Search

Background Globally, emergency departments (EDs) are overcrowded and unable to meet an ever-increasing demand for care. The aim of this study is to comprehensively review and synthesise literature on potential solutions and challenges throughout the entire health system, focusing on ED patient fow. Methods An umbrella review was conducted to comprehensively summarise and synthesise the available evidence from multiple research syntheses. A comprehensive search strategy was employed in four databases alongside government or organisational websites in March 2023. Gray literature and reports were also searched. Quality was assessed using the JBI critical appraisal checklist for systematic reviews and research syntheses. We summarised and classifed fndings using qualitative synthesis, the Population-Capacity-Process (PCP) model, and the input/ throughput/output (I/T/O) model of ED patient fow and synthesised intervention outcomes based on the Quadruple Aim framework. Results The search strategy yielded 1263 articles, of which 39 were included in the umbrella review. Patient fow interventions were categorised into human factors, management-organisation interventions, and infrastructure and mapped to the relevant component of the patient journey from pre-ED to post-ED interventions. Most interventions had mixed or quadruple nonsignifcant outcomes. The majority of interventions for enhancing ED patient fow were primarily related to the ’within-ED’ phase of the patient journey. Fewer interventions were identifed for the ’post-ED’ phase (acute inpatient transfer, subacute inpatient transfer, hospital at home, discharge home, or residential care) and the ’pre-ED’ phase. The intervention outcomes were aligned with the aim (QAIM), which aims to improve patient care experience, enhance population health, optimise efciency, and enhance staf satisfaction. Conclusions This study found that there was a wide range of interventions used to address patient fow, but the efectiveness of these interventions varied, and most interventions were focused on the ED. Interventions for the remainder of the patient journey were largely neglected. The metrics reported were mainly focused on efciency measures rather than addressing all quadrants of the quadruple aim. Further research is needed to investigate and enhance the efectiveness of interventions outside the ED in improving ED patient fow. It is essential to develop interventions that relate to all three phases of patient fow: pre-ED, within-ED, and post-ED. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion We aimed to assess the impact a Virtual Toxicology Service had on the ALOS of poisoned patients.This single‐centre before‐after study compares the ALOS of poisoned patients (diagnosis‐related group X62, poisoning/toxic effects of drugs and other substances) following the introduction of a Virtual Toxicology Service in 2020.The ALOS decreased from 0.89 days in the 2‐year pre‐intervention period to 0.62 days in the 3‐year post‐intervention period, with a potential bed saving of 703 days.The introduction of a Virtual Toxicology Service appeared to be associated with a decreased ALOS of poisoned patients. [ABSTRACT FROM AUTHOR]

The provision of waiting time information in emergency departments (ED) has become an increasingly popular practice due to its positive impact on patient experience and ED demand management. However, little scientific attention has been given to the quality and quantity of waiting time information presented to patients. To improve both aspects, we propose a set of state space models with flexible error structures to forecast ED waiting time for low acuity patients. Our approach utilizes a Bayesian framework to generate uncertainties associated with the forecasts. We find that the state‐space models with flexible error structures significantly improve forecast accuracy of ED waiting time compared to the benchmark, which is the rolling average model. Specifically, incorporating time‐varying and correlated error terms reduces the root mean squared errors of the benchmark by 10%. Furthermore, treating zero‐recorded waiting times as unobserved values improves forecast performance. Our proposed model has the ability to provide patient‐centric waiting time information. By offering more accurate and informative waiting time information, our model can help patients make better informed decisions and ultimately enhance their ED experience. [ABSTRACT FROM AUTHOR]

The article presents the discussion on telemedicine and digital technologies supporting the provision of emergency care for more than 20 years. Topics include enabling ubiquitous, high quality, secure video conferencing, remote monitoring and digital ordering and review of investigations; and implications for the emergency and primary care workforces, particularly in rural and regional centres.

Digital transformation of Australian hospitals is occurring rapidly. Although the clinical community has had limited ability to influence high-level decision making and investments into digital health technologies, as these technologies increasingly transform the way patients are cared for, the clinical community must influence the digital health agenda and be an integral part of the decision-making process. This case study details the process and lessons learnt during the development of the state-wide consensus statement detailing the clinical requirements for digital health initiatives to form the Queensland Digital Health Clinical Charter. To the best of our knowledge, Queensland is the first Australian jurisdiction to create a Digital Clinical Charter to be specifically referenced in the investment in and governance of digital health in hospitals. By developing this clinical charter for digital health, and in articulating the needs of clinicians, a clinical framework will be added to both the decision-making process around the investments in digital health and the definition and realisation of the expected benefits from these sizable investments. What is known about the topic?: Digital transformation of healthcare is occurring rapidly. The clinical community has had limited ability to influence high-level decision making and investments into these digital health technologies. Tension currently exists between the clinical community who must use the new digital technologies and the technical groups that govern the introduction of the new technologies. This tension can be manifest as clinicians refusing to adopt new systems, safety concerns and an inability to reach consensus on direction. There are few peer reviewed publications addressing this tension between the clinical community and technical providers. What does this paper add?: This paper is the first attempt to create a list of clinical requirements for digital transformation that crosses professional streams and is endorsed by the state-wide executive leadership team to inform the acquisition and governance of digital health technologies. What are the implications for practitioners?: Clinicians can feel excluded and marginalised during the decision-making process for new digital technologies, despite the fact that they are often using these technologies to deliver hands-on care to patients. This charter clearly articulates the requirements of clinicians for digital transformation and has been endorsed by the executive leadership team of Queensland Health. The charter adds a clinical framework to be referenced during the decision-making process around the investments in digital health, and the definition and realisation of the expected benefits from these sizable investments. As the digital landscape in public hospitals evolves, clinicians are becoming increasingly reliant upon digital technologies. It is critical that clinicians have a strong effect on technology acquisition and governance to maximise the quality and efficiency of the care they provide. [ABSTRACT FROM AUTHOR]

As the focus of clinicians and government shifts from speciality-based care to system-based key performance indicators such as the National Emergency Access Target (NEAT) or the 4-h rule, integration between emergency department (ED) and inpatient clinical workflows and information systems is becoming increasingly necessary. Such system measures drive the implementation of integrated electronic medical records (ieMR) to digitally integrate these workflows. The objective of this case study was to describe the impact of digital transformation of the ED–in-patient interface (EDii) of a large tertiary hospital on process measures and clinical outcomes for patients requiring emergency admission to hospital. Data were collected from routine clinical and administrative information systems to measure process and clinical outcome measures, including ED length of stay, compliance with the 4-h rule and in-patient mortality between 28 November 2014 and 28 February 2017. The 4-h rule compliance for all patients, as well as for the EDii group (admitted to hospital excluding short stay ward), declined after digitisation. There were 55 fewer deaths in the postintervention group (15% relative reduction; P = 0.02) and a 10% relative reduction in adjusted mortality as measured by the Hospital Standardised Mortality Ratio for emergency patients (eHSMR), which did not reach statistical significance. Digital deceleration in ED performance did occur with an ieMR rollout, but worsening of key patient outcomes was not observed. What is known about this topic?: Much has been written about the introduction of electronic medical records (EMRs) in emergency departments. This work sits alongside a substantial body of evidence outlining the relationship between process measures of ED performance and important patient outcomes. However, much less is known about the impact of digital transformation on the complex adaptive system that is the EDii and the impact of digitisation on the vulnerable group of patients who require emergency admission to hospital. What does this paper add?: The objective of this case study was to describe the effect of a rapid rollout of an integrated EMR. This EMR simultaneously transformed care delivery both in the ED and the inpatient space and impacted on the politically and clinically sensitive performance and outcome measures of the EDii in a large tertiary hospital. The present study is the first that specifically examined the effect of digitisation at the EDii. What are the implications for practitioners?: The understanding that digital deceleration will occur, but that with good patient outcome monitoring worsening of key patient outcomes is not likely to occur, now holds a key place in digital transformation planning. The measures of the EDii examined in this case study provide a foundation for this montoring. [ABSTRACT FROM AUTHOR]

After successfully avoiding the situations experienced by some countries, Australasian EDs now face a future in which the ongoing threat of COVID‐19 is added to the traditional challenges in providing quality emergency care. The contribution of emergency medicine to the national containment strategy adds a new dimension to the demands placed on emergency medicine in Australia and similarly, to the elimination strategy employed in New Zealand. These demands will best be met by a considered, planned and resourced approach that will challenge traditional measures of 'ED efficiency'. [ABSTRACT FROM AUTHOR]

The digital transformation of hospitals in Australia is occurring rapidly in order to facilitate innovation and improve efficiency. Rapid transformation can cause temporary disruption of hospital workflows and staff as processes are adapted to the new digital workflows. The aim of this paper is to outline various types of digital disruption and some strategies for effective management.Alarge tertiary university hospital recently underwent a rapid, successful roll-out of an integrated electronic medical record (EMR). We observed this transformation and propose several digital disruption "syndromes" to assist with understanding and management during digital transformation: digital deceleration, digital transparency, digital hypervigilance, data discordance, digital churn and post-digital 'depression'. These 'syndromes' are defined and discussed in detail. Successful management of this temporary digital disruption is important to ensure a successful transition to a digital platform. [ABSTRACT FROM AUTHOR]

Unwell patients in the ED requiring inpatient admission must negotiate the interface between the ED and inpatient wards. Despite its importance and scale, this ED-inpatient interface (EDii) is poorly characterised. The aim of this paper is to clearly define the EDii and to describe its importance to (i) the patient: delays to admission and errors in communication across the EDii can increase adverse outcomes; (ii) the hospital: poor EDii function reduces hospital efficiency and effectiveness; and (iii) the healthcare system: half of all hospital inpatient admissions occur via the EDii and so EDii affects system-wide performance. The EDii can be defined as the dynamic, transitional phase of patient care in which responsibility for, and delivery of care, is shared between ED and inpatient hospital services. The EDii is characterised by a complex interplay of patient, hospital and system factors. A clear definition of the EDii and an understanding of its importance will assist future research and interventions to improve patient outcomes. [ABSTRACT FROM AUTHOR]

The COVID‐19 pandemic has led to the development of alternative means of accessing unplanned care in order to avoid unnecessary ED presentations and hospital admissions. We explore the definition of emergency medicine, which patients are better served by accessing unplanned hospital care via alternative pathways, and the concept of emergency care completion. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was to provide a summary of a systematic review of literature reporting benefits and limitations of implementing National Emergency Access Target (NEAT), a target stipulating that a certain proportion of patients presenting to hospital emergency departments are admitted or discharged within 4 h of presentation. Methods: A systematic review of published literature using specific search terms, snowballing techniques applied to retrieved references and Google searches was performed. Results are presented as a narrative synthesis given the heterogeneity of included studies. Results: Benefits of a time-based target for emergency care are improved timeliness of emergency care and reduced in-hospital mortality for emergency admissions to hospital. Limitations centre on using a process measure (time) alone devoid of any monitoring of patient outcomes, the threshold nature of a time target and the fact that currentlyNEATcombines the measurement of clinical management of two very different patient cohorts seeking emergency care: less acute patients discharged home and more acute patients admitted to hospital. Conclusions: Time-based access targets for emergency presentations are associated with significant improvements in in-hospital mortality for emergency admissions. However, other patient-important outcomes are deserving of attention, choice of targets needs to be validated by empirical evidence of patient benefit and single targets need to be partitioned into separate targets pertaining to admitted and discharged patients. [ABSTRACT FROM AUTHOR]

Objective. The aim of the present study was to identify patient and non-patient factors associated with reduced mortality among patients admitted from the emergency department (ED) to in-patient wards in a major tertiary hospital that had previously reported a near halving in mortality in association with a doubling in National Emergency Access Target (NEAT) compliance over a 2-year period from 2012 to 2014. Methods. We retrospectively analysed routinely collected data from the Emergency Department Information System (EDIS) and hospital discharge abstracts on all emergency admissions during calendar years 2011 (pre-NEAT interventions) and 2013 (post-NEAT interventions). Patients admitted to short-stay wards and then discharged home, as well as patients dying in the ED, were excluded. Patients included in the study were categorised according to age, time and day of arrival to the ED, mode of transport to the ED, emergency triage category, type of clinical presentation and major diagnostic codes. Results. The in-patient mortality rate for emergency admissions decreased from 1.9% (320/17 022) in 2011 to 1.2% (202/17 162) in 2013 (P < 0.001). There was no change from 2011 to 2013 in the percentage of deaths in the ED (0.19% vs 0.17%) or those coded as in-patient palliative care (17.9% vs 22.2%). Although deaths were not associated with age by itself, the mortality rate of older patients admitted to medical wards decreased significantly from 3.5% to 1.7% (P = 0.011). A higher mortality rate was seen among patients presenting to ED triage between midnight and 12 noon than at other times in 2011 (2.5% vs 1.5%; P < 0.001), but this difference disappeared by 2013 (1.3% vs 1.1%; P = 0.150).A similar pattern was seen among patients presenting on weekends versus weekdays: 2.2% versus 1.7% (P = 0.038) in 2011 and 1.3% versus 1.1% (P = 0.150) in 2013. Fewer deaths were noted among patients with acute cardiovascular or respiratory disease in 2013 than in 2011 (1.7% vs 3.6% and 1.5% vs 3.4%, respectively; P < 0.001 for both comparisons). Mode of transport to the ED or triage category was not associated with changes in mortality. These analyses took account of any possible confounding resulting from differences over time in emergency admission rates. Conclusions. Improved NEAT compliance as a result of clinical redesign is associated with improved in-patient mortality among particular subgroups of emergency admissions, namely older patients with complex medical conditions, those presenting after hours and on weekends and those presenting with time-sensitive acute cardiorespiratory conditions. [ABSTRACT FROM AUTHOR]

Objective. To implement and evaluate strategies for improving access to emergency department (ED) care in a tertiary hospital. Methods. A retrospective pre-post intervention study using routinely collected data involving all patients presenting acutely to the ED of a major tertiary hospital over a 2-year period. Main outcome measures were changes in: the percentage of patients exiting the ED (all patients, patients discharged directly from the ED, patients admitted to inpatient wards); mean patient transit times in the ED; inpatient mortality rates; rates of ED 'did not wait' and re-presentations within 48 h of ED discharge; and selected safety indicators. Qualitative data on staff perceptions of interventions were also gathered. Results. Working groups focused on ED internal processes, ED-inpatient unit interface, hospital-wide discharge processes and performance monitoring and feedback. Twenty-five different reforms were enacted over a 9-month period from April to December 2012. Comparing the baseline period (January-March 2012) with the post-reform period (January-March 2013), the percentage of patients exiting the ED within 4 h rose for all patients presenting to the ED (from 32% to 62%), for patients discharged directly from the ED (from 41% to 75%) and for admitted patients (from 12% to 32%; P < 0.001 for all comparisons). The mean (±s.d.) time all patients spent in the ED was reduced from 7.2 ± 5.8 to 4.4 ± 3.5 h (P < 0.001) and, for admitted patients, was associated with reduced in-hospital mortality (from 2.3% to 1.7%; P = 0.045). The 'did not wait' rates in ED fell from 6.9% to 1.9% (P < 0.001), whereas ED re-presentations within 48 h among patients discharged from the ED rose slightly (from 3.1% to 3.8%; P = 0.023). Improvements in outcome measures were maintained over the subsequent 12 months. Conclusions. Multiple reforms targeting processes both within the ED and its interface with inpatient units greatly improved access to ED care over 12 months and were associated with decreased in-hospital mortality. [ABSTRACT FROM AUTHOR]

Objective: To investigate the impact of QScript implementation on pregabalin‐related poisoning presentations to the ED. Methods: This is a retrospective review of pregabalin‐related poisoning presentations to a tertiary Australian ED in the 4 years prior to, and 1 year following the introduction of QScript real‐time prescription monitoring system. Results: Pregabalin‐related poisoning presentations fell by 28% from an average of 98 presentations annually over the 4 years prior to QScript implementation to 71 in 2022. The severity of poisonings was similar over the periods. Conclusions: The introduction of QScript was associated with a reduction in pregabalin‐related poisoning presentations. [ABSTRACT FROM AUTHOR]

Abstract Objective: The aim of the study was to determine the range of cerebrospinal fluid findings associated with emergency department disposition and treatment of patients with headache suspicious of subarachnoid haemorrhage but a negative or equivocal computed tomoraphy head scan, in particular the role of xanthochromic index. Methods: A retrospective review of medical records of 196 adult patients who underwent cerebrospinal fluid examination for red cell count and xanthochromia for suspected subarachnoid haemorrhage but had a normal or equivocal computed tomography scan. Results: Included in the study were 196 patients. Only one patient out of 189 with a negative computed tomography scan was found to have a subarachnoid haemorrhage caused by a ruptured aneurysm (0.5%; 95% confidence intervals 0–2.9%). Three other patients were diagnosed with benign subarachnoid haemorrhage. Ninety-one patients were stratified into the lowest possible risk group for subarachnoid haemorrhage and discharged home from the emergency department. All patients with equivocal computed tomography head scans and a positive xanthochromic index were admitted for cerebral angiography. In many cases, cerebrospinal fluid findings did not appear to influence clinical decision-making. Conclusions: In the study institution, cerebrospinal fluid results appeared to have a variable influence on clinical decision-making for patients with suspected subarachnoid haemorrhage and a non-diagnostic computed tomography head scan. Of particular concern is the lack of validation of the tests used in this investigative approach, the frequency of patients having a lumbar puncture where the results did not influence their management, the inconsistency in the laboratory’s technique for performing tests on cerebrospinal fluid and the very low yield of detecting patients with subarachnoid haemorrhage and a potentially treatable causative lesion. [ABSTRACT FROM AUTHOR]

Objectives: To compare time metrics associated with a temporary disruption to ED computed tomography (CT) scanner location from adjacent to the ED with direct access from resuscitation rooms, to a location remote to the ED. Methods: A retrospective before and after study was conducted in a public metropolitan ED with over 66 000 presentations annually. Time‐to‐CT metrics, operational time metrics and ED length of stay were extracted and analysed from presentations between October 2020 and January 2021. Results: There were 3031 CT scans during the study period. Overall, the disruption was associated with a significant 27–36 min delay (P < 0.01) in time‐to‐CT start; these delays were also observed in a subset of trauma patients. In a subset of presumed stroke patients, time‐to‐brain perfusion was significantly delayed by up to 10 min (P < 0.01). There was a 14% (P < 0.01) greater demand for operational services and a time imposition of up to 8 min (P < 0.01) to transport patients to or from CT scanning when the CT scanner was located away from the ED. ED length of stay was consistent at all time points. Conclusion: Although rapid, proximate access to CT scanning is often considered desirable in terms of the management of trauma and other time‐critical emergencies, the wider time and resource implications demonstrated in this study suggest a potential broader benefit to co‐located CT scanning in ED. Our experience could be considered in future re‐design of EDs. [ABSTRACT FROM AUTHOR]

Objective: Many factors influence patient flow through an ED, including streaming, treatment spaces and staff resources. This pilot study explored and compared real time patient flow using a single‐stream system versus varying configurations of possible two‐stream systems using computer simulation. Methods: Simulation modelling was used to assess the delay in treatment of a rapid‐antigen‐tested‐based, two‐stream model for patient flow through ED during the peak phase of the COVID pandemic. Results: Modelling two‐stream configuration for all patients (minimum time to be seen for both COVID‐positive and COVID‐negative patients) showed that in the case study ED, a two‐stream system and linked changes in bed configuration for managing the risks of infection can impact delays in treatment. Conclusions: Data‐driven modelling within specific clinical settings can inform the (in)efficiency of patient flow processes and help clinicians and managers make evidence‐based decisions about patient transition through EDs. This can assist with reconfiguration of ED patient streaming particularly during periods of unique need, such as the recent COVID‐19 pandemic. [ABSTRACT FROM AUTHOR]

Objective: This study provides insights into the reported early impacts of the digital transformation of a large Australian hospital and healthcare service (HHS) by surveying staff perceptions of an integrated electronic medical record (ieMR). Methods: The information systems success model was used as a tool to evaluate perceptions of system quality, information quality, individual benefits and expected organisational benefits of the ieMR soon after its introduction at the HHS. A questionnaire was distributed to staff in all five hospitals in the HHS immediately after implementation. Overall staff perceptions were examined, in addition to how perceptions differed by site and profession. Results: Overall, staff held mildly positive early perceptions of system quality, information quality, individual benefits and expected organisational benefits. These views were largely consistent across sites. In terms of professions, allied health held more positive perceptions, followed by administrative and nursing professionals. Medical professionals held negative perceptions, but were neutral regarding their future expectations. Conclusion: On average, staff viewed the ieMR mildly positively immediately after implementation (despite significant changes to work practices), but differences exist across professional groups. What is known about the topic?: Hospitals globally are in the midst of a digital transformation. Yet, reported impacts are mixed and there have been few studies of the effects of comprehensive electronic medical record (EMR) implementations. What does this paper add?: This paper evaluates a comprehensive EMR immediately after go-live. We found positive early perceptions of system quality, information quality, individual benefits and expected organisational benefits. We also found that perceptions of medical professionals were largely negative, but they were neutral in terms of their future expectations. What are the implications for practitioners?: Health services may be unsure of the effect of implementing a comprehensive EMR because of conflicting reports in the literature, some touting major benefits, others stressing major costs. Our results paint a middle-ground picture immediately after implementation. Staff perceptions are mildly positive on average, which is reassuring given the results were obtained during the early disruptive period after implementation. [ABSTRACT FROM AUTHOR]

Patients who require emergency admission to hospital require complex care that can be fragmented, occurring in the ED, across the ED-inpatient interface (EDii) and subsequently, in their destination inpatient ward. Our hospital had poor process efficiency with slow transit times for patients requiring emergency care. ED clinicians alone were able to improve the processes and length of stay for the patients discharged directly from the ED. However, improving the efficiency of care for patients requiring emergency admission to true inpatient wards required collaboration with reluctant inpatient clinicians. The inpatient teams were uninterested in improving time-based measures of care in isolation, but they were motivated by improving patient outcomes. We developed a dashboard showing process measures such as 4 h rule compliance rate coupled with clinically important outcome measures such as inpatient mortality. The EDii dashboard helped unite both ED and inpatient teams in clinical redesign to improve both efficiencies of care and patient outcomes. [ABSTRACT FROM AUTHOR]

Objective: In an era of rapid digitisation of Australian hospitals, practical guidance is needed in how to successfully implement electronic medical records (EMRs) as both a technical innovation and a major transformative change in clinical care. The aim of the present study was to develop a checklist that clearly and comprehensively defines the steps that best prepare hospitals for EMR implementation and digital transformation. Methods: The checklist was developed using a formal methodological framework comprised of: literature reviews of relevant issues; an interactive workshop involving a multidisciplinary group of digital leads from Queensland hospitals; a draft document based on literature and workshop proceedings; and a review and feedback from senior clinical leads. Results: The final checklist comprised 19 questions, 13 related to EMR implementation and six to digital transformation. Questions related to the former included organisational considerations (leadership, governance, change leaders, implementation plan), technical considerations (vendor choice, information technology and project management teams, system and hardware alignment with clinician workflows, interoperability with legacy systems) and training (user training, post-go-live contingency plans, roll-out sequence, staff support at point of care). Questions related to digital transformation included cultural considerations (clinically focused vision statement and communication strategy, readiness for change surveys), management of digital disruption syndromes and plans for further improvement in patient care (post-go-live optimisation of digital system, quality and benefit evaluation, ongoing digital innovation). Conclusion: This evidence-based, field-tested checklist provides guidance to hospitals planning EMR implementation and separates readiness for EMR from readiness for digital transformation. What is known about the topic?: Many hospitals throughout Australia have implemented, or are planning to implement, hospital wide electronic medical records (EMRs) with varying degrees of functionality. Few hospitals have implemented a complete end-to-end digital system with the ability to bring about major transformation in clinical care. Although the many challenges in implementing EMRs have been well documented, they have not been incorporated into an evidence-based, field-tested checklist that can practically assist hospitals in preparing for EMR implementation as both a technical innovation and a vehicle for major digital transformation of care. What does this paper add?: This paper outlines a 19-question checklist that was developed using a formal methodological framework comprising literature review of relevant issues, proceedings from an interactive workshop involving a multidisciplinary group of digital leads from hospitals throughout Queensland, including three hospitals undertaking EMR implementation and one hospital with complete end-to-end EMR, and review of a draft checklist by senior clinical leads within a statewide digital healthcare improvement network. The checklist distinguishes between issues pertaining to EMR as a technical innovation and EMR as a vehicle for digital transformation of patient care. What are the implications for practitioners?: Successful implementation of a hospital-wide EMR requires senior managers, clinical leads, information technology teams and project management teams to fully address key operational and strategic issues. Using an issues checklist may help prevent any one issue being inadvertently overlooked or underemphasised in the planning and implementation stages, and ensure the EMR is fully adopted and optimally used by clinician users in an ongoing digital transformation of care. [ABSTRACT FROM AUTHOR]

Evidence suggests improved outcomes for patients requiring emergency admission to hospital are associated with improved emergency department (ED) efficiency and lower transit times. Factors preventing timely transfers of emergency patients to in-patient beds across the ED–in-patient interface are major causes for ED crowding, for which several remedial strategies are possible, including parallel processing of probable admissions, direct-to-ward admissions and single-point medical registrars for receiving and processing all referrals directed at specific speciality units. Dynamic measures of ED overcrowding that focus on boarding time are more indicative of EDs with exit block involving the ED–in-patient interface than static proxy measures such as hospital bed occupancy and numbers of ED presentations. The ideal 4-h compliance rate for all ED presentations is around 80%, based on a large retrospective study of more than 18 million presentations to EDs of 59 Australian hospitals over 4 years, which demonstrated a highly significant linear reduction in risk-adjusted in-patient mortality for admitted patients as the compliance rate for all patients rose to 83%, but was not confirmed beyond this rate. Closely monitoring patient outcomes for emergency admissions in addition to compliance with time-based access targets is strongly recommended in ensuring reforms aimed at decongesting EDs do not compromise the quality and safety of patient care. [ABSTRACT FROM AUTHOR]

Objective. The aim of the present study was to determine the effects of hospital-based eHealth technologies on quality, safety and efficiency of care and clinical outcomes. Methods. Systematic reviews and reviews of systematic reviews of eHealth technologies published in PubMed/ Medline/Cochrane Library between January 2010 and October 2015 were evaluated. Reviews of implementation issues, nonhospital settings or remote care or patient-focused technologies were excluded from analysis. Methodological quality was assessed using a validated appraisal tool. Outcome measures were benefits and harms relating to electronic medical records (EMRs), computerised physician order entry (CPOE), electronic prescribing (ePrescribing) and computerised decision support systems (CDSS). Results are presented as a narrative overview given marked study heterogeneity. Results. Nineteen systematic reviews and two reviews of systematic reviews were included from 1197 abstracts, nine rated as high quality. For EMR functions, there was moderate-quality evidence of reduced hospitalisations and length of stay and low-quality evidence of improved organisational efficiency, greater accuracy of information and reduced documentation and process turnaround times. For CPOE functions, there was moderate-quality evidence of reductions in turnaround times and resource utilisation. For ePrescribing, there was moderate-quality evidence of substantially fewer medications errors and adverse drug events, greater guideline adherence, improved disease control and decreased dispensing turnaround times. For CDSS, there was moderate-quality evidence of increased use of preventive care and drug interaction reminders and alerts, increased use of diagnostic aids, more appropriate test ordering with fewer tests per patient, greater guideline adherence, improved processes of care and less disease morbidity. There was conflicting evidence regarding effects on in-patient mortality and overall costs. Reported harms were alert fatigue, increased technology interaction time, creation of disruptive workarounds and new prescribing errors. Conclusion. eHealth technologies in hospital settings appear to improve efficiency and appropriateness of care, prescribing safety and disease control. Effects on mortality, readmissions, total costs and patient and provider experience remain uncertain. [ABSTRACT FROM AUTHOR]

Objectives. The aim of the present study was to assess the relationship between and the effect of the 4-h target or National Emergency Access Target (NEAT) on the time-to-analgesia (TTA), as well as the provision of analgesia in an adult emergency department (ED). Methods. The present study was a pilot descriptive explorative retrospective cohort study conducted in a public metropolitan ED. Eligible presentations for analysis were adults presenting with a documented pain score of ≥4 out of 10 between 1 and 14 September 2014. Triage Category 1, pregnant, chest pain and major trauma cases were excluded from the study. As a result, data for 260 patients were analysed. Results. Of 260 patients, 176 had analgesia with a median TTA of 49 min. Increased NEAT compliance did not significantly decrease TTA. However, when the factors that affected the provision of analgesia were analysed, an association was demonstrated between Admitted and Short Stay NEAT performance and the provision of analgesia. The likelihood of receiving analgesia at all increased as Admitted and Short Stay NEAT compliance improved. Conclusion. NEAT is a significant health policy initiative with little clinical evidence supporting its implementation. However, as the Admitted NEAT compliance increases, the probability of receiving analgesia increases, demonstrating a possible link between hospital function and clinical care provision that needs to be explored further. [ABSTRACT FROM AUTHOR]

Discusses the issue of the misleading interpretation of the term xanthochromic in immunohistochemistry. Guidelines regarding the use of the term proposed by the British NEQAS; Functions of the guidelines.

Background: The current systems of reporting waiting time to patients in public emergency departments (EDs) has largely relied on rolling average or median estimators which have limited accuracy. This study proposes to use machine learning (ML) algorithms that significantly improve waiting time forecasts.Methods: By implementing ML algorithms and using a large set of queueing and service flow variables, we provide evidence of the improvement in waiting time predictions for low acuity ED patients assigned to the waiting room. In addition to the mean squared prediction error (MSPE) and mean absolute prediction error (MAPE), we advocate to use the percentage of underpredicted observations. The use of ML algorithms is motivated by their advantages in exploring data connections in flexible ways, identifying relevant predictors, and preventing overfitting of the data. We also use quantile regression to generate time forecasts which may better address the patient's asymmetric perception of underpredicted and overpredicted ED waiting times.Results: Using queueing and service flow variables together with information on diurnal fluctuations, ML models outperform the best rolling average by over 20 % with respect to MSPE and quantile regression reduces the number of patients with large underpredicted waiting times by 42 %.Conclusion: We find robust evidence that the proposed estimators generate more accurate ED waiting time predictions than the rolling average. We also show that to increase the predictive accuracy further, a hospital ED may decide to provide predictions to patients registered only during the daytime when the ED operates at full capacity, thus translating to more predictive service rates and the demand for treatments. [ABSTRACT FROM AUTHOR]

Objective: This study aims to assist hospitals contemplating digital transformation by assessing the reported qualitative effects of rapidly implementing an integrated eHealth system in a large Australian hospital and determining whether existing literature offers a reliable framework to assess the effects of digitisation. Methods: A qualitative, single-site case study was performed using semistructured interviews supplemented by focus groups, observations and documentation. In all, 92 individuals across medical, nursing, allied health, administrative and executive roles provided insights into the eHealth system, which consisted of an electronic medical record, computerised decision support, computerised physician order entry, ePrescribing systems and wireless device integration. These results were compared against a known framework of the effects of hospital digitisation. Results: Diverse, mostly positive, effects were reported, largely consistent with existing literature. Several new effects not reported in literature were reported, namely: (1) improvements in accountability for care, individual career development and time management; (2) mixed findings for the availability of real-time data; and (3) positive findings for the secondary use of data. Conclusions: The overall positive perceptions of the effects of digitisation should give confidence to health services contemplating rapid digital transformation. Although existing literature provides a reliable framework for impact assessment, new effects are still emerging, and research and practice need to shift towards understanding how clinicians and hospitals can maximise the benefits of digital transformation. What is known about the topic?: Hospitals outside the US are increasingly becoming engaged in eHealth transformations. Yet, the reported effects of these technologies are diverse and mixed with qualitative effects rarely reported. What does this paper add?: This study provides a qualitative assessment of the effects of an eHealth transformation at a large Australian tertiary hospital. The results provide renewed confidence in the literature because the findings are largely consistent with expectations from prior systematic reviews of impacts. The qualitative approach followed also resulted in the identification of new effects, which included improvements in accountability, time management and individual development, as well as mixed results for real-time data. In addition, substantial improvements in patient outcomes and clinician productivity were reported from the secondary use of data within the eHealth systems. What are the implications for practitioners?: The overall positive findings in this large case study should give confidence to other health services contemplating rapid digital transformation. To achieve substantial benefits, hospitals need to understand how they can best leverage the data within these systems to improve the quality and efficiency of patient care. As such, both research and practice need to shift towards understanding how these systems can be used more effectively. [ABSTRACT FROM AUTHOR]

The Australian Commission for Safety and Quality in Health Care has created the National Safety and Quality Health Service standards that all hospitals must address in order to remain accredited. This case study details the first known digitisation of the 10 national quality and safety standards mandated in a quaternary integrated digital hospital. A team of clinical informaticians, information technology experts and clinicians was assembled. Data were chosen and the data were then extracted and validated and presented (often in near real time) in an easily consumable dashboard format with appropriate governance to allow clinicians and executives to monitor the quality and safety standards across the hospital. All 10 standards were defined and extracted contemporaneously from the digital hospital for every patient, every time. This is in stark contrast with traditional retrospective point prevalence surveys. This case study details the first known fully digital accreditation in a sophisticated integrated digital hospital. Digitisation of hospital quality and safety to produce real-time data is the future of clinical redesign to improve patient care. What is known about the topic?: Healthcare delivery is complex and the ability of healthcare providers to maintain consistent standards of quality and safety is variable. Traditionally, these standards have been assessed by intermittent retrospective point-prevalence survey activity. Sophisticated digital hospitals provide the opportunity to develop data and analytics that monitor quality and safety standards across every patient, every time in near real time. What does this paper add?: This paper describes a digital hospital which has created streaming analytics to monitor live performance of quality and safety standards. The necessary skills, leadership and governance for this process are outlined and the products described. What are the implications for practitioners?: Shifting from retrospective paper-based point prevalence surveys to a digital platform has several implications. Firstly, it is an imperative to drive digital transformation of Australian hospitals. Secondly, it provides data for intervention to the hospital staff, so that issues can be addressed and improved in real-time, rather than waiting for survey results. Lastly, this new model of maintaining quality and safety also requires the development of new skills in the hospital setting including data literacy, digital clinical governance and clinical informatics. [ABSTRACT FROM AUTHOR]

Objective: The transition to digital hospitals is fast-moving. Although US hospitals are further ahead than some others in implementing eHealth technologies, their early experiences are not necessarily generalisable to contemporary healthcare because both the systems and technologies have been rapidly evolving. It is important to provide up-to-date assessments of the evidence available. The aim of this paper is to provide an assessment of the current literature on the effects to be expected from hospital implementations of eHealth technologies. Methods: A narrative review was conducted of systematic reviews investigating the effects of eHealth technologies (clinical decision support systems (CDSS), computerised provider order entry (CPOE), ePrescribing, electronic medical records (EMRs)) published between November 2015 and August 2017 and compared the findings with those of a previous narrative review that examined studies published between January 2010 and October 2015. The same search strategy and selection criteria were used in both studies. Results: Of the seven relevant articles, three (42.9%) examined the effects of more than one eHealth system: only two (28.6%) studies were high quality, three (42.9%) were of intermediate quality and two (28.6%) were of low quality. We identified that EMRs are largely associated with conflicting findings. Previous reviews suggested that CPOE are associated with significant positive results of cost savings, organisational efficiency gains, less resource utilisation and improved individual performance. However, these effects were not investigated in the more recent reviews, and only mixed findings for communication between clinicians were reported. Similarly, for ePrescribing, later reviews reported limited evidence of benefits, although when coupled with CDSS, more consistent positive findings were reported. Conclusion: This overview can help inform other hospitals in Australia and elsewhere of the likely effects resulting from eHealth technologies. The findings suggest that the effects of these systems are largely mixed, but there are positive findings, which encourage ongoing digital transformation of hospital practice. What is known about the topic?: Governments are increasingly devoting substantial resources towards implementing eHealth technologies in hospital practice with the goals of improving clinical and financial outcomes. Yet, these outcomes are yet to be fully realised in practice and conflicting findings are often reported in the literature. What does this paper add?: This paper extends a previous narrative review of systematic reviews and categorises the effects of eHealth technologies into a typology of outcomes to enable overall findings to be reported and comparisons to be made. In doings so, we synthesise 7 years of eHealth effects. Mixed results are largely reported for EMRs, with many benefits being compromised by practices stemming from resistance to EMRs. Limited evidence of effectiveness exists for CPOE and ePrescribing. CDSS are associated with the most consistent positive findings for clinician- and hospital-level effects. We observed renewed interest in the literature for the effect of eHealth technologies on communication both between clinicians and with patients. Other new insights have emerged relating to effects on clinical judgement, changing practice and staff retention. What are the implications for practitioners?: eHealth technologies have the potential to positively affect clinical and financial outcomes. However, these benefits are not guaranteed, and mixed results are often reported. This highlights the need for hospitals and decision makers to clearly identify and act on the drivers of successful implementations if eHealth technologies are to facilitate the creation of new, more effective models of patient care in an increasingly complex healthcare environment. [ABSTRACT FROM AUTHOR]

Objectives. The aim of this study was to assess the relationship between compliance with time-based Emergency Department (ED) targets (known as NEAT) and the time taken to collect an electrocardiogram (TTE) in patients presenting with chest pain. Methods. This was a pilot descriptive retrospective cohort study completed in a large inner city tertiary ED. Patients who presented with active or recent chest pain between July 2014 and June 2015 were eligible for inclusion. Pregnant patients, inter-hospital transfers, and traumatic chest pain were excluded. A random selection of 300 patients from the eligible cohort comprised the final sample. The differences of TTE between categories of NEAT compliance were compared using Kruskal-Wallis test. Also, the factors affecting with the acquisition of ECG within ten minutes of arrival were explored using proportional hazards regression. Results. There was a significant inverse association between the percentage of admitted patients leaving the ED within four hours (admitted NEAT) and TTE. As admitted NEAT compliance increased TTE decreased (p = 0.004). A number of variables including triage score, arrival time, total NEAT, first location, doctor wait time and cardiac diagnosis were all significant predictors of TTE. After adjusting for other variables Admitted NEAT remained as an independent predictor of TTE. Conclusion. There is likely to be a relationship between NEAT and TTE that is reflective of overall hospital and not just ED functioning; however the exact relationship remains uncertain. Further study in a multisite study is warranted to further explore the relationship between NEAT, TTE and other important clinical metrics of ED performance. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was to investigate the feasibility of using a store-and-forward Skin Emergency Telemedicine Service (SETS) to provide rapid specialist diagnostic and management advice for dermatological cases in an ED. Methods: This pilot study was conducted at the Princess Alexandra Hospital between August 2008 and August 2009. Study subjects were consenting patients over 18 years of age who presented with a dermatological condition to the ED. The ED doctor sent the patient's history, examination findings and the digital images of the skin conditions to a secure email address, which automatically forwarded this to the teledermatologist. The teledermatologist reviewed the cases and sent advice on diagnosis and management to the referring ED doctor via email and/or telephone. Face-to-face follow-up consultations with the patients were conducted within 2 weeks. The diagnostic and management concordance between ED doctors, teledermatologists and reviewing dermatologists were analysed. Results: A total of 60 patients participated in the present study. SETS provided a rapid response with 56 (93%) of ED consultations receiving a dermatology opinion within 2 h. Face-to-face follow up occurred in 50 patients (83%). Statistical analysis showed significant levels of agreement between tele-diagnosis and ED diagnosis of 71.2% (Kappa 0.42) and tele-diagnosis and final clinical diagnosis of 98% (Kappa: 0.93). The clinical management concordance was 96% in complete agreement and 4% in relative agreement between the teledermatologists and reviewing dermatologists, based on chart review. Conclusion: The present study has shown that SETS can provide rapid and accurate diagnostic and treatment advice from a specialist for dermatological presentations to the ED. [ABSTRACT FROM AUTHOR]