Gaye Moore

Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study

Abstract Objectives: To determine whether earlier clinical intervention by a medical emergency team prompted by clinical instability in a patient could reduce the incidence of and mortality from unexpected cardiac arrest in hospital. Design: A non-randomised, population based study before (1996) and after (1999) introduction of the medical emergency team. Setting: 300 bed tertiary referral teaching hospital. Participants: All patients admitted to the hospital in 1996 (n=19 317) and 1999 (n=22 847). Interventions: Medical emergency team (two doctors and one senior intensive care nurse) attended clinically unstable patients immediately with resuscitation drugs, fluid, and equipment. Response activated by the bedside nurse or doctor according to predefined criteria. Main outcome measures: Incidence and outcome of unexpected cardiac arrest. Results: The incidence of unexpected cardiac arrest was 3.77 per 1000 hospital admissions (73 cases) in 1996 (before intervention) and 2.05 per 1000 admissions (47 cases) in 1999 (after intervention), with mortality being 77% (56 patients) and 55% (26 patients), respectively. After adjustment for case mix the intervention was associated with a 50% reduction in the incidence of unexpected cardiac arrest (odds ratio 0.50, 95% confidence interval 0.35 to 0.73). Conclusions: In clinically unstable inpatients early intervention by a medical emergency team significantly reduces the incidence of and mortality from unexpected cardiac arrest in hospital. What is already known on this topic In most studies mortality from unexpected cardiac arrest in hospital exceeds 50% Such events are usually preceded by signs of clinical deterioration in the hours before cardiac arrest What this paper adds Early intervention by a medical emergency team significantly reduced the incidence of and mortality from unexpected cardiac arrest in hospital

Socio-demographic and clinical characteristics of re-presentation to an Australian inner-city emergency department: implications for service delivery

BackgroundPeople who have complex health care needs frequently access emergency departments for treatment of acute illness and injury. In particular, evidence suggests that those who are homeless, or suffer mental illness, or have a history of substance misuse, are often repeat users of emergency departments. The aim of this study was to describe the socio-demographic and clinical characteristics of emergency department re-presentations. Re-presentation was defined as a return visit to the same emergency department within 28 days of discharge from hospital.MethodsA retrospective cohort study was conducted of emergency department presentations occurring over a 24-month period to an Australian inner-city hospital. Characteristics were examined for their influence on the binary outcome of re-presentation within 28 days of discharge using logistic regression with the variable patient fitted as a random effect.ResultsFrom 64,147 presentations to the emergency department the re-presentation rate was 18.0% (n = 11,559) of visits and 14.4% (5,894/40,942) of all patients. Median time to re-presentation was 6 days, with more than half occurring within one week of discharge (60.8%; n = 6,873), and more than three-quarters within two weeks (80.9%; n = 9,151). The odds of re-presentation increased three-fold for people who were homeless compared to those living in stable accommodation (adjusted OR 3.09; 95% CI, 2.83 to 3.36). Similarly, the odds of re-presentation were significantly higher for patients receiving a government pension compared to those who did not (adjusted OR 1.73; 95% CI, 1.63 to 1.84), patients who left part-way through treatment compared to those who completed treatment and were discharged home (adjusted OR 1.64; 95% CI, 1.36 to 1.99), and those discharged to a residential-care facility compared to those who were discharged home (adjusted OR 1.46: 95% CI, 1.03 to 2.06).ConclusionEmergency department re-presentation rates cluster around one week after discharge and rapidly decrease thereafter. Housing status and being a recipient of a government pension are the most significant risk factors. Early identification and appropriate referrals for those patients who are at risk of emergency department re-presentation will assist in the development of targeted strategies to improve health service delivery to this vulnerable group.

Palliative and supportive care needs of patients with high-grade glioma and their carers: A systematic review of qualitative literature

OBJECTIVE Patients diagnosed with primary malignant glioma (PMG) face substantial challenges with poor prognosis, high symptom burden and care needs. This study aims to collate current literature detailing the supportive and palliative care needs of patients with PMG and their carers, and to subject it to a novel approach of formal evaluation. METHODS Medline, EMBASE, CINAHL, PsychInfo were searched with core concepts: (1) glioma, (2) high-grade disease, and (3) palliative and supportive care needs. A narrative synthesis approach was undertaken including a quality appraisal of the 21 included studies. RESULTS Key themes related to the need for consistent well-delivered information around disease sequelae, treatment, and resources available; health service needs including a key professional identified to coordinate care; the need for psychological and social supports, and clear avenues of communication with treating professionals. CONCLUSION The literature remains limited in the number and quality of evidence with two level I, eight level II, and eleven level III studies. The findings call for improved information, communication and support practices to address the complexity and breadth of needs. PRACTICE IMPLICATIONS Specialised and individually tailored information, attention to clear, consistent communication and support practices should be incorporated into a future needs-based model of care.

I'm just waiting…: an exploration of the experience of living and dying with primary malignant glioma

PurposeReferral to supportive and palliative care services for people with high-grade primary malignant glioma (PMG) often occurs late in the illness course, despite significant care needs and overall poor prognosis. This study aimed to understand patient experience at the end of life and document supportive and palliative care needs.MethodsA qualitative study was conducted involving ten PMG patients who were at different stages in the illness course including the end of life and had varying levels of physical and cognitive function. Consecutive, eligible patients attending neurosurgery, oncology, and palliative care services of two metropolitan hospitals were recruited. In-depth interviews explored supportive and palliative care needs across the disease trajectory. Interviews were analysed independently by three investigators consistent with a grounded theory approach, and emerging ideas were compared and refined to define key patient experiences.ResultsDespite the medical treatment and supportive care available, there remains a gap in services addressing complex existential and psychosocial needs that were markedly valued by patients. Patient experience was characterised by a pervasive loss of all that encompassed their former sense of self and a focus on immediate needs.ConclusionsPatients in this study had substantial needs, which were often not shared and not addressed by the current medical system of care. An improved multidisciplinary care model is indicated, which proactively (1) engages care coordination and advocacy; (2) minimises patients’ sense of waiting and uncertainty through mapping out a plan, including involvement of palliative care in a timely fashion; and (3) actively invites discussion around goals and preferences for care to promote patients’ sense of self.

The challenges and suffering of caring for people with primary malignant glioma: qualitative perspectives on improving current supportive and palliative care practices

Objectives Carers of patients with high-grade primary malignant glioma (PMG) are known to face extraordinary challenges, as they care for patients with multiple profound and often devastating physical, cognitive and behavioural changes. This study aimed to understand the supportive and palliative care needs in this setting, with a particular focus upon care at the end-of-life, which has hitherto been neglected. Methods This prospective qualitative study undertook in-depth interviews with 23 current and bereaved carers of adults with PMG. Carers were recruited from outpatient and inpatient services of two Australian metropolitan hospitals, including neurosurgery, oncology and palliative care. Thematic analysis was conducted by three independent researchers, using methods informed by grounded theory. Results Carers described significant needs in relation to three distinct domains: the challenge of caring; the lack of support available to carers and the suffering of caring. The need for care coordination was highlighted as it may enable a series of recommendations for improved care, including: navigation between health providers, individualised, staged information; routine, proactive telephone needs-assessment and emotional support; and early routine integration of palliative care services. Conclusions The results of this study shed new light on providing timely information and palliative care to support carers. We call for health services to reconsider the current medical model for this patient group, where patients are the centre of care, information and support, towards a more collaborative model which places carers and patients into a partnership.

Complex health service needs for people who are homeless

BACKGROUND Homeless people face many challenges in accessing and utilising health services to obtain psychosocial supports offered in hospital and community settings. The complex nature of health issues is compounded by lack of accessibility to services and lack of appropriate and safe housing. OBJECTIVE To examine the perceptions and experiences of homeless people in relation to their health service needs as well as those of service providers involved with their care. DESIGN A purposive sampling approach was undertaken with a thematic framework analysis of semi-structured interviews. Participants. Interviews were undertaken with 20 homeless people who accessed the emergency department in an acute hospital in Melbourne, Australia and 27 service providers involved in hospital and community care. RESULTS Six key themes were identified from interviews: complexity of care needs, respect for homeless people and co-workers, engagement as a key strategy in continued care, lack of after-hour services, lack of appropriate accommodation and complexity of services. CONCLUSIONS Findings revealed the complex and diverse nature of health concerns in homeless people. The demand on hospital services continues to increase and unless government policies take into consideration the psychosocial demands of the communities most vulnerable people efforts to divert hospital demand will continue to fail.

Caring for caregivers after a stroke

Stroke usually occurs in the latter years of life, is sudden and all too often unexpected and unforgiving. When non-fatal, stroke, the second leading cause of disability after dementia, is nearly always disabling (World Health Organization (WHO), 2011). Due to common ensuing physical and cognitive impairments, many stroke survivors are unable to care for themselves in the following weeks, months, and possibly years (Lutz et al., 2011). Thus, the caregiver role is instant and often long-term with no or very little time to adapt to the many, varied and immediate challenges.

Homelessness: patterns of emergency department use and risk factors for re-presentation

Objectives To describe patterns of service use and to predict risk factors for re-presentation to a metropolitan emergency department (ED) among people who are homeless. Methods A retrospective cohort analysis was undertaken over a 24-month period from a principal referral hospital in Melbourne, Australia. All ED visits relating to people classified as homeless were included. A predictive model for risk of re-presentation was developed using logistic regression with random effects. Rates of re-presentation, defined as the total number of visits to the same ED within 28 days of discharge, were measured. Results The study period was 1 January 2003 to 31 December 2004. The re-presentation rate for homeless people was 47.8% (3199/6689) of ED visits and 45.5% (725/1595) of the patients. The final predictive model included risk factors, which incorporated both hospital and community service use. Those characteristics that resulted in significantly increased odds of re-presentation were leaving hospital at own risk (OR 1.31; 95% CI 1.10 to 1.56), treatment in another hospital (OR 1.45, 95% CI 1.23 to 1.72) and being in receipt of community-based case management (OR 1.31, 95% CI 1.11 to 1.54) or pension (OR 1.34, 95% CI 1.12 to 1.62). Conclusions The predictive model identified nine risk factors of re-presentation to the ED for people who are homeless. Early identification of these factors among homeless people may alert clinicians to the complexity of issues influencing an individual ED visit. This information can be used at admission and discharge by ensuring that homeless people have access to services commensurate with their health needs. Improved linkage between community and hospital services must be underscored by the capacity to provide safe and secure housing.

Health care professionals' perspectives of living and dying with primary malignant glioma: Implications for a unique cancer trajectory

OBJECTIVES Health care professionals (HCPs) caring for people with primary malignant glioma (PMG) and their carers see many of the profound challenges facing this group, yet their perspectives are not documented. This study aimed to understand and document the unique perspective of HCPs in relation to the supportive and palliative care needs of patients with PMG and their carers, with a view to developing a model of care. METHODS Qualitative study involving semi-structured focus groups and interviews with 35 medical, nursing and allied health staff actively engaged in providing care for this patient group. Purposive and theoretical sampling from two major metropolitan hospitals and one community palliative care service in Australia was utilised to seek perspectives from a variety of disciplines and health care settings. Thematic analysis was conducted by three independent researchers, using a constant comparative method influenced by grounded theory. RESULTS Key themes relating to the needs of people with PMG which were apparent from the HCPs included: The difference in the illness course of glioma compared to other cancers; Limitations of current medical care; Challenges in balancing hope with reality of the illness; and Recommendations to improve care, including recognising the role of family and moving from a model where services are offered in response to demonstrated needs. Significance of the results: Current models of care based upon the classic cancer trajectory are unresponsive to the needs of people with PMG. Care may be enhanced by moving towards a proactive approach, extending the goals of care beyond medical needs and broadening the focus of care to include family needs.

Prospective validation of a predictive model that identifies homeless people at risk of re-presentation to the emergency department

OBJECTIVE To prospectively evaluate the accuracy of a predictive model to identify homeless people at risk of representation to an emergency department. METHODS A prospective cohort analysis utilised one month of data from a Principal Referral Hospital in Melbourne, Australia. All visits involving people classified as homeless were included, excluding those who died. Homelessness was defined as living on the streets, in crisis accommodation, in boarding houses or residing in unstable housing. Rates of re-presentation, defined as the total number of visits to the same emergency department within 28 days of discharge from hospital, were measured. Performance of the risk screening tool was assessed by calculating sensitivity, specificity, positive and negative predictive values and likelihood ratios. RESULTS Over the study period (April 1, 2009 to April 30, 2009), 3298 presentations from 2888 individuals were recorded. The homeless population accounted for 10% (n=327) of all visits and 7% (n=211) of all patients. A total of 90 (43%) homeless people re-presented to the emergency department. The predictive model included nine variables and achieved 98% (CI, 0.92-0.99) sensitivity and 66% (CI, 0.57-0.74) specificity. The positive predictive value was 68% and the negative predictive value was 98%. The positive likelihood ratio 2.9 (CI, 2.2-3.7) and the negative likelihood ratio was 0.03 (CI, 0.01-0.13). CONCLUSION The high emergency department re-presentation rate for people who were homeless identifies unresolved psychosocial health needs. The emergency department remains a vital access point for homeless people, particularly after hours. The risk screening tool is key to identify medical and social aspects of a homeless patients presentation to assist early identification and referral.