Timothy Green

PSYCHIATRIC MANIFESTATIONS OF SYSTEMIC ILLNESS

Many behavioral manifestations of systemic disease exist, including delirium, psychosis, mania, catatonia, depression, and anxiety. The features and medical causes of each of those manifestations are described. The indications from history and physical examination that suggest underlying medical illness are reviewed. The psychiatric presentations of several specific conditions are discussed in detail.

Outcomes from the evaluation of an emergency department-based mental health nurse practitioner outpatient service in Australia.

Purpose: To evaluate an emergency department (ED)‐based mental health nurse practitioner (MHNP) outpatient service in Sydney, Australia. Data sources: Data collection incorporated waiting times for follow‐up outpatient appointments, two brief self‐report measures (the K‐10 measure of psychological distress and the General Self‐Efficacy Scale), a satisfaction tool, and interviews conducted with a random selection of outpatients and a stratified, purposive sample of ED staff. Conclusions: Over 60% of outpatients were followed up within 5 days of their initial presentation. The mean K‐10 score at baseline was 32 (very high psychological distress, n= 101) but this had decreased by two categories to 24 at follow‐up (moderate psychological distress, n= 51). There was a modest association between decreased psychological distress and an increase in perceived self‐efficacy. Participant satisfaction with aspects of the outpatient service was generally rated as high to very high. Interviewed outpatients (n= 23) were particularly positive about the accessibility, immediacy, and flexibility of the service and overall therapeutic benefits. Emergency staff (n= 20) considered the outpatient service enhanced service provision by facilitating access to a population of patients who were previously underserved. Implications for practice: The ED‐based MHNP role enhances access to specialized mental health care and also supports emergency staff.Abstract Purpose: To evaluate an emergency department (ED)-based mental health nurse practitioner (MHNP) outpatient service in Sydney, Australia. Data sources: Data collection incorporated waiting times for follow-up outpatient appointments, two brief self-report measures (the K-10 measure of psychological distress and the General Self-Efficacy Scale), a satisfaction tool, and interviews conducted with a random selection of outpatients and a stratified, purposive sample of ED staff. Conclusions: Over 60% of outpatients were followed up within 5 days of their initial presentation. The mean K-10 score at baseline was 32 (very high psychological distress, n= 101) but this had decreased by two categories to 24 at follow-up (moderate psychological distress, n= 51). There was a modest association between decreased psychological distress and an increase in perceived self-efficacy. Participant satisfaction with aspects of the outpatient service was generally rated as high to very high. Interviewed outpatients (n= 23) were particularly positive about the accessibility, immediacy, and flexibility of the service and overall therapeutic benefits. Emergency staff (n= 20) considered the outpatient service enhanced service provision by facilitating access to a population of patients who were previously underserved. Implications for practice: The ED-based MHNP role enhances access to specialized mental health care and also supports emergency staff.

An emergency department-based mental health nurse practitioner outpatient service: Part 2, staff evaluation

The nurse practitioner role incorporates enhancing access to health-care services, particularly for populations that are underserved. This entails working collaboratively with colleagues across multidisciplinary teams and emphasizing a nursing model of practice within the nurse practitioner role. In Australia, the added value associated with establishing mental health nurse practitioner (MHNP) positions based in the emergency department (ED) is emerging. This paper presents qualitative findings from a study using a mixed-method design to evaluate an ED-based MHNP outpatient service in Sydney, Australia. One component of the evaluation involved semistructured interviews conducted with a random selection of study participants and a stratified sample of ED staff. This is the second of a two-part paper that presents an analysis of the qualitative data derived from the staff interviews (n = 20). Emergency staff were very supportive of the outpatient service, and perceived that it enhanced overall service provision and improved outcomes for patients. Moreover, staff expressed interest in receiving more formal feedback on the outcomes of the service. Staff also felt that service provision would be enhanced through additional mental health liaison nurses working in the department, especially after hours. An ED-based MHNP outpatient service expedites access to follow up to individuals with a broad range of problems, and supports ED staff in the provision of safe, effective, and more holistic care.

Randomised control trial of humidified high flow nasal cannulae versus standard oxygen in the emergency department

The aim of the study was to determine if oxygen delivered through humidified high flow nasal cannulae (HHFNC) reduced the need for escalation in ventilation management and work of breathing in the ED patients presenting with acute undifferentiated shortness of breath compared with standard oxygen therapy.

Senior work‐up assessment and treatment team in an emergency department: A randomised control trial

To evaluate the impact of a senior early assessment model of care on performance measures in a single ED.

Patient perceptions of emergency department fast track: A prospective pilot study comparing two models of care

BACKGROUND Emergency department (ED) fast track has been shown to improve patient flow for low complexity presentations.(1) The optimal model of care and service delivery for fast track patients has not been established. AIMS The objective of this pilot study was to compare patient satisfaction using two models of ED fast track - one in a tertiary hospital emergency department staffed by doctors and the other in a nearby urban district hospital staffed by nurse practitioners. We also wanted to determine the proportion of fast track patients who would prefer to see a General Practitioner (GP) instead of presenting to the ED. This pilot study was the foundation for subsequent studies later conducted by Dinh et al.(2,3) METHODS: This was an observational study using a convenience sample of patients. Eligible fast track patients were asked to complete a standardised satisfaction survey. Presenting problems and waiting times of patients were collected using patient information systems. Primary outcome measure was satisfaction rating using a 5-point Likert scale. Secondary outcomes were surrogate satisfaction measures encompassing questions on likelihood of returning to ED. A multivariate analysis was performed to obtain odds ratio for higher satisfaction scores. RESULTS In total, 353 patients were recruited: 212 patients in the doctor treated group (DR) and 141 were in the nurse practitioner treated group (NP). The two groups had similar baseline characteristics in terms of age, gender, referral source and waiting times. Overall, 320/353(86%) patients rated their care as either very good or excellent, with only 0.6% rating their care as poor. Satisfaction scores in the NP group were higher than those in the DR group (median score 4 vs. 3, p<0.01). A greater proportion of patients in the NP group reported that they would return to the ED for a similar problem (99% vs. 91% p<0.01). Overall, 175/353 (50%) of patients indicated that they would prefer to see a general practitioner for a similar problem if available nearby. These numbers were slightly lower in the NP group (43% vs. 53%, p=0.05). CONCLUSIONS Most patients were satisfied with ED fast track, irrespective of model of care. Patient satisfaction was greater in the group of patients using the nurse practitioner model of care. Around half of the fast track patients would prefer to see a general practitioner for a similar problem if available nearby.

Emergency department clinical redesign, team-based care and improvements in hospital performance: A time series analysis.

The objective was to evaluate the impact of an ED clinical redesign project that involved team‐based care and early senior assessment on hospital performance.

Involuntary admissions under the Mental Health Act 2007 (New South Wales): A comparison of patients detained by ambulance officers, medical practitioners and accredited persons in an emergency department

The Mental Health Act (MHA) 2007 (New South Wales [NSW]) is used to transport to, detain and treat individuals in a mental health facility. Patients are frequently taken to EDs under the MHA or detained in the ED for a mental health assessment. In NSW, medical practitioners, accredited persons, police and more recently ambulance officers, are authorised to write certificates under the MHA. There is an absence of research on the use of the MHA in NSW EDs. The primary research question for this study was: ‘What is the involuntary admission rate for persons detained under the MHA in an NSW tertiary referral ED?’

Bedside review of patient care in an emergency department: The Cow Round

Objective: Clinical handover is a critical point in medical care in the ED, which can contribute to adverse effects for patient care and staff workloads. Over a 4 and a half months in a tertiary referral hospital ED, a centralized whiteboard handover was performed followed by a multidisciplinary review of each patient. This round was referred to as the ‘Cow Round’.

Factors affecting length of stay for women presenting with early pregnancy complications to a public hospital emergency department

This study aimed to determine factors associated with length of stay (LOS) for women presenting with early pregnancy complications to a public hospital ED. In particular, we sought to investigate the impact the involvement of the Clinical Midwife Consultant (CMC), specialising in early pregnancy care, had on the ED LOS.