ED Re-presentations Research Articles

Process and implementation evaluation of a virtual hospital model of care for low back pain (Back@Home).

Low back pain was the sixth most common reason for an ED visit in 2022-2023 in Australia, one-third of these patients were subsequently admitted to hospital. Therefore, we have assessed whether some patients could be diverted to alternate clinical pathways, via admission to a virtual hospital (rpavirtual), and be cared for remotely in their own homes. Ethics approval was granted for protocols X21-0278 & 2021/ETH10967 and X21-0094 & 2021/ETH00591. We conducted a mixed-method process evaluation, using the RE-AIM framework (reach, effectiveness, adoption, implementation and maintenance) to answer key questions regarding the Back@Home model of care. This preliminary evaluation describes a cohort of the first 50 patients who received care between 13 February and 31 July 2023. The service had high levels of reach and adoption, very low levels of ED representation, and no AEs. Virtual care cost a median of AU$2215 (interquartile range = AU$1724-AU$2855) per admission. Patients admitted virtually had the same high satisfaction with care as traditionally admitted patients and reported less pain and better physical function. Preliminary findings suggest that this model of care is a safe, acceptable, and feasible alternative to hospitalisation for non-serious low back pain, in a select cohort of patients meeting inclusion criteria. Further data collection will inform whether Back@Home has had an impact on length of stay or traditional admission rates.

Risk factors for older people re-presenting to the emergency department with falls: A case-control analysis.

Falls are a leading cause for ED presentations among older adults. Existing secondary falls prevention interventions have not been shown to decrease fall-related ED re-presentation, indicating a need to better understand contributing factors. Our aim was to evaluate risk factors for fall re-presentations among the older patient population presenting to the ED. This is a single-centre case-control study. Cases were patients aged ≥65 years with two falls-related ED presentations within 6 months. Age- and sex-matched controls had a corresponding index, but no subsequent ED fall presentation. Data collected included falls risk factors and clinical features of the index presentation. Univariate and multivariate analyses were conducted to assess the relationship between potential exposures and fall re-presentation. A total of 300 patients (mean age 83.8 years) were studied. On univariate analysis, factors significantly associated with ED fall re-presentation included increasing multimorbidity (P < 0.0001), increasing number of medications (P < 0.0001) and residing in residential aged care facility (RACF) (odds ratio [OR] 3.06, P < 0.001). No factors remained significant on multivariate analysis. Post-hoc analyses for the RACF subgroup showed that psychotropic medication use (OR 1.65, P = 0.04) and prior fall within 12 months (OR 2.68, P < 0.001) were significantly associated with re-presentation. Initial presentation with serious musculoskeletal injury was a significant protective factor (OR 0.21, P = 0.02). The present study failed to identify factors independently associated with ED fall re-presentation, suggesting that the factors are complex and inter-related. Two high-risk populations were identified - those from RACF and those initially presenting with falls not resulting in serious injury.

Short waits, happy patients and expert care, moving basic musculoskeletal care from the emergency department to a physiotherapist-led diversion pathway.

Patients with musculoskeletal conditions (MSKCs) are highly prevalent in ED. This project explores the impact of the pilot phase of a 'diversion pathway', which directed patients with MSKCs from the ED waiting room to an outpatient clinic led by advanced-scope physiotherapists. A prospective intervention study comparing care outcomes between patients in the 'diversion pathway' with usual ED care. The characteristics of patients considered eligible and non-eligible are described. Between May and December 2022, 1099 patients were diverted. For diverted patients, mean length of stay (LOS) in ED was reduced by 110 (95% confidence interval [CI]: 99-120) min and 4 h rule compliance improved by 19.3% compared to usual ED care. There were fewer patients who 'did not wait' (DNW) with the diversion pathway. The diverted group was young (median age 22 years and 41% paediatric), mostly low urgency, self-referred and arrived by private transport with minor limb trauma. The diversion pathway triage process appropriately identified 182 patients ineligible for diversion. 96.7% of patients reported satisfaction with care received from the diversion pathway. There was no change in ED representation rates for diverted patients. A new pathway resulted in reduced LOS, reduced DNW, high patient satisfaction and more people being discharged within 4 h for diverted patients compared to usual ED care. The pathway increased ED capacity, improved key ED performance metrics and safely expedited care delivery for patients.

The effectiveness of allied health and nurse practitioner models-of-care in managing musculoskeletal conditions in the emergency department: a systematic review and meta-analysis

BackgroundMusculoskeletal conditions are the most common health condition seen in emergency departments. Hence, the most effective approaches to managing these conditions is of interest. This systematic review aimed to evaluate the effectiveness of allied health and nursing models of care for the management of musculoskeletal pain in ED.MethodsMEDLINE, EMBASE, CINAHL and LILACS databases were searched from inception to March 2023 for published randomised trials that compared the effectiveness of allied health and nursing models of care for musculoskeletal conditions in ED to usual ED care. Trials were eligible if they enrolled participants presenting to ED with a musculoskeletal condition including low back pain, neck pain, upper or lower limb pain and any soft tissue injury. Trials that included patients with serious pathology (e.g. malignancy, infection or cauda equina syndrome) were excluded. The primary outcome was patient-flow; other outcomes included pain intensity, disability, hospital admission and re-presentation rates, patient satisfaction, medication prescription and adverse events. Two reviewers performed search screening, data extraction, quality and certainty of evidence assessments.ResultsWe identified 1746 records and included 5 randomised trials (n = 1512 patients). Only one trial (n = 260) reported on patient-flow. The study provides very-low certainty evidence that a greater proportion of patients were seen within 20 min when seen by a physician (98%) than when seen by a nurse (86%) or physiotherapist (77%). There was no difference in pain intensity and disability between patients managed by ED physicians and those managed by physiotherapists. Evidence was limited regarding patient satisfaction, inpatient admission and ED re-presentation rates, medication prescription and adverse events. The certainty of evidence for secondary outcomes ranged from very-low to low, but generally did not suggest a benefit of one model over another.ConclusionThere is limited research to judge the effectiveness of allied health and nursing models of care for the management of musculoskeletal conditions in ED. Currently, it is unclear as to whether allied health and nurse practitioners are more effective than ED physicians at managing musculoskeletal conditions in ED. Further high-quality trials investigating the impact of models of care on service and health outcomes are needed.

P70. Predictors of extended length of stay and discharge disposition following elective lumbar spine surgery

<h3>BACKGROUND CONTEXT</h3> In the context of increased attention afforded to hospital efficiency and safe patient throughput, safely decreasing hospital length of stay (LOS) is imperative. About 10% of patients contribute to 63% of all US health care expenditures. Given that lumbar spine procedures can be among a hospital's most profitable services, identifying patients at risk of extended LOS (eLOS) prior to surgery is a valuable opportunity to develop targeted pre- and perioperative intervention and quality improvement initiatives. We sought to elucidate patient factors that predict prolonged LOS as well as discharge disposition following elective lumbar spine surgery. <h3>METHODS</h3> We performed a retrospective cohort analysis on data collected between 2015 and 2021 from a single, large academic center following elective posterior, nonendoscopic, lumbar laminectomy, discectomy, microdiscectomy, foraminotomy and/or facetectomy without fusion. The primary outcome measure was eLOS following surgery, defined as the 90^th percentile or greater in the number of midnights admitted postprocedurally (three or more). Patient sociodemographic, procedural and discharge characteristics were collected. Sociodemographic variables included Area of Deprivation Index (ADI), a comprehensive metric of socioeconomic status, utilizing income, education, employment and housing quality based on patient zip code. Multivariable logistic and ordinal logistic regression analyses were performed to assess whether covariates were independently predictive of eLOS and discharge disposition, respectively. Discharge to home served as a reference category with the other two dispositions being to home with services and to a SNF or acute rehab. <h3>RESULTS</h3> There were 779 patients in the study, with a median age of 66 years (±15) and a median LOS of 1 midnight (range, 1-10 midnights). Results demonstrated that patients in the most disadvantaged ADI quintile (OR 2.48 95% CI 1.14-5.40), who underwent minimally invasive surgery (OR 3.03 95% CI 1.06-8.74), who had an intraoperative drain placed (OR 4.46 95% CI 2.50-7.17), who had a CSF leak (OR 3.46 95% CI 1.57-7.62), who were discharged anywhere but home (OR 17.11 95% CI 9.07-32.26), and who were evaluated by PT (OR7.2395% CI 1.69-30.87) or OT (OR 2.20 95% CI 1.14-4.23) had a significantly increased chance of an eLOS. Preoperative opioid use was not associated with an increased LOS following surgery (OR 1.12 95% CI 0.69-1.80). Extended LOS was not associated with ED representation and readmission risk within 90 days following discharge (p=0.148). Patients who were older (OR 1.99 95% CI 1.62-2.48), in higher quintiles on ADI (3rdquintile; OR 1.90 95% CI 1.12-3.23, 4^thquintile; OR 1.79, 95% CI 1.05-3.05, 5thquintile; OR 2.16 95% CI 1.26-3.75), who had a CSF leak (OR 2.18 95% CI 1.22-3.86), or who had a longer procedure duration (OR 1.38 95% CI 1.17-1.62) were more likely to be discharged with some kind of support service. <h3>CONCLUSIONS</h3> Patient sociodemographics, along with procedural factors, and discharge characteristics were all associated with an increased chance of eLOS and disproportionate health care utilization with elective lumbar spine surgery. Notably, some of these identified factors could be reliably identified in a preoperative visit and therefore may be amenable to targeted preoperative intervention. Improving discharge disposition planning in the perioperative period may allow for reduced inpatient length of stays. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Emergency department utilisation by patients with a diagnosis of borderline personality disorder: An acute response to a chronic disorder.

Patients with borderline personality disorder (BPD) are likely to attend the ED while experiencing crises and associated self-injury and suicidality. Our study describes the prevalence, features, and outcomes associated with ED presentations by patients diagnosed with BPD in Outer Eastern Melbourne, Australia. A retrospective electronic audit of 157 364 ED attendances identified 700 unique BPD-related ED presentations between May 2015 and April 2016. For the purpose of comparison, 583 (81% female) of these 700 cases were matched with 'depression only' cases. ED re-presentation data were also extracted. The 583 matched BPD patients attended ED a total of 2807 times during the audit year compared with 1092 attendances for matched depression-only patients. BPD patients were more likely to: arrive by ambulance (50%); have comorbid substance abuse (44%); have a psychotic (15%) or bipolar disorder (17%); be under the care of a psychiatrist (31%); be case-managed (42%); and be admitted to an inpatient unit (21%). ED doctors saw 38% of BPD or depression patients within the recommended time according to their triage category. The majority (73%) of BPD patients attended ED more than once during the audit year (average 4.81 ± 6.63 times; range 2-78). Repeated ED attendance of a subset of patients diagnosed with BPD highlights both the severity of their presentation and the inadequacy of community mental health services for meeting their complex needs. Development of effective ED referral pathways with follow-up to engage patients in BPD-appropriate treatment will reduce the likelihood of crises and reliance on hospital EDs for acute episodic care.

Examining emergency department inequities in Aotearoa New Zealand: Findings from a national retrospective observational study examining Indigenous emergency care outcomes.

There is increasing evidence that EDs may not operate equitably for all patients, with Indigenous and minoritised ethnicity patients experiencing longer wait times for assessment, differential pain management and less evaluation and treatment of acute conditions. This retrospective observational study used a Kaupapa Māori framework to investigate ED admissions into 18/20 District Health Boards in Aotearoa New Zealand (2006-2012). Key pre-admission variable was ethnicity (Māori:non-Māori), and outcome variables included: ED self-discharge; ED arrival to assessment time; hospital re-admission within 72 h; ED re-presentation within 72 h; ED length of stay; ward length of stay; access block and mortality (in ED or within 10 days of ED departure). Generalised linear regression models controlled for year of presentation, sex, age, deprivation, triage category and comorbidity. Despite some ED process measures favouring Māori, for example arrival to assessment time (mean difference -2.14 min; 95% confidence interval [CI] -2.42 to -1.86) and access block (odds ratio [OR] 0.89, 95% CI 0.87-0.91), others showed no difference, for example self-discharge (OR 0.98, 95% CI 0.97-1.00). Despite this, Māori mortality (OR 1.60, 95% CI 1.50-1.71) and ED re-presentation (OR 1.11, 95% CI 1.09-1.12) were higher than non-Māori. To our knowledge, this is the most comprehensive investigation of acute outcomes by ethnicity to date in New Zealand. We found ED mortality inequities that are unlikely to be explained by ED process measures or comorbidities. Our findings reinforce the need to investigate health professional bias and institutional racism within an acute care context.

Frailty: A key concept to improve older person care.

Frailty is associated with increased hospitalization, hospital length of stay, intensive care unit admission, ED re-presentations, discharge to long-term care, mortality, and healthcare costs The CFS demonstrated higher sensitivity for predicting mortality and, when used in combination with systemic inflammatory response criteria and the Quick Sequential Organ Failure Assessment, improved prognostication than any individual score alone Fernando SM, Guo KH, Lukasik M, Frailty and associated prognosis among older emergency department patients with suspected infection: a prospective, observational cohort study

Retrospective chart review of minor tibial fractures in preschoolers: immobilisation and complications

ObjectiveTo compare the treatment practices (immobilisation vs non-immobilisation) of toddler fractures and other minor tibial fractures (both proven and suspected) in preschoolers, aged 9 months–4 years, and examine rates of...

Characteristics of short-term re-presentations to a regional emergency department.

The present study aims to describe the characteristics of early ED re-presentations in a regional hospital in New South Wales, Australia. This was a retrospective review of all patients re-presenting within 72 h of discharge from Coffs Harbour Base Hospital ED, a regional ED, for the 2016-2017 financial year. Presentations were categorised according to their diagnosis and cause for re-presentation. Of the 38 986 presentations to the ED within the study period, 2125 patients met re-presentation inclusion criteria (5.45%). Diagnoses most likely to re-present were injury/trauma (18.8%), gastrointestinal (14.8%) and psychiatric (12.5%). The most common cause for re-presentation was disease progression (32.7%). Patients aged over 66 were the most likely to be admitted on re-presentation (35.8%) followed by the 17-65 age group (24.2%) and the <16 age group (18.7%). Re-presentations were common, but did not lead to increased admissions. The regional hospital in the present study had a higher 72 h ED re-presentation rate than the comparative major city hospital. In particular, paediatric and psychiatric re-presentations were a greater burden to the regional ED. This may be secondary to a lack of alternative services, particularly for these patient groups. Improving these outpatient services may help to reduce the burden of 72 h ED re-presentations.

One hundred and counting: Centenarian use of emergency departments in New South Wales.

To study ED utilisation by people aged 100 years and over with a focus on patient demographics, reasons for presentation and patient flow factors. This is a retrospective descriptive analysis of linked ED Data Collection Registry for presentations to New South Wales (NSW) EDs over a 5 year period. Patients were included if they presented to an ED and were aged 100 years and over at the time of presentation. Demographics, triage category, presenting problem, ED length of stay, disposition and ED re-presentation were determined for this age group. A total of 4033 presentations to 115 NSW EDs during 2010-2014 were analysed. We found that 78% of the patients were females and 76% still living at home. This group were the second most common age group to present to ED, after the 90-99 year age group, with 87% arriving via ambulance. Most presentations were triaged as a category 3 or 4, with the most common presenting problem being because of injury (28.5%) followed by respiratory disease (11.4%) and cardiovascular disease (10.0%). Overall, 64% required hospital admission and the average length of stay for all patients was 5.7 h. Centenarians ED presentations are increasing over time with injuries as the most common reason for presentation. Most patients have prolonged ED length of stay and many require hospital admission. Early streaming of these patients through specialised geriatric assessment units may be more appropriate to reduce the demand on EDs and improve patient care. Models that facilitate rapid access to supported living arrangements and improved advanced care planning may be more realistic for many centenarians and different models of care need to be considered for this age group.

The effectiveness of pharmacist- led discharge medication counselling in the emergency department (ExPLAIN): A pilot quasi-experimental study

ObjectiveTo evaluate the effectiveness of pharmacist-led discharge medication counselling using a structured, multimodal educational strategy with teach-back (intervention) against standard care. MethodsThis was a quasi-experimental study in a public, metropolitan ED. Participants discharged home with new medications were allocated to receive the intervention or standard care using convenience sampling. Participant characteristics (i.e. age, sex, socio-economic status, medications) and health literacy were collected. The outcomes measured were satisfaction with information, ED re-presentation and length of stay. ResultsThere were 51 participants: 14 received intervention, 37 had standard care. Overall, 12% had inadequate health literacy. Group characteristics and health literacy were similar. Participants who received the intervention were significantly reported higher satisfaction with information about their new medications compared to standard care (p = 0.009). Specifically, the intervention was associated with a 98% increase in satisfaction with information relating to side-effects. There were no differences in re-presentation and length of stay. ConclusionPharmacist-led discharge medication counselling incorporating a structured, multimodal educational strategy and teach-back was effective in improving patient satisfaction with medication information in the ED. Practice implicationsA similar intervention could be trialled in other EDs, but outcomes other beyond satisfaction should be considered.

Predicting re-presentation following discharge from the emergency department with non-specific chest pain.

To determine the 30 day major adverse cardiac events (MACE) and re-presentation rates of non-specific chest pain (NSCP) patients following four different disposition pathways and to contrast re-presentation rates of patients with NSCP with those for all other patients presenting to the ED. Cases were derived from the ED database for two large teaching hospitals where patients aged 18 or over were triaged between 2009 and 2016, and their diagnosis on leaving the ED was NSCP. Statewide 30 day rates of MACE and ED re-presentations were calculated, and multivariable logistic regression analysis identified significant predictors of both. A total of 40 183 cases were included; 16 014 discharged directly from the ED, while the remainder were admitted under Cardiology (n = 7286), General Medicine (n = 7739) or an ED observation unit (n = 4086). Compared to discharge directly from the ED, admission was associated with a decreased 30 day re-presentation rate (OR = 0.857; 95% CI 0.795-0.923; P < 0.001). However, there was no significant difference in adjusted re-presentation between admitting units. The rates of 30 day MACE were higher in admitted patients, particularly in those admitted to general medicine; however, this difference was accounted for by differing patient characteristics. Despite a slightly increased rate of re-presentation in patients with NSCP sent home from the ED, we conclude that there is minimal advantage in admitting many patients who lack a diagnosis for their chest pain. For a selected patient population, discharge from the ED may become a safe and cost-effective approach. A prospective randomised study is required.

Controlled clinical trial exploring the impact of a brief intervention for prevention of falls in an emergency department.

To establish the effectiveness of a brief intervention to prevent falls in older patients presenting to the ED post-discharge. The present study is a prospective single-centre, quasi-randomised controlled clinical trial of a brief targeted educational intervention to prevent falls. The intervention group received brief scripted education and were advised of their percentage probability of falling in the next 6 months. The key message was to reinforce the importance of falls prevention strategies and the seriousness of falls. A total of 412 over 65 years old were recruited; 63 (32.1%) patients in the intervention group and 67 (36.8%) in the control group reported falls in the 6 month follow up period (OR 0.81, 95% confidence interval [CI] 0.53-1.25, P = 0.34). No significant differences were noted for mortalities (P = 0.54), ED representations (P = 0.15) and medication changes (P = 0.17). Patients receiving intervention had less hospital admissions (P = 0.002) after adjustment for confounding variables. Intervention patients who presented with a fall had significant (P = 0.007) improvement in function at 6 months, whereas those not presenting with a fall experienced functional decline. A brief intervention was associated with maintenance of function in fallers and reduced hospital admissions, without preventing falls post-discharge.

Review article: Effectiveness of ultra-brief interventions in the emergency department to reduce alcohol consumption: A systematic review.

To assess the effectiveness of ultra-brief interventions (ultra-BI) or technology-involved preventive measures in the ED to reduce alcohol harm and risky drinking. Medline, Embase, PsycINFO, CINAHL and EBM reviews were searched for articles published between 1996 and 2015. Randomised controlled trials and quasi-randomised trials, which compared an ultra-BI with screening, standard care or minimal intervention for adults and adolescents at risk for alcohol-related harm presenting to an ED, were included. Outcomes of interest were frequency of alcohol consumption, quantity of alcohol consumed, binge drinking and ED representation. Thirteen studies (nine single centre and four multicentre) were included. Six studies showed a significant reduction in the quantity consumed with intermediate effect size at 3months (d=-0.40) and small effect size at 12months (d=-0.15). Two studies showed a significant reduction in binge drinking with small effect size at 3months (d=-0.12) and 12months (d=-0.09). No studies showed an effect on frequency of alcohol consumption or ED representation. Heterogeneity in study design, definition of risky, harmful or hazardous alcohol use, intervention types, outcomes, outcome timeframes and outcome measures prevented the performance of quantitative meta-analysis. Despite its limited effectiveness in reducing alcohol use in the short-term, with the large number of people attending EDs with risky drinking, the use of an effective ultra-BI would have the potential to have a measurable population effect.

Imaging for patients presenting to an emergency department with back pain: Impact on patient pathway.

The objective of the present study is to quantify utilisation of imaging for patients presenting to an ED with back pain, their characteristics and dispositions. A retrospective cohort study of 1132 ED presentations for back pain to an Australian metropolitan ED in 2013 was performed. Patient demographics, rates of radiography, computed tomography or magnetic resonance imaging and rates of subsequent admission and ED re-presentation were analysed. Patients aged 26-35 years were the largest group presenting with back pain (19.4% of presentations), with the majority being female (52.3%). Imaging was requested at 29.5% (n = 334) of presentations (radiography n = 297; advanced imaging n = 63). Patients over 70 years had higher imaging rates than younger patients (49.4% vs 25.5%, P < 0.001). Imaging was not associated with attendance during or outside office hours (29.3% vs 31.8%, P = 0.4). Of presentations, 34.1% resulted in admission, with no association between imaging and admission (31.8% vs 36.0%, P = 0.2) or ED re-presentation for back pain in the same year (6.5% vs 9.7%, P = 0.09). This study provides benchmark data on the use of imaging for back pain in an Australian ED, an area which has been largely unexplored. The rate of imaging in the ED was higher than previously reported in a General Practice setting. Consistent with guidelines, patients older than 70 were more than twice as likely to receive imaging compared to younger patients. It was beyond the scope of the current study to determine whether these images were clinically indicated and further research is required to determine if initiatives to reduce imaging in this population are warranted.

Trends and characteristics of short-term and frequent representations to emergency departments: A population-based study from New South Wales, Australia.

The objective of this study is to describe the trends and characteristics of short-term and frequent representations to EDs in New South Wales, Australia. This was a retrospective analysis of a linked population-based registry of ED representations in New South Wales, conducted as part of the Demand for Emergency Services in Years 2010-2014 project. Trend analysis of unplanned representations to ED within 3 days of discharge from ED, readmission to an in-patient unit within 30 days of index in-patient admission from ED and demographic data and trends for frequent and very frequent ED presenters is discussed. A total of 10 798 797 ED presentations were identified from 4 188 283 individual patients. Within 1 year, 48.9% of ED presentations had a previous presentation, and 4.9% had represented within 3 days of a previous presentation. The readmission rate within 30 days was 2.8%, the proportion of frequent (representing 5212 [0.1%] individual patients) and very frequent representations (representing 1186 [0.03%] individual patients) were 1.7% and 1.0%, respectively. The overall rate of representations within 3 days has decreased from 5.1% in 2010 to 4.7% in 2014 (P < 0.001). The rate of readmissions within 30 days has increased from 2.4% in 2010 to 3.1% in 2014 (P < 0.001). In this population-based study, short-term representations were highest in the infant patient population, in-patient readmission rates were highest in the elderly and very frequent representations to ED were characterised by middle-aged patients with mental health or drug and alcohol related presentations.

Antimicrobial stewardship in Australian emergency departments.

The present study aims to determine and describe the involvement of Australian EDs in antimicrobial stewardship (AMS) and the role of Emergency Medicine Pharmacists (EMPs). A Surveymonkey® questionnaire was devised, piloted and distributed to all members of the Society of Hospital Pharmacists of Australia Committee of Specialty Practice EM via the online discussion forum and email distribution list. There were 41 respondents, 35 (85%) of which had an EMP at their hospital. Of respondents, 30 (73%) were EMP, nine were involved in ED and wanted to contribute to the survey and two were neither. Thirty-four (83%) had a hospital AMS programme. All other questions had 29 respondents. Twenty-three of 29 (79%) had an AMS committee, and 14/23 (61%) had an ED representation. Twenty-eight of 29 (97%) had a restricted antimicrobial policy. Twenty-one of 29 (72%) had a specialist AMS pharmacist, and 12/21 (57%) were involved in the ED. Eleven of 29 (37%) had ED-specific antimicrobial guidelines. A variety of electronic AMS support is available in EDs. EDs had access to a hospital antibiogram (6) and used it to inform AMS. Point prevalence surveys often involved the ED. EMPs were involved with antimicrobial education via ward rounds (6) and didactic sessions (7), guideline development (4), and monitoring of ED antimicrobial prescribing, 21/29 (72%). Multiple ways of controlling ED antimicrobials were used including: providing a limited range of after-hours antimicrobials, predetermined trauma packs, review of ED stock and follow up of restricted antimicrobials. Fourteen of 29 (48%) had conducted ED antimicrobial drug use evaluations. The ED can be a focus for AMS and is at many sites surveyed. The EMP can provide an important role in this programme.

Redesigning emergency patient flow with timely quality care at the Alfred.

The 4 h National Emergency Access Target was introduced in 2011. The Alfred Hospital in Melbourne implemented a hospital-wide clinical service framework, Timely Quality Care (TQC), to enhance patient experience and care quality by improving timeliness of interventions and investigations through the emergency episode and admission to discharge in 2012. We evaluated TQC's effect on achieving the National Emergency Access Target and associated safety and quality indicators. Retrospective analysis with piecewise regression of 215 125 ED attendances before/after implementation, November 2009 to August 2013; with comparison of proportions of patients discharged, admitted or transferred from ED within 4 h of arrival; left at risk; unplanned ED re-attendances up to 28 days; ED length of stay; and in-hospital mortality. The percentage of patients admitted, discharged or transferred within 4 h rose from 60% in 2010, to 74% in 2013. Median ED length of stay decreased significantly. Rate of unplanned ED re-presentations decreased by 27%, 22% and 17% within 24 h, 48 h and 7 days, respectively; and patient numbers leaving at risk halved from 8% to 4%. Mortality for admitted patients declined from 3.5% to 2.2%. All results were statistically significant. TQC resulted in improvement in timeliness of care for emergency patients without compromising safety and quality. Success is attributed to effective engagement of stakeholders with a hospital-wide approach to redesigning the care pathway and establishing a new set of principles that underpin care from the time of ED arrival.

Early emergency department representations

The present study aims to describe early ED representation rates and identify the causes for this commonly seen problem. This was a retrospective chart review of all patients that represented within 72 h of discharge from a tertiary level ED in Sydney, Australia, over a 2 month period between 1 May 2010 and 30 June 2010. Presentations were categorised according to their diagnosis and cause for representation. Each representation was then classified as being avoidable or unavoidable. There were 10 141 presentations to the ED during the study period, with 497 patients (4.9%, 95% confidence interval [CI] 4.5-5.3) representing within 72 h of discharge. Disease-related causes of representation were seen in 55.1% (95% CI 50.7-59.5), with 39% (95% CI 34.8-43.4) of these caused by disease progression and 12.3% (95% CI 9.6-15.5) for scheduled review. Patient-related causes were seen in 32.2% (95% CI 28.2-36.4) of representations with 20.9% (95% CI 17.6-24.7) of these for patients who did not wait or left against medical advice. Physician-related causes were seen in 3.2% (95% CI 2.0-5.2) of representations. Furthermore, 23.7% (95% CI 20.2-27.7) of patients who represented to the ED required hospital admission. A total of 37.0% (95% CI 32.9-41.4) of representations were assessed as being preventable. Early ED representations are a common problem. The majority of preventable representations are patient related, and interventions to target these areas might be of benefit in reducing this problem.