The effects of therapeutic activity kits in emergency department patients with dementia: Study protocol for a pragmatic randomized control trial.

AIM: To determine the effectiveness of therapeutic activity kits on health service use and treatment delivered in the emergency department (ED) in patients with pre-morbid dementia. DESIGN: Pragmatic randomized control trial with equal parallel groups. METHODS: Participants with dementia will be randomly assigned to the control group (N = 56) or the intervention group (N = 56). The intervention group will be given access to a therapeutic activity kit containing several different activities and sensory stimuli to engage the person with dementia during their ED stay in addition to usual care, and the control group will be given usual care only. A research nurse will observe participants at 30-60-min intervals throughout their ED stay for responsive behaviours, one-on-one nursing, and the use of chemical and physical restraint. This study has received Research Ethics Committee approval from the institutional review board and funding from the Rosemary Bryant Foundation (May 2019). DISCUSSION: Emergency departments are busy and noisy environments and can be intimidating and disorientating for patients with dementia, which can result in responsive behaviours. Responsive behaviours are often managed with restrictive interventions, such as chemical or physical restraint, or with constant bedside nursing (one-on-one nursing) to ensure patient safety. Alternatively, non-restrictive and non-pharmacological interventions that divert or occupy the attention of patients such as those contained in the therapeutic activity kit can be considered as a more person-centred strategy. Therapeutic activity kits have been reported as feasible for the use in ED; however, there is limited quality evidence at present to support the implementation of such interventions in the ED. IMPACT: If this study is successful, it will demonstrate that a therapeutic activity kit containing activities (puzzles, colouring, music, and tactile activities) is inexpensive, easily implemented intervention that can prevent this patient group from demonstrating unsafe behaviours and requiring one-on-one nursing and restraints.

Increasing the Rate of Documentation of Security Interventions in the Emergency Department: Big Orange Security Sticker (BOSS) Project.

BACKGROUND: Security interventions in aggressive and violent patients in the emergency department (ED) are not always documented in the clinical record, which can compromise the effectiveness of communication, and increase clinical risks. LOCAL PROBLEM: Fewer than half of all security interventions are documented in the clinical record. METHODS: The study had a pre- and posttest design including a retrospective audit of patient medical records and a staff survey. INTERVENTION: A dedicated sticker, to be completed by nursing and security staff, was placed into the clinical notes as a record of the security intervention. RESULTS: From 1 month before to 1 month after implementation, the rate of documentation of security interventions in clinical notes increased from 43.3% to 68.8% (P = .01), and was maintained for 3 months after implementation. CONCLUSIONS: The rate of documentation of ED security interventions in clinical notes can be increased by encouraging clinicians and security staff to collaborate and share documentation responsibilities.

Development and implementation of the Specialist Palliative Care in Aged Care (SPACE) Project across Queensland.

There is an urgent and unmet need for specialist palliative care services in residential aged care. The Specialist Palliative Care in Aged Care (SPACE) Project aimed to improve palliative and end-of-life care for older people living in residential aged care facilities in Queensland. A representative working group developed a series of service principles around palliative care practice in aged care (comprehensive resident-focused care, streamlined service, and capacity building). Funding was allocated by population to the health services in Queensland to adapt and implement models of care aligned with these principles. SPACE successfully implemented a variety of decentralised models of care across Queensland. The critical elements for the success of SPACE were the use of an expert working group to define the core innovation, networking and implementation support from the central project team and community of practice, and adaptable models of care led by local facilitators. Lessons learned from this real-world case study could be adopted to guide and ensure the successful implementation and sustainability of future complex interventions in healthcare settings, both nationally and internationally.

Affecting emergency department oxycodone discharge prescribing: An educational intervention.

OBJECTIVE: To describe the impact of an educational intervention for ED prescribers on discharge oxycodone prescribing both for the number of oxycodone prescriptions per 1000 discharged patients, and the number of tablets per prescription. Secondary outcomes included the quality of general practitioner communication. METHODS: An interrupted time series assessment was conducted in the ED of a tertiary referral hospital to establish the pre-intervention, peri-intervention and post-intervention prescribing profile of ED medical practitioners. Prescriber numbers were used to obtain drug data for all oxycodone-containing prescriptions from the Queensland Health Medicines Regulation and Quality Unit database. The intervention included education sessions, a staff information email, posters within the ED, and a patient brochure. It was conducted with relevant nurses, pharmacists and prescribing doctors. RESULTS: In the pre-intervention period, 656/17 371 (38 per 1000) discharged patients were prescribed oxycodone, compared to 180/5938 (30 per 1000) during the intervention, and 602/20 505 (29 per 1000) post-intervention. This equated to a decrease of 8 per 1000 (95% CI 5-12 per 1000) and a 22% (95% CI 13-31%) relative prescribing reduction. The mean total number of tablets of oxycodone per prescription decreased from 16.7 (SD 16.5) pre-intervention, to 12.7 (SD 6.0) peri-intervention, to 10.7 (SD 5.2) post-intervention. After the intervention, there was an increase in discharge communications to general practitioners by 15.4% (95% CI 9.7-21.1%). CONCLUSIONS: An ED prescriber-targeted intervention reduced overall prescribing of oxycodone and improved communication at discharge. The prescribing intervention is one strategy that may be used by ED medical staff to improve patient safety and opioid stewardship in Australia.