Acute Hospital Services Research Articles

Sociodemographic Patterns of Patients Engaging with an Acute Hospital Alcohol Care Team: An Underused Resource

ABSTRACT Alcohol care teams represent a unique resource to deliver holistic care for those presenting to acute hospital services with alcohol-related ill-health. However, most existing data regarding the characteristics of individuals engaging with alcohol support services concern those involved with community services. We reviewed the sociodemographic and alcohol-use characteristics of patients presenting to the Sandwell and West-Birmingham NHS Trust Alcohol Care team between 2018 and 2023. Patients engaging with Alcohol Care Teams in hospitals represent a population of significant vulnerability, driven by multiple sociodemographic and alcohol-use characteristics. These patients are distinct from those in community service treatment.

The Aftermath: Investigating Readmission And Mortality Trends In Older Adults

Abstract Background Acute hospital readmissions have significant implications for both the patient and the health service. Research has shown that up to 70 percent of hospital readmissions may be avoidable, while patients who are readmitted to hospital have a higher in-hospital mortality risk. The Health Service Executive has set a Key Performance Indicator of a readmission rate within 30 days of less than 11.1 percent. The purpose of this study is to identify the number of patients aged 75 years and older readmitted to a busy model four hospital within 30 days of their discharge. It will also quantify the number of deaths within this patient group. We aim to identify key areas where pathways for older adults could be developed to improve quality of care and reduce the overall burden on both the patient and acute hospital service. Methods Data was collected retrospectively for patients admitted between September 1st, 2023, and September 30th, 2023. Results In total 272 patients aged 75 years and older were admitted within a one-month period. 47 patients were admitted under the geriatric medicine service. The mean length of stay for all patients was 12.41 days. 160 patients were discharged directly home while 27 were discharged to long term care. The remaining patients were discharged to rehab, convalescence or hospice. 28 patients died during their inpatient stay. 6 patients died within one month of discharge. In total 13 patients were readmitted to hospital within one month following their discharge. 23 percent of patients died following readmission. The most common reason for readmission was a respiratory illness. Conclusion 4.7 percent of patients aged 75 years and older were readmitted to hospital within one month of discharge. This falls below the national target set by the HSE. However, there was a high mortality rate amongst those readmitted to hospital.

Adjusting the risk-adjustment: Accounting for variation between organisations in the responsiveness of their expenditure to need

There is concern that basing healthcare budgets on risk adjustment estimates derived from historical utilisation data may reinforce patterns of unmet need. We propose a method to avoid this, based on a measure of how closely local health organisations align resources to the needs of their populations. We refer to this measure as the ‘responsiveness of expenditure to need’ and estimate it using national person-level data on use of acute hospital and secondary mental health services in England. We find large variation in responsiveness in both services and show that higher expenditure responsiveness in mental health is associated with fewer suicides. We then re-estimate the national risk-adjustment model removing the data from the organisations with the lowest expenditure responsiveness to need. As expected, higher need individuals are estimated to have higher expenditure needs when less responsive organisations are removed from the estimation of the risk-adjustment. Removal of organisations with below-average responsiveness results in the neediest deciles of individuals having an extra £163 (7%) annual need for acute hospital care and an additional £79 (27%) annual need for mental health services. The application of this approach to risk adjustment would result in more resources being directed towards organisations serving higher-need populations.

Patterns of acute hospital and specialist palliative care use among people with non-curative upper gastrointestinal cancer

PurposeUpper gastrointestinal (GI) cancers contribute to 16.7% of UK cancer deaths. These patients make high use of acute hospital services, but detail about palliative care use is lacking. We aimed to determine the patterns of use of acute hospital and hospital specialist palliative care services in patients with advanced non-curative upper GI cancer.MethodsWe conducted a service evaluation of hospital use and palliative care for all patients with non-curative upper GI cancer seen in one large hospital, using routinely collected data (2019–2022). We report and characterise hospital admissions and palliative care within the study time period, using descriptive statistics, and multivariable Poisson regression to estimate the unadjusted and adjusted incidence rate ratio of hospital admissions.ResultsThe total with non-curative upper GI cancer was 960. 86.7% had at least one hospital admission, with 1239 admissions in total. Patients had a higher risk of admission to hospital if: aged ≤ 65 (IRR for 66–75 years 0.71, IRR 76–85 years 0.68; IRR > 85 years 0.53; p < 0.05), or lived in an area of lower socioeconomic status (IMD Deciles 1–5) (IRR 0.90; p < 0.05). Over the 4-year period, the rate of re-admission was higher in patients not referred to palliative care (rate 0.52 readmissions/patient versus rate 1.47 readmissions/patient).ConclusionPeople with advanced non-curative gastrointestinal cancer have frequent hospital admissions, especially if younger or from areas of lower socioeconomic status. There is clear association between specialist palliative care referral and reduced risk of hospitalisation. This evidence supports referral to specialist palliative care.

Hospital admissions among patients with Comorbid Substance Use disorders: a secondary analysis of predictors from the NavSTAR Trial

BackgroundIndividuals with substance use disorders (SUDs) frequently use acute hospital services. The Navigation Services to Avoid Rehospitalization (NavSTAR) trial found that a patient navigation intervention for hospitalized patients with comorbid SUDs reduced subsequent inpatient admissions compared to treatment-as-usual (TAU).MethodsThis secondary analysis extends previous findings from the NavSTAR trial by examining whether selected patient characteristics independently predicted hospital service utilization and moderated the effect of the NavSTAR intervention. Participants were 400 medical/surgical hospital patients with comorbid SUDs. We analyzed 30- and 90-day inpatient readmissions (one or more readmissions) and cumulative incidence of inpatient admissions through 12 months using multivariable logistic and negative binomial regression, respectively.ResultsConsistent with primary findings and controlling for patient factors, NavSTAR participants were less likely than TAU participants to be readmitted within 30 (P = 0.001) and 90 (P = 0.03) days and had fewer total readmissions over 12 months (P = 0.008). Hospitalization in the previous year (P < 0.001) was associated with cumulative readmissions over 12 months, whereas Medicaid insurance (P = 0.03) and index diagnoses of infection (P = 0.001) and injuries, poisonings, or procedural complications (P = 0.004) were associated with fewer readmissions. None of the selected covariates moderated the effect of the NavSTAR intervention.ConclusionsPrevious findings showed that patient navigation could reduce repeat hospital admissions among patients with comorbid SUDs. Several patient factors were independently associated with readmission. Future research should investigate risk factors for hospital readmission among patients with comorbid SUDs to optimize interventions.Trial RegistrationNIH ClinicalTrials.gov NCT02599818, Registered November 9, 2015 https://classic.clinicaltrials.gov/ct2/show/NCT02599818.

The association of demographics, frailty and multiple health conditions with outcomes from acute medical admissions to hospitals in England: exploratory analysis of an administrative dataset

Emergency and acute hospital services in England are under increasing pressure. The aim of this study was to investigate the association between key case-mix indicators and outcomes for adults admitted to hospital with an acute medical condition in England. All patients aged ≥16 years admitted to hospital in England as an acute unselected medical admission and who survived to discharge during the financial year 2021-2022 were included. Length of hospital stay was the primary outcome of interest. Data were available for 1,586,168 unique patients. A case-mix index was developed with a score that ranged from 0 to 12. Frailty was the most important variable in the index, followed by multiple health conditions and patient age. The mean case-mix score across hospital trusts in England ranged from 5.3 to 7.8. The case-mix index will support initiatives to better understand factors contributing to outcomes from acute medical admissions to hospital.

Generating actionable evidence from free-text feedback to improve maternity and acute hospital experiences: A computational text analytics &amp; predictive modelling approach

Abstract Background Patient experience surveys are a key source of evidence for supporting decision-making and quality improvement in healthcare services. These surveys contain two main types of questions: closed and open-ended, asking about patients’ care experiences. Apart from the knowledge obtained from analysing closed-ended questions, invaluable insights can be gleaned from free-text data. Advanced analytics techniques are increasingly used to harness free-text data, yet existing approaches do not offer the rigour required to support formal decision-making through free-text. Methods This study addresses the challenge of effectively and rigorously analysing patients’ free-text feedback to improve maternity and acute hospital services in Ireland. Aspects of healthcare services (i.e. themes) that could be improved were determined using computational text analytics and predictive modelling. Themes extracted from comments were prioritised based on volume, the intensity of negative affect expressed in the texts, and the estimated influence of the themes on overall patient satisfaction. Results Results demonstrate the viability of producing rigorous evidence for prioritising interventions to improve healthcare services based on free-text feedback. Specifically, consistency in advice and support in breastfeeding were among the most important issues for maternity services. For acute hospital services, meals quality and access, A&amp;E waiting time, ward hygiene and communication at discharge were among the most important issues. Women also wanted more emphasis on prior birth experience and complications in future maternity care surveys. Conclusions Advances in computational text modelling enable the extraction of concrete and actionable insights from the analysis of free-text data. This approach also allows decision-makers to prioritise emergent themes and inform actions that will positively impact overall patient satisfaction.

Impact of the workforce allocation on the technical performance of mental health services: the collective case of Helsinki-Uusimaa (Finland)

BackgroundLong-term mental health (MH) policies in Finland aimed at investing in community care and promoting reforms have led to a reduction in the number of psychiatric hospital beds. However, most resources are still allocated to hospital and community residential services due to various social, economic and political factors. Despite previous research focussing on the number and cost of these services, no study has evaluated the emerging patterns of use, their technical performance and the relationship with the workforce structure.ObjectiveThe purpose of this study was to observe the patterns of use and their technical performance (efficiency) of the main types of care of MH services in the Helsinki-Uusimaa region (Finland), and to analyse the potential relationship between technical performance and the corresponding workforce structure.MethodsThe sample included acute hospital residential care, non-hospital residential care and outpatient care services. The analysis was conducted using regression analysis, Monte Carlo simulation, fuzzy inference and data envelopment analysis.ResultsThe analysis showed a statistically significant linear relationship between the number of service users and the length of stay, number of beds in non-hospital residential care and number of contacts in outpatient care services. The three service types displayed a similar pattern of technical performance, with high relative technical efficiency on average and a low probability of being efficient. The most efficient acute hospital and outpatient care services integrated multidisciplinary teams, while psychiatrists and nurses characterized non-hospital residential care.ConclusionsThe results indicated that the number of resources and utilization variables were linearly related to the number of users and that the relative technical efficiency of the services was similar across all types. This suggests homogenous MH management with small variations based on workforce allocation. Therefore, the distribution of workforce capacity should be considered in the development of effective policies and interventions in the southern Finnish MH system.

268 Specialist stroke rehabilitation needs in a tertiary hospital—are needs being met?

Abstract Background Stroke specific rehabilitation is essential to recovery and return to independence following acute stroke. With increasing cases and improvements in stroke care rehabilitation needs are rising, placing significant pressures on acute stroke units and acute hospital services. We used a point prevalence study to assess the rehabilitation needs of our stroke service. Methods Patients admitted under the stroke service were identified using the electronic patient admissions system on February 17th, 2023. Data was collected by teams of two healthcare professionals. Data collected: demographics, ward location; most appropriate location of care—Hospital, Community, Rehabilitation Unit; Clinical Frailty Score (CFS); Rehabilitation Complexity Score (RCS); estimated Length of Stay (LoS). Results 53 patients admitted under the stroke service, 60% (32/53) patients were on the stroke unit, 40% (21/53) on an outlier ward, 9% (5/53) in the emergency department. Female 45% (24/53) Male 55% (29/53). Of patients &amp;gt;75 years 67% (22/32) had a CFS &amp;gt; 4. 41% (22/53) had primary rehabilitation needs, 30% (16/53) community, and 28% (15/53) hospital care. 17% (9/53) had an estimated LoS &amp;gt; 3 months of those 55% (5/9) had primary rehabilitation needs that could be in a rehabilitation unit. Average RCS 9.7, average RCS 12.6 for patients with an estimated LoS &amp;gt; 3 months. Conclusion Our study shows that limited access to suitable rehabilitation facilities has a direct impact on the coordination of stroke services in the acute setting. A high proportion of patients were not located on the stroke unit, an intervention shown to reduce mortality and disability. This study highlights the importance of ongoing improvement of rehabilitation services.

333 Integrated care and impact on length of Time-At-Home, a retrospective cohort study

Abstract Background The Integrated Care Programme for Older People (ICPOP) shifts care from unscheduled hospital attendance to planned ambulatory community care. The impact of these services should be measured to inform service delivery in the provision of sustainable healthcare for older adults. We aimed to measure the average Time-At-Home for patients attending an ICPOP service. Time-At-Home was defined as the time from review to next unscheduled attendance. Methods A retrospective cohort study was carried out on consecutive attendances at the ICPOP service, between January–March 2023 inclusive. Electronic health records of the Comprehensive Geriatric Assessment were reviewed and any subsequent unscheduled hospital attendance at our institution were recorded to measure the length of Time-At-Home for each patient (days). Predictors of longer Time-At-Home were calculated by regression analysis. Results 191 patients were analysed, 56% female (n = 107), mean age 81.9 years (SD 6.5), 82.7% GP referrals (n = 158). Reasons for referral included memory assessment (n = 90), falls (n = 43), frailty (n = 28), decreased mobility (n = 12), Parkinson’s disease (n = 6), home supports (n = 4) and miscellaneous (n = 8). Mean Clinical Frailty Score (CFS) was 4.72 (SD 1.6), median number of medications was 9 (IQR 5). Median duration of follow-up was 109 days (IQR 61 days). 25.7% (n = 49) of patients were admitted during period of follow-up. Reasons for attendance included delirium/memory-related issues (n = 4), falls/pre-syncope/syncope (n = 13), infection (n = 12), mobility (n = 4) and miscellaneous (n = 17). Those admitted were more likely have been referred from an acute hospital service (p = 0.03), had higher Clinical Frailty Scores (CFS) (p = 0.02) and higher degrees of polypharmacy (p = 0.01). Median length of Time-At-Home was 61 days (IQR 91). There was no difference in length of Time-At-Home by age, CFS or number of medications. Conclusion Reasons for and predictors of acute hospital attendance following ICPOP review are important to measure. This will inform the delivery of services going forward and areas to address to further reduce acute hospital attendance rates.

238 An age related acute medical unit: creating an age-attuned model of acute care

Abstract Background Multi-morbidity increases with age and older adults are more likely to present to acute hospital services with complex health states/Geriatric syndromes. For people with underlying physical or cognitive illnesses, these issues can be compounded by the built environment of acute hospitals. Meeting the needs of a frail older population is a key challenge for acute hospital services. The main aims of this development quality improvement project were to create a dedicated Age-related acute medical unit using the concept of universal design, with dedicated, Gerontological staffing including a Registered Advanced Nurse Practitioner (RANP) in Gerontology. Methods A project team was convened with representation from Geriatric nursing, Geriatric Medicine, Health and Social Care Professionals (HSCP), Estates, Technical services and the executive management team. An appropriate area was identified on the acute floor which was co-located with a newly developed Acute Medical Unit. Using a universal design approach, a 4-cubicle Age Related Assessment Unit (ARAU) including a dedicated multidisciplinary assessment room was created. The role of the RANP in ARAU was developed to provide comprehensive geriatric assessment to older medical patients presenting to unscheduled care. Results Following the implementation of the ARAU there has been a 40% increase in the number of unscheduled older patients (&amp;gt;65’s) assessed in the Acute Medical Unit (Q1 2019 to Q1 2023). Conclusion Operating within a defined scope of practice, the RANP in ARAU/AMU provides advanced specialist geriatric nursing skills and knowledge allowing for the identification of medical, psychosocial and functional needs of older adults for older adults who present to unscheduled care with common geriatric syndromes.

18 Early supported discharge for older adults admitted to hospital with medical complaints: a qualitative study exploring the views of stakeholders

Abstract Background Early Supported Discharge (ESD) is well established as a model of health service delivery for people with stroke. Emerging evidence indicates that ESD reduces length of stay for older medical inpatients. There is a dearth of evidence exploring the views of stakeholders on ESD as a model of care for older medical inpatients. The overall aim of this study is to explore the views and perceptions of older adults, family carers and healthcare professionals on the potential role of ESD for older adults admitted to hospital with medical complaints. Methods We conducted a qualitative interview and focus group study at University Hospital Limerick (UHL) from November 2021 to January 2022. Purposeful sampling was used to recruit older adults and family carers for interview. For Healthcare Professionals (HCPs), snowball purposeful sampling was used for focus groups. Braun and Clarke’s approach to thematic analysis was used. Ethical approval was granted by the HSE Mid-Western Area Regional Ethics Committee in November 2021 (REC Ref. 096/2021). Results Fifteen HCPs took part across three focus groups, with six older adults and two family members participating in one-to-one interviews. Three themes were identified: (1) Pre-ESD experiences of providing and receiving older adult inpatient care, (2) Navigating discharge procedures from acute hospital services and (3) A vision for more integrated model of care and a medical ESD team. Conclusion This qualitative study was the first to explore the views and perceptions of older adults and healthcare professionals on the potential role of ESD for older adults admitted to hospital with medical complaints. The current experiences and barriers to efficient and safe discharge home from hospital were highlighted by stakeholders. The potential role for ESD in this population group was discussed, as well as the key factors to be considered in running an ESD service for medical older adults.

Does a Community Care programme reach a high health need population and high users of acute care hospital services in Melbourne, Australia? An observational cohort study

ObjectiveThe Community Care programme is an initiative aimed at reducing hospitalisations and emergency department (ED) presentations among patients with complex needs. We aimed to describe the characteristics of the programme...

Performance of admission pathways within acute medicine services: Analysis from the Society for Acute Medicine Benchmarking Audit 2022 and comparison with performance 2019 - 2021

Urgent and emergency care services face increasing pressure, impacting patient care. We evaluated the performance of acute medicine services, assessing clinical quality indicators for unplanned medical admissions to acute hospital services.152 acute UK hospital services accepting unplanned admissions to acute and general internal medicine completed a day-of-care survey incorporating organisational structure questionnaire and patient-level data over a pre-defined 24-hour period in June 2022. Clinical quality indicators were: Early Warning Score (EWS) measurement within 30 min of hospital arrival; clinician assessment within 4 h; assessment by consultant physician within 6 h (daytime) or 14 h (night-time). Results were compared with 2019, 2020, 2021.7293 sequential patients were included (and compared with 19,817 patients across 2019–2021). In 2022, 69% of patients (95%CI 67.7–69.9%) had an EWS documented within 30 min. 79% of patients (95%CI 77.8–79.7%) were reviewed by a clinical decision maker within 4 h of hospital arrival. Patients assessed in Same Day Emergency Care services were more likely to meet this target than those assessed in Acute Medical Units or Emergency Departments (OR 2.4, 95%CI 2.02–2.87, p<0.001). Overall, 50% of patients received consultant physician review within the target time (3065/6161, 95%CI 48.5–51.0%); performance varied with time of arrival and location of initial assessment. Performance against all three clinical quality indicators was lower than 2019, 2020 and 2021 (p<0.001 for all).Performance against all quality indicators within acute medicine services is deteriorating. However, performance in Same Day Emergency Care Units is greater than in Acute Medical Units or Emergency Departments.

The effect of palliative outpatient units on resource use for cancer patients in Finland

Background As cancer incidences are increasing, the means to provide effective palliative care (PC) are called for. There is evidence, that PC may prevent futile treatment at the end of life (EOL) thus implicating that PC decreases resource use at the EOL, however, the effects of outpatient PC units remain largely unknown. We surveyed the national use of Finnish tertiary care PC units and their effects on resource use at the EOL in real-life environments. Patients and Methods Cancer patients treated in the departments of Oncology at all five Finnish university hospitals in 2013 and deceased by 31 December 2014 were identified; of the 6010 patients 2007 were randomly selected for the study cohort. The oncologic therapies received and the resource usage of emergency services and hospital wards were collected from the hospitals’ medical records. Results A PC unit was visited by 37% of the patients a median 112 days before death. A decision to terminate all life-prolonging cancer treatments was more often made for patients visiting the PC unit (90% vs. 66%, respectively). A visit to a PC unit was associated with significantly fewer visits to emergency departments (ED) and hospitalization during the last 90 days of life; the mean difference in ED visits decreased by 0.48 (SD 0.33 − 0.62, p < 0.001), and the mean inpatient days by 7.1 (SD 5.93 − 8.25, p < 0.001). A PC visit unit was independently associated with decreased acute hospital resource use during the last 30 and 90 days before death in multivariable analyses. Conclusion Cancer patients’ contact with a PC unit was significantly associated with the reduced use of acute hospital services at the EOL, however; only one-third of the patients visited a PC unit. Thus, systematic PC unit referral practices for patients with advanced cancer are called for.

Using Mean Anesthesia Workload to Plan Anesthesia Workforce Allocations: The “Flaw of Averages”

(Anesth Analg. 2022;135:1138–1141) Workforce planning within acute care hospital services is especially important, though especially complicated due to inherently unpredictable, unstable, and frequently emergent needs. This editorial comments on the Im et al article “Obstetric Anesthesia Procedure-Based Workload and Facility Utilization of Society of Obstetric Anesthesia and Perinatology Centers of Excellence Designated Institutions,” which studies procedure-based obstetric anesthesia workload and staff utilization using self-reported data collected from the Society of Obstetric Anesthesia and Perinatology Centers of Excellence.

Impact of specialized obesity management services on the reduction in the use of acute hospital services.

Severe obesity affects 4% of Australians and is associated with increased use of healthcare services and higher healthcare costs. This study evaluates the effect of attending a public tertiary obesity service on acute hospital use. This record-linkage study included people aged ≥16 years with severe obesity who attended the Nepean Blue Mountains Family Metabolic Health Service (FMHS), New South Wales, Australia between January 2017, and September 2021. Emergency department (ED) presentations and acute hospital admissions and respective costs in the 1-year and 3-years pre-and-post first FMHS attendance were compared, overall and for adequate attendance (≥5 visits). A total of 640 patients (74% female, 50% <45 years) attended the FMHS, totalling 15 303 occasions of service, average 24 per person. There was a 31.0% and 17.6% reduction in acute admissions and ED presentations, respectively, translating into 34.0% and 23.4% decrease in costs. Adequate engagement was associated with a 48% decreased risk of acute admission (odds ratio 0.52; 95% confidence interval 0.29-0.94). Over 3-years, there was a 19.8% and 20.7% reduction in acute hospital admissions and ED presentations, respectively. Findings indicate that tertiary obesity services reduce acute hospital use. Improved access to specialized obesity management may offload hospitals and contribute to acute healthcare cost avoidance.

DIFFERENCES IN MORTALITY AND COMPLICATION RATES FOLLOWING REVISION KNEE ARTHROPLASTY PERFORMED FOR URGENT VERSUS ELECTIVE INDICATIONS

Revision knee arthroplasty is a complex procedure with the number and cost of knee revision procedures performed per year expected to rise. Few studies have examined adverse events following revision arthroplasty.The objective of this study was to determine rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications) and to compare these with primary arthroplasty and re-revision arthroplasty.Patients undergoing primary knee arthroplasty were identified in the UK Hospital Episode Statistics. Subsequent revision and re-revision arthroplasty procedures in the same patients and same knee were identified. The primary outcome was 90-day mortality and a logistic regression model was used to investigate factors associated with 90-day mortality and secondary adverse outcomes including infection (undergoing surgery), pulmonary embolism, myocardial infarction, stroke. Urgent indications for revision arthroplasty were defined as infection or fracture, and all other indications were included in the elective indications cohort.939,021 primary knee arthroplasty cases were included of which 40,854 underwent subsequent revision arthroplasty, and 9,100 underwent re-revision arthroplasty. Revision surgery for elective indications was associated with a 90-day rate of mortality of 0.44% (135/30,826; 95% CI 0.37-0.52) which was comparable to primary knee arthroplasty (0.46%; 4,292/939,021; 95% CI 0.44-0.47). Revision arthroplasty for infection, however, was associated with a much higher mortality of 2.04% (184/9037; 95% CI 1.75-2.35; odds ratio [OR] 3.54; 95% CI 2.81-4.46), as was revision for periprosthetic fracture at 5.25% (52/991; 95% CI 3.94-6.82; OR 6.23; 95% CI 4.39-8.85). Higher rates of pulmonary embolism, myocardial infarction, and stroke were also observed in the infection and fracture cohort.These findings highlight the burden of complications associated with revision knee arthroplasty. They will inform shared decision-making for patients considering revision knee arthroplasty for elective indications. Patients presenting with infection of a knee arthroplasty or a periprosthetic fracture are at very high risk of adverse events. It is important that acute hospital services and tertiary referral centres caring for these patients are appropriately supported to ensure appropriate urgency and an anticipation for increased care requirements.

A tohu (sign) to open our eyes to the realities of Indigenous Māori registered nurses: A qualitative study.

Identify the experiences of Māori nurses and priorities for a Māori model of relational care working with Māori patients and their whānau (extended family network) in acute hospital services. Māori, the Indigenous peoples of Aotearoa (New Zealand), have a relational and holistic worldview fundamental to establishing relationships with Māori patients and their whānau. Increasing the Indigenous Māori nursing workforce can improve Māori patient experiences but is challenged by ongoing recruitment and retention issues. A qualitative Māori-centred research methodology with 12 Māori nurses. Data were collected using wānanga (learning through discussion, deliberation and consideration) using he aha ō hikoi (journey mapping) and kōrero mai (storytelling). Inductive thematic analysis was undertaken using a mahi a roopū (group process) approach. This study was conducted between May 2022 and June 2022. Three key themes: (1) Māori first, nurse second, (2) Cultural loading and (3) Compromised realities were identified. Māori nurses' praxis used their complex cultural and clinical intelligence to engage in a mana-enhancing way (strengths-based) to improve the care delivery for whānau Māori during their hospitalization journey. Cultural loading meant Māori nurses were often burdened with unrecognized workloads as they provided care for Māori patients and whānau, which often compromised their cultural integrity. Nurses' commitment to care for whānau and their assigned patient load created extra burdens and threatened their cultural integrity. Their experiences highlighted modes of practice rather than models of care required to improve healthcare delivery for Māori entering the hospital. These findings signal issues and areas nursing leaders need to heed, necessary for addressing the retention of Māori in nursing and improving workload equity. Māori nurses and service users were involved in the interpretation of the data.

Return on investment from service transformation for young people experiencing mental health problems: Approach to economic evaluations in ACCESS Open Minds (Esprits ouverts), a multi-site pan-Canadian youth mental health project.

Mental health problems are common globally, and typically have their onset in adolescence and early adulthood-making youth (aged 11-25) an optimal target for prevention and early intervention efforts. While increasing numbers of youth mental health (YMH) initiatives are now underway, thus far few have been subject to economic evaluations. Here we describe an approach to determining the return on investment of YMH service transformation via the pan-Canadian ACCESS Open Minds (AOM) project, for which a key focus is on improving access to mental health care and reducing unmet need in community settings. As a complex intervention package, it is hoped that the AOM transformation will: (i) enable early intervention through accessible, community-based services; (ii) shift care away toward these primary/community settings and away from acute hospital and emergency services; and (iii) offset at least some of the increased costs of primary care/community-based mental health services with reductions in the volume of more resource-intensive acute, emergency, hospital or specialist services utilized. Co-designed with three diverse sites that represent different Canadian contexts, a return on investment analysis will (separately at each site) compare the costs generated by the intervention, including volumes and expenditures associated with the AOM service transformation and any contemporaneous changes in acute, emergency, hospital or service utilization (vs. historical or parallel comparators). Available data from health system partners are being mobilized to assess these hypotheses. Across urban, semi-urban and Indigenous sites, the additional costs of the AOM transformation and its implementation in community settings are expected to be at least partially offset by a reduction in the need for acute, emergency, hospital or specialist care. Complex interventions such as AOM aim to shift care "upstream": away from acute, emergency, hospital and specialist services and toward community-based programming which is more easily accessible, often more appropriate for early-stage presentations, and more resource-efficient. Carrying out economic evaluations of such interventions is challenging given the constraints of available data and health system organization. Nonetheless, such analyses can advance knowledge, strengthen stakeholder engagement, and further implementation of this public health priority.