Resuscitation preferences of older acutely admitted medical and mentally competent patients with one and six months follow-up.

AIM: Determining patients' cardiopulmonary resuscitation (CPR) preferences in the emergency department (ED) is common practice but the stability of these preferences and their recollection by patients has been questioned. Therefore, this study assessed the stability and recall of CPR preferences of older patients at and following ED discharge. METHODS: This survey-based cohort study was conducted between February and September 2020 at three EDs in Denmark. It consecutively asked mentally competent patients aged 65 years or older who were admitted to hospital through the ED and then one and six months later "In your current state of health, do you wish that physicians should try to intervene if your heart stops beating?" Possible responses were confined to "definitely yes", "definitely no", "uncertain", and "prefer not to answer". RESULTS: In total, 3688 patients admitted to hospital via the ED patients were screened, 1766 were eligible and 491 (27.8%) were included: median age was 76 (IQR 71-82) years, and 257 (52.3%) were men. One third of patients who expressed definite yes or no preferences in ED had changed their preference at one month follow-up. Only 90 (27.4%) and 94 (35.7%) patients recalled their preferences at one and six months follow-up, respectively. CONCLUSION AND RELEVANCE: In this study, one-in-three older ED patients who initially expressed definite resuscitation preferences had changed their minds at one month follow-up. Preferences were more stable at six months but only a minority were able to recall their preferences.

What matters and influence resuscitation preference? Development, field testing, and structural validation of items among older patients in the emergency department.

BACKGROUND: Decisions about resuscitation preference is an essential part of patient-centered care but a prerequisite is having an idea about which questions to ask and understand how such questions may be clustered in dimensions. The European Resuscitation Council Guidelines 2021 encourages resuscitation shared decision making in emergency care treatment plans and needs and experiences of people approaching end-of-life have been characterized within the physical, psychological, social, and spiritual dimensions. We aimed to develop, test, and validate the dimensionality of items that may influence resuscitation preference in older Emergency Department (ED) patients. METHODS: A 36-item questionnaire was designed based on qualitative interviews exploring what matters and what may influence resuscitation preference and existing literature. Items were organized in physical, psychological, social, and spiritual dimensions. Initial pilot-testing to assess content validity included ten older community-dwelling persons. Field-testing, confirmatory factor analysis and post-hoc bifactor analysis was performed on 269 older ED patients. Several model fit indexes and reliability coefficients (explained common variance (ECV) and omega values) were computed to evaluate structural validity, dimensionality, and model-based reliability. RESULTS: Items were reduced from 36 to 26 in field testing. Items concerning religious beliefs from the spiritual dimension were misunderstood and deemed unimportant by older ED patients. Remaining items concerned physical functioning in daily living, coping, self-control in life, optimism, overall mood, quality of life and social participation in life. Confirmatory factor analysis displayed poor fit, whereas post-hoc bifactor analysis displayed satisfactory goodness of fit (χ2 =562.335 (p<0.001); root mean square error of approximation=0.063 (90% CI [0.055;0.070])). The self-assessed independence may be the bifactor explaining what matters to older ED patients' resuscitation preference. CONCLUSIONS: We developed a questionnaire and investigated the dimensionality of what matters and may influence resuscitation preference among older ED patients. We could not confirm a spiritual dimension. Also, in bifactor analysis the expected dimensions were overruled by an overall explanatory general factor suggesting independence to be of particular importance for clinicians practicing resuscitation discussions in EDs. Studies to investigate how independence may relate to patients' choice of resuscitation preference are needed.

Review article: Has the implementation of time-based targets for emergency department length of stay influenced the quality of care for patients? A systematic review of quantitative literature.

Time-based targets (TBTs) for ED stays were introduced to improve quality of care but criticised as having harmful unintended consequences. The aim of the review was to determine whether implementation of TBTs influenced quality of care. Structured searches in medical databases were undertaken (2000-2019). Studies describing a state, regional or national TBTs that reported processes or outcomes of care related to the target were included. Harvest plots were used to summarise the evidence. Thirty-three studies (n = 34 million) were included. In some settings, reductions in mortality were seen in ED, in hospital and at 30 days, while in other settings mortality was unchanged. Mortality reductions were seen in the face of increasing age and acuity of presentations, when short-stay admissions were excluded, and when pre-target temporal trends were accounted for. ED crowding, time to assessment and admission times reduced. Fewer patients left prior to completing their care and fewer patients re-presented to EDs. Short-stay admissions and re-admissions to wards within 30 days increased. There was conflicting evidence regarding hospital occupancy and ward medical emergency calls, while times to treatment for individual conditions did not change. The evidence for associations was mostly low certainty and confidence in the findings is accordingly low. Quality of care generally improved after targets were introduced and when compliance with targets was high. This depended on how targets were implemented at individual sites or within jurisdictions, with important implications for policy makers, health managers and clinicians.

Review article: Emergency department crowding measures associations with quality of care: A systematic review.

ED crowding has been reported to reduce the quality of care. There are many proposed crowding metrics, but the metric most strongly associated with care quality remains unknown. The present study aims to determine the crowding metric with the strongest links with processes and outcomes of care linked to the Institute of Medicine quality domains. Systematic searches in healthcare databases were conducted using terms for 'crowding', 'metrics' and 'performance', supplemented by grey literature and citation searches. The level of evidence for each association was assessed using an explicit tool. The body of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. Evidence was synthesised using harvest plots. Titles and abstracts of 2052 studies were screened, 452 selected for full-text review and 183 included. Inter-observer agreement was moderate κ = 0.54 (95% confidence interval 0.50-0.59). Two thirds were from urban tertiary hospitals in North America (65%), Australasia (13%), Europe (12%) and Asia (8%). One third provided Level 3 or higher evidence. Metrics were based on occupancy (38%), time (31%), workload (19%) or combinations (9%). Data were synthesised from 25 607 375 patients, 2368 staff, 9089 hospitals and 101 177 sampling times. Almost all crowding metrics were patient-centred and reflect timeliness and efficiency. ED length of stay, boarding time and total occupancy had the strongest association with safety and effectiveness of care. ED length of stay was also associated with equity. The certainty of evidence for associations between crowding measures varied across domains of quality, from very low to moderate certainty.

Review article: Have emergency department time-based targets influenced patient care? A systematic review of qualitative literature.

Time-based targets for ED length of stay were introduced in England in 2000, followed by the rest of the UK, Canada, Ireland, New Zealand, and Australia after ED crowding was associated with poor quality of care and increased mortality. This systematic review evaluates qualitative literature to see if ED time-based targets have influenced patient care quality. We included 13 studies from four countries, incorporating 617 interviews. We conclude that time-based targets have impacted on the quality of emergency patient care, both positively and negatively. Successful implementation depends on whole hospital resourcing and engagement with targets.

Impact of the Four-Hour Rule policy on emergency medical services delays in Australian EDs: a longitudinal cohort study.

INTRODUCTION: Delayed handover of emergency medical services (EMS) patients to EDs is a major issue with hospital crowding considered a primary cause. We explore the impact of the 4-hour rule (the Policy) in Australia, focusing on ambulance and ED delays. METHODS: EMS (ambulance), ED and hospital data of adult patients presenting to 14 EDs from 2002 to 2013 in three jurisdictions were linked. Interrupted time series 'Before-and-After' trend analysis was used for assessing the Policy's impact. Random effects meta-regression analysis was examined for associations between ambulance delays and Policy-associated ED intake, throughput and output changes. RESULTS: Before the Policy, the proportion of ED ambulances delayed increased between 1.1% and 1.7% per quarter across jurisdictions. After Policy introduction, Western Australia's increasing trend continued but Queensland decreased by 5.1% per quarter. In New South Wales, ambulance delay decreased 7.1% in the first quarter after Policy introduction. ED intake (triage delay) improved only in New South Wales and Queensland. Each 1% ambulance delay reduction was significantly associated with a 0.91% reduction in triage delay (p=0.014) but not ED length of stay ≤4 hours (p=0.307) or access-block/boarding (p=0.605) suggesting only partial improvement in ambulance delay overall. CONCLUSION: The Policy was associated with reduced ambulance delays over time in Queensland and only the immediate period in New South Wales. Associations may be due to local jurisdictional initiatives to improve ambulance performance. Strategies to alleviate ambulance delay may need to focus on the ED intake component. These should be re-examined with longer periods of post-Policy data.

When a health policy cuts both ways: Impact of the National Emergency Access Target policy on staff and emergency department performance.

OBJECTIVE: To explore the impact of the Four-Hour Rule/National Emergency Access Target (4HR/NEAT) on staff and ED performance. METHODS: A mixed-methods study design was used to link performance data from 16 participating hospitals with the experiences reported by 119 ED staff during policy implementation. Quantitative and qualitative measures were triangulated to identify the staff and organisational effects on hospital performance. An overall score was developed to categorise hospitals into: high, moderate and low performers, then compared with four qualitative themes: social factors, ED management, ED outcomes and 4HR/NEAT compliance. RESULTS: Key factors identified were stress and morale; intergroup dynamics; interaction with patients; resource management; education and training; financial incentives; impact on quality and safety; perceived improvements on access block and overcrowding. High performing hospitals reported increased stress and decreased morale, decreased staff-patient communication and staff shortages; significant changes in ED management and effective use of the whole-of-hospital approach. Moderate performing hospitals reported similar characteristics to a lesser degree, and the perception that 4HR/NEAT did not impact ED practice. Low performing hospitals also reported increased stress and low morale and a less effective whole-of-hospital approach. ED staff also reported a reduction in communication with patients. CONCLUSIONS: There was strong evidence of an association between high stress and low morale and the implementation of the 4HR/NEAT across all levels of performance. These adverse consequences of the 4HR/NEAT implementation indicate that a more nuanced approach to efficiency improvements is required. This would balance processes measured by 4HR/NEAT against a range of other clinical and organisational performance measures.

Gaming National Emergency Access Target performance using Emergency Treatment Performance definitions and emergency department short stay units.

OBJECTIVE: To evaluate potential gaming of the 4 h ED length of stay metric known as the National Emergency Access Target (NEAT) in Australia and Emergency Treatment Performance (ETP) in New South Wales (NSW). METHODS: Descriptive statistical analysis was used to recalculate and compare the scores for NEAT and the NSW ETP using variations in the definitions of their measurement on 32 184 presentations during 2016. A computer simulation using a discrete event model illustrated the effect of the use of ED short stay beds on the ETP scores. RESULTS: Using the timestamp of the intent to discharge a patient, called, 'ready for departure' instead of the time of a patient physically leaving the department, resulted in an apparent 6% performance improvement. A local interpretation of the NSW state definition of the 'transferred' patient resulted in the ETP for 'admitted' patients improving by 16%. The discrete event model demonstrated that without changing patient length of stay, ETP scores can be improved by optimising the time of the admit decision or increasing the number of ED short stay beds. CONCLUSIONS: The opportunity of NEAT may be squandered unless gaming of the definitions and use of ED short stay beds is addressed. We argue that the longstanding issue of 'departure time' should be defined as 'physically leaving' the department, in accordance with the Australasian College for Emergency Medicine (ACEM) definition. Patient occupancy is a real measure of ED resource use and NSW and national recommendations should be adjusted. ACEM accreditation of EDs should include review of their application of NEAT definitions to ensure they truly reflect patient flow processes.

Perceptions and experiences of emergency department staff during the implementation of the four-hour rule/national emergency access target policy in Australia: a qualitative social dynamic perspective.

BACKGROUND: The Four-Hour Rule or National Emergency Access Target policy (4HR/NEAT) was implemented by Australian State and Federal Governments between 2009 and 2014 to address increased demand, overcrowding and access block (boarding) in Emergency Departments (EDs). This qualitative study aimed to assess the impact of 4HR/NEAT on ED staff attitudes and perceptions. This article is part of a series of manuscripts reporting the results of this project. METHODS: The methodology has been published in this journal. As discussed in the methods paper, we interviewed 119 participants from 16 EDs across New South Wales (NSW), Queensland (QLD), Western Australia (WA) and the Australian Capital Territory (ACT), in 2015-2016. Interviews were recorded, transcribed, imported to NVivo 11 and analysed using content and thematic analysis. RESULTS: Three key themes emerged: Stress and morale, Intergroup dynamics, and Interaction with patients. These provided insight into the psycho-social dimensions and organisational structure of EDs at the individual, peer-to-peer, inter-departmental, and staff-patient levels. CONCLUSION: Findings provide information on the social interactions associated with the introduction of the 4HR/NEAT policy and the intended and unintended consequences of its implementation across Australia. These themes allowed us to develop several hypotheses about the driving forces behind the social impact of this policy on ED staff and will allow for development of interventions that are rooted in the rich context of the staff's experiences.

Qualitative analysis of perceptions and experiences of emergency department staff in relation to implementation and outcomes of the Four-Hour Rule/National Emergency Access Target in Australia.

OBJECTIVE: The implementation of the time target policy (Four-Hour Rule/National Emergency Access Target [4HR/NEAT]) constituted a major change for ED, and potentially on quality of care. The present study aimed to understand perceptions and experiences of ED staff during 4HR/NEAT implementation. METHODS: A semi-structured interview was used to explore views and perceptions of 119 ED staff from 16 EDs in New South Wales, Australian Capital Territory, Queensland and Western Australia. The interviews covered aspects such as perceived changes in quality of clinical care, whether the capacity to deliver education was diminished or enhanced and whether the policy affected access to care. Interviews were transcribed, imported to NVivo 11 and analysed using content and thematic analysis. RESULTS: Three themes were identified: quality and safety of care; access block and overcrowding; and medical education and training. Participants described both positive and negative aspects of the policy. Although some reported negative impacts on care quality and access block, more cited overall improvements in these areas. The majority perceived that medical education and training was negatively affected, mainly because of restricted training opportunities and reduced time for procedural skills. CONCLUSIONS: ED staff perceived important effects on quality and safety of care; access block and overcrowding; and medical education and training. In relation to an optimised ED role, quality of care and access block were overall felt to be improved, while education and training deteriorated. Our study increases understanding of the complexity of policy implementation processes and its impact on staff. Staff perceptions are a valuable measure of system performance and should be incorporated into system change evaluations.

Impact of the Four-Hour Rule/National Emergency Access Target policy implementation on emergency department staff: A qualitative perspective of emergency department management changes.

OBJECTIVE: It has been 10 years since the ACEM Access Block Solutions Summit and 5 years since the introduction of the Four-Hour Rule/National Emergency Access Target (4HR/NEAT) policy. The impact of this policy on ED management and on ED staff has been poorly understood. The aim of the present study was to identify changes in ED management resulting from the policy based on ED staff experiences. METHODS: Semi-structured interviews were conducted and transcribed, imported to NVivo 11 and analysed using a combination of content, thematic analysis and phenomenological focus within a theoretical framework known as the 'logic model'. RESULTS: One hundred and nineteen ED staff participated in 2015-2016 to assess the impact of the policy implementation. Participants were drawn from 16 EDs in New South Wales, Queensland, Western Australia and Australian Capital Territory. In relation to ED management, three themes were identified: changes in ED management; activities and changes driven by the hospital in relation to 4HR/NEAT; and participant experiences in relation to policy compliance by staff. CONCLUSIONS: Policy implementation is a complex process that had both positive and negative consequences on how ED staff managed the implementation of the 4HR/NEAT policy and how it changed their work environment. Understanding the perceptions of staff involved in policy implementation has significance for the design of future implementation strategies. The biggest insight from the present study is that ED management is very complex and the policy generated multiple positive and negative changes demonstrating the wide range of processes involved in this area of health services research.

Impact of the National Emergency Access Target policy on emergency departments' performance: A time-trend analysis for New South Wales, Australian Capital Territory and Queensland.

OBJECTIVE: To evaluate the impact of the Australian National Emergency Access Target (NEAT) policy introduced in 2012 on ED performance. METHODS: A longitudinal cohort study of NEAT implementation using linked data, for 12 EDs across New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD) between 2008 and 2013. Segmented regression in a multi-level model was used to analyse ED performance over time before and after NEAT introduction. The main outcomes measures were ED length of stay ≤4 h, access block, number of ED presentations, short-stay admission (≤24 h), >24 h admissions, unplanned ED re-attendances within 7 days and 'left at own risk' (including 'did not wait for assessment'). RESULTS: Two years after NEAT introduction, ED length of stay ≤4 h increased in NSW and QLD (odds ratio [OR] = 2.48 and 3.24; P < 0.001) and access block decreased (OR = 0.41 and 0.22; P < 0.001), but not in ACT (OR = 1.28; P > 0.05). ED presentations increased over time before and after NEAT introduction with a significant increase above the projected trend in NSW after NEAT (mean ratio = 1.07). Short-stay admissions increased in QLD (OR = 2.60), ACT (OR = 1.68) and NSW (OR = 1.35). Unplanned ED re-attendances did not change significantly. Those who left at their own risk decreased significantly in NSW and QLD (OR = 0.38 and 0.67). CONCLUSION: ED presentations continued to increase over time in all jurisdictions. NSW and QLD, but not ACT, showed significant improvements in time-based measures. Significant increases in short-stay admissions suggest a strategic change in ED process associated with NEAT implementation. Rates of unplanned ED re-attendances and those leaving at their own risk showed no evidence for adverse effects from NEAT.

Impact of the four-hour National Emergency Access Target on 30 day mortality, access block and chronic emergency department overcrowding in Australian emergency departments.

OBJECTIVE: Previous research reported strong associations between ED overcrowding and mortality. We assessed the effect of the Four-Hour Rule (4HR) intervention (Western Australia (WA) 2009), then nationally rolled out as the National Emergency Access Target (Australia 2012) policy on mortality and patient flow. METHODS: A longitudinal cohort study of a population-wide 4HR, for 16 hospitals across WA, New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD). Mortality trends were analysed for 2-4 years before and after 4HR using interrupted time series technique. Main outcomes included the effect of 4HR on patient flow markers; admitted 30 day mortality trends; and patient flow marker performance during the study period. RESULTS: There were 40 281 deaths from 952 726 emergency admissions. All jurisdictions, except ACT, had improved flow and access block after 4HR. Age-standardised mortality was decreasing before the intervention. Post-intervention, WA had a significant reduction in mortality rate of -0.28 per 1000 patients per quarter (P = 0.040) while QLD had mixed results and NSW/ACT trends did not change significantly. Meta-regression of aggregated data for hospitals grouped on flow performances did not show significant mortality changes associated with the policy. CONCLUSIONS: The 4HR was introduced as a means of driving hospital performance by applying a time target. Patient flow improved, but the evidence for mortality benefit is controversial with improvement only in WA. Further research with more representative data from a larger number of hospitals over a longer time across Australia is needed to increase statistical power to detect long-term effects of the policy.

States worse than death.

PURPOSE OF REVIEW: This review aims to discuss situations where patients would prefer to consider dying rather than survive, particularly in the context of choosing whether to be subjected to active medical management aimed at increasing their life span. RECENT FINDINGS: Obviously, there are no randomized trials on evaluating whether patients would choose death rather than life. Moreover, the topic of the review is rarely addressed in a conventional scientific way. Instead, we review the suffering that people may go through when receiving futile care in both the short and long-term in acute hospitals and how this may influence people's decisions about their own Goals of Care. SUMMARY: The review describes the failure of acute hospitals to recognize people at the end of life until very late and, when they are recognized, the failure to manage the dying process well. The inference is that if patients were genuinely aware of the potential short and long-term suffering involved in futile care, they would consider those states worse, may be worse than death, especially when death is almost certainly inevitable with or without conventional treatment.

Impact of the Four-Hour Rule in Western Australian hospitals: Trend analysis of a large record linkage study 2002-2013.

BACKGROUND: In 2009, the Western Australian (WA) Government introduced the Four-Hour Rule (FHR) program. The policy stated that most patients presenting to Emergency Departments (EDs) were to be seen and either admitted, transferred, or discharged within 4 hours. This study utilised de-identified data from five participating hospitals, before and after FHR implementation, to assess the impact of the FHR on several areas of ED functioning. METHODS: A state (WA) population-based intervention study design, using longitudinal data obtained from administrative health databases via record linkage methodology, and interrupted time series analysis technique. FINDINGS: There were 3,214,802 ED presentations, corresponding to 1,203,513 ED patients. After the FHR implementation, access block for patients admitted through ED for all five sites showed a significant reduction of up to 13.2% (Rate Ratio 0.868, 95%CI 0.814, 0.925) per quarter. Rate of ED attendances for most hospitals continued to rise throughout the entire study period and were unaffected by the FHR, except for one hospital. Pattern of change in ED re-attendance rate post-FHR was similar to pre-FHR, but the trend reduced for two hospitals. ED occupancy was reduced by 6.2% per quarter post-FHR for the most 'crowded' ED. ED length of stay and ED efficiency improved in four hospitals and deteriorated in one hospital. Time to being seen by ED clinician and Did-Not-Wait rate improved for some hospitals. Admission rates in post-FHR increased, by up to 1% per quarter, for two hospitals where the pre-FHR trend was decreasing. CONCLUSIONS: The FHR had a consistent effect on 'flow' measures: significantly reducing ED overcrowding and access block and enhancing ED efficiency. Time-based outcome measures mostly improved with the FHR. There is some evidence of increased ED attendance, but no evidence of increased ED re-attendance. Effects on patient disposition status were mixed. Overall, this reflects the value of investing resources into the ED/hospital system to improve efficiency and patient experience. Further research is required to illuminate the exact mechanisms of the effects of FHR on the ED and hospital functioning across Australia.

Application of four-dimension criteria to assess rigour of qualitative research in emergency medicine.

BACKGROUND: The main objective of this methodological manuscript was to illustrate the role of using qualitative research in emergency settings. We outline rigorous criteria applied to a qualitative study assessing perceptions and experiences of staff working in Australian emergency departments. METHODS: We used an integrated mixed-methodology framework to identify different perspectives and experiences of emergency department staff during the implementation of a time target government policy. The qualitative study comprised interviews from 119 participants across 16 hospitals. The interviews were conducted in 2015-2016 and the data were managed using NVivo version 11. We conducted the analysis in three stages, namely: conceptual framework, comparison and contrast and hypothesis development. We concluded with the implementation of the four-dimension criteria (credibility, dependability, confirmability and transferability) to assess the robustness of the study, RESULTS: We adapted four-dimension criteria to assess the rigour of a large-scale qualitative research in the emergency department context. The criteria comprised strategies such as building the research team; preparing data collection guidelines; defining and obtaining adequate participation; reaching data saturation and ensuring high levels of consistency and inter-coder agreement. CONCLUSION: Based on the findings, the proposed framework satisfied the four-dimension criteria and generated potential qualitative research applications to emergency medicine research. We have added a methodological contribution to the ongoing debate about rigour in qualitative research which we hope will guide future studies in this topic in emergency care research. It also provided recommendations for conducting future mixed-methods studies. Future papers on this series will use the results from qualitative data and the empirical findings from longitudinal data linkage to further identify factors associated with ED performance; they will be reported separately.

Impact of emergency department discharge stream short stay unit performance and hospital bed occupancy rates on access and patient flowmeasures: A single site study.

OBJECTIVE: The ED discharge stream short stay units (EDSSUs) aim to facilitate patient flows through EDs. We investigate the relationship between EDSSU census and hospital bed occupancy rates (BORs) on National Emergency Access Target (NEAT) performance and did-not-wait (DNW) rates at a tertiary metropolitan adult ED in Sydney, Australia. METHODS: We collated data for all ED presentations between 1 January 2012 and 31 December 2014. Daily ED, EDSSU census and ED-accessible hospital BORs were tabulated with daily ED NEAT performance and DNW rates. Non-parametric regression analyses was conducted on cohorts of appropriate, inappropriate, successful and failed EDSSU admissions based on local admission policies and BOR for NEAT and DNW outcomes. RESULTS: Among all presentations (n = 192 506) during the study period, 43.8% of patients were admitted in hospital including 10.4% for EDSSU (n = 20 081). Analyses reveal modest positive correlation of EDSSU admissions with NEAT performance (τ = 0.35, P < 0.001) and weak negative correlation with DNW rates (τ = -0.29, P < 0.001). These associations were more pronounced on days when BOR >100% (τ = 0.39 and τ = -0.36, P < 0.001). BOR of >100% were associated with reduced EDSSU admits, NEAT performance and increased DNW rates (P < 0.001). Appropriate EDSSU admissions had shorter EDSSU length of stay than inappropriate EDSSU admissions (350 vs 557 min, median difference -158 min, P < 0.001). CONCLUSION: Appropriate use of EDSSU provides effective conduit for ongoing patients' management beyond mandated timelines. Health systems should focus on reducing hospital BORs to mitigate exclusive ED pressure to deliver NEAT performance targets.