Mental Health Nurses' Experiences of Working in the Emergency Department of Two Rural Australian Settings.

Providing effective mental health care in Emergency Departments (ED) is a fundamental expectation, as EDs increasingly become the first point of contact with health services for people in mental distress. As part of a larger multi-site translational research project this study explored the experiences, perspectives and recommendations of mental health liaison nurses (MHLN) employed in the EDs of two rural hospitals in New South Wales, Australia. Participants identified numerous benefits associated with embedding the MHLNs within the ED team. Some challenges associated with changing thinking and practice were recognised and recommendations for improving ED mental health care provided.

"Completely and utterly flummoxed and out of my depth": patient and caregiver experiences during and after treatment for head and neck cancer-a qualitative evaluation of barriers and facilitators to best-practice nutrition care.

BACKGROUND: Malnutrition is prevalent in patients with head and neck cancer (HNC), impacting on outcomes. Despite publication of best-practice nutrition care clinical guidelines, evidence-practice gaps persist. AIM: This project aimed to understand the perspectives of patients and their caregivers about nutritional care and how their unmet supportive care needs can be better addressed in designing a new model of care (MOC). The results will contribute to documenting the barriers and enablers to implementing best practice nutrition care for patients with HNC. METHOD: Qualitative interviews were conducted with patients who had completed radiotherapy with or without (+/-) other treatment modality (surgery and/or systematic therapy) of curative intent for HNC. Patients were purposively sampled from a major tertiary referral centre in Sydney, Australia. Patients' primary caregivers were also invited to participate if both parties consented. A semi-structured interview schedule was developed to elicit information about barriers and facilitators to change and inform development of the new MOC. Interviews were transcribed verbatim then analysed using an inductive thematic approach. This study was one component of a mixed methods design to explore the barriers and facilitators to best-practice nutrition care in a head and neck oncology unit. RESULTS: Eleven participants (seven patients, four caregivers) took part in the interviews. Four key themes were identified with branching themes within each: (1) being ill-prepared for the impact of treatment, even when advised; (2) navigating complex systems to meet significant care needs; (3) depleted by overwhelming and prolonged suffering; and (4) information lost in translation. CONCLUSIONS: This study highlights the unique and complex care needs of people with HNC and those caring for them. To design and successfully deliver a patient-centred MOC, specific strategies will be required to address: early and ongoing access to expert supportive care clinicians; integrated and coordinated care; individual information, education and support needs and; and education of MDT staff in accurate and consistent messaging, ensuring nutrition care is a collective responsibility. Nutrition care did not appear to be viewed separately to overall care from the patient perspective as the importance of nutrition ultimately became viewed as vital treatment.

Patients' experience of lung cancer care coordination: a quantitative exploration.

PURPOSE: Improving the coordination of care for people with lung cancer is a health priority. This study aimed to tailor an existing care coordination survey for a lung cancer population, investigate coordination experiences for patients who had received hospital-based treatment and identify any factors that may be associated with poor care coordination. METHODS: We conducted a cross-sectional survey of lung patients within two tertiary hospitals in Sydney, Australia. The Cancer Care Coordination Questionnaire for Patients (CCCQ-P) is a psychometrically valid and reliable survey originally developed for colorectal cancer. We pilot tested a survey adaptation with lung cancer patients, support group members and medical specialists (n = 49). A revised survey was mailed to eligible patients via their medical specialist. RESULTS: Fifty-three of 118 eligible participants (45%) completed the CCCQ-P; most had early-stage disease and were about 70 years old. Overall, participants reported positive experiences of care coordination (mean total score 78.1), with high scores on communication and navigation subscales. The most problematic areas related to administrative aspects of care coordination and communication and information provision. Two patient groups (those residing in regional and rural areas, or no experience with the health system prior to diagnosis) reported significantly lower scores on the navigation subscale. CONCLUSIONS: This study found that lung cancer patients' experience of care coordination was positive, but highlighted the need for strategies to assist patients living in rural areas, and those with no experience of the health care system. The CCCQ-P survey instrument can be used in future lung cancer studies.

Patient and staff experience with a new model of emergency department based mental health nursing care implemented in two rural settings.

BACKGROUND: As part of a larger multi-site translational research project this study explored patient and staff experiences, perspectives and recommendations in relation to a mental health liaison nursing (MHLN) service implemented in the emergency department (ED) of two rural hospitals in New South Wales, Australia. METHODS: Semi-structured interviews were conducted across the two sites with a sample of ED patients (n = 32), ED nurses (n = 14), ED medical officers (n = 11) and psychiatrists (n = 3). Data were analysed thematically. FINDINGS: Patients highlighted the therapeutic benefits of the MHLNs, particularly being listened to and understood. Patients appreciated being seen promptly and having effective follow-up. Some negative experiences were encountered. Staff recognized that embedding the new model of care in the ED impacted positively on ED culture and practice. A nurse practitioner position as clinical lead instituted at one site made the most substantial contribution to integrating mental health care within the ED. Room for improvement was also noted. CONCLUSIONS: Findings from this study indicate that an ED-based model of MHLN care developed in a metropolitan setting was successfully translated to two rural EDs. While translating a model of care from one context to another is not without its challenges, adherence to the key principles of this model of MHLN care was associated with the most positive outcome.

Cardiovascular risk factors in those born preterm - systematic review and meta-analysis.

Emerging evidence demonstrates a link between preterm birth (PTB) and later life cardiovascular disease (CVD). We conducted a systematic review and meta-analysis to compare conventional CVD risk factors between those born preterm and at term. PubMed, CINAHL, SCOPUS, and EMBASE databases were searched. The review protocol is registered in PROSPERO (CRD42018095005). CVD risk factors including systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index, lipid profile, blood glucose, and fasting insulin among those born preterm (<37 weeks' gestation) were compared with those born at term (≥37 weeks' gestation). Subgroup analyses based on gender, age, gestational at birth (<32 weeks' gestation and <28 weeks' gestation), and PTB associated with small for gestational age or average for gestational age were also performed. Fifty-six studies provided data on 308,987 individuals. Being born preterm was associated with 3.26 mmHg (95% confidence interval [CI] 2.08 to 4.44) higher mean SBP and 1.32 mmHg (95% CI: 0.61 to 2.04) higher mean DBP compared to being born at term. Subgroup analyses demonstrated that SBP was higher among (a) preterm compared to term groups from early adolescence until adulthood; (b) females born preterm but not among males born preterm compared to term controls; and (c) those born at <32 weeks or <28 weeks compared to term. Our meta-analyses demonstrate higher SBP and DBP among those born preterm compared to term. The difference in SBP is evident from early adolescence until adulthood.

Evaluating an emergency department-based mental health liaison nurse service: A multi-site translational research project.

OBJECTIVE: We aimed to translate and evaluate a model of mental health liaison nursing (MHLN) care that was embedded within EDs. METHODS: The 12 month mixed-methods translational research study incorporated descriptive data on ED presentations, waiting times for MHLN intervention, time spent in ED and discharge arrangements across three EDs in New South Wales. The study involved an inner-city ED (where the model was first established) and two rural sites. Surveys were conducted on a subset of ED patients (n = 58), and emergency and psychiatry staff (n = 52). RESULTS: Triage category 3 presentations accounted for 49% of the MHLN team workload. Response times and ED length of stay varied between city and rural sites, with rural sites demonstrating prompt response times and reduced ED length of stay. The model was strongly endorsed by patients and staff, with 95% of staff and 85% of patients across the three sites recommending the model be implemented in other emergency settings. The need for adequate resources to maintain designated levels of staffing and sustain this model of care was highlighted. CONCLUSION: Findings from the present study indicate that a model of ED-based MHLN care developed in a metropolitan setting was successfully translated to two rural sites. However, the model needs to adhere to certain key principles, and be adequately resourced in order to be sustainable and improve outcomes for ED patients and access to community care.

Patient and clinician experiences with an emergency department-based mental health liaison nurse service in a metropolitan setting.

As part of a larger multi-site translational research project this study explored patient and staff experiences, perspectives, and recommendations in relation to a mental health liaison nursing (MHLN) team established in the emergency department (ED) of a metropolitan hospital in New South Wales, Australia. Semi-structured interviews were conducted with a sample of ED patients (n = 26), ED nurses (n = 10), ED consultants (n = 9), and members of the consultation-liaison psychiatry team (n = 5). Data were analysed thematically. Patients emphasized the numerous therapeutic qualities of the MHLN role, the promptness with which they were seen and the value of follow-up. Privacy was identified as important, and some negative experiences were reported. Staff identified that the MHLN team are able to respond to a variety of ED presentations in a timely manner. There was recognition that the MHLN team needs to be integrated within the ED as a specialist resource that builds ED capacity. Consistent staffing of the MHLN team with designated clinicians was also considered essential. Integrating a nurse practitioner-led MHLN team within the ED has demonstrated multiple benefits for patients, ED staff, and overall service provision. Incorporating a specialist mental health nursing service within the ED builds confidence in ED clinicians. Members of the psychiatry team also acknowledge the value of aligning the clinical governance of the MHLN team within the ED and the reduced workload this model of care has on their service provision to ED, freeing them up to concentrate on their broader general hospital role.

Multi-site study exploring the experiences of security staff responding to mental health, drug health and behavioural challenges in the emergency department.

OBJECTIVE: This multi-site study aimed to give voice to the views and experiences of security staff in assisting with the response to the growing number of people with mental health, drug health and behavioural problems attending EDs. METHODS: Explorative qualitative research design, using semi-structured interviews were conducted with security staff (n = 26) working in three different emergency settings across New South Wales, Australia. The data were analysed thematically. RESULTS: Participants recognised that long waiting times in the ED 'guarding' patients frequently accounted for escalating behaviour and increased the likelihood of restrictive interventions. Security staff expressed concerns about safety and were uncomfortable with a sense of uncertainty regarding their legal position. They voiced frustration over limited communication and lack of information provided by clinical staff on patient background, and the coordination of incidents and ongoing patient care. There was a perception that security staff are not treated with respect and their input was not valued. CONCLUSION: Expecting non-clinicians to undertake a clinical role (often under stressful circumstances involving close patient contact) places security staff and patients in a precarious position. Greater clarity regarding the role of security staff and information that allows them to adequately and safely undertake their work is required. If security staff are expected to participate in patient care then access to relevant information and the ability to document their activities and patient interactions should be provided. The vital support role that security staff perform needs to be valued and respected.

Best Evidence to Best Practice: Implementing an Innovative Model of Nutrition Care for Patients with Head and Neck Cancer Improves Outcomes.

Malnutrition is prevalent in patients with head and neck cancer (HNC), impacting outcomes. Despite publication of nutrition care evidence-based guidelines (EBGs), evidence-practice gaps exist. This study aimed to implement and evaluate the integration of a patient-centred, best-practice dietetic model of care into an HNC multidisciplinary team (MDT) to minimise the detrimental sequelae of malnutrition. A mixed-methods, pre-post study design was used to deliver key interventions underpinned by evidence-based implementation strategies to address identified barriers and facilitators to change at individual, team and system levels. A data audit of medical records established baseline adherence to EBGs and clinical parameters prior to implementation in a prospective cohort. Key interventions included a weekly Supportive Care-Led Pre-Treatment Clinic and a Nutrition Care Dashboard highlighting nutrition outcome data integrated into MDT meetings. Focus groups provided team-level evaluation of the new model of care. Economic analysis determined system-level impact. The baseline clinical audit (n = 98) revealed barriers including reactive nutrition care, lack of familiarity with EBGs or awareness of intensive nutrition care needs as well as infrastructure and dietetic resource limitations. Post-implementation data (n = 34) demonstrated improved process and clinical outcomes: pre-treatment dietitian assessment; use of a validated nutrition assessment tool before, during and after treatment. Patients receiving the new model of care were significantly more likely to complete prescribed radiotherapy and systemic therapy. Differences in mean percentage weight change were clinically relevant. At the system level, the new model of care avoided 3.92 unplanned admissions and related costs of $AUD121K per annum. Focus groups confirmed clear support at the multidisciplinary team level for continuing the new model of care. Implementing an evidence-based nutrition model of care in patients with HNC is feasible and can improve outcomes. Benefits of this model of care may be transferrable to other patient groups within cancer settings.

Implementation of a lung cancer multidisciplinary team standardised template for reporting to general practitioners: a mixed-method study.

OBJECTIVES: Few interventions have been designed that provide standardised information to primary care clinicians about the diagnostic and treatment recommendations resulting from cancer multidisciplinary team (MDT) (tumour board) meetings. This study aimed to develop, implement and evaluate a standardised template for lung cancer MDTs to provide clinical information and treatment recommendations to general practitioners (GPs). Specific objectives were to (1) evaluate template feasibility (acceptability, appropriateness and timeliness) with GPs and (2) document processes of preimplementation, implementation and evaluation within the MDT setting. DESIGN: A mixed-method study design using structured interviews with GPs and qualitative documentation of project logs about implementation processes. SETTING: Two hospitals in Central Sydney, New South Wales, Australia. PARTICIPANTS: 61 GPs evaluated the template. Two lung cancer MDTs, consisting of 33 clinicians, and eight researchers participated in template development and implementation strategy. RESULTS: The MDT-reporting template appears to be a feasible way of providing clinical information to GPs following patient presentation at a lung cancer MDT meeting. Ninety-five per cent of GPs strongly agreed or agreed that the standardised template provided useful and relevant information, that it was received in a timely manner (90%) and that the information was easy to interpret and communicate to the patient (84%). Implementation process data show that the investment made in the preimplementation stage to integrate the template into standard work practices was a critical factor in successful implementation. CONCLUSIONS: This study demonstrates that it is feasible to provide lung cancer MDT treatment recommendations to GPs through implementation of a standardised template. A simple intervention, such as a standardised template, can help to address quality gaps and ensure that timely information is communicated between tertiary and primary care healthcare providers.

Efficacy and safety of gabapentin for uremic pruritus and restless legs syndrome in conservatively managed patients with chronic kidney disease.

CONTEXT: Pruritus and restless legs syndrome (RLS) frequently affect patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD), impacting the quality of life. Gabapentin (1-aminomethyl cyclohexane acetic acid) alleviates these symptoms in hemodialysis (HD) patients, but data are lacking for patients on the conservative pathway. OBJECTIVES: To determine the safety and effectiveness of gabapentin for pruritus or RLS in conservatively managed patients (n = 34) with CKD and ESKD. METHODS: This was a single-center retrospective cohort study. We compared dosing and side effects in 34 CKD/ESKD patients with similar patients receiving HD (n = 15). RESULTS: Forty-four percent of conservatively managed patients complained of RLS and/or pruritus; 18% were excluded for a nonuremic cause of symptom. Thirty-four patients were included in the final analysis. The most common starting daily dose of gabapentin was the equivalent of 50 mg (44.1%) or 100 mg (38.2%) daily, with the median daily dose of 100 mg (range 39-455 mg). Side effects occurred in 47% of patients, with 17% discontinuing gabapentin. Gabapentin reduced symptoms of pruritus (P < 0.001) and RLS (P < 0.05). There was no statistical difference when comparing HD and conservatively managed patients for daily starting dose (P = 0.88), median dose (P = 0.84), and final dose (P = 0.18). Patients conservatively managed were more likely to manifest side effects compared with HD patients (47.1% vs. 14.3%, P = 0.023). Dose was not found to be a factor associated with side effects in univariate analysis. CONCLUSION: Gabapentin is a viable treatment for conservatively managed CKD and ESKD patients with pruritus and/or RLS, but side effects are common. Gabapentin should be used with caution although higher doses do not appear to be a factor associated with side effects.

CKD in elderly patients managed without dialysis: survival, symptoms, and quality of life.

BACKGROUND AND OBJECTIVES: Survival, symptom burden, and quality of life (QOL) are uncertain for elderly patients with advanced CKD managed without dialysis. We examined these outcomes in patients managed with renal supportive care without dialysis (RSC-NFD) and those planned for or commencing dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this prospective observational study, symptoms were measured using the Memorial Symptom Assessment Scale and the Palliative care Outcomes Scale - Symptoms (renal) inventory and QOL was measured using the Short Form-36 survey. This study comprised 273 predialysis patients who had usual nephrology care and 122 nondialysis pathway patients who also attended a renal supportive care clinic adding the skills of a palliative medicine team. A further 72 patients commenced dialysis during this period without attending either clinic. RESULTS: Nondialysis patients were older than the predialysis group (82 versus 67 years; P<0.001) but had similar eGFR at the first clinic visit (16 ml/min per 1.73 m(2); P=0.92). Of the predialysis patients, 92 (34%) commenced dialysis. Compared with the RSC-NFD group, the death rate was lower in the predialysis group who did not require dialysis (hazard ratio, 0.23; 95% confidence interval, 0.12 to 0.41] and in those requiring dialysis (0.30; 0.13 to 0.67) but not in dialysis patients who had not attended the predialysis clinic (0.60; 0.35 to 1.03). Median survival in RSC-NFD patients was 16 (interquartile range, 9, 37) months and 32% survived >12 months after eGFR fell below 10 ml/min per 1.73 m(2). For the whole group, age, serum albumin, and eGFR <15 ml/min per 1.73 m(2) were associated with poorer survival. Of the nondialysis patients, 57% had stable or improved symptoms over 12 months and 58% had stable or improved QOL. CONCLUSIONS: Elderly patients who choose not to have dialysis as part of shared decision making survive a median of 16 months and about one-third survive 12 months past a time when dialysis might have otherwise been indicated. Utilizing the skills of palliative medicine helps provide reasonable symptom control and QOL without dialysis.