Number Of Emergency Department Presentations Research Articles

Development of a Multivariable Risk Prediction Tool to Predict Adverse Outcomes among Children with Type 1 Diabetes: A Pilot Study

Background. Children and adolescents with type 1 diabetes mellitus (T1DM) are frequently hospitalised for severe hypoglycaemia, hyperglycaemia, and diabetic ketoacidosis (DKA). While several risk factors have been recognised, clinically identifying these children at high risk of acute decompensation remains challenging. Objective. To develop a risk prediction model to accurately estimate the risk of acute healthcare utilisation due to severe hypoglycaemia, hyperglycaemia, and DKA in children and adolescents with T1DM. Materials and Methods. Using a retrospective dataset, baseline demographic and clinical data were collected from patients (<18 years) seen at a regional paediatric diabetes clinic from 1 January 2018 to 1 January 2020. The outcome was the number of emergency department presentations or hospital admissions for severe hypoglycaemia, hyperglycaemia, and DKA across the study period. Variables that were significant in univariate analysis were entered into a multivariable model. Receiver operator characteristic (ROC) curves assessed the model’s discrimination and generated cut-offs for risk group stratification (low, medium, and high). Kaplan–Meier survival analysis measured time to acute healthcare utilisation across the risk groups. Results. Our multivariable risk prediction model consisted of five predictors (continuous glucose monitoring device, previous acute healthcare utilisation, missed appointments, and child welfare services involvement and socioeconomic status). The model exhibited good discrimination (area under the ROC = 0.81), accurately stratified children into low-, medium-, and high-risk groups, and demonstrated significant differences between median time to healthcare utilisation. Conclusion. Our model identified patients at an increased risk of acute healthcare utilisation due to severe hypoglycaemia, hyperglycaemia, and DKA.

Improving care for chronic conditions may take longer than expected: Evaluation of the Health Links chronic care flexible funding model of care

Introduction: Current models of care and funding systems in Australia for managing chronic disease are largely designed to be responsive to single episodes of acute care. The Victorian Department of Health developed a flexible funding model which aimed to improve care for patients at high risk of unplanned hospital admissions, many of whom had chronic and complex conditions. The initiative investigated whether the model could remove several barriers that inhibit integrated models of care and promote innovation to produce better outcomes for patients. Four hospital and health services participated in the trial with three acting as control hospitals. Each of the participating hospitals undertook their own unique intervention, ranging from redesigns of existing services to advanced coaching models using tele-care guides.
 Methods: We undertook an analysis of HealthLinks enrolled intervention patient outcomes compared to a usual care patient cohort. In addition, we compared outcomes from participating individual health services compared to control health services. Outcomes measured were inpatient length of stay, number of inpatient admissions and 30-day readmissions, and emergency department (ED) length of stay and number of ED presentations.
 Administrative datasets of enrolled patients were converted into monthly panels where outcomes were summed to a count per patient per month for the period 12-months prior to the trial start date for participating health services and the 1st of July 2016 for control health services and for 24 months after. 
 Results: A total of 2,400 Healthlinks enrolees received an intervention model of care during the two year trial out of 49,000 enrolees.
 Compared to patients from control hospitals there were significantly fewer ED presentations per month (-0.1) and shorter ED lengths of stay (-40 mins), but more admissions per month( 0.03) and longer inpatient lengths of stay (0.2 days) for patients at intervention hospitals. A similar pattern was observed for individual hospital compared to controls.
 Patterns of hospital use varied by health service for intervention patients compared with usual care patients. Compared with usual care patients there were significant increases in ED length of stay at all hospitals; significantly fewer 30-day readmissions per month (–0.004 ) at Hospital C; significantly more hospital admissions per month at hospitals B (0.2) and C (0.1) ; and significantly shorter inpatient lengths of stay for hospital b (-2 days) but longer for hospital D (0.5 days) compared with usual care patients. 
 Discussion: Most outcomes measured in this evaluation showed little effect for those patients directly involved in an intervention apart from hospital and ED length of stay measures for one health service. Patients from flexibly funded health services seemed to have reduced ED presentations and length of stay in the ED; however, it is unclear whether this is because of flexible funding or differences in outcome trajectories before flexible funding commenced. There is an emerging view that the effects on patient outcomes from chronic disease models of care may be more apparent in the longer term, suggesting health policy takes a similar view when trialling new initiatives.
 
 
 
 
 
 
 

Improving Palliative and End of Life Care on the Central Coast, Australia: Results from Two Clinically-Led Mixed-Methods Research Projects

In 2019, New South Wales Regional Health Partners commissioned the Central Coast Local Health District to undertake clinician-driven research that would lead to the implementation of new service models designed to improve palliative and end-of-life care to the Central Coast community.
 During 2020, a series of five stakeholder workshops with clinicians, healthcare managers, consumers and other local stakeholders involved in palliative and end of life care led to the development of two translational research projects: palliative and end of life care for people with advanced dementia; and the experiences of people who access emergency care towards the end of life. The subsequent clinically-led research programs were undertaken between January 2021 and September 2022. In this presentation, we discuss the results of these two mixed-methods research projects.
 To understand the patient journey, both projects undertook audits. For people who died with dementia, a retrospective case notes audit of 705 people who died between January 2015 and December 2019 found half died in public hospitals, and the other half in other settings. Less than one in five patients dying in public hospitals had an advanced care directive recorded, and fewer than one in 13 had an advanced care plan. The second audit of 1730 Central Coast residents who died between August 2020 and July 2021 found nearly half had 1 (45%) emergency department presentation in the 90 days before their death, and more than one in four had 2 presentations. There was a significant difference in the number of emergency department presentations and hospital admissions when comparing patient age and place of death.
 Across both projects, a total of 303 bereaved carers completed a postal survey. Respondents reported high levels of satisfaction with end of life care across settings. Most people receiving care were always treated with respect and dignity. Pain was managed best in hospital, compared to residential aged care and home settings. Less than half of carers said the person cared for had enough choice about where they died, but on balance, more than four in five said the person died in the right place. 
 Thematic analysis of 19 in-depth interviews with bereaved carers found three themes were common across projects: 1) There is a lack of acknowledgement of end of life, and discussions about death usually happen in the final days; 2) Services and supports are complex and fragmented, knowledge is needed to navigate them and experiences vary; and 3) End of life caring is challenging and there is limited support for carers to care.
 Drawing on previous evidence that was presented during ICIC22, we examine the lessons learned from these research projects on the importance of clinically-led research and how this is translating into the implementation of an integrated model of end of life care on the Central Coast. Key lessons for international colleagues from this research are considered.

Surgical intervention for acute pancreatitis in the COVID-19 era.

Approximately 15%-19% of patients with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infections develop gastrointestinal symptoms. Acute pancreatitis (AP) has been reported in 0.1% of patients with coronavirus disease 2019 (COVID-19). Biliary AP was most common (78.4%) before the COVID-19 pandemic; idiopathic AP is most common in patients with COVID-19 (up to 57.1%). The number of emergency department presentations decreased by 23.3% during the pandemic and many governments made national recommendations to delay nonurgent endoscopic procedures, leading to decrements of 22% in combined esophagogastroduodenoscopy (EGD) and colonoscopy and 20% in EGD after the COVID-19 pandemic. The symptoms and signs of COVID-19-related AP are fever (63%), abdominal pain (58%), respiratory symptoms (40%), nausea and vomiting (39%), and headache (4%). Approximately 5-10% of patients develop necrotizing or hemorrhagic AP, and patients who required surgical intervention had a higher mortality risk. Compared to 2019, the rates of elective surgery decreased by 41.8% in 2020; including cholecystectomy (40.1% decrease) and pancreas (111.1% decrease). Surgical volumes also decreased by 18.7% in 2020; device-assisted laparoscopic and robot-assisted procedures reduced by 45.4% and 61.9% during the COVID-19 Lockdown in 2020.

PSUN189 Psychological Treatment for Diabetes Distress is Associated with Reduction in HbA1c, Emergency Department Presentations and Improvement in Psychological Health.

Abstract Introduction Patients with diabetes distress (DD) experience poorer health outcomes than patients with diabetes mellitus (DM) who do not experience DD. However, few studies have examined whether treatment for DD delivered by a psychologist embedded in a multi-disciplinary team (MDT) improves not only psychological health, but glycaemic control and other physical health outcomes, especially in low socioeconomic populations. Method: This study examined the impact of intervention by a clinical psychologist, as part of an outpatient MDT at a tertiary referral hospital diabetes service, on glycaemic control, emergency presentations and hospital admissions, diabetes distress, depression, anxiety and stress symptoms. Inclusion criteria were high DD indicated by a Problem Areas in Diabetes (PAID) questionnaire score ≥ 40, together with either 1) recent diabetes-related hospitalisation, 2) HbA1c >8% or 3) conflict over diabetes management with family or healthcare professionals, such as difficulty aligning diabetes management goals. Measures at baseline and treatment completion were the PAID questionnaire, the 21-item Depression, Anxiety, Stress Scale (DASS21), HbA1c, and number of emergency department presentations and hospital admissions in the three months before and after treatment commencement. Participants were assessed and treated by a clinical psychologist in addition to existing treatment by the MDT (which could include a diabetes educator, endocrinologist and dietician). Psychological treatment was individually determined, based on participants’ needs, and included cognitive therapy for health beliefs, mindfulness, distress tolerance, behavioural activation, problem solving, interpersonal effectiveness, Cognitive Behaviour Therapy (CBT) for disordered eating, and blood glucose awareness training. CBT for depression or anxiety was used as an adjunct where clinically indicated. Length of treatment and frequency of sessions varied depending on individual needs. Results Participants were 67 outpatients with DM aged 16-82 years, (72% female) in an area with a high prevalence of socio-economic disadvantage. Forty five patients had Type 1DM, 21 had Type 2DM and 2 had other or undefined DM type. Mean HbA1c decreased from 9.25% pre-treatment to 8.27% in the three months post treatment (p<0.001). Emergency department presentations halved (p<0.05). All psychological variables showed significant improvement: DD measured by PAID decreased from 57.5 to 33.03 (p <0.0001); DASS21 depression scores reduced from 11.17 to 7.36, anxiety scores reduced from 9.4 to 6.03, and stress scores from 12.29 to 9.46 (p<0.0001 for all). Hospital admission numbers did not change post intervention. Controlling for diabetes type, duration and gender did not have a significant impact on any outcome variable. Conclusion This study provides evidence that treatment by a clinical psychologist can improve both physical and psychological health outcomes for people with diabetes distress and should be considered standard of care for people experiencing diabetes distress with high HbA1c, diabetes related hospitalisation or conflict with family or healthcare professionals around diabetes management. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Outcomes of patients coming to the emergency department after kidney transplantation

Introduction: In kidney transplantation (KT) practice, improvements in patient care led to increased graft and patient survival. This study aimed to determine the symptomatology of KT patients presenting to emergency department (ED), their final diagnoses, and outcomes.
 Material and Method: Data including demographic data (age and gender), chief complaints (CCs), number of ED presentations, ED presentation date, KT date, donor type (live/deceased), patient disposition (discharge/admission), final diagnosis, and outcomes (acute renal graft dysfunction/graft loss/death) were retrieved and analyzed. 
 Results: Twenty-five KT patients presented to ED during the study period. These patients presented to ED for 46 times with 50 CCs. Fever was the most frequent CC (20%). The ED presentation led to a final diagnosis of infection in 32 presentations (69.4%). The most frequent infection was urinary tract infection (UTI) (26.1%) followed, by acute gastroenteritis (17.4%) and upper respiratory tract infection (17.4%). Acute graft dysfunction was the most common “non-infectious diagnosis” (17.4%) followed by cardiovascular disease (8.5%). The ED presentation led to admission in 32.6% (15/46) of the cases. Among 15 admissions, 7 (46.7%) were due to UTI. No rejections, graft loss, or mortality occurred following any ED presentations.
 Conclusion: When evaluating KT patients in the ED, physcians should bear in mind that they could have an infectious pathology that is often associated by fever, also they should check for acute graft dysfunction and cardiac pathologies.

Financial Costs of Emergency Department Presentations for Australian Patients With Heart Disease in the Last 3 Years of Life.

Aims:This study described emergency department (ED) resource use patterns and associated costs among patients with heart disease in their last 3 years of life in a high-income country.Methods:This study used linked data from ED and death registry databases in Australia. A random sample of 1000 patients who died due to any cause in 2017, and who had been living with heart disease for at least the prior 10-years were included. The outcomes of interest were number of ED presentations over each of the last 3 years prior to death and relative cost contributions of ED-related items.Results:The number of patients needing ED care and number of ED presentations per patient increased as patients were closer to death, with 85% experiencing at least one ED presentation in their last year of life. Mean per patient ED presentation cost increased with each year closer to death. Costs related to labor, pathology, patient travel, and goods and services contributed more than 85% of the total cost in each of the 3 years.Conclusion:The increase in cost burden as patients neared death was attributable to more frequent ED presentations per person rather than more expensive ED presentations. The scope of this study was limited to ED presentations, and may not be representative of heart-disease-related end-of-life care more broadly.

Changes in paediatric Ambulatory Care Sensitive Conditions in Victoria, 2018-20: the COVID-19 effect?

Objectives This study sought to describe the patterns in emergency department (ED) presentations and hospital admissions in children with Ambulatory Care Sensitive Conditions (ACSCs) before and during the coronavirus disease 2019 (COVID-19) pandemic restrictions in Victoria, Australia, to assess if changes in out-of-hospital care resulted in an increase in delayed/severe presentations. Methods This study involved secondary analysis of Victorian Emergency Minimum Dataset and Victorian Admitted Episode Dataset data. Patients (<18 years) attending EDs with a diagnosis of an ACSC were included. We compared the number and severity of ASCS presentations pre-COVID-19 (1January 2018-27 March 2020) and during COVID-19 (28 March-31 October 2020). A linear regression prediction model was built to compare the observed versus predicted presentation number in the 2020 period. Results In total, there were 108 104 paediatric ACSC ED presentations in Victoria during the study period. Females accounted for 51 462/108 104 (47.6%) of all presentations, with a median age of 3 years. A significant decrease in ED presentations was seen in 2020 (41 319 in 2018; 44 978 in 2019; and 21 807 until October 2020), predominantly due to reductions in conditions that are typically mediated by viruses in childhood (i.e. asthma, convulsions/epilepsy and ear, nose and throat conditions). The proportion of high-urgency presentations and those requiring admission was stable in 2020. Conclusions An overall reduction in the number of ED presentations and admissions with paediatric ACSCs was seen in Victoria in 2020, indicating that rates of delayed or more severe presentations did not occur as a result of changes in out-of-hospital care.

The use of computed tomography in the management of injury in tertiary emergency departments in Western Australia: Evidence of overtesting?

This study investigated trends in computed tomography (CT) utilization across different triage categories of injury presentations to tertiary emergency departments (EDs) and associations with diagnostic yield measured by injury severity, hospitalization and length of stay (LOS), and mortality. A total of 411,155 injury-related ED presentations extracted from linked records from Western Australia from 2004 to 2015 were included in the retrospective study. The use of CT scanning and diagnostic yield measured by rate of diagnosis with severe injury, hospitalizations and LOS, and mortality were captured annually for injury-related ED presentations. Multivariable regression models were used to calculate the annual adjusted rate of CT scanning for injury presentations and hospitalizations across triage categories, diagnosis with severe injury, LOS, and mortality. The significance of changes observed was compared among patients with CT imaging relative to those without CT. While the number of ED presentations with injury increased by 65% from 2004 to 2015, the use of CT scanning in these presentations increased by 176%. The largest increase in CT use was among ED presentations triaged as semi-/nonurgent (+256%). Injury presentations with CT, compared to those without, had a higher rate of diagnosis with moderate/severe injury and hospitalization but no difference in LOS and mortality. The probability/rate observed in the outcomes of interest had a greater decrease over time in those with CT scanning compared with those without CT scanning across triage categories. The reduction in diagnostic yield in terms of injury severity and hospitalization found in our study might indicate a shift toward overtesting using CT in ED for injury or a higher use of CT to assist in the management of injuries. This helps health care policymakers consider whether the current increase in CT use meets the desired levels of quality and efficient care.

Clinical Presentations of Adolescents Aged 16-18 Years in the Adult Emergency Department.

Background: In many large hospitals in Switzerland, adolescents 16 years and older are treated in adult emergency departments (ED). There have been few publications about this specific patient population, especially in Switzerland. This study aims to provide an overview of emergency presentations of adolescents between 16–18 years of age when compared to adults and focuses on their principle complaints. Methods: We conducted a single-centre, retrospective, cross-sectional study of all patients aged 16 years and older presenting to the adult ED at the University Hospital (Inselspital) in Bern, Switzerland, from 2013 to 2017. This analysis gives an overview of emergency presentations of adolescents between 16–18 years of age in this time period and compares their consultation characteristics to those of adult patients. Results: Data of a total of 203,817 patients who presented to our adult ED between 2013 and 2017 were analysed. Adolescents account for 2.5% of all emergency presentations. The number of ED presentations in the reviewed time period rose for adults (+2368, 95% CI: 1695, 3041, p = 0.002 consultations more per year; +25% comparing 2013 with 2017), while adolescent presentations did not significantly increase (p = 0.420). In comparison to adult patients, adolescents presented significantly more often during the night (39.1% vs. 31.5%, p < 0.001), as walk-ins (54.2% vs. 44.9%, p < 0.001), or with less highly acute complaints at triage (21% vs. 31%, p < 0.001). They were more likely to be discharged (70.8% vs. 52.2%, p < 0.001). We found a significant association between the two age groups and principle complaints. In comparison to adults, trauma and psychiatric problems were significantly more common among adolescents. Conclusions: Our data showed that complaints in adolescent patients under 18 years of age significantly differ from those in older patients. The artificial age cut-off therefore puts this vulnerable population at risk of receiving inadequate diagnostic testing and treatment adapted only for adults. Additional studies are needed on the reasons adolescents and young adults seek ED care, as this could lead to improvements in the care processes for this vulnerable population.

Access, Use, and Patient-Reported Experiences of Emergency Care During the COVID-19 Pandemic: Population-Based Survey

BackgroundAn increase in the number of people presenting to emergency departments (EDs) is contributing to ED overcrowding. In the early stages of the COVID-19 pandemic, there was a significant reduction in the number of ED presentations in Australia, creating an opportunity to learn from patients’ experiences of alternative management options.ObjectiveThe aim of this study is to report on the use and experience of health services by Australian adults experiencing a health issue during the COVID-19 pandemic for which they would have presented at an ED prior to the pandemic.MethodsAn online survey was conducted in May 2020. Reported health issues were categorized using an existing classification system. Data collected included demographics, care pathways, levels of concern at times of health issue and survey completion, and patient-reported experiences with care.ResultsA total of 1289 eligible respondents completed the survey. Almost 25% (309/1289) of respondents avoided an ED presentation, of which 58% (179/309) used an alternative form of health care and 42% (130/309) self-managed. Respondents making face-to-face or telehealth appointments with their general practitioner (GP) reported high levels of ED avoidance (135/286, 47%) and mostly positive experiences of care provided by GPs. A high proportion of those who self-managed reported high levels of concern at the time of completing the survey (42/130, 32%).ConclusionsTelehealth consultations with GPs may be a more promotable alternative to the ED beyond the COVID-19 pandemic, providing easier access to a doctor with access to patients’ medical histories than an appointment for a face-to-face consultation. GP telehealth consultations may also address barriers to accessing health care for those with potentially the greatest need. The reported use and positive experiences with GP telehealth appointments should inform further research on their appropriateness as an alternative to the ED.

Healthcare Costs of Emergency Department Presentations Related to Heatwave Intensity and Severity

BACKGROUND AND AIM: The health impacts of heatwaves are a growing public health concern. However, little is known about the healthcare costs of heatwave-related morbidity. This study aims to examine the relationship between heatwaves and costs of emergency department (ED) presentations and to quantify heat-attributable presentations and costs in Adelaide, South Australia. METHODS: Daily data on ED presentations and associated costs for the period 2014-2017 were obtained from the South Australian Department of Health and Wellbeing. Heatwave severity and intensity were determined using the excess heat factor (EHF) index, obtained from the Australian Bureau of Meteorology. A distributed lag non-linear model (DLNM) was used to quantify the cumulative risk of heatwave-intensity over a lag of 0-7 days on ED presentations and costs. Effects of heatwaves were estimated relative to no heatwave. The number of ED presentations and costs attributable to heatwaves was calculated separately for two EHF severity categories (low-intensity and severe heatwaves). Subgroup analyses by disease-diagnosis groups and age categories were performed. RESULTS:For most disease diagnosis and age categories, low-intensity and severe heatwaves were associated with higher rates of ED presentations and costs. We estimated a total of 1,161 (95% empirical confidence interval (eCI): 342, 1,944) heatwave-attributable all-cause ED presentations and an associated healthcare costs of AU$1,020,330 (95% eCI: 224,851, 1,804,745) during the warm seasons of 2014-2017. Heat-related illness was the disease category contributing most to ED presentations and costs. CONCLUSIONS:Heatwaves produced a significant case-load and cost burden to the ED. The young and old peoples were most susceptible to heat. Developing tailored interventions for the most vulnerable populations may help reduce the health impacts of heatwaves and to minimise the cost burden to the healthcare system. KEYWORDS: Temperature, Climate, Temperature extremes

Provision of training for accommodation providers in the London Borough of Hackney – results of a scoping exercise and educational session pilot

AimsTo understand the level of training given to staff in providers of accommodation in the London Borough of Hackney across mental and physical health.MethodThe Urgent and Emergency Care Collaborative (Health Education England) put out a call for funding bids around a number of workforce priority areas. This included upskilling care home staff to reduce admissions. We considered care home staff as those working across supported living schemes, housing with care, residential and nursing homes. Some of these settings exclusively support people with mental health needs.We obtained a list of accommodation providers across the borough via the Local Authority. As a Community Rehabilitation team we work closely with many of the providers. We also co-facilitate the Hackney Mental Health Supported Accommodation panel and review all funded placements annually. We made contact via email and phonecall and arranged face to face meetings with 11 providers. We asked a standard set of questions about the organisation and training provision. We also asked them to identify gaps in training.ResultThe level of training provided to staff varies vastly across different settings. There was a predominance of e-learning for some providers. Most staff in mental health settings are support worker level which limits the level of training offered/received.Providers varied greatly in size of project and management structure and this directly impacts on access to training, often as a result of cost.Providers were able to identify training gaps and were keen to have additional training.Some common themes emerged – dual diagnosis, psychosis, medication – and some setting specific themes – dementia.Based on the gaps identified we provided training sessions to a total of ~40 staff across a number of settings. Content included mental health awareness, crisis signposting and medicines management. All sessions were well received with pre and post-training questionnaires demonstrating an improvement in knowledge and confidence.ConclusionThere is potential for knowledge sharing across accommodation settings and for stronger links between accommodation providers and healthcare providers. We plan to explore the possibility of quantitative data on the number of Emergency Department presentations from accommodation settings locally.

Analysis of the contents of consultations requested by the emergency department

Background and objectives: Every year several thousand patients attend the hospital emergency department (ED). The aim of the present study was to evaluate the content of the consultations requested from the emergency department.&#x0D; Methods: The patients who had presented to the adult emergency department between January 1, 2020 and January 31, 2020, and who had undergone consultation by at least one clinic were included in the study. Age, gender, the number of consultation required at the same admission, the clinic from which the consultation sought, time required to respond to the request and the outcomes of the consultations were analyzed.&#x0D; Results: The total number of emergency department presentations was 8930 patients and at least one consultation had been requested for 6.64% (n = 593) patients. The mean duration of answering the consultation was 85.76 ± 90.33 minutes. Consultations were requested from the cardiology most frequently (n = 188, 19%), followed by the pulmonology department (n = 181, 18.3%). Discharge was recommended with prescription in 235 (39.6%) consultations. Internal medicine was the clinic, which recommended treatment at the emergency room most frequently (n = 45, 22.4%) and the most commonly recommended treatment was erythrocyte suspension replacement (n = 7). The clinic that demanded additional tests most commonly was determined to be the pulmonology department (n = 41, 22.9%) and arterial blood gases analysis was the most commonly demanded test (n = 16).&#x0D; Conclusion: In our study, the rate of consultations requested was seen to be lower and the rate of cases that required hospitalization was seen to be higher. The duration of answering consultations was found to be longer than desired and institutional protocols should be developed for shortening this duration.&#x0D; Ibrahim Med. Coll. J. 2021; 15(1): 9-15

Impact of heatwave intensity using excess heat factor on emergency department presentations and related healthcare costs in Adelaide, South Australia

BackgroundThe health impacts of heatwaves are a growing public health concern with the frequency, intensity, and duration of heatwaves increasing with global climate change. However, little is known about the healthcare costs and the attributable morbidity associated with heatwaves ObjectiveThis study aims to examine the relationship between heatwaves and costs of emergency department (ED) presentations, and to quantify heat-attributable burden during the warm seasons of 2014–2017, in Adelaide, South Australia. MethodsDaily data on ED presentations and associated costs for the period 2014–2017 were obtained from the South Australian Department of Health and Wellbeing. Heatwave intensity was determined using the excess heat factor (EHF) index, obtained from the Australian Bureau of Meteorology. A distributed lag non-linear model (DLNM) was used to quantify the cumulative risk of heatwave-intensity over a lag of 0–7 days on ED presentations and costs. Effects of heatwaves were estimated relative to no heatwave. The number of ED presentations and costs attributable to heatwaves was calculated separately for two EHF severity categories (low-intensity and severe/extreme heatwaves). Subgroup analyses by disease-diagnosis groups and age categories were performed. ResultsFor most disease diagnosis and age categories, low-intensity and severe heatwaves were associated with higher rates of ED presentations and costs. We estimated a total of 1161 (95% empirical confidence interval (eCI): 342, 1944) heatwave-attributable all-cause ED presentations and associated healthcare costs (thousands) of AU$1020.3 (95% eCI: 224.9, 1804.7) during the warm seasons of 2014–2017. The heat-related illness was the disease category contributing most to ED presentations and costs. Age groups 0–14 and ≥ 65 years were most susceptible to heat. ConclusionsHeatwaves produced a statistically significant case-load and cost burden to the ED. Developing tailored interventions for the most vulnerable populations may help reduce the health impacts of heatwaves and to minimise the cost burden to the healthcare system.

Models of care for frail older persons who present to the emergency department: a scoping review protocol

BackgroundPeople aged ≥ 65 years comprise around 1 in 5 emergency department (ED) presentations. Many of these presentations occur due to complications associated with chronic diseases and frailty. This review aims to provide a comprehensive understanding of available research regarding models of care for frail older people presenting to the ED.MethodsThe Joanna Briggs Institute scoping review framework will be used to guide this review. Literature searches will be conducted in the following electronic databases (from January 2009 onwards): CINAHL via EBSCOhost, Ovid MEDLINE, Embase, SocINDEX. Grey literature will be identified through searching Google Scholar. This review will consider primary research studies (including observational and interventional studies) published in English on models of care for frail older people (aged ≥ 65) presenting to the ED. Two researchers will independently screen all citations, full-text articles, and abstract data. Potential disagreements will be resolved through discussion with a third researcher. Data extracted from included studies will include the following: author(s), year of publication, country, research design and aim, time frame of the study, study population and sample size, data collection methods, definition of frailty, model of care, and key findings that pertain to the ability to inform this review. The strength of the body of evidence will be assessed using the National Health and Medical Research Council level of evidence hierarchy body of evidence matrix. Data will be presented in a tabular format and accompanied by a narrative that describes the characteristics of the body of literature.DiscussionDespite the increased number of ED presentations for frail older people, there has been no synthesis of the sources of evidence of model of care for frail older people in the setting of emergency care. The results of this scoping review will provide an overview of different models of care and help inform future research in the development of models of care for frail older persons, tailored to the healthcare system in the emergency context.Systematic review registrationThis scoping review has been registered in the Open Science Framework (osf.io/h2t94).

767-P: Psychological Treatment Is Associated with Improved Diabetes Distress and Glycaemic Control

Introduction: Diabetes distress (DD) is associated with poorer health outcomes in diabetes mellitus (DM). Addressing DD through diabetes education improves glycaemic control. However, few studies have examined the effects of psychological therapy on DD and physical health outcomes, especially in low socioeconomic populations. Methods: This study examines the impact of intervention by a clinical psychologist as part of a multidisciplinary team (MDT) on glycaemic control, hospital presentations and admissions, DD, and psychological factors. Participants were 50 outpatients aged 17-67 at a public hospital diabetes service in a socioeconomically disadvantaged area of Sydney, Australia. Inclusion criteria were DD, indicated by a PAID score ≥ 40, together with either 1) recent diabetes-related hospitalisation, 2) high HbA1c or 3) conflict over diabetes management. Measures used at baseline and treatment completion were the PAID, the 21-item Depression, Anxiety, Stress Scale (DASS-21), HbA1c, and number of emergency department presentations and hospital admissions in the three months before and after treatment commencement. Results: All psychological variables showed a significant reduction: DD measured by PAID scores decreased by 36.8% from 57 to 36 (p&amp;lt;0.001); DASS21 scores showed depression reduced by 36.4 % from 11 to 7 (p&amp;lt;0.0001), anxiety by 33.4% from 10 to 6 (p&amp;lt;0.0001) and stress by 16.7% from 12 to 10 (p&amp;lt;0.0002). HbA1c decreased from 9.0% pre-treatment to 8.2% in the three months after treatment commenced. For 25 participants with matched pre and post treatment HbA1cs, mean HbA1c reduction was 0.7% (95% CI 0.1-1.3, p = 0.02). Emergency department presentations halved from 22% (11/50) of participants in the pre- treatment 3 months to 10% (5/50) in the 3 months post treatment. Hospital admissions halved, from 8% (4/49) to 4% (2/49). Conclusion: This study provides preliminary evidence that treatment by a clinical psychologist can improve health outcomes for people with diabetes. Disclosure V.M. Croker: None. C. Calderwood: None. S. Hayes: None. E. Hibbert: None.

1646-P: The Impact of a Diabetes Codiagnosis on Hospitalisation and Mortality in Patients with Malignancy

Objective: To document the characteristics and outcomes for patients with malignancies with or without diabetes at a tertiary referral hospital. Research Design and Methods: Emergency department and hospital discharge data between 1 Jan 2015 and 31 Dec 2017 were used to identify patients with a diagnosis of a malignancy and diabetes. Multivariate Cox-regression models were used to estimate the effect of diabetes on all-cause mortality. A truncated negative binomial regression model was used to assess the impact of diabetes on length of hospital inpatient stay. Prentice, Williams and Peterson Total Time (PWP-TT) models were used to assess the effect of diabetes on number of Emergency Department presentations and inpatient admissions. Results are presented as incidence-rate ratios (IRR) or hazard ratios (HR). These models were adjusted for age, gender, type of malignancy and Charlson comorbidities. Results: For 7,058 patients identified with malignancies, 1,230(17.4%) were also diagnosed with diabetes. During the three-year study period a diagnosis of diabetes was associated with an increased number of inpatient admissions (adjusted Hazard Ratio (adjHR): 1.14, 95% CI: 1.04, 1.25), increased number of emergency department presentations (adjHR: 1.19, 95% CI: 1.11, 1.28) and length of stay for patients with diabetes (adjIRR: 1.16, 95% C.I: 1.06, 1.28). A co-diagnosis of diabetes was also associated with a 48% increased risk of all-cause mortality (adjHR 1.48, 95% CI: 1.23-1.77). Conclusions: Patients with diabetes had significantly higher numbers of emergency department presentations, inpatient admissions, length of hospital stay and higher rates of all-cause mortality compared to cancer patients without diabetes. This adverse link between diabetes and health outcomes in patients with malignancies requires further exploration. Disclosure K.V. Kiburg: None. G. Ward: None. K.M. Steele: None. E.M. Mulrooney: None. M.M. Loh: None. S. McLachlan: None. V. Sundararajan: None. R. MacIsaac: Advisory Panel; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Eli Lilly and Company, Novo Nordisk Inc. Speaker's Bureau; Self; AstraZeneca, Novo Nordisk Inc. Other Relationship; Self; AstraZeneca, Novo Nordisk Inc. Funding Australian Government Research Training Program (to K.V.K.)

Variation in Hospital Use at the End of Life Among New South Wales Residents Who Died in Hospital or Soon After Discharge.

Objective: Hospital use increases in the last 3 months of life. We aimed to examine its association with where people live and its variation across a large health jurisdiction. Methods: We studied a number of emergency department presentations and days spent in hospital, and in-hospital deaths among decedents who were hospitalized within 30 days of death across 153 areas in New South Wales (NSW), Australia, during 2010-2015. Results: Decedents' demographics and health status were associated with hospital use. Primary care and aged care supply had no or minimal influence, as opposed to the varying effects of areal factors-socioeconomic status, remoteness, and distance to hospital last admitted. Overall, there was an approximate 20% difference in hospital use by decedents across areas. In all, 18% to 57% of areas had hospital use that differed from the average. Discussion: The observed disparity can inform targeted local efforts to strengthen the use of community care services and reduce the burden of end-of-life care on hospitals.

Development of Relationship between Triaging of Patients and Emergency Department Performance

Triage is a very important step in today's Emergency Departments (EDs). While triage mainly focuses on prioritizing patients based on their medical conditions, this is also an effective management tool to organize, monitor and evaluate the ED patients and resources. As the waiting time of a patient is highly influenced by the triage category, there is a possibility that the length of stay in ED (EDLOS) and overall performance of ED have a relationship with this classification. The main aim of this study is to investigate how the actual ED performance is affected by the number of ED presentations in different triage categories. A comprehensive case study has been conducted and ED patient data of two hospitals in Brisbane have been collected. Based on a statistical analysis of the collected data, a relationship has been identified between the arrival of patients in each category and ED performance. Descriptive statistics have been used to analyze the patients' data for each category. This result will help in managing the necessary resources to avoid the long waiting times as well as a drop in the performance level. Eventually, the outcome will facilitate the ED practitioners to maintain the quality of care in the health sector and also the patients' satisfaction.