIDs on the psychological health of older versus younger adults. METHODS: A meta-analysis was conducted on papers identified through a systematic review. The primary outcomes measured were post-traumatic stress disorder (PTSD), depression, anxiety disorders, adjustment disorder, and psychological distress. RESULTS: We identified 11 papers from 10 studies on HIDs (N = 26,753), of which 8 had sufficient data for a random-effects meta-analysis. Older adults were 2.85 times less likely to experience PTSD symptoms following HID (95% CI: 1.42-5.70) when compared with younger adults. There was no statistically significant difference in terms of anxiety and depressive symptoms. CONCLUSION: Health and emergency services need to be increasingly prepared to meet the psychological needs of older people, given the global rise in the numbers of older adults affected by disasters of all kinds. Preliminary evidence suggests that old age may be a protective factor for the development of PTSD in the wake of HID.

Mental health implications for older adults after natural disasters--a systematic review and meta-analysis.

BACKGROUND: Natural disasters affect the health and well-being of adults throughout the world. There is some debate in the literature as to whether older persons have increased risk of mental health outcomes after exposure to natural disasters when compared with younger adults. To date, no systematic review has evaluated this. We aimed to synthesize the available evidence on the impact of natural disasters on the mental health and psychological distress experienced by older adults. DESIGN: A meta-analysis was conducted on papers identified through a systematic review. The primary outcomes measured were post-traumatic stress disorder (PTSD), depression, anxiety disorders, adjustment disorder, and psychological distress. RESULTS: We identified six papers with sufficient data for a random effects meta-analysis. Older adults were 2.11 times more likely to experience PTSD symptoms and 1.73 more likely to develop adjustment disorder when exposed to natural disasters when compared with younger adults. CONCLUSIONS: Given the global rise in the number of older adults affected by natural disasters, mental health services need to be prepared to meet their needs following natural disasters, particularly around the early detection and management of PTSD.

Establishing a centralised telehealth service increases telehealth activity at a tertiary hospital.

BACKGROUND: The Princess Alexandra Hospital Telehealth Centre (PAH-TC) is a project jointly funded by the Australian national government and Queensland Health. It seeks to provide a whole-of-hospital telehealth service using videoconferencing and store-and-forward capabilities for a range of specialities. The aim of this study was to investigate whether the introduction of a new telehealth coordination service provided by a tertiary hospital centre increased telehealth activities of a tertiary hospital. Evaluation included service delivery records and stakeholder satisfaction. METHODS: Telehealth service delivery model before and after the establishment of the centre is described as well as the project implementation. The study retrieved data related to the number and scope of previous, and current, telehealth service episodes, to ascertain any change in activity levels following the introduction of the new telehealth coordination service. In addition, using a cross-sectional research design, the satisfaction of patients, clinicians and administrators was surveyed. The survey focused on technical utility and perceived clinical validity. RESULTS: Introduction of a new centralised telehealth coordination service was associated with an increase in the scope of telehealth from five medical disciplines, in the year before the establishment, to 34 disciplines two years after the establishment. The telehealth consultations also increases from 412 (the year before), to 735 (one year after) and 1642 (two years after) the establishment of the centre. Respondents to the surveys included patients (27), clinicians who provided the consultations (10) and clinical or administrative staff who hosted the telehealth consultations in the remote site (8). There were high levels of agreement in relation to the telehealth option saving time and money, and an important health service delivery model. There was evidence from the remote site that modifying roles to incorporate this new service was challenging. CONCLUSION: The introduction of a centralised coordination for telehealth service of a tertiary hospital was associated with the increase in the scope and level of telehealth activity of the hospital. The project and model of health care delivery described in this paper can be adopted by tertiary hospitals to grow their telehealth activities, and potentially reduce costs associated with the delivery of services at a distance.

Design of a randomized, non-inferiority trial to evaluate the reliability of videoconferencing for remote consultation of diabetes.

BACKGROUND: An estimated 366 million people are living with diabetes worldwide and it is predicted that its prevalence will increase to 552 million by 2030. Management of this disease and its complications is a challenge for many countries. Optimal glycaemic control is necessary to minimize complications, but less than 70% of diabetic patients achieve target levels of blood glucose, partly due to poor access to qualified health care providers. Telemedicine has the potential to improve access to health care, especially for rural and remote residents. Video teleconsultation, a real-time (or synchronous) mode of telemedicine, is gaining more popularity around the world through recent improvements in digital telecommunications. If video consultation is to be offered as an alternative to face-to-face consultation in diabetes assessment and management, then it is important to demonstrate that this can be achieved without loss of clinical fidelity. This paper describes the protocol of a randomised controlled trail for assessing the reliability of remote video consultation for people with diabetes. METHODS/DESIGN: A total of 160 people with diabetes will be randomised into either a Telemedicine or a Reference group. Participants in the Reference group will receive two sequential face-to-face consultations whereas in the Telemedicine group one consultation will be conducted face-to-face and the other via videoconference. The primary outcome measure will be a change in the patient's medication. Secondary outcome measures will be findings in physical examination, detecting complications, and patient satisfaction. A difference of less than 20% in the aggregated level of agreement between the two study groups will be used to identify if videoconference is non-inferior to traditional mode of clinical care (face-to-face). DISCUSSION: Despite rapid growth in application of telemedicine in a variety of medical specialties, little is known about the reliability of videoconferencing for remote consultation of people with diabetes. Results of this proposed study will provide evidence of the reliability of specialist consultation offered by videoconference for people with diabetes. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry ACTRN12612000315819.

Identification and information management of cognitive impairment of patients in acute care hospitals: An integrative review.

Objectives: Recognition of the cognitive status of patients is important so that care can be tailored accordingly. The objective of this integrative review was to report on the current practices that acute care hospitals use to identify people with cognitive impairment and how information about cognition is managed within the healthcare record as well as the approaches required and recommended by policies. Methods: Following Whittemore & Knafl's five-step method, we systematically searched Medline, CINAHL, and Scopus databases and various grey literature sources. Articles relevant to the programs that have been implemented in acute care hospitals regarding the identification of cognitive impairment and management of cognition information were included. The Mixed Methods Appraisal Tool and AACODS (Authority, Accuracy, Coverage, Objectivity, Date, Significance) Checklist were used to evaluate the quality of the studies. Thematic analysis was used to present and synthesise results. This review was pre-registered on PROSPERO ( CRD42022343577). Results: Twenty-two primary studies and ten government/industry publications were included in the analysis. Findings included gaps between practice and policy. Although identification of cognitive impairment, transparency of cognition information, and interaction with patients, families, and carers (if appropriate) about this condition were highly valued at a policy level, sometimes in practice, cognitive assessments were informal, patient cognition information was not recorded, and interactions with patients, families, and carers were lacking. Discussion: By incorporating cognitive assessment, developing an integrated information management system using information technology, establishing relevant laws and regulations, providing education and training, and adopting a national approach, significant improvements can be made in the care provided to individuals with cognitive impairment.

A survey of the Queensland healthcare workforce: attitudes towards dementia care and training.

BACKGROUND: Positive attitudes of healthcare staff towards people with dementia promote higher quality care, although little is known about important factors that underlie positive attitudes. Key aims of this project were to explore the relationships between staff attitudes towards dementia, self-confidence in caring for people with dementia, experience and dementia education and training. METHODS: A brief online survey was developed and widely distributed to registered nurses and allied health professionals working in Queensland in 2012. Regression analyses were performed to identify important predictors of self-confidence in caring for people with dementia and positive attitudes towards people with dementia. RESULTS: Five hundred and twenty-four surveys were completed by respondents working in a range of care settings across Queensland. Respondents were predominantly female (94.1%), and most were registered nurses (60%), aged between 41 and 60 years (65.6%). Around 40% regularly worked with people with dementia and high levels of self-confidence in caring for this population and positive attitudes towards people with dementia were reported. The majority of respondents (67%) had participated in a dementia education/training activity in the past 12 months. More experience working with people with dementia predicted greater self-confidence while recent participation in a dementia education/training and higher self-confidence in caring for a person with dementia significantly predicted more positive attitudes towards people with dementia. CONCLUSIONS: These results confirm the importance of self-confidence and dementia education in fostering positive attitudes and care practices towards people with dementia. Our results also indicate that the demand for ongoing dementia education is high amongst health care workers and it is recommended that regular dementia education/ training be provided and promoted for all healthcare personnel who work with people with dementia.

Methodology for developing quality indicators for the care of older people in the Emergency Department.

BACKGROUND: Compared with younger people, older people have a higher risk of adverse health outcomes when presenting to emergency departments. As the population ages, older people will make up an increasing proportion of the emergency department population. Therefore it is timely that consideration be given to the quality of care received by older persons in emergency departments, and to consideration of those older people with special needs. Particular attention will be focused on important groups of older people, such as patients with cognitive impairment, residents of long term care and patients with palliative care needs. This project will develop a suite of quality indicators focused on the care of older persons in the emergency department. METHODS/DESIGN: Following input from an expert panel, an initial set of structural, process, and outcome indicators will be developed based on thorough systematic search in the scientific literature. All initial indicators will be tested in eight emergency departments for their validity and feasibility. Results of the data from the field studies will be presented to the expert panel at a second meeting. A suite of Quality Indicators for the older emergency department population will be finalised following a formal voting process. DISCUSSION: The predicted burgeoning in the number of older persons presenting to emergency departments combined with the recognised quality deficiencies in emergency department care delivery to this population, highlight the need for a quality framework for the care of older persons in emergency departments. Additionally, high quality of care is associated with improved survival & health outcomes of elderly patients. The development of well-selected, validated and economical quality indicators will allow appropriate targeting of resources (financial, education or quality management) to improve quality in areas with maximum potential for improvement.

Appraisal of the quality of care of older adults with cognitive impairment in the emergency department.

The medical records of 273 patients 75 years and older were reviewed to evaluate quality of emergency department (ED) care through the use of quality indicators. One hundred fifty records contained evidence of an attempt to carry out a cognitive assessment. Documented evidence of cognitive impairment (CI) was reported in 54 cases. Of these patients, 30 had no documented evidence of an acute change in cognitive function from baseline; of 26 patients discharged home with preexisting CI (i.e., no acute change from baseline), 15 had no documented evidence of previous consideration of this issue by a health care provider; and 12 of 21 discharged patients who screened positive for cognitive issues for the first time were not referred for outpatient evaluation. These findings suggest that the majority of older adults in the ED are not receiving a formal cognitive assessment, and more than half with CI do not receive quality of care according to the quality indicators for geriatric emergency care. Recommendations for improvement are discussed.

The implementation and impacts of national standards for comprehensive care in acute care hospitals: An integrative review.

Objectives: To synthesise current evidence addressing implementation approaches, challenges and facilitators, and impacts of national standards for comprehensive care in acute care hospitals. Methods: Using Whittemore & Knafl's five-step method, a systematic search was conducted across five databases, including Medline (EBSCO), CINAHL (EBSCO), Cochrane Library, Web of Science, and Scopus, to identify primary studies and reviews. In addition, grey literature (i.e., government reports and webpages) was also searched via Google and international government/organisation websites. All searches were limited to January 1, 2000 to January 31, 2023. Articles relevant to the implementation or impacts of national standards for comprehensive care in acute care hospitals were included. Included articles underwent a Joanna Briggs Institute quality review, followed by qualitative content analysis of the extracted data adhering to PRISMA reporting guidelines. Results: A total of 16 articles were included in the review (5 primary studies, 5 government reports, and 6 government webpages). Three countries (Australia, Norway, and the United Kingdom [UK]) were identified as having a national standard for comprehensive care. The Australian standard contains a unique component of minimising patient harm. Norway does not have a defined implementation framework for the standard, whereas Australia and the UK do. Limited research suggests that challenges in implementing a national standard for comprehensive care in acute care hospitals include difficulties in implementing governance processes, end-of-life care actions, minimising harms actions, and developing comprehensive care plans with multidisciplinary teams, the absence of standardised care plans and patient-centred goals in documentation, and excessive paperwork. Implementation facilitators include a new care plan template using the Identify, Situation, Background, Assessment and Recommendation framework for handover, promoting efficient documentation, clinical decision-making and direct patient care, and proactivity among patients and care professionals with collaboration skills. Limited research suggests introducing the Australian standard demonstrated some positive effects on patient outcomes. Conclusion: The components and implementation approaches of the national standards for comprehensive care in Australia, Norway and the UK were slightly different. The scarcity of studies found during the review highlights the need for further research to evaluate the implementation challenges and facilitators, and impacts of national standards for comprehensive care in acute care hospitals.

Comparison of in-person and telegeriatric follow-up consultations.

INTRODUCTION: Telehealth has the potential to support the care of older adults and their desire to age at home by providing a videoconferencing connection to specialist geriatric care. However, more information is needed to determine how telehealth services affect the care of older adults, and how telehealth services for older adults compare to traditional in-person methods of care provision. The aim of this study was to compare telegeriatric and in-person geriatric consultation methods with respect to outcomes and costs. METHODS: This was a retrospective chart analysis of consultation letters from patients' first follow-up appointment with a geriatric specialist during the 2017/2018 fiscal year (N = 95) in a health jurisdiction of a Western Canadian province. RESULTS: Patients seen through telehealth and in person were similar in mean age (M = 79.1 and 78.1 years, respectively) and were predominately female. Telegeriatric consultations resulted in more requests for further testing and screening (p = 0.003), new diagnoses (p = 0.002), medication changes (p = 0.009) and requests for follow-up (p = 0.03) compared to in-person consultations. An average one-day clinic with one geriatric specialist providing consultations through telehealth cost Can$1684-$1859 less than an equivalent in-person clinic. DISCUSSION: Although additional research is needed to explain the differences in outcomes further between telehealth and in-person consultations found in this work, telehealth consultations cost substantially less than in-person consultations and are a promising way to improve access to geriatric care for older adults in underserved areas.

A comparison of prospective observations and chart audits for measuring quality of care of musculoskeletal injuries in the emergency department.

BACKGROUND: Accurate and efficient data collection is crucial for effective evaluation of quality of care. The objective of this study is to compare two methods of data collection used to score quality indicators for musculoskeletal injury management in Emergency departments: prospective observation, and chart audit. METHODS: An analysis was undertaken of data collected from 633 patients who presented with a musculoskeletal injury to eight emergency departments in Queensland, Australia in 2016-17. Twenty-two quality indicators were scored using both prospective observation and chart audit data for each occasion of service. Quality indicators were included if they were originally published with both collection methods. Analyses were performed to compare firstly, the quality indicator denominators, and secondly, the quality indicator trigger rates, scored using each collection method. Chi Square statistics were used to identify significant differences. RESULTS: Prospectively collected data scored quality indicator denominators significantly (p value<0.05) more often than chart audit data for five (22.7 %) of the 22 quality indicators. The remaining 17 quality indicators (77.3 %) showed no statistical differences. When comparing quality indicator trigger rates, 16 (72.7 %) had significantly different results between methods with 12 (54.5 %) scoring higher using prospective data and four (18.2 %) with chart audit data. The remaining six quality indicators (27.3 %) in this comparison showed no significant difference between chart and prospective data. CONCLUSION: Quality indicators including aspects of care associated with patient safety, and those relying on clinician written orders or forms were adequately scored using either prospective observation or chart audit data. Whereas quality indicators relying on time-sensitive information, elements of a social history, general physical exams and patient education and advice scored higher using prospective observation data collection.

'Online' geriatric assessment procedure for older adults referred for geriatric assessment during an acute care episode for consideration of reliability of triage decisions.

BACKGROUND: Comprehensive geriatric assessment has been shown to improve patient outcomes, but the geriatricians who deliver it are in short-supply. A web-based method of comprehensive geriatric assessment has been developed with the potential to improve access to specialist geriatric expertise. The current study aims to test the reliability and safety of comprehensive geriatric assessment performed "online" in making geriatric triage decisions. It will also explore the accuracy of the procedure in identifying common geriatric syndromes, and its cost relative to conventional "live" consultations. METHODS/DESIGN: The study population will consist of 270 acutely hospitalized patients referred for geriatric consultation at three sites. Paired assessments (live and online) will be conducted by independent, blinded geriatricians and the level of agreement examined. This will be compared with the level of agreement between two independent, blinded geriatricians each consulting with the patient in person (i.e. "live"). Agreement between the triage decision from live-live assessments and between the triage decision from live-online assessments will be calculated using kappa statistics. Agreement between the online and live detection of common geriatric syndromes will also be assessed using kappa statistics. Resource use data will be collected for online and live-live assessments to allow comparison between the two procedures. DISCUSSION: If the online approach is found to be less precise than live assessment, further analysis will seek to identify patient subgroups where disagreement is more likely. This may enable a protocol to be developed that avoids unsafe clinical decisions at a distance. TRIAL REGISTRATION NUMBER: ACTRN12611000936921.