Harvey Newnham

Unplanned early return to the emergency department by older patients: the Safe Elderly Emergency Department Discharge (SEED) project

BACKGROUND an emergency department (ED) visit is a sentinel event for an older person, with increased likelihood of adverse outcomes post-discharge including early re-presentation. OBJECTIVES to determine factors associated with early re-presentation. METHODS prospective cohort study conducted in the ED of a large acute Melbourne tertiary hospital. Community-dwelling patients ≥65 years were interviewed including comprehensive assessment of cognitive and functional status, and mood. Logistic regression was used to identify risk factors for return within 30 days. RESULTS nine hundred and fifty-nine patients, median age 77 years, were recruited. One hundred and forty patients (14.6%) re-presented within 30 days, including 22 patients (2.3%) on ≥2 occasions and 75 patients (7.8%) within 7 days. Risk factors for re-presentation included depressive symptoms, cognitive impairment, co-morbidity, triaged as less urgent (ATS 4) and attendance in the previous 12 months, with a decline in risk after 85 years of age. Logistic regression identified chronic obstructive pulmonary disease (OR 1.78, 95% CI 1.02-3.11), moderate cognitive impairment (OR 2.07, 95% CI 1.09-3.90), previous ED visit (OR 2.11, 95% CI 1.43-3.12) and ATS 4 (OR 2.34, 95% CI 1.10-4.99) as independent risk factors for re-presentation. Age ≥85 years was associated with reduced risk (OR 0.81, 95% CI 0.70-0.93). CONCLUSION older discharged patients had a high rate of early re-presentation. Previously identified risk factors-increased age, living alone, functional dependence and polypharmacy-were not associated with early return in this study. It is not clear whether these inconsistencies represent a change in patient case-mix or strategies implemented to reduce re-attendance. This remains an important area for future research.

Reducing potentially fatal errors associated with high doses of insulin: a successful multifaceted multidisciplinary prevention strategy

Background Insulin is a high-risk medicine which may cause significant patient harm or death when given incorrectly. A 10-fold error in administered insulin dose commonly occurs when the abbreviation ‘u’ is used for ‘units’ and subsequently misinterpreted as a ‘zero.’ Method A multidisciplinary working party was convened and mapped insulin prescribing, dispensing and administration. All inpatient orders above 25 units for short-acting insulin and 50 units for other insulin require validation by an additional source. Educational strategies to support adherence to the guideline and product-labelling alerts were developed. Results Implementation occurred in August 2008 across the three hospital sites. In 90 weeks after implementation, there were 150 patients identified in which 200 high doses of insulin were prescribed (>25 units for short-acting insulin and 50 units for other insulin). There were eight instances where high doses of insulin were prescribed in error but were detected and rectified through the new validation process. There were 12 dosing errors that occurred, including two 10-fold dosing errors. In contrast, seven major errors resulting in excessive insulin administration were identified over a 2-year period prior to the introduction of the insulin high-dose validation system. Conclusion A structured validation process was successful in reducing incorrect prescription and administration of high-dose insulin and has reduced the risk of associated fatalities or significant patient harm. Consideration should be given to adopting this process in any setting where insulin is prescribed and administered.

Partnered medication review and charting between the pharmacist and medical officer in the Emergency Short Stay and General Medicine Unit.

OBJECTIVE A partnered medication review and charting model involving a pharmacist and medical officer was implemented in the Emergency Short Stay Unit and General Medicine Unit of a major tertiary hospital. The aim of the study was to describe the safety and effectiveness of partnered medication charting in this setting. METHODS A partnered medication review and charting model was developed. Credentialed pharmacists charted pre-admission medications and venous thromboembolism prophylaxis in collaboration with the admitting medical officer. The pharmacist subsequently had a clinical discussion with the treating nurse regarding the medication management plan for the patient. A prospective audit was undertaken of all patients from the initiation of the service. RESULTS A total of 549 patients had medications charted by a pharmacist from the 14th of November 2012 to the 30th of April 2013. A total of 4765 medications were charted by pharmacists with 7 identified errors, corresponding to an error rate of 1.47 per 1000 medications charted. CONCLUSIONS Partnered medication review and charting by a pharmacist in the Emergency Short Stay and General Medicine unit is achievable, safe and effective. Benefits from the model extend beyond the pharmacist charting the medications, with clinical value added to the admission process through early collaboration with the medical officer. Further research is required to provide evidence to further support this collaborative model.

Reducing medication errors in hospital discharge summaries: a randomised controlled trial.

Objectives: To evaluate whether pharmacists completing the medication management plan in the medical discharge summary reduced the rate of medication errors in these summaries.

Partnered pharmacist charting on admission in the General Medical and Emergency Short‐stay Unit – a cluster‐randomised controlled trial in patients with complex medication regimens

Patients admitted to general medical units and emergency short‐stay units are often complex with multiple comorbidities, polypharmacy and at risk for drug‐related problems associated with increased morbidity and mortality. The aim of this study was to evaluate the effectiveness of a partnered pharmacist charting model completed at the time of admission to prevent medication errors.

A feasibility study of the provision of a personalized interdisciplinary audiovisual summary to facilitate care transfer care at hospital discharge: Care Transfer Video (CareTV)

OBJECTIVE To assess the feasibility and patient acceptance of a personalized interdisciplinary audiovisual record to facilitate effective communication with patients, family, carers and other healthcare workers at hospital discharge. DESIGN Descriptive pilot study utilizing a study-specific patient feedback questionnaire conducted from October 2013 to June 2014. SETTING AND PARTICIPANTS Twenty General Medical inpatients being discharged from an Acute General Medical Ward in a metropolitan teaching hospital. INTERVENTION Audiovisual record of a CareTV filmed at the patients bedside by a consultant-led interdisciplinary team, within 24 h prior to discharge from the ward, provided immediately for the patient to take home. Patient surveys were completed within 2 weeks of discharge. MAIN OUTCOME MEASURES Technical quality, utilization, acceptability, patient satisfaction and recall of diagnosis, medication changes and post-discharge review arrangements. RESULTS All patients had watched their CareTV either alone or in the presence of a variety of others: close family, their GP, a medical specialist, friends or other health personnel. Participating patients had good understanding of the video content and recall of their diagnosis, medication changes and post-discharge plans. Patient feedback was overwhelmingly positive. CONCLUSIONS In the context of a General Medical Unit with extensive experience in interdisciplinary bedside rounding and teamwork, CareTV is simple to implement, inexpensive, technically feasible, requires minimal staff training and is acceptable to patients. The results of this pilot study will inform and indicate the feasibility of conducting a larger randomized control trial of the impact of CareTV on patient satisfaction, medication adherence and recall of key information, and primary healthcare provider satisfaction.

Managing older patients safely in the time critical environment of an emergency department

Demand for emergency department (ED) services is increasing worldwide. The fastest growth in ED presentations is by patients aged ≥65 years, currently representing 18% of all attendances. Older patients present with more complex clinical conditions and multiple co-morbidities. This means they are likely to spend more time in ED, are more likely to be admitted to hospital, and are more likely to re-attend. The Safe Elderly Emergency Discharge (SEED) project aims to determine whether current models of emergency care ensure safe discharge and facilitate optimal health outcomes for older patients; and develop a tailored evidence-based care framework applicable to Australian and international settings. Risk screening for unsafe discharge will be conducted on patients aged ≥65 years discharged home from ED. Patients will be followed for 6 months post-ED presentation to monitor health outcomes and map their care journey. Demographic, clinical, and functional characteristics will be collected. The primary outcome is unsafe discharge, defined as unplanned re-presentation/admission within 30 days of the index presentation. Secondary outcomes include unplanned ED re-presentation/hospital admission within 6 months; patient experience; change in functional status; functional decline; health service utilisation; and death within 6 months. The effectiveness of the ED discharge risk screening tools for predicting unsafe discharge will be evaluated at 30 days and 6 months. SEED will determine the risk factors for unplanned ED re-presentation/hospital admission at 30 days for patients aged ≥65 years presenting to ED; which will inform the development of an evidence-based older patient care framework for EDs.

Resuscitation orders in acute hospitals: A point prevalence study

To determine the prevalence of resuscitation orders and Advance Care Plans, and the relationship with Medical Emergency Team (MET) calls.

Ironing out iron infusions – does premedication reduce adverse reactions during iron polymaltose infusion: a single‐centre retrospective review

Iron polymaltose infusions are increasingly prescribed in the management of iron deficiency but the efficacy of premedication to prevent complications of infusion remains uncertain. In order to simplify our infusion protocol, we retrospectively reviewed our experience of patients receiving iron polymaltose infusion to assess its safety profile, identify risk factors for adverse reactions and evaluate the efficacy of premedication in preventing adverse reactions.

PB10 Safe Elderly Emergency Discharge (SEED) project: determining best practice for safe discharge of the older emergency patient

Background and Objectives Increasing numbers of older patients presenting for emergency hospital care is a major worldwide concern. The fastest growth is in people aged ≥65 years representing 18% of all presentations. An ED visit for older people is a sentinel health event that can lead to substantial functional decline and adverse outcomes. This age group present with more complex conditions, consume more resources, have longer ED stays, are more likely to be admitted, have long hospital stays, and a higher rate of re-presentation. This will increase with population ageing. Although social/psychological support is often required there is little evidence this occurs in a systematic coordinated manner. SEED aims to Determine whether current models of emergency care ensure safe discharge and facilitate optimal health outcomes for older patients. Develop a tailored evidence-based care framework applicable to Australian and international settings. Methods PHASE 1: Review of best practice: Systematic review of best evidence for models of care for older patients in ED or short stay units. PHASE 2: Evaluation of methods for assessment of unsafe discharge risk: Evaluation of effectiveness of discharge risk screening tools designed to reduce risk of unsafe discharge. PHASE 3: Audit current practice against published best practice: Prospective process mapping of the patient care journey in 3 EDs in Australia and UK: during ED stay and post-discharge, with monitoring of health outcomes in the following 6 months. Expected Outcomes Development of an Older Patient Care Service Framework: Redesign of emergency care for older patients. To include: Development of policy and principles of management, care pathways, and performance improvement measures. Validation of an unsafe discharge screening tool in an Australian & English cohort. Development of a stream-lined care pathway. Reduced ED length of stay. Improved patient experience. Safe discharge with optimisation of health outcomes, reduced unplanned emergency re-presentations; reduced need for higher level residential care; reduced unplanned deaths. Reduced emergency demand and improved patient flow.