Do clinical pathways enhance access to evidence-based acute myocardial infarction treatment in rural emergency departments?

OBJECTIVE: The objective of this study is to measure the impact of a five-step implementation process for an acute myocardial infarction (AMI) clinical pathway (CPW) on thrombolytic administration in rural emergency departments. DESIGN: Cluster randomised controlled trial. SETTING: Six rural Victorian emergency departments participated. INTERVENTION: The five-step CPW implementation process comprised (i) engaging clinicians; (ii) CPW development; (iii) reminders; (iv) education; and (v) audit and feedback. MAIN OUTCOME MEASURES: The impact of the intervention was assessed by measuring the proportion of eligible AMI patients receiving a thrombolytic and time to thrombolysis and electrocardiogram. RESULTS: Nine hundred and fifteen medical records were audited, producing a final sample of 108 patients eligible for thrombolysis. There was no significant difference between intervention and control groups for median door-to-needle time (29 mins versus 29 mins; P = 0.632), proportion of those eligible receiving a thrombolytic (78% versus 84%; P = 0.739), median time to electrocardiogram (7 mins versus 6 mins; P = 0.669) and other outcome measures. Results showed superior outcome measures than other published studies. CONCLUSIONS: The lack of impact of the implementation process for a chest pain CPW on thrombolytic delivery or time to electrocardiogram in these rural hospitals can be explained by a ceiling effect in outcome measures but was also compromised by the small sample. Results suggest that quality of AMI treatment in rural emergency departments (EDs) is high and does not contribute to the worse mortality rate reported for AMIs in rural areas.

A cluster randomised trial to assess the impact of clinical pathways on AMI management in rural Australian emergency departments.

BACKGROUND: People living in rural Australia are more likely to die in hospital following an acute myocardial infarction than those living in major cities. While several factors, including time taken to access hospital care, contribute to this risk, it is also partially attributable to the lower uptake of evidence-based guidelines for the administration of thrombolytic drugs in rural emergency departments where up to one-third of eligible patients do not receive this life-saving intervention. Clinical pathways have the potential to link evidence to practice by integrating guidelines into local systems, but their impact has been hampered by variable implementation strategies and sub-optimal research designs. The purpose of this study is to determine the impact of a five-step clinical pathways implementation process on the timely and efficient administration of thrombolytic drugs for acute myocardial infarctions managed in rural Australian emergency departments. METHODS/DESIGN: The design is a two-arm, cluster-randomised trial with rural hospital emergency departments that treat and do not routinely transfer acute myocardial infarction patients. Six rural hospitals in the state of Victoria will participate, with three in the intervention group and three in the control group. Intervention hospitals will participate in a five-step clinical pathway implementation process: engagement of clinicians, pathway development according to local resources and systems, reminders, education, and audit and feedback. Hospitals in the control group will each receive a hard copy of Australian national guidelines for chest pain and acute myocardial infarction management. Each group will include 90 cases to give a power of 80% at 5% significance level for the two primary outcome measures: proportion of those eligible for thrombolysis receiving the drug and time to delivery of thrombolytic drug. DISCUSSION: Improved compliance with thrombolytic guidelines via clinical pathways will increase acute myocardial infarction survival rates in rural hospitals and thereby help to reduce rural-urban mortality inequalities. Such knowledge translation has the potential to be adapted for a range of clinical problems in a wide array of settings. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry code ACTRN12608000209392.

How far can systematic reviews inform policy development for "wicked" rural health service problems?

Policy makers and researchers increasingly look to systematic reviews as a means of connecting research and evidence more effectively with policy. Based on Australian research into rural and remote primary health care services, we note some concerns regarding the suitability of systematic review methods when applied to such settings. It suggests that rural and other health services are highly complex and researching them is akin to dealing with "wicked" problems. It proposes that the notion of "wicked" problems may inform our understanding of the issues and our choice of appropriate methods to inform health service policy. Key issues including the complexity of health services, methodological limitations of traditional reviews, the nature of materials under review, and the importance of the service context are highlighted. These indicate the need for broader approaches to capturing relevant evidence. Sustained, collaborative synthesis in which complexity, ambiguity and context is acknowledged is proposed as a way of addressing the wicked nature of these issues.

Forecasting emergency department presentations.

OBJECTIVE: To forecast the number of patients who will present each month at the emergency department of a hospital in regional Victoria. METHODS: The data on which the forecasts are based are the number of presentations in the emergency department for each month from 2000 to 2005. The statistical forecasting methods used are exponential smoothing and Box-Jenkins methods as implemented in the software package SPSS version 14.0 (SPSS Inc, Chicago, Ill, USA). RESULTS: For the particular time series, of the available models, a simple seasonal exponential smoothing model provides optimal forecasting performance. Forecasts for the first five months in 2006 compare well with the observed attendance data. CONCLUSIONS: Time series analysis is shown to provide a useful, readily available tool for predicting emergency department demand. The approach and lessons from this experience may assist other hospitals and emergency departments to conduct their own analysis to aid planning.