Lis Young

Findings of the First Consensus Conference on Medical Emergency Teams

Background:Studies have established that physiologic instability and services mismatching precede adverse events in hospitalized patients. In response to these considerations, the concept of a Rapid Response System (RRS) has emerged. The responding team is commonly known as a medical emergency team (MET), rapid response team (RRT), or critical care outreach (CCO). Studies show that an RRS may improve outcome, but questions remain regarding the benefit, design elements, and advisability of implementing a MET system. Methods:In June 2005 an International Conference on Medical Emergency Teams (ICMET) included experts in patient safety, hospital medicine, critical care medicine, and METs. Seven of 25 had no experience with an RRS, and the remainder had experience with one of the three major forms of RRS. After preconference telephone and e-mail conversations by the panelists in which questions to be discussed were characterized, literature reviewed, and preliminary answers created, the panelists convened for 2 days to create a consensus document. Four major content areas were addressed: What is a MET response? Is there a MET syndrome? What are barriers to METS? How should outcome be measured? Panelists considered whether all hospitals should implement an RRS. Results:Patients needing an RRS intervention are suddenly critically ill and have a mismatch of resources to needs. Hospitals should implement an RRS, which consists of four elements: an afferent, “crisis detection” and “response triggering” mechanism; an efferent, predetermined rapid response team; a governance/administrative structure to supply and organize resources; and a mechanism to evaluate crisis antecedents and promote hospital process improvement to prevent future events.

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.

Asthma, Health Behaviors, Social Adjustment, and Psychosomatic Symptoms in Adolescence

The association of health behaviour, indicators of social adjustment, and psychosomatic symptoms with diagnosed asthma was assessed in a community-based sample of 4550 adolescents in South Western Sydney, Australia. The results of this survey found an asthma prevalence among 11-15-year-olds of 17.5%, being consistent with previous studies. Tobacco use and alcohol consumption were higher among asthmatic compared with nonasthmatic adolescents. Asthmatics reported feeling lonely more often, having a number of negative social perceptions and feelings, and having more frequent psychosomatic symptoms. The findings of the study suggest that adolescents with asthma represent an important vulnerable group of school children. Asthma education may need a greater life-style change focus, besides asthma self-management training.

Asthma prevalence and management in Australian adolescents: Results from three community surveys

Three population surveys of asthma, conducted as part of a community-based asthma education program in southwestern Sydney, Australia, illustrate the relationship between health behaviors and asthma morbidity. The first survey was carried out in five secondary schools (n = 2514, 52% participation rate); the second survey, in eight schools (n = 4550, 82% participation rate); and, the third survey was conducted among patients who attended 38 general practices in the region (n = 633 adolescents, 72% participation rate). The prevalence of diagnosed asthma in Australian adolescents across all three studies was 16.5% (95% CI, 15.7%-17.3%). Asthma prevalence declined in males, but increased in females from ages 12-15 years. It was noted that smoking prevalence was similar in asthmatic adolescents, compared with nonasthmatics, and that the adoption of smoking occurred at similar ages. Further, behavioral self-management of asthma was infrequent in this group, with low levels of preventive practice and preventive medication use. We present a conceptual model of the barriers to optimal asthma management among asthmatic adolescents. The results of these surveys have led to community-wide efforts to improve asthma management and decrease smoking prevalence among these adolescents.

Risk factors for low birth weight in a socio-economically disadvantaged population: Parity, marital status, ethnicity and cigarette smoking

Low birth weight (LBW) is a public health problem, because it is associated with increased risk of morbidity and mortality. The principal aim of this study was to assess risk factors for LBW in a large multi-ethnic and socio-economically disadvantaged population. Data from 3242 mothers, who attended the Well Baby Clinic (Southwestern Sydney, Australia) for the first time, were analysed in relation to their demographic characteristics and socio-economic indices. The overall birthweight was 3377 ± 577 g (mean ± SD). In multiple linear regression analysis, smoking during pregnancy, marital status, parity, and country of birth were independently associated with birth weight. According to this analysis, lower birth weight was associated with mothers who had smoked during pregnancy (by 215.2 ± 18.6 g), who were single (46.9 ± 21 g), and of Asian background (108.5 ± 38.2 g). However, higher parity was associated with significantly higher birth weight. The presence of each factor was coded as 1 and the absence, 0. A ‘risk score’ was then derived by summing up the individual scores. When birth weight was classified as ‘low birth weight’ (defined as those with birth weight being less than 2500 g) or normal birth weight, the overall prevalence of LBW was 1.9%. Each unit increase in the risk score was associated with a 1.9-fold (95% confidence interval: 1.5–2.6) increase in the risk of LBW. These data suggest that apart from marital status, ethnicity and parity, maternal smoking is the single most important preventable risk factors for LBW.

“The Happy Migrant Effect”: perceptions of negative experiences of healthcare by patients with little or no English: a qualitative study across seven language groups

Background: The subjective experiences of patients with little or no English who either attended the Emergency Department or were admitted to the wards of a tertiary referral hospital were explored. Setting and methods: The reports of experiences from 49 patients of a tertiary referral hospital were analysed using grounded theory methods applied to translated transcriptions from focus groups held with discharged patients in seven languages. Results: Inability to communicate in English, poor patient and family involvement with staff, a lack of control or powerlessness, staff shortages, staff negligence or incompetence, and treatment delays were reported by some patients. Others tended to discount or minimise the significance of similar experiences, suggesting a construct, “The Happy Migrant Effect,” in which there is reluctance to assert healthcare rights. Patients appear “happy” and satisfied, despite problems with their hospital care. Explanatory factors for the construct include extreme powerlessness related to being unable to communicate, a positive comparison of healthcare in the new country compared with the old, patriotism for the new country, cultural norms that proscribe acceptance, politeness or social desirability, self-denigration for not having learnt English and, for a few, a fear of reprisals if they spoke out in complaint. Conclusions: Some immigrant patients with poor language skills might not report serious problems with healthcare delivery. In all patients in this study where problems with healthcare were reported, the events were considered to be largely preventable by appropriate language facilitation, patient and family involvement, and provider respect and compassion.

Factors associated with walkout of patients from New South Wales hospital emergency departments, Australia.

Objective  To explore the association between daily patient numbers, sociodemographic, clinical and system characteristics and walkout rates of patients from New South Wales (NSW) public hospital ED (without seeing a medical officer).

Ecological and individual predictors of maternal smoking behaviour: Looking beyond individual socioeconomic predictors at the community setting

The aim of this study is to examine the prevalence of smoking during pregnancy by the individual mothers sociodemographic characteristics and ecological factors at the community level (suburbs). This analysis combined 1996 Australia Census and data on 3424 women attending Well-Baby-Clinics (WBC) between January 1996 and February 1998 within a region in South Western Sydney (SWS), Australia. The prevalence of maternal smoking was 31%. Maternal factors such as marital status, country of birth, education, occupation, socioeconomic status (SES), and types of antenatal care (ANC) were independent risk factors for maternal smoking. Small area analysis revealed suburbs within SWS with high rates of maternal smoking (47-57%). Community level characteristics such as low income, low educational level, young mothers, and unemployment can explain 85.7% of the variation in maternal smoking in SWS. Smoking during pregnancy is recognised as a serious risk factor to the unborn child. The present study draws attention to local community level factors, other than individual SES, which may be important when developing strategies for maternal smoking prevention programs.

Asthma Education: The Perceptions of Family Physicians

Education and training are important for people with asthma and for their family doctors in order to reduce the morbidity and mortality associated with the disease, but the most appropriate educational strategies have not been clarified. This study was conducted as a needs-assessment survey to examine the perceptions of 193 family physicians in Sydney (Australia) regarding various aspects of asthma management and patient education. Part of this sample of physicians were subsequently involved in a communitywide asthma education program. Although the measurement of airway function by doctors and patients is the cornerstone of the national asthma strategy in Australia, only 43% of family physicians surveyed regularly measured airway function in their offices and most considered that their patients rarely used a peak flow meter. Most physicians agreed with statements suggesting that asthma education was useful but some felt that education could be dangerous, or might result in fewer consultations by asthma patients. These results have provided clear directions for educating family physicians about optimal asthma management. They also provide some insight into potential barriers to the successful implementation of asthma education programs.

Electronic Health Record System Risk Assessment: A Case Study from the MINET:

This article discusses the risk assessment of a health information system. A case study was conducted at the South Western Sydney Area Health Service to examine the potential risks of the Maternal and Infant Network (MINET) health information system using Failure Mode Effect Analysis (FMEA). FMEA was conducted by utilising safety attributes identified by the authors. Potential failure modes of the system were identified by the study. From this study, it can be concluded that FMEA is an appropriate risk-assessment method for MINET.