Evaluating a new emergency department avoidance service for older people: patient and relative experiences.

BACKGROUND: High emergency department (ED) usage by older individuals for non-emergencies is a global concern. ED avoidance initiatives have proven effective in addressing this issue. To specifically cater to individuals aged 65 and above, the Southern Adelaide Local Health Network introduced an innovative ED avoidance service. This study assessed the acceptability of the service among its users. METHOD: The Complex And RestorativE (CARE) Centre is a six-bed unit staffed by a multidisciplinary geriatric team. Patients are transported directly to CARE after calling for an ambulance and being triaged by a paramedic. The evaluation took place between September 2021 and September 2022. Semi-structured interviews were conducted with patients and relatives who had accessed the service. Data analysis was performed using a six-step thematic analysis. RESULTS: Seventeen patients and 15 relatives were interviewed, who described the experience of 32 attendances to the urgent CARE centre between them. Patients accessed the service for several reasons but over half were associated with falls. There was a hesitation to call emergency services for several reasons, the primary being long wait times in ED and/or the prospect of an overnight stay in hospital. Some individuals attempted to contact their General Practitioner (GP) for the presenting problem but were unable to get a timely appointment. Most participants had previously attended a local ED and had a negative experience. All individuals reported favouring the CARE centre over the traditional ED for numerous reasons including a quieter and safer environment and specially trained geriatric staff who were less rushed than ED staff. Several participants would have appreciated a standardised follow-up process after discharge. CONCLUSION: Our findings suggest that ED admission avoidance programmes may be an acceptable alternative treatment for older people requiring urgent care, potentially benefiting both public health systems and user experience.

Trauma-informed care in geriatric inpatient units to improve staff skills and reduce patient distress: a co-designed study protocol.

BACKGROUND: Geriatric hospital wards are highly medicalised environments with limited opportunities for choice and control, and can be distressing for older survivors of psychological trauma. While trauma-informed models of care (TIC) are effectively applied across mental health and other settings, the utility of these models in aged care settings has not been assessed. The objective of this study was to examine whether TIC can reduce responsive behaviour, chemical restraint, and improve staff skills and patient experiences in inpatient geriatric settings. METHODS: Four wards participated in this type I hybrid implementation-effectiveness study across southern Adelaide, Australia, including 79 beds. Using a co-design method, the principles of TIC were transformed into an implementation strategy including staff training, establishment of highly trained 'champions' on each ward, screening for trauma-related needs, and amending ward policies and procedures. Primary outcomes will be examined using an interrupted time-series design and are monthly incidence of responsive behaviour incidents and use of chemical restraint. Process evaluation will be used to examine secondary, implementation outcomes including the acceptability, feasibility, and fidelity to the implementation strategy. DISCUSSION: Trauma-informed care has potential to improve the safety and accessibility of hospital wards for older people who have survived psychologically traumatic events and has an extensive evidence base supporting its effectiveness in other settings. Identifying trauma-related needs and amending care to reduce the risk of re-traumatisation and distress may also reduce the incidence of responsive behaviour change, which has a significant impact on the quality of life of hospital patients and staff and is very costly. The inclusion of a process evaluation will allow us to identify and report changes made on each ward and make recommendations for future implementation efforts.

'Put in a room and left': a qualitative study exploring the lived experiences of COVID-19 isolation and quarantine among rehabilitation inpatients.

BACKGROUND: The SARS-CoV-2 (COVID-19) pandemic has resulted in significant changes to health care delivery and the patient's experience in hospital. Changes for those who contracted COVID-19 or were close contacts included isolation and quarantine, visitor restrictions and changes to usual models of care to reduce viral transmission. Traditional models of inpatient rehabilitation utilise communal spaces (e.g. shared gyms and dining rooms) and involve a multidisciplinary team interacting with the patient daily. OBJECTIVES: To report the experience of COVID-19 related isolation and quarantine among rehabilitation inpatients and their family members who experienced a nosocomial outbreak and to make recommendations for rehabilitation units. METHODS: A qualitative phenomenological methodology using semi-structured telephone interviews. RESULTS: 19 semi-structured interviews were conducted comprising of 13 general rehabilitation inpatients and 6 family members. Five themes were established: (1) the impact of social and physical isolation; (2) boredom and limited access to therapy; (3) the impact of technology; (4) inadequate information sharing and (5) positive experiences and things done well. Several novel insights were identified including: the desire for increased social interaction from staff to compensate for a lack of visitors; the impact of physical and cognitive deficits on a patient's ability to reach basic items around their room or call for help, and the unique impact of isolation and quarantine on individuals who have a history of trauma, discrimination or mental illness. CONCLUSIONS: This study establishes key areas that should be considered by rehabilitation units globally to adjust traditional models which are not suitable in this pandemic. Strategies to mitigate the impact of isolation include providing training to increase use of technologies such as tablet devices, increased staff social engagement to reduce isolation and tailoring the environment to suit specific patient groups.KEY MESSAGESCOVID-19 related isolation and quarantine has a significant and unique impact on patients with cognitive and physical impairments such as those in inpatient rehabilitation. Patients who are required to isolate in inpatient settings expressed a desire for compensatory increased social interaction from staff and required specific assistance with basic daily tasks while isolated. The study makes key recommendations for other rehabilitation units to integrate into their approach for managing patients required to isolate or quarantine.

Participant perceptions of a rapid response team training course.

BACKGROUND: Rapid response team (RRT) responders would benefit from training, to ensure competent and efficient management of the deteriorating patient. DESIGN, SETTING AND PARTICIPANTS: We obtained delegate feedback on a pilot training course for RRTs, commissioned by the Australian and New Zealand Intensive Care Society (ANZICS), at the second ANZICS: The Deteriorating Patient Conference. METHODS: We surveyed participants on their perceptions of the course overall, and their perceptions of sessions containing presentations and videotaped and live demonstrations of simulated scenarios of patients whose conditions were deteriorating. RESULTS: The survey response rate was 64% (96 of 150 potential attendees). Responses were positive, with 79.8% of responses (912/1143) agreeing that the participants had learnt something new, that the course would increase their confidence and competence during RRT calls, and that it had assisted them as an educator. The course was well received overall, with the interactive and live demonstration components of the course garnering positive feedback in the comments section of surveys. CONCLUSIONS: There was unanimous agreement by participants for further development of a formalised RRT training course for responding to the deteriorating patient. Participants who were RRT educators also supported the development of an RRT train-the-trainer course.

Conventional coagulation and thromboelastograph parameters and longevity of continuous renal replacement circuits.

OBJECTIVE: To determine the relationship between conventional and thromboelastograph (TEG) coagulation parameters and continuous renal replacement therapy (CRRT) circuit longevity. DESIGN: Conventional coagulation and TEG parameters were measured at the commencement of and during CRRT. Time to circuit cessation was measured and only circuits reaching a predetermined rise from baseline in the pressure gradient across the haemofilter were diagnosed as failing due to clotting. All other circuits were excluded from analysis. SETTING: A general critical care unit of a metropolitan tertiary hospital. PATIENTS AND PARTICIPANTS: Fourteen consecutive patients requiring CRRT were studied. The CRRT technique used was continuous veno-venous haemodialysis. INTERVENTIONS: Thromboelastograph measurements were made prior to the commencement of CRRT and daily thereafter for each circuit. The international normalised ratio (INR), activated partial thromboplastin time (APTT) and platelet numbers were measured at commencement and 8 hourly thereafter. Heparin was used for anticoagulation unless considered contraindicated. MEASUREMENTS AND RESULTS: Forty-seven circuits with a mean (SD) circuit life of 33.0 (30.2) h were entered. Twenty-five circuits fulfilled circuit clotting criteria; the mean circuit life was 30.8 (22.1) h. Heparin anticoagulation was found to prolong circuit life significantly despite adequate mean circuit life, 33.2 (35.7) h, in heparin-free circuits. The starting APTT and the TEG variables reaction time (R) and coagulation time (RK) were significantly correlated. The starting APTT, starting RK and mean time taken for the amplitude to increase from 2 to 20 mm (K) were predictive of circuit life. None of these variables predicted which patients would need heparin. CONCLUSION: While TEG variables more closely predicted circuit longevity than conventional coagulation variables, the clinical benefit of TEG monitoring of anticoagulation for CRRT would appear to be minimal.