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Background: This study aims to examine the costs associated with a Hospital in the Nursing Home (HiNH) program in Queensland Australia directed at patients from residential aged care facilities (RACFs) with emergency care needs. Methods: A cost analysis was undertaken comparing the costs under the HiNH program and the current practice, in parallel with a pre-post controlled study design. The study was conducted in two Queensland public hospitals: the Royal Brisbane and Women’s Hospital (intervention hospital) and the Logan Hospital (control hospital). Main outcome measures were the associated incremental costs or savings concerning the HiNH program provision and the acute hospital care utilisation over one year after intervention. Results: The initial deterministic analysis calculated the total induced mean costs associated with providing the HiNH program over one year as AU$488,116, and the total induced savings relating to acute hospital care service utilisation of AU$8,659,788. The total net costs to the health service providers were thus calculated at -AU$8,171,671 per annum. Results from the probabilistic sensitivity analysis (based on 10,000 simulations) showed the mean and median annual net costs associated with the HiNH program implementation were -AU$8,444,512 and–AU$8,202,676, and a standard deviation of 2,955,346. There was 95% certainty that the values of net costs would fall within the range from -AU$15,018,055 to -AU$3,358,820. Conclusions: The costs relating to implementing the HiNH program appear to be much less than the savings in terms of associated decreases in acute hospital service utilisation. The HiNH service model is likely to have the cost-saving potential while improving the emergency care provision for RACF residents. [ABSTRACT FROM AUTHOR]

Only recently has the potential (unmet) palliative care (PC) workload in the ED been recognised. While confident in PC symptom management, we underestimate the role of a palliative approach in non-cancer diagnoses and seek education in areas such as individual patient care pathways, ethical and legal issues and difficult conversations at the end of life. PC is best introduced early for a range of life-limiting cancer and non-cancer diagnoses. Allowing patients time to tell their story with active listening, acknowledgement of suffering and a compassionate presence leads to treatment 'success' that is not defined by cure. This patient-centred, rather than disease-centred approach, is the essence of PC, and one that is easily incorporated into emergency practice. PC and disease-specific treatments can comfortably coexist, and with meticulous symptom management, may actually prolong life. PC is everyone's business, and emergency medicine needs to be part of it. [ABSTRACT FROM AUTHOR]

Background Emergency department (ED) clinicians are more frequently providing care, including end-of-life care, to older people. Objectives To estimate the need for ED end-of-life care for people aged ≥65 years, describe characteristics of those dying within 48 hours of ED presentation and compare those dying in ED with those dying elsewhere. Methods We conducted a retrospective cohort study analysing data from 177 hospitals in Australia and New Zealand. Data on older people presenting to ED from January to December 2018, and those who died within 48 hours of ED presentation, were analysed using simple descriptive statistics and univariate logistic regression. Results From participating hospitals in Australia or New Zealand, 10,921 deaths in older people occurred. The 48-hour mortality rate was 6.43 per 1,000 ED presentations (95% confidence interval: 6.31–6.56). Just over a quarter (n = 3,067, 28.1%) died in ED. About one-quarter of the cohort (n = 2,887, 26.4%) was triaged into less urgent triage categories. Factors with an increased risk of dying in ED included age 65–74 years, ambulance arrival, most urgent triage categories, principal diagnosis of circulatory system disorder, and not identifying as an Aboriginal or Torres Strait Islander person. Of the 7,677 older people admitted, half (n = 3,836, 50.0%) had an encounter for palliative care prior to, or during, this presentation. Conclusions Our findings provide insight into the challenges of recognising the dying older patient and differentiating those appropriate for end-of-life care. We support recommendations for national advanced care planning registers and suggest a review of triage systems with an older person-focused lens. [ABSTRACT FROM AUTHOR]

Objectives: To describe the characteristics of, and care provided to, older people who died within 48 h of ED presentation. Methods: A descriptive retrospective cohort study of people 65 years and older presenting to two EDs in Queensland, Australia, between April 2018 and March 2019. Data from electronic medical records were collected and analysed. Results: Two hundred and ninety‐five older people who died within 48 h of ED presentation were included. Nearly all arrived by ambulance (92%, n = 272) and 36% (n = 106) were from aged care facilities. Three‐quarters (75%, n = 222) were triaged into the most urgent triage categories (i.e. Australasian Triage Scale; ATS 1/2). Fewer than half were previously independent with mobility (38%, n = 111) and activities of daily living (43%, n = 128). Sixty‐one per cent (n = 181) had a pre‐existing healthcare directive. Twenty‐two per cent (n = 66) died in ED, most commonly due to pneumonia, intracerebral haemorrhage, cardiac arrest and/or sepsis. Over half had one or more ED visits (52%, n = 154) and/or hospital admissions (52%, n = 152) 6 months prior. Conclusions: Identification of patients at end‐of‐life (EoL) is not always straightforward; consider recent reduction in independence and recent ED visits/hospital admissions. System‐based strategies that span pre‐hospital, ED and in‐patient care are recommended to facilitate EoL pathway implementation and care continuity. [ABSTRACT FROM AUTHOR]

The article offers the author's insights on the case of a 35-year-old Ms. K with Rett syndrome who was referred for percutaneous enterogastrostomy tube (PEG) insertion. The author states that Ms. K was inserted with naso-gastric tube for supplemental feeding due to lost weight but, this caused her vomiting. Moreover, she was referred for PEG insertion, causing aspiration risk and made her not to meet nutritional requirements. He contends that PEG was unconvincing to prolong the life of Ms. K.

The article presents a case study of a 35-year-old female diagnosed with Rett syndrome and referred for percutaneous enterogastrostomy tube (PEG) insertion. The patient's mother decides not to proceed PEG and to stop her nasogastric feeding with an explanation that artificial feeding was not in the best interests of her daughter. The mother knows too well on the risk of her decision and thinks that she is doing her daughter a favor.

Objective: To determine the burden, on the ED, of harm from unintentional adverse drug events (ADEs) in the community. Methods: A retrospective, observational study of 936 randomly selected presentations to a level 6 ED at a principal referral hospital in Brisbane, Australia, in November 2017. Clinical records were screened by a pharmacist, who identified suspected ADEs. All suspected ADEs and a random selection of presentations without ADEs were reviewed by an expert panel, which classified, by consensus: occurrence and type of ADE, contribution of ADE to presentation, severity of harm and preventability of presentation. Medication‐related ED presentations (ADE‐Ps) and potential ADEs were, respectively, defined as presentations directly attributable to an ADE, and medication events that occurred but did not cause the ED presentation. Descriptive data analysis was performed. Results: The median (interquartile range) age of patients was 40 (27–58) years, with 49.7% (95% confidence interval [CI] 46.5–52.9) being male. The prevalences of ADE‐Ps and potential ADEs were 9.2% (95% CI 7.5–11.3) and 5.0% (95% CI 3.8–6.6), respectively. The severity of harm was classified as 'death or likely permanent harm' in 4.7% (95% CI 0.2–9.1) of ADE‐Ps, 'temporary harm' (89.5%, 95% CI 83.1–96.0) and 'minimal or no harm' (5.8%, 95% CI 0.9–10.8). Most (79.1%, 95% CI 70.5–87.7) ADE‐Ps were preventable. Conclusions: There is a high burden on emergency care because of unintended medication harm in the community. Interventions to reduce such harm are likely to require a co‐ordinated primary, acute and public healthcare response. The high proportion of presentations with potential ADEs indicates opportunity for harm mitigation in the ED. [ABSTRACT FROM AUTHOR]

Background: There has been considerable publicity regarding population ageing and hospital emergency department (ED) overcrowding. Our study aims to investigate impact of one intervention piloted in Queensland Australia, the Hospital in the Nursing Home (HiNH) program, on reducing ED and hospital attendances from residential aged care facilities (RACFs).Methods: A quasi-experimental study was conducted at an intervention hospital undertaking the program and a control hospital with normal practice. Routine Queensland health information system data were extracted for analysis.Results: Significant reductions in the number of ED presentations per 1000 RACF beds (rate ratio (95 % CI): 0.78 (0.67-0.92); p = 0.002), number of hospital admissions per 1000 RACF beds (0.62 (0.50-0.76); p < 0.0001), and number of hospital admissions per 100 ED presentations (0.61 (0.43-0.85); p = 0.004) were noticed in the experimental hospital after the intervention; while there were no significant differences between intervention and control hospitals before the intervention. Pre-test and post-test comparison in the intervention hospital also presented significant decreases in ED presentation rate (0.75 (0.65-0.86); p < 0.0001) and hospital admission rate per RACF bed (0.66 (0.54-0.79); p < 0.0001), and a non-significant reduction in hospital admission rate per ED presentation (0.82 (0.61-1.11); p = 0.196).Conclusions: Hospital in the Nursing Home program could be effective in reducing ED presentations and hospital admissions from RACF residents. Implementation of the program across a variety of settings is preferred to fully assess the ongoing benefits for patients and any possible cost-savings. [ABSTRACT FROM AUTHOR]