Trends in fall-related ambulance use and hospitalisation among older adults in NSW, 2006-2013: a retrospective, population-based study.

Objective and importance of study: To describe characteristics and temporal trends of fall-related ambulance service use and hospital admission in older adults in New South Wales (NSW), Australia. Such information will facilitate a more targeted approach to planning and delivery of health services to prevent falls and their adverse sequelae in different groups of older adults. STUDY TYPE: Retrospective population-based descriptive study. METHODS: Fall-related ambulance use and hospital admissions for all falls and injurious falls in NSW residents aged ≥65 years between 2006 and 2013 were obtained from two discrete sources of routinely collected data. Rates of use are presented descriptively. RESULTS: There were 314 041 occasions of fall-related ambulance use by older adults and 331 311 fall-related hospitalisations, of which 69% (n = 227 753) were for injurious falls. Fractures accounted for 57% of injurious hospitalisations. Slips and trips were the most common mechanism of falls requiring hospitalisation (52%). Residents of aged care facilities had a greater proportion of fall injury hospitalisations compared with people living in the community (85% and 65%, respectively). CONCLUSIONS: Rates of fall-related ambulance use and hospitalisation were similar and continued to increase over time. Increased effort is needed to prevent falls and associated injury among older people in NSW, particularly among people living in aged care facilities. Ongoing monitoring of rates and the characteristics of people who fall are needed to determine the long-term impact of fall prevention interventions.

Accuracy of Cuff-Measured Blood Pressure: Systematic Reviews and Meta-Analyses.

BACKGROUND: Hypertension (HTN) is the single greatest cardiovascular risk factor worldwide. HTN management is usually guided by brachial cuff blood pressure (BP), but questions have been raised regarding accuracy. OBJECTIVES: This comprehensive analysis determined the accuracy of cuff BP and the consequent effect on BP classification compared with intra-arterial BP reference standards. METHODS: Three individual participant data meta-analyses were conducted among studies (from the 1950s to 2016) that measured intra-arterial aortic BP, intra-arterial brachial BP, and cuff BP. RESULTS: A total of 74 studies with 3,073 participants were included. Intra-arterial brachial systolic blood pressure (SBP) was higher than aortic values (8.0 mm Hg; 95% confidence interval [CI]: 5.9 to 10.1 mm Hg; p < 0.0001) and intra-arterial brachial diastolic BP was lower than aortic values (-1.0 mm Hg; 95% CI: -2.0 to -0.1 mm Hg; p = 0.038). Cuff BP underestimated intra-arterial brachial SBP (-5.7 mm Hg; 95% CI: -8.0 to -3.5 mm Hg; p < 0.0001) but overestimated intra-arterial diastolic BP (5.5 mm Hg; 95% CI: 3.5 to 7.5 mm Hg; p < 0.0001). Cuff and intra-arterial aortic SBP showed a small mean difference (0.3 mm Hg; 95% CI: -1.5 to 2.1 mm Hg; p = 0.77) but poor agreement (mean absolute difference 8.0 mm Hg; 95% CI: 7.1 to 8.9 mm Hg). Concordance between BP classification using the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure cuff BP (normal, pre-HTN, and HTN stages 1 and 2) compared with intra-arterial brachial BP was 60%, 50%, 53%, and 80%, and using intra-arterial aortic BP was 79%, 57%, 52%, and 76%, respectively. Using revised intra-arterial thresholds based on cuff BP percentile rank, concordance between BP classification using cuff BP compared with intra-arterial brachial BP was 71%, 66%, 52%, and 76%, and using intra-arterial aortic BP was 74%, 61%, 56%, and 65%, respectively. CONCLUSIONS: Cuff BP has variable accuracy for measuring either brachial or aortic intra-arterial BP, and this adversely influences correct BP classification. These findings indicate that stronger accuracy standards for BP devices may improve cardiovascular risk management.

Demand for Emergency Services Trends in New South Wales Years 2010-2014 (DESTINY): Age and Clinical Factors Associated with Ambulance Transportation to Emergency Departments.

OBJECTIVES: The study aimed to analyze ambulance transportations to Emergency Departments (EDs) in New South Wales (NSW) and to identify temporal changes in demographics, acuity, and clinical diagnoses. METHODS: This was a retrospective analysis of a population based registry of ED presentations in New South Wales. The NSW Emergency Department data collection (EDCC) collects patient level data on presentations to designated EDs across NSW. Patients that presented to EDs by ambulance between January 2010 and December 2014 were included. Patients dead on arrival, transferred from another hospital, or planned ED presentations were excluded. RESULTS: A total of 10.8 million ED attendances were identified of which 2.6 million (23%) were transported to ED by ambulance. The crude rate of ambulance transportations to EDs across all ages increased by 3.0% per annum over the five years with the highest rate observed in those 85 years and over (620.5 presentations per 1,000 population). There was an increase in the proportion of category 1 and 2 (life-threatening or potentially life-threatening) cases from 18.1% to 24.0%. CONCLUSION: Demand for ambulance services appears to be driven by older patients presenting with higher acuity problems. Alternative models of acute care for elderly patients need to be planned and implemented to address these changes.

Quantification of NSW Ambulance Record Linkages with Multiple External Datasets.

This study has two aims: 1) to describe linkage rates between ambulance data and external datasets for "episodes of care" and "patient only" linkages in New South Wales (NSW), Australia; and 2) to detect and report any systematic issues with linkage that relate to patients, and operational or clinical variables that may introduce bias in subsequent studies if not adequately addressed. During 2010-11, the Centre for Health Record Linkage (CHeReL) in NSW, linked the records for patients attended by NSW Ambulance paramedics for the period July 2006 to June 2009, with four external datasets: Emergency Department Data Collection; Admitted Patient Data Collection; NSW Registry of Births, Deaths and Marriages death registration data; and the Australian Bureau of Statistics mortality data. This study reports linkage rates in terms of those "expected" to link and those who were "not expected" to link with external databases within 24 hours of paramedic attendance. Following thorough data preparation processes, 2,041,728 NSW Ambulance care episodes for 1,116,509 patients fulfilled the inclusion criteria. The overall episode-specific hospital linkage rate was 97.2%. Where a patient was not transported to hospital following paramedic care, 8.6% of these episodes resulted in an emergency department attendance within 24 hours. For all care episodes, 5.2% linked to a death record at some time within the 3-year period, with 2.4% of all death episodes occurring within 7 days of a paramedic encounter. For NSW Ambulance episodes of care that were expected to link to an external dataset but did not, nonlinkage to hospital admission records tended to decrease with age. For all other variables, issues relating to rates of linkage and nonlinkage were more indiscriminate. This quantification of the limitations of this large linked dataset will underpin the interpretation and results of ensuing studies that will inform future clinical and operational policies and practices at NSW Ambulance.

Right care, right time, right place: improving outcomes for people with spinal cord injury through early access to intervention and improved access to specialised care: study protocol.

BACKGROUND: Traumatic spinal cord injury is a devastating condition impacting adversely on the health and wellbeing, functioning and independence, social participation and quality of life of the injured person. In Australia, there are approximately 15 new cases per million population per year; economic burden estimates suggest 2 billion dollars annually. For optimal patient outcomes expert consensus recommends expeditious transfer ("<24 hours of injury") to a specialist Spinal Cord Injury Unit, where there is an interdisciplinary team equipped to provide comprehensive care for the many and complex issues associated with traumatic spinal cord injury. No study of this patient population has been undertaken, that assessed the extent to which care received reflected clinical guidelines, or examined the patient journey and outcomes in relation to this. The aims of this study are to describe the nature and timing of events occurring before commencement of specialist care, and to quantify the association between these events and patient outcomes. METHODS AND DESIGN: The proposed observational study will recruit a prospective cohort over two years, identified at participating sites across two Australian states; Victoria and New South Wales. Included participants will be aged 16 years and older and diagnosed with a traumatic spinal cord injury. Detailed data will be collected from the point of injury through acute care and subacute rehabilitation, discharge from hospital and community reintegration. Items will include date, time, location and external cause of injury; ambulance response, assessments and management; all episodes of hospital care including assessments, vital signs, diagnoses and treatment, inter-hospital transfers, surgical interventions and their timing, lengths of stay and complications. Telephone follow-up of survivors will be conducted at 6, 12 and 24 months. DISCUSSION: There is limited population level data on the effect of delayed commencement of specialist care (>24 hours) in a Spinal Cord Injury Unit. Examining current health service and clinical intervention pathways in this Australian population-based sample, in relation to their outcomes, will provide an understanding of factors associated with patient flow, resource utilisation and cost, and patient and family quality of life. Barriers to streamlined effective early-care pathways and facilitators of optimal treatment for these patients will be identified.

Informing clinical policy decision-making practices in ambulance services.

AIM: This study aims to identify the processes and frameworks that support an evidence-based approach to clinical policy decision-making practices in ambulance services. METHODS: This literature review focused on: (i) the setting (pre-hospital); and (ii) the process of evidence translation, for studies published after the year 2000. Searches of Medline, CINAHL and Google were undertaken. Reference lists of eligible publications were searched for relevant articles. RESULTS: A total of 954 articles were identified. Of these, 20 full text articles were assessed for eligibility and seven full text articles met the inclusion criteria. Three provided detailed descriptions of the evidence-based practice processes used to inform ambulance service protocol or guideline development or review. CONCLUSIONS: There is little published literature that describes the processes involved, and frameworks required, to inform clinical policy decision making within ambulance services. This review found that processes were iterative and involved collaborations across many internal and external stakeholders. In several jurisdictions, these were coordinated by a dedicated team. Success appears dependent on committed leadership and purposive human and structural resources. Although time consuming, structured processes have been developed in some jurisdictions to assist decision-making processes. Further insight is likely to be obtained from literature published by those from other disciplines.

Level of agreement between prehospital and emergency department vital signs in trauma patients.

OBJECTIVES: Describe the level of agreement between prehospital (emergency medical service [EMS]) and ED vital signs in a group of trauma patients transported to an inner city Major Trauma Centre. We also sought to determine factors associated with differences in recorded vital sign measurements. METHODS: All adult patients meeting trauma triage criteria and transported directly from scene of injury by New South Wales Ambulance to our institution were included. The primary outcome was the difference in vital signs: heart rate (HR), systolic blood pressure (SBP), respiratory rate (RR) and Glasgow Coma Scale (GCS), between ED and EMS recorded measurements. Agreement was assessed using intraclass correlation coefficients and enhanced Bland-Altman plots. Multivariable linear regression models were used to determine factors associated with vital sign differences. RESULTS: The 1181 trauma patients met inclusion criteria. Intraclass correlation coefficients were as follows: GCS 0.74 (95% confidence interval [CI], 0.37, 1.12); HR 0.41 (95% CI, 0.30, 0.53); SBP 0.37 (95% CI, 0.27, 0.46); and RR 0.29 (95% CI, 0.06, 0.51). Bland-Altman derived 95% limits of agreement lay outside a priori limits of clinical agreement for SBP and RR and were within limits of clinical agreement for GCS and HR. SBP and HR differences were associated with prehospital airway and fluid intervention. CONCLUSIONS: Agreement was demonstrated between EMS and ED GCS scores but not RR and SBP recordings. Discrepancies appeared to reflect physiological changes in response to EMS initiated interventions. Trauma triage algorithms and risk models might need to take these measurement differences, and factors associated with them, into account.

The mean prehospital machine; accurate prehospital non-invasive blood pressure measurement in the critically ill patient.

OBJECTIVE: Non-invasive blood pressure recordings may be inaccurate in the critically ill patient and measurement difficulties are intensified in the prehospital setting. This may adversely impact upon outcomes for many critically ill patients, particularly those with traumatic brain injury and/or lengthy prehospital times. This study aimed to validate a non-invasive, oscillometric, ambulatory blood pressure measuring device, the Oscar 2, Model 222 (SunTech Medical, Morrisville, USA) during the ambulance transport of critically ill patients. METHODS: We have previously shown that mean arterial blood pressures observed by Intensive Care Unit nurses from a patient monitor can be considered interchangeable with reference intra-arterial integrated mean pressures. In the current study, we compared non-invasive device mean pressures to intra-arterial pressures observed by retrieval nurses from the patient monitor, during the ambulance transportation of critically ill patients. Device performance was required to fulfil the Association for the Advancement of Medical Instrumentation (AAMI) protocol requirements. Additionally, linear mixed effects analyses and Bland-Altman comparisons were undertaken. RESULTS: For 157 measurements recorded from 23 patients, when the Oscar 2 did not indicate a measurement was associated with a fault, the device fulfilled the AAMI protocol requirements, with a mean error of -1.1 mmHg (standard deviation 7.8 mmHg), 95% confidence intervals (linear mixed effects analysis) -2.9, 0.8; P = 0.26. Bland-Altman plots indicated uniform agreement across a wide range of blood pressures. Sixteen percent of recordings were associated with a patient, environment, or device generated fault. CONCLUSIONS: When the Oscar 2 does not indicate a fault has occurred, clinicians may be confident the mean pressure, within acceptable limits, is accurate, even during ambulance motion, administration of high doses of vasopressors and mechanical ventilation. The Oscar 2 appears to be an accurate and rugged out-of-hospital device.

Validation of arterial blood pressures observed from the patient monitor; a tool for prehospital research.

OBJECTIVES: For some time, the inaccuracies of non-invasive blood pressure measurement in critically ill patients have been recognised. Measurement difficulties can occur even in optimal conditions, but in prehospital transportation vehicles, problems are exacerbated. Intra-arterial pressures must be used as the reference against which to compare the performance of non-invasive methods in the critically ill patient population. Intra-arterial manometer data observed from the patient monitor has frequently been used as the reference against which to assess the accuracy of noninvasive devices in the emergency setting. To test this method's validity, this study aimed to determine whether numerical monitor pressures can be considered interchangeable with independently sampled intra-arterial pressures. METHODS: Intensive Care Unit nurses were asked to document arterial systolic, diastolic and mean pressures numerically displayed on the patient monitor. Observed pressures were compared to reference intra-arterial pressures independently recorded to a computer following analogue to digital conversion. Differences between observed and recorded pressures were evaluated using the Association for the Advancement of Medical Instrumentation (AAMI) protocol. Additionally, two-level linear mixed effects analyses and Bland-Altman comparisons were undertaken. RESULTS: Systolic, diastolic and integrated mean pressures observed during 60 data collection sessions (n = 600) fulfilled AAMI protocol criteria. Integrated mean pressures were the most robust. For these pressures, mean error (reference minus observed) was 0.5 mm Hg (SD 1.4 mm Hg); 95% CI (two-level linear mixed effects analysis) 0.4-0.6 mm Hg; P < 0.001. Bland-Altman plots demonstrated tight 95% limits of agreement (-2.3 to 3.2 mm Hg), and uniform agreement across the range of mean blood pressures. CONCLUSIONS: Integrated mean arterial pressures observed from a well maintained patient monitor can be considered interchangeable with independently sampled intra-arterial pressures and may be confidently used as the reference against which to test the accuracy of non-invasive blood pressure measuring methods in the prehospital or emergency setting.

The mean machine; accurate non-invasive blood pressure measurement in the critically ill patient.

OBJECTIVE: Accurate indirect prehospital blood pressure measurement in the critically ill patient remains an important challenge to both patient management and prehospital research. Ambulatory blood pressure measuring devices have not been trialled for prehospital use in critically ill patients. Prior to prehospital validation where conditions are suboptimal, we aimed to test under favourable conditions in the Intensive Care Unit, a selection of ambulatory devices that may be suitable for use in the field. METHODS: Systolic, diastolic and mean pressures of three ambulatory devices were compared to the average of 1 min of independently recorded, high fidelity intra-arterial reference pressures. Eighteen critically ill patients were recruited. Device performance was required to fulfil the Association for the Advancement of Medical Instrumentation (AAMI) protocol. Additionally, agreement between measurement methods was examined using Bland-Altman plots. Two-level linear mixed model analyses were under- taken. RESULTS: For each device, 150 paired measurements (arterial reference and device) were analysed. According to the AAMI protocol, no device measured systolic pressures accurately. One device measured diastolic pressures accurately. Integrated mean pressures were accurately measured by all devices. Overall, SunTech Medical's Oscar 2 performed best with mean pressure error not exceeding 17 mmHg. For this device, Bland-Altman plots showed uniform agreement across a wide range of mean pressures. Two-level linear mixed effects analyses showed that Oscar 2 mean error reduced during vasopressor use by (-) 3.9 mmHg (95% CI -5.9, -1.9; P < 0.001), and clinically, performance was little affected during mechanical ventilation. For the Oscar 2, there was up to (-) 7.0 mmHg (95% CI -10.3, -3.5; P < 0.001) l ess mean error during hypotension compared to normo- tension. CONCLUSIONS: In the Intensive Care Unit, the performance of one device, the Oscar 2, surpassed the others and fulfilled the AAMI protocol criteria for mean pressure measurement. This device is suitable for prehospital validation.

Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals.

OBJECTIVES: To assess the effectiveness of an intervention package comprising intense education, a range of reporting options, changes in report management and enhanced feedback, in order to improve incident-reporting rates and change the types of incidents reported. DESIGN, SETTING AND PARTICIPANTS: Non-equivalent group controlled clinical trial involving medical and nursing staff working in 10 intervention and 10 control units in four major cities and two regional hospitals in South Australia. MAIN OUTCOME MEASURES: Comparison of reporting rates by type of unit, profession, location of hospital, type of incident reported and reporting mechanism between baseline and study periods in control and intervention units. RESULTS: The intervention resulted in significant improvement in reporting in inpatient areas (additional 60.3 reports/10,000 occupied bed days (OBDs); 95% CI 23.8 to 96.8, p<0.001) and in emergency departments (EDs) (additional 39.5 reports/10,000 ED attendances; 95% CI 17.0 to 62.0, p<0.001). More reports were generated (a) by doctors in EDs (additional 9.5 reports/10,000 ED attendances; 95% CI 2.2 to 16.8, p = 0.001); (b) by nurses in inpatient areas (additional 59.0 reports/10,000 OBDs; 95% CI 23.9 to 94.1, p<0.001) and (c) anonymously (additional 20.2 reports/10,000 OBDs and ED attendances combined; 95% CI 12.6 to 27.8, p<0.001). Compared with control units, the study resulted in more documentation, clinical management and aggression-related incidents in intervention units. In intervention units, more reports were submitted on one-page forms than via the call centre (1005 vs 264 reports, respectively). CONCLUSIONS: A greater variety and number of incidents were reported by the intervention units during the study, with improved reporting by doctors from a low baseline. However, there was considerable heterogeneity between reporting rates in different types of units.

Effects of rotating night shifts: literature review.

AIM: This paper reports a review examining the concept of sleep and its antithesis of fatigue, and considers the evidence on nurses' ability to cope with the demands of continually changing hours of work, their safety, and the impact any manifestations of sleep disruption may have on the care of their patients. While many aspects of this paper may apply to nursing in general, special consideration is given to nurses in the critical care environment. BACKGROUND: Night duty rotations are common practice in nursing, and particularly in specialist units. It is essential that nurses working in these environments are able to maintain careful and astute observation of their vulnerable patients, and concern arises when they may be unable to do so. Research suggests that fatigue can negatively affect nurses' health, quality of performance, safety and thus patient care, and that the effects of fatigue may be exacerbated for nurses over 40 years of age. METHOD: The literature was examined for the 10-year period up to December 2003. The databases searched were Ovid, Proquest, Blackwell Science, EBSCO Online, Australian Health Review and WebSPIRS, using the keywords of, shiftwork, rosters, intensive care, fatigue, sleep deprivation and sleep studies. FINDINGS: There is consensus amongst researchers on the adverse psychological and physiological effects of night rotations on nurses when compared with their permanent night duty peers, particularly for those over 40 years of age. Evidence also suggests that the effects of fatigue on nurse performance may negatively affect the quality of patient care. CONCLUSIONS: The literature reinforces concerns about the adverse relationship between fatigue and performance in the workplace. Optimal standards for patient care may be difficult to achieve for more mature nurses, who may suffer from sleep deprivation and health problems associated with rotational night work and disrupted physiological rhythms.