Effective discharge planning - timely assignment of an estimated date of discharge.

OBJECTIVE: To examine the implementation of estimated date of discharge (EDD) for planned admissions and admissions via the emergency department, to assess the variance between EDD and the actual date of discharge (ADD), and to explore the determinants of delayed discharge in a tertiary referral centre, Sydney, Australia. METHODS: Primary data from a convenience sample of 1958 admissions for allocation of EDDs were linked with administrative data. The window for assigning EDDs for planned admissions was 24h, for admissions via the emergency department it was 48h. Logistic regression models were used to examine the key factors associated with an EDD being assigned within 24h or 48h of an admission. An ordinal logistic regression model was used to explore the determinants of delayed discharge. RESULTS: Only 13.4% of planned admissions and 27.5% of admissions via the emergency department were allocated a timely EDD. Older patients, patients with significant burdens of chronic morbidity (OR=0.903; P=0.011); and patients from a non-English-speaking background (OR=0.711; P=0.059) were less likely to be assigned a timely EDD. The current Charlson Index score was a significant predictor of a positive variance between EDD and ADD. CONCLUSIONS: The prevalence of the timely assignment of an EDD was low and was lowest for planned admissions. The current Charlson Index score is an effective tool for identifying patients who are more likely to experience delayed discharge.

How do CNCs construct their after hours support role in a major metropolitan hospital.

AIM: To explore how CNCs who provide hospital wide support after hours (AHCSs) construct their role. METHODS: This is an ethnographic study involving two AHCSs as participants. Audio visual data was collected in 2007 at a Major Metropolitan Hospital, Sydney during after hours shifts. The data was coded using the standards defined in the Nurse Practitioner (NP) competencies. RESULTS: Four hours of videotape (observed clinical practice) and 2 h of audio tape (interviews) were coded. They performed procedures (22%), gathered information to identify at risk patients (21%), conducted patient assessments (20%) and relayed information/findings to ward nurses (12%) and doctors (12%). The roles/responsibilities of AHCSs were similar to those defined for NPs. For the domain "dynamic practice" 388 activities were identified. The two participants used advanced and comprehensive assessment skills and demonstrated a high level of proficiency in performing procedures/interventions. For the domain "professional efficacy" 174 activities were coded, for "clinical Leadership" there were 135 activities. "Pro-actively identifying at risk patients in general wards" was added as a new performance indicator within the domain "clinical leadership". An analysis of the interviews corroborated the results derived from the visual data. CONCLUSION: A significant capacity for critical thinking and clinical decision making were the hallmarks of the performance of the two AHCSs; their style of practice was collaborative, flexible and autonomous. While their formal role were as CNCs the two participants operationalised their roles/responsibilities as would a Nurse Practitioner. Their practice demonstrated a new competency: "the pro-active identification of at risk patients".

Discharge delay in acute care: reasons and determinants of delay in general ward patients.

To identify the reasons and determinants of discharge delay in acute care patients, information associated with delayed discharge was extracted from the medical record of 1958 patients in a tertiary referral hospital in New South Wales. A logistic regression model was used to examine the association between demographic factors and reasons for discharge delay. Delayed discharge was most commonly associated with the patient's medical conditions, delayed health care or medical consultation, delayed diagnostic services and delayed allied health services. Elderly patients, those living alone and patients from a non-English-speaking background were more likely to have these reasons for delayed discharge.

Analysis of medical emergency team calls comparing subjective to "objective" call criteria.

OBJECTIVE: To explore the reasons why nursing staff use the subjective "worried" Medical Emergency Team (MET) calling criterion and compare the outcomes of calls activated using the "worried" criterion with those calls activated using "objective" criteria such as vital sign abnormalities. METHODS: A descriptive study of MET calls in six acute hospitals over a 12 months period. Outcomes for "objective" and "worried" calls were compared. RESULTS: The "worried" criterion was used to activate 29% of 3194 MET calls studied; it was the single most common reason for a MET call. Half (51.7%) of the "worried" calls were related to problems with Airway, Breathing, Circulation or Neurology. 'Breathing' problems accounted for the largest proportion (35.2%). A low oxygen saturation by pulse oximetry (SpO2) (n=249, 26.9%) and 'respiratory distress' (n=133, 14.4%) were the most common reasons for a "worried" call. Only 1.1% (10) of calls triggered by the "worried" criteria had cardiac arrest as an outcome compared with 170 calls (7.6%) for "objective" criteria. The proportion of patients who remained in a general ward area after MET calls was higher for the "worried" calls. CONCLUSIONS: The "worried" criterion was the most frequent reason for MET calls, implying a high degree of empowerment and independent action by nursing staff. Low SpO2 and respiratory distress were the most common causes for concern. There was a significant difference between MET calls triggered by "worried" criteria and "objective" criteria for outcomes immediately following MET (p < 0.001). Further assessment and refinement of MET triggers particularly in relation to respiratory distress and pulse oximetry may be needed.

Problems and solutions arising during a study in visual semantics of the medical emergency team system.

A study of the medical emergency team (MET) to explore communication within the team, leadership, handover, and MET resuscitation practice was performed using audiovisual recording in hospitals of Sydney South West Area Health Service, Sydney, Australia. In this article, we report on the process of data collection: the completion of 25 video recordings of MET calls across three of the six study hospitals. We describe how we gained entry into hospital environments to film events characterized by the unpredictability and uncertainties associated with resuscitating a patient and the strategies that we implemented during the fieldwork to develop and maintain rapport with both clinicians and managers. We describe how we addressed some of the practical constraints related to collecting audiovisual data at the point of acute care as well as their implications for the theoretical and methodological aspects of the study.

Prevalence of morphine use and time to initial analgesia in an Australian emergency department.

OBJECTIVE: To explore the association of morphine use with factors influencing time to initial analgesia (T-A). METHODS: A retrospective cohort review was conducted. Morphine data were collected from a register for restricted drugs located in the ED. T-A was the time interval between triage and signing out of morphine's first dose. Statistical analyses were performed to determine the association between morphine use and patient volume. RESULTS: In total, 8% of ED attendees received at least one dose of morphine sulphate in the ED. Prevalence of morphine use significantly (P < 0.05) varied by patient's age, Australasian Triage Scale category, time of arrival and type of illness. The median time of T-A was 79 min (95% CI 71-85) with substantially longer (median 107 min) for those who arrived during the afternoon and triaged as less urgent (median 127 min). Patients who arrived late at night (median 47 min), triaged as immediately/imminently life-threatening (median 58 min) and diagnosed as renal colic (median 27 min) or fractures/injuries (median 67 min) were more likely to receive i.v. morphine faster than other patients. The findings confirmed that large volume of patients in ED was associated with longer T-A. Patient volume in the ED showed a significant positive association with T-A (r = 0.568, 32% variation explained, P < 0.01). CONCLUSION: T-A is an important indicator of the quality of ED services. Severity of illness and patient volume were significant factors associated with extended T-A. Strategies for improving pain management in the complex ED environment are discussed.

A population follow-up study of patients who left an emergency department without being seen by a medical officer.

OBJECTIVES: To describe the population of emergency department patients who leave without being seen by a medical officer, to investigate the circumstances of their visit and to ascertain whether they subsequently receive alternative medical care. METHODS: A follow-up study was conducted of patients who were initially triaged, but left without being seen by a medical officer between July 2003 and October 2003 in a tertiary referral hospital emergency department in Sydney, Australia. Emergency Department Information System data were reviewed for population demographics, presenting complaints and acuity rating of patients. Follow-up telephone interviews were conducted within 7 days after the patient left the emergency department. RESULTS: During the study period, 8.6% (1272 of 14 741) of the emergency department patients left without seeing a doctor and 35.9% (457 of 1272) of these patients who walks out were contacted for follow-up. The results from bivariate and multivariate analyses showed that walkout rates significantly varied by sociodemographic and clinical characteristics of the patients. Young patients aged 0-29 years, and those with longer waiting time for triage and triaged as "less urgent" were more likely to walk out than others. Overcrowding in the emergency department had a significant association with walkout of patients. Prolonged waiting time was the most common reason for leaving emergency departments without being seen by a doctor. Only 12.7% (58 of 457) of the walkout patients revisited emergency departments within 7 days of their departure and of those who were subsequently admitted following their return to hospital accounted for 5.0% (23 of 457). Of the follow-up patients, 39.4% felt angry about their emergency department experiences. CONCLUSIONS: The number of patients who leave an emergency department without seeing a doctor is strongly correlated with waiting time for medical review. Achieving shorter emergency department waiting times is central to reducing the numbers of people leaving without being seen. The rate of patients who leave without being seen is also strongly correlated with triage category. These findings highlight the importance of accurate triaging, as this clearly influences waiting time. It is also likely that there are patients who benefit from the reassurance of the triage assessment, and therefore feel less urgency for medical review. These may be cases where immediate medical review is not essential. This area should be further explored. These results are important for planning and staffing health services. Decision makers should identify and target factors to minimise walkouts from public hospital emergency departments.

Guidelines for the uniform reporting of data for Medical Emergency Teams.

It is more than 15 years since the first Medical Emergency Team (MET) system was introduced to identify patients at risk and prevent serious adverse events in Liverpool Hospital, Sydney, Australia. Since then the MET system has been introduced to many other hospitals in Australia and around the world. Standardised and complete reporting of data related to MET activity is increasingly important to identify the role and benefits of the system and to facilitate quality improvement in health care in general. A uniform method for reporting data related to MET activity will aid interpretation of results, comparisons, review and changes to the MET system. The guidelines for uniform reporting of data in relation to MET activities used in our group of hospitals are presented. Future refinement and consensus agreement on the reporting of MET data internationally should enable comparisons between MET systems in several countries.

Registered nurses' self-perceived level of competence following completion of a specialist graduate certificate.

Utilising the Competency Standards for Specialist Critical Care Nurses (CSSCCN) as a framework, this study sought to examine the perceived level of competence (PLC) of the graduates of a Graduate Certificate in Intensive Care Nursing (GCICN) and the level at which the GCICN influenced the graduates' PLC. A rating scale of 1-5 and an open-ended questionnaire were utilised. The graduates' mean PLC in the competency 'engaging in research' was rated as the lowest and 'recognising own abilities and professional competence' as the highest. Graduates of 1991-1994 rated their PLC on all the competencies lower in comparison to graduates of 1995-1997. Graduates' PLC on enabling and clinical problem solving domains were rated better than the reflective and leadership domains. A significant correlation was demonstrated between the graduates' PLC and their perceptions as to the course's influence on their PLC.