Screening tools to identify hospitalised elderly patients at risk of functional decline: a systematic review

Background: The elderly patient admitted to the emergency department (ED) of an acute care hospital is at risk of declining functionally, both during the stay at the hospital as an inpatient and postdischarge. Accurate and early identification of this population may lead to improved outcomes through targeted early interventions. Objectives: To identify, critically appraise and characterise available screening tools to screen for elderly patients at risk of functional decline presenting to the ED of acute care hospitals. Selection criteria: Screening tools administered in the ED to identify elderly patients at risk of functional decline during hospital stay and/or postdischarge. All primary quantitative and qualitative study types were included. Population included age > 65 years presenting to the ED of an acute care hospital. Results: Six studies reporting on five screening tools were identified. Two instruments reported acceptable discriminative ability; however, one of these has not been prospectively validated. No studies that validated any of the instruments in a setting other than the development setting were identified. A single study reported good test–retest reliability data for one instrument, the Identification of Seniors at Risk. Conclusion: This review was unable to identify a ‘gold standard’ tool to screen for risk of functional decline for the elderly patient admitted to the ED. Further research should be carried out to determine adjunctive processes to increase the accuracy of the identification of elderly patients at risk of functional decline. Further research should also be carried out to determine the appropriateness, or generalisability of these tools in different healthcare settings.     

Predicting pressure ulcer risk: a multifactorial approach to assess risk factors in a large university hospital population

Aims. The purpose of this study was: (1) to determine the combination of risk factors which best predicts the risk of developing pressure ulcers among inpatients in an acute care university hospital; (2) to determine the appropriate weight for each risk factor; and (3) to derive a concise and easy‐to‐use risk assessment tool for daily use by nursing staff. Background. Efficient application of preventive measures against pressure ulcers requires the identification of patients at risk. Adequate risk assessment tools are still needed because the predictive value of existing tools is sometimes unsatisfactory. Design. Survey. Methods. A sample of 34,238 cases admitted to Essen University Clinics from April 2003 and discharged up to and including March 2004, was enrolled into the study. Nursing staff recorded data on pressure ulcer status and potential risk factors on admission. Predictors were identified and weighted by multivariate logistic regression. We derived a risk assessment scale from the final logistic regression model by assigning point values to each predictor according to its individual weight. Results. The period prevalence rate of pressure ulcers was 1·8% (625 cases). The analysis identified 12 predictors for developing pressure ulcers. With the optimum cut‐off point sensitivity and specificity were 83·4 and 83·1%, respectively, with a positive predictive value of 8·4% and a negative predictive value of 99·6%. The diagnostic probabilities of the derived scale were similar to those of the original regression model. Conclusions. The predictors mostly correspond to those used in established scales, although the use of weighted factors is a partly novel approach. Both the final regression model and the derived scale show good prognostic validity. Relevance to clinical practice. The derived risk assessment scale is an easy‐to‐understand, easy‐to‐use tool with good prognostic validity and can assist in effective application of preventive measures against pressure ulcer.     

Emergency care workload units: A novel tool to compare emergency department activity

Introduction: Funding bodies have traditionally used attendance figures as a way of determining the allocation of funding for resources in the EDs. Using attendance figures only might not accurately reflect the funding and resources required. The need to create an easily implemented tool to compare workload and resources required was identified. Using the Australasian Triage Scale, a tool was developed to estimate staffing requirements and resource use within each ED. This, although currently not validated, provides a promising start in finding a way to accurately determine ED workload. Methods: Existing data on patient acuity, disposition, numbers of patients and the individual costing of each presentation was used to estimate and define the workload of an ED in emergency care workload units (ECWU). The tool is applied to six de‐identified hospitals within Queensland to demonstrate its potential use for equitable budget and staffing allocation. Results: The tool was applied to a selection of de‐identified EDs within Queensland hospitals. An increased number of ECWU is generated for a patient with a more urgent triage category reflecting a higher resource consumption and workload. Discussion: Although a few studies have been completed in Canada linking workload, resource consumption and cost to triage category, this tool will need to be validated before its use can be fully appreciated. Conclusion: This tool provides a simple method to calculate equitable distribution of staffing and budget allocation based on workload across the different EDs within Australia.     

The changing role of the emergency department in the Northern Territory: a Delphi study

Objective: To explore the changing role of EDs in Northern Territory hospitals. Methods: A two‐round Delphi study was undertaken by recruiting a panel of health professionals from the EDs of the five Northern Territory public hospitals. Participants in round one were asked to list changes they have encountered and how these changes have affected health service delivery, as well as five factors that were responsible for the changes. During the second round they prioritized the factors identified in order of importance. Results: Twenty‐four ED staff returned their questionnaire. Global changes identified were more verbal/physical abuse from patients, followed by increase in acuity of patient presentations. The most important factor perceived as responsible for the changes was budget cuts, resulting in fewer inpatient beds, an increase in access block and sicker patients being discharged too early. Conclusion: The Delphi evaluation provided insights into the problems facing the ED from the staff perspective and offered some suggestions to deal with the emerging issues.     

Screening for Behavioral Health Patient Aggression in Emergency Departments to Reduce Workplace Violence

IntroductionPatient violence in health care facilities occurs daily. Structured risk assessments, when regularly completed, have been effective in prompting interventions to reduce aggression in Behavioral Health (BH) settings.MethodsThis quasi-experimental study evaluated the effectiveness of the Dynamic Appraisal of Situational Aggression – Inpatient Version (DASA) validated screening tool to reduce aggressive outbursts in an emergency department (ED) setting with BH patients awaiting transfer to a psychiatric facility. The tool was used in 4 non-psychiatric EDs from a large health care system. Chart audits were completed to record initial patient DASA scores observed at triage and at subsequent intervals during the ED encounter. ED staff documented interventions used for patients. Inclusion criteria included adults 21 years and older following a telepsychiatry consultation with a recommendation for BH inpatient admission. Pre-/post-implementation aggressive events were collected to assess ED DASA use. DASA scores from BH ED patients were examined to increase understanding of patient utilization. Staff workplace safety was examined to compare staff safety perception pre- and post-DASA implementation.ResultsViolent events were reported statistically significantly higher post-DASA implementation. There was an increased risk of elevated DASA scores for specific diagnoses and genders. An increased awareness of the importance of reporting workplace violence improved documentation.DiscussionUsing an evidence-based screening tool helped identify BH patients with behaviors associated with aggressive ED events. Proactive use of interventions, including use of Comfort Cart items, de-escalation, and prescribed medications, can positively influence reduction of risk from aggressive behaviors within BH patient populations in EDs.     

Fall risk factors assessment tool: enhancing effectiveness in falls screening

A quasi-experimental study was conducted to explore the effectiveness of fall prevention among hospital patients based on the modified fall risk factors assessment tool. We investigated the frequency of falls among hospital patients at a medical center in Taiwan. The experimental group of falls victims was selected from patients (n = 39) hospitalized in 2002 after falls. The control group of patients falls was selected by means of a retrospective incident report review which identified patients (n = 43) hospitalized one year earlier. The results showed that there was no significant difference in the incidence of falls between the two groups. Nevertheless, there were significant differences in age, indications of falls, use of sedatives, walking ability and evaluated grade of fall risk factors. In addition, the average level of satisfaction under recently modified fall risk factors evaluation guideline was 2.68 points (upper limit = 4 points) based upon investigation derived from nursing staff ' s opinions. Moreover, nursing staff from GYN/OBS and orthopedics departments acknowledged the enhanced effectiveness of these new guidelines. The screening rate for high-risk orthopedic patients was increased from 20.7 % to 41.9 %. Furthermore, the screening rate among the experimental group (74.4 % ) was also higher than that among the control group (60.5 % ) ( p <.01). In line with our effective tool to screen high-risk patients, we also added the concept of continuous quality improvement in nursing care to implement a fall prevention program to reduce unnecessary injury. This strategy may assist nursing personnel in providing immediate and individualized care as well as health education for high-risk patients. It may also cause the incidence of patient falls in hospitals to continue to decline.     

Review article: Improving the hospital clinical handover between paramedics and emergency department staff in the deteriorating patient

Clinical communication and recognising and responding to a deteriorating patient are key current patient safety issues in healthcare. The aim of this literature review is to identify themes associated with aspects of the hospital clinical handover between paramedics and ED staff that can be improved, with a specific focus on the transfer of care of a deteriorating patient. Extensive searches of scholarly literature were conducted using the main medical and nursing electronic databases, including Cumulative Index to Nursing and Allied Health Literature, Medline and PubMed, during 2011 and again in July 2012. Seventeen peer‐reviewed English‐language original quantitative and qualitative studies from 2001 to 2012 were selected and critically appraised using an evaluation tool based on published instruments. Relevant themes identified were: professional relationships, respect and barriers to communication; multiple or repeated handovers; identification of staff in the ED; significance of vital signs; need for a structured handover tool; documentation and other communication methods and education and training to improve handovers. The issues raised in the literature included the need to: produce more complete and concise handovers, create respectful and effective communication, and identify staff in the ED. A structured handover tool such as ISBAR (a mnemonic covering Introduction, Situation, Background, Assessment and Recommendations) would appear to provide a solution to many of these issues. The recording of vital signs and transfer of these data might be improved with better observation systems incorporating early warning strategies. More effective teamwork could be achieved with further clinical communications training.     

Nurses' perceptions of quality and the factors that affect quality care for older people living in long-term care settings in Ireland

Aim. The aim of this research was to determine the factors that facilitate or hinder high quality nursing care for older people in long‐term care settings in Ireland. Background. The quality of care for older people living in long‐term care has been identified as an issue of concern in many nursing research studies. While many factors which have an impact on care have been identified, it is difficult to determine key factors from current research. Method. This was a mixed method study, which involved qualitative and quantitative approaches. A self‐response questionnaire was generated from data gathered by interview and analysis of literature. Information was collected from 498 nurses working in long‐term care settings within a Health Board. A 68% response rate was achieved. Factor analysis was used to identify facilitating and hindering factors of quality care for older people. Results. Nine factors where identified six facilitating factors of quality and three hindering factors of quality care. The six factors, which facilitate quality, were: an ethos of promoting independence and autonomy; a homelike social environment; person centred, holistic care; knowledgeable, skilled staff; knowing the person and adequate multidisciplinary resources. The three factors which hindered quality care; these were: a lack of time and patient choice, resistance to change and bound by routine. Conclusions. The findings of this research provide nurses with a clear set of facilitating and hindering factors of quality care for older people and reveal some of the complexities and challenges of providing this care. Relevance to clinical practice. Long‐term care is the home of many older people and attention within these environments to the facilitating and hindering factors of quality is required. It is hoped that the factors generated in this study add to understanding in relation to quality care and the factors that influence this.     

Malnutrition in a home‐living older population: prevalence,incidence and risk factors. A prospective study

Aims and objectives. To prospectively investigate and describe the prevalence and incidence of malnutrition among home‐living older people, related to demographic and medical factors, self‐perceived health and health‐related quality of life. Another aim was to find predictors for developing risk of malnutrition. Background. Risk factors for malnutrition have previously been identified as diseases, several medications, low functional status, symptoms of depression and inadequate nutrient intake. Most studies are cross‐sectionally performed at hospitals or in nursing care settings. Design. A prospective study with a sample of 579 home‐living older people, randomly selected from a local national register. Examinations were performed at baseline and yearly follow‐ups two to four times. Method. Questionnaires validated and tested for reliability, to detect risk of malnutrition (Mini Nutritional Assessment), symptoms of depression (Geriatric Depression Scale‐20), cognitive function (Mini Mental State Examination), health‐related quality of life (Nottingham Health Profile), well‐being (Philadelphia Geriatric Center Multilevel Assessment Instrument) self‐perceived health, demographic factors, anthropometry and biochemical examinations. Predictors were searched for through multiple logistic regression analysis with the MNA as dependent factor. Results. The prevalence of risk for malnutrition was 14·5%, according to the MNA. Two risk factors for malnutrition were lower handgrip strength and lower self‐perceived health. The incidence of risk for malnutrition at follow‐ups was between 7·6% and 16·2%. Predictors for developing malnutrition were higher age, lower self‐perceived health and more symptoms of depression. Men with symptoms of depression had a higher risk of developing malnutrition. Conclusion. Lower self‐perceived health had the highest power to predict risk for malnutrition, with increased number of depression symptoms and higher age as second and third predictors. Relevance to clinical practice. A regular and combined assessment using the Mini Nutrition Assessment, Geriatric Depression Scale‐20 and self‐perceived health as a base for identifying people in need, is one way to prevent the development of malnutrition.     

Postdischarge Nausea and Vomiting Risk Assessment in Breast and Gynecologic Surgical Patients

PurposePostdischarge nausea, vomiting, and retching often occur after the time of discharge from the postanesthesia care unit (PACU) in patients who have undergone outpatient surgeries. At a large mid-Atlantic Academic Hospital, 40% of gynecologic outpatient surgical patients had postdischarge nausea and vomiting (PDNV). The purpose of this quality improvement project was to implement and evaluate the effectiveness of and staff compliance with the Apfel Postdischarge Nausea and Vomiting Risk Assessment tool to improve PDNV risk screening in the PACU.DesignThis quality improvement project was part of an evidence-based practice project.MethodsAfter identification and recruitment of key stakeholders and unit champions, a force-field analysis, as part of Lewin's change theory, was completed to identify the driving and restraining forces. All PACU registered nurses received education on the risk assessment protocol using the Apfel risk assessment tool. The Apfel risk assessment tool has been validated to identify five independent risk factors for PDNV in outpatient ambulatory surgical populations. Implementation of the tool with data collection occurred for 8 weeks on all scheduled outpatient breast and gynecologic surgical patients. Staff compliance was measured throughout implementation.FindingsIn patients with at least three risk factors present, the Apfel tool correctly identified the risk for PDNV in 68% of patients. In patients with four and five risk factors present, the tool correctly identified the risk for PDNV in 88% and 100% of patients, respectively. Compliance with the tool was high with an average compliance rate of 92% for the 8-week data collection period.ConclusionsData analysis demonstrated that the Apfel risk assessment tool adequately predicted the risk for PDNV in outpatient surgical breast and gynecologic patients. Use of Lewin's change theory was successful in maintaining a high compliance rate throughout implementation. In addition, this quality improvement project resulted in increased compliance of the standing follow-up phone call policy. Efforts toward sustainment include expansion to all outpatient surgical populations and implementation of a PDNV prevention and management guideline.     

Comparison of finasteride and alpha-blockers as independent risk factors for erectile dysfunction

There are insufficient data on the effects of alpha-blockers and finasteride on erectile function in men who have other risk factors for erectile dysfunction (ED). This study was conducted to compare the relative effects of these medications on ED in men who may be on other medications or have other risk factors for ED. Patients attending urology and primary care clinics were asked to complete an IRB-approved questionnaire that combined the validated Sexual Health Inventory for Men (SHIM) and a detailed medical history. A total of 123 patients completed the questionnaire. The age range was 28-88 years (mean: 68 years). Eighty-one per cent of patients had SHIM scores <21, indicating some degree of ED. The average SHIM scores in a population of patients with similar age and risk factors who had been on finasteride or alpha-blockers indicated the presence of ED but did not reveal a significant difference between the two groups. The scores were no different from an age-matched group of patients who were not on either medication, demonstrating the relatively greater importance of various other risk factors for ED. There was an inverse linear relationship between the number of ED risk factors and SHIM scores. There does not appear to be a significant difference between alpha-blockers and finasteride as independent risk factors for ED. Age and other risk factors (heart disease, diabetes, hypertension, smoking, and hypercholesterolaemia) tend to have a much stronger influence on the severity of ED as assessed by SHIM scores.     

Emergency clinician‐delivered screening and intervention for high‐risk alcohol use: A qualitative analysis

Objectives: To evaluate qualitative feedback from patients who received opportunistic screening and brief intervention for harmful alcohol use during an ED attendance; to evaluate emergency staff attitudes to performing alcohol screening and delivering opportunistic brief intervention; and to document process issues associated with the introduction of routine clinician‐initiated opportunistic screening and training and administration of brief intervention. Methods: Structured and semi‐structured interviews with emergency staff and recipients of brief intervention. Results: Sixty‐nine patients were interviewed 3 months after an ED attendance where they received emergency clinician‐delivered brief intervention for high‐risk alcohol use. Twenty‐two (32%; 95% CI 21–43%) reported a positive effect of brief intervention on thoughts or behaviour, but 29% (95% CI 18–40%) felt the intervention was not relevant for them or could not recall it. Four people (6%; 95% CI 1–12%) felt confronted or embarrassed, and 17 (25%; 95% CI 15–36%) felt timing or delivery could be improved. Staff had a positive attitude to delivering brief intervention, but nominated lack of time as the main barrier. Fourteen of 15 staff felt brief intervention should become routine in emergency care. Conclusion: Emergency clinicians can be trained to provide brief intervention for high‐risk alcohol in an ED. The use of emergency clinician brief intervention is acceptable to most staff and patients.     

Prehospital 12-lead Electrocardiography Impact on Acute Myocardial Infarction Treatment Times and Mortality: A Systematic Review

Objectives: Prehospital 12‐lead electrocardiogram (PHECG) interpretation and advance emergency department (ED) notification may improve time‐to‐treatment intervals for a variety of treatment strategies to improve outcome in acute myocardial infarction. Despite consensus guidelines recommending this intervention, few emergency medical services (EMS) employ this. The authors systematically reviewed the literature to report whether mortality or treatment time intervals improved when compared with standard care. Methods: The authors used the Cochrane strategy to search MEDLINE, EMBASE, Current Contents, Dissertation Abstracts, Cochrane Library, and Index of Scientific and Technical Proceedings. Bibliographies and grant‐agency Websites were reviewed, and primary investigators and industry were contacted for published and unpublished studies. Inclusion criteria included PHECG and advance ED notification versus standard EMS care; controlled trials; English only; and evaluation of treatment time intervals, all‐cause mortality, or both. Study selection was hierarchical, blinded, and independent. Agreement at each level of review was evaluated by using a kappa statistic. Study quality was measured with a validated scale and was interpreted by two independent reviewers. Results: A total of 1,283 citations were identified, and five studies met the inclusion criteria. The weighted kappa for selection was 0.61 (standard error [SE], 0.045) for titles, 0.63 (SE, 0.051) for abstracts, and 0.79 (SE, 0.146) for full articles. Mean study quality measures by two independent reviewers were 6.0/15 and 5.5/15 (correlation coefficient, 0.85; p = 0.06). PHECG and advance ED notification increased the weighted mean on‐scene time by 1.2 minutes (95% confidence interval [95% CI] =?0.84 to 3.2). The weighted mean door‐to‐needle interval was shortened by 36.1 minutes (95% CI = 9.3 to 63.0: range of means, 22–48 minutes vs. 50–97 minutes). One study reported all‐cause mortality, with a statistically nonsignificant reduction from 15.6% to 8.4%. Conclusions: For patients with AMI, the literature would suggest that PHECG and advanced ED notification reduces in hospital time to fibrinolysis. One controlled trial found no difference in mortality with this out‐of‐hospital intervention.     

Assessment of malnutrition in mental health clients: nurses' judgement vs. a nutrition risk tool

BACKGROUND: The existence of malnutrition in general hospitals is well documented. Psychiatric patients are known to have increased risk of malnutrition, yet physical examinations and nutritional assessments rarely take place in psychiatric hospitals. AIM: The purpose of this study was to adapt an established nutrition risk score for use with psychiatric patients, using criteria previously agreed by the care team, and to assess whether the clinical judgement of ward staff alone identified a similar group of patients to be at risk. METHOD: The risk score assessment was compared with a subjective risk assessment made by nursing staff as patients were admitted to the unit. Data were collected for 112 patients. RESULTS: The comparison revealed that nurses did not identify malnutrition in the same patients as the risk score, overlooking 27 (29%) at risk patients. Nurses associated malnutrition with psychotic illness, suggesting that depressed patients are more likely to be overlooked. STUDY LIMITATIONS: Although the risk score was based on a validated tool and its content and face validity were established, it has not itself been validated against criteria of nutritional status (malnutrition). CONCLUSIONS: Implementing routine nutritional screening on such units would assist in identifying at risk patients, enabling referral for dietetic intervention to be made. Providing nutrition education for staff might help to improve knowledge and awareness of malnutrition for this patient group.     

Portable Advanced Medical Simulation for New Emergency Department Testing and Orientation

Objectives: Efforts to mitigate unexpected problems during transition of an active emergency department (ED) to a new physical plant are imperative to ensure effective health care delivery and patient safety. The authors used advanced medical simulation (SIM) to evaluate the capacity of a new ED for emergent resuscitative processes and assist facility orientation before opening day. Methods: Operational readiness testing and orientation to the new ED of a large academic center were arranged through a Transportable Enhanced Simulation Technologies for Pre‐Implementation Limited Operations Testing (TESTPILOT) project. Using a portable life‐sized computerized manikin, the project required participants to perform assorted patient care interventions on‐site. Cardiac arrest, multitrauma, uroseptic shock, and pediatric toxicology scenarios elicited the dynamics of real‐life ED activities. Debriefings and surveys assessed participants' perceptions of the new facility's clinical readiness and identified areas needing administrative attention. Subjective utility of SIM orientation was compared with that of standard facility orientation. Results: Fourteen ED clinicians and five SIM facilitators participated over two sessions. The new facility received mean (± SD) and median five‐point Likert scale scores of 4.4 (± 0.8) and 5 for ability of clinical staff to perform resuscitations. The respective scores for ability of simulated scenarios to prepare staff for new ED function were 4.6 (± 0.5) and 5, compared with 4.2 (± 1.0) and 4 for non‐SIM orientation (p = 0.22; not significant). Problems with equipment location, inadequate procedural surfaces, and insufficient orientation were discovered and rapidly corrected. Conclusions: Transportable SIM was used to evaluate the clinical functions of a new ED. Significant operational issues identified by participants were corrected before opening of the facility. Limited comparison did not reveal SIM enhancement of orientation.     

A Preliminary Report of Knowledge Translation: Lessons From Taking Screening and Brief Intervention Techniques From the Research Setting Into Regional Systems of Care

This article describes a limited statewide dissemination of an evidence‐based technology, screening, brief intervention, and referral to treatment (SBIRT), and evaluation of the effects on emergency department (ED) systems of care, utilizing the knowledge translation framework of reach, effectiveness, adoption, implementation, and maintenance (RE‐AIM), using both quantitative and qualitative data sources. Screening and brief intervention (SBI) can detect high‐risk and dependent alcohol and drug use in the medical setting, provide early intervention, facilitate access to specialty treatment when appropriate, and improve quality of care. Several meta‐analyses demonstrate its effectiveness in primary care, and the federal government has developed a well‐funded campaign to promote physician training and adoption of SBI. In the busy environment of the ED, with its competing priorities, researchers have tested a collaborative approach that relies on peer educators, with substance abuse treatment experience and broad community contact, as physician extenders. The ED‐SBIRT model of care reflects clinician staff time constraints and resource limitations and is designed for the high rates of prevalence and increased acuity typical of ED patients. This report tracks services provided during dissemination of the ED‐SBIRT extender model to seven EDs across a northeastern state, in urban, suburban, and rural community settings. Twelve health promotion advocates (HPAs) were hired, trained, and integrated into seven ED teams. Over an 18‐month start‐up period, HPAs screened 15,383 patients; of those, 4,899 were positive for high risk or dependent drinking and/or drug use. Among the positive screens, 4,035 (82%) received a brief intervention, and 57% of all positives were referred to the substance abuse treatment system and other community resources. Standardized, confidential interviews were conducted by two interviewers external to the program with 24 informants, including HPAs and their supervisors, clinicians, nurse managers, and ED directors across five sites. A detailed semistructured format was followed, and results were coded for thematic material. Barriers, challenges, and successes are described in the respondents’ own words to convey their experience of this demonstration of SBIRT knowledge translation. Five of seven sites were sustained through the second year of the program, despite cutbacks in state funding. The dissemination process provided a number of important lessons for a large rollout. Successful implementation of the ED‐SBIRT HPA model depends on 1) external funding for start‐up; 2) local ED staff acting as champions to support the HPA role, resolve territorial issues, and promote a cultural shift in the ED treatment of drug and alcohol misuse from “treat and street” to prevention, based on a knowledge of the science of addiction; 3) sustainability planning from the beginning involving administrators, the billing and information technology departments, medical records coders, community service providers, and government agencies; and 4) creation and maintenance of a robust referral network to facilitate patient acceptance and access to substance abuse services.     

Why patients attend emergency departments for conditions potentially appropriate for primary care: reasons given by patients and clinicians differ

Objectives: To compare reasons identified by clinical staff for potential primary care attendances to the ED with those previously identified by patients. Methods: Survey of staff and primary care patients in five ED in New South Wales, Australia using questionnaire based on reasons identified in published studies. Results: Clinicians in the survey identify a broader spectrum of reasons for potential primary care cases presenting to the ED than the patients themselves report. Doctors reported on average 4.1 very important reasons and nurses 4.8 compared with patients 2.4 very important reasons. The main reasons identified by both doctors and nurses were similar and quite different to those identified by patients. Clinicians were more likely to emphasize cost and access issues rather than acuity and complexity issues. There was no difference within the clinician group between doctors and nurses nor by varying levels of experience. Furthermore doctors with significant experience in both primary care and emergency medicine did not differ from the overall clinicians' pattern. Conclusions: These data confirm that clinician perspectives on reasons for potential primary care patients' use of ED differ quite markedly from the perspectives of patients themselves. Those differences do not necessarily represent a punitive or blaming philosophy but will stem from the very different paradigms from which the two protagonists approach the interactions, reflecting the standard tension in a provider – consumer relationship. If policy is to be developed to improve system use and access, it must take both perspectives into account with respect to redesign, expectations and education.     

Review article: Diagnostic accuracy of risk stratification tools for patients with chest pain in the rural emergency department: A systematic review

Risk stratification tools for patients presenting to rural EDs with undifferentiated chest pain enable early definitive treatment in high‐risk patients. This systematic review compares the most commonly used risk stratification tools used to predict the risk of major adverse cardiac event (MACE) for patients presenting to rural EDs with chest pain. A comprehensive search of MEDLINE and Embase for studies published between January 2011 and January 2015 was undertaken. Study quality was assessed using QUADAS‐2 criteria and the PRISMA guidelines.Eleven studies using eight risk stratification tools met the inclusion criteria. The percentage of MACE in the patients stratified as suitable for discharge, and the percentage of patients whose scores would have recommended admission that did not experience a MACE event were used as comparisons. Using the findings of a survey of emergency physicians that found a 1% MACE rate acceptable in discharged patients, the EDACS‐ADP was considered the best performer. EDACS‐ADP had one of the lowest rates of MACE in those discharged (3/1148, 0.3%) and discharged one of the highest percentage of patients (44.5%). Only the GRACE tool discharged more patients (69% – all patients with scores <100) but had a MACE rate of 0.3% in discharged patients. The HFA/CSANZ guidelines achieved zero cases of MACE but discharged only 1.3% of patients.EDACS‐ADP can potentially increase diagnostic efficiency of patients presenting at ED with chest pain. Further assessment of tool in a rural context is recommended.