Showing papers by "Jonathan C Knott published in 2016"

Presentation patterns and outcomes of patients with cancer accessing care in emergency departments in Victoria, Australia

Abstract: People with cancer attend emergency departments (EDs) for many reasons. Improved understanding of the specific needs of these patients may assist in optimizing health service delivery. ED presentation and hospital utilization characteristics were explored for people with cancer and compared with those patients without cancer. This descriptive, retrospective, multicentre cohort study used hospital administrative data. Descriptive and inferential statistics were used to summarise and compare ED presentation characteristics amongst cancer and non-cancer groups. Predictive analyses were used to identify ED presentation features predictive of hospital admission for cancer patients. Outcomes of interest were level of acuity, ED and inpatient length of stay, re-presentation rates and admission rates amongst cancer patients and non-cancer patients. ED (529,377) presentations occurred over the 36 months, of which 2.4 % (n = 12,489) were cancer-related. Compared with all other attendances, cancer-related attendances had a higher level of acuity, requiring longer management time and length of stay in ED. Re-presentation rates for people with cancer were nearly double those of others (64 vs 33 %, p < 0.001), with twice the rate of hospital admission (90 vs 46 %, p < 0.001), longer inpatient length of stay (5.6 vs 2.8 days, p < 0.001) and had higher inpatient mortality (7.9 vs 1.0 %, p < 0.001). Acuity and arriving by ambulance were significant predictors of hospital admission, with cancer-related attendances having ten times the odds of admission compared to other attendances (OR = 10.4, 95 % CI 9.8–11.1). ED presentations by people with cancer represent a more urgent, complex caseload frequently requiring hospital admission when compared to other presentations, suggesting that for optimal cancer care, close collaboration and integration of oncology, palliative care and emergency medicine providers are needed to improve pathways of care.

Implementation research in emergency medicine: a systematic scoping review

Abstract: Introduction Implementation research aims to increase the uptake of research findings into clinical practice to improve the quality of healthcare. This scoping systematic study aims to assess the volume and scope of implementation research in emergency medicine (EM) to obtain an overview and inform future implementation research. Methods Studies were identified by searching electronic databases and reference lists of included studies for the years 2002, 2007 and 2012. Titles/abstracts were screened, full papers checked and data extracted by one author, with a random sample checked by a second author. Results A total of 3581 citations were identified with 197 eligible papers included. The number of papers significantly increased over time from 26 in 2002 to 77 in 2007 and 94 in 2012 (p Conclusions Although there was a significant increase in the number of implementation research papers, most studies focused on identifying evidence–practice gaps or used weak study designs to evaluate the effects of implementation interventions. Recommendations for improving implementation research in EM include identifying barriers and enablers to implementation, using theory in areas where proven important gaps exist, improving the reporting of the content of interventions and using rigorous study designs to evaluate their effectiveness.

The Many Organisational Factors Relevant to Planning Change in Emergency Care Departments: A Qualitative Study to Inform a Cluster Randomised Controlled Trial Aiming to Improve the Management of Patients with Mild Traumatic Brain Injuries.

Abstract: BACKGROUND: The Neurotrauma Evidence Translation (NET) Trial aims to design and evaluate the effectiveness of a targeted theory-and evidence-informed intervention to increase the uptake of evidence-based recommended practices for the management of patients who present to an emergency department (ED) with mild head injuries. When designing interventions to bring about change in organisational settings such as the ED, it is important to understand the impact of the context to ensure successful implementation of practice change. Few studies explicitly use organisational theory to study which factors are likely to be most important to address when planning change processes in the ED. Yet, this setting may have a unique set of organisational pressures that need to be taken into account when implementing new clinical practices. This paper aims to provide an in depth analysis of the organisational context in which ED management of mild head injuries and implementation of new practices occurs, drawing upon organisational level theory. METHODS: Semi-structured interviews were conducted with ED staff in Australia. The interviews explored the organisational context in relation to change and organisational factors influencing the management of patients presenting with mild head injuries. Two researchers coded the interview transcripts using thematic content analysis. The "model of diffusion in service organisations" was used to guide analyses and organisation of the results. RESULTS: Nine directors, 20 doctors and 13 nurses of 13 hospitals were interviewed. With regard to characteristics of the innovation (i.e. the recommended practices) the most important factor was whether they were perceived as being in line with values and needs. Tension for change (the degree to which stakeholders perceive the current situation as intolerable or needing change) was relatively low for managing acute mild head injury symptoms, and mixed for managing longer-term symptoms (higher change commitment, but relatively low change efficacy). Regarding implementation processes, the importance of (visible) senior leadership for all professions involved was identified as a critical factor. An unpredictable and hectic environment brings challenges in creating an environment in which team-based and organisational learning can thrive (system antecedents for innovation). In addition, the position of the ED as the entry-point of the hospital points to the relevance of securing buy-in from other units. CONCLUSIONS: We identified several organisational factors relevant to realising change in ED management of patients who present with mild head injuries. These factors will inform the intervention design and process evaluation in a trial evaluating the effectiveness of our implementation intervention. Language: en

Clinical impact of a high-sensitivity troponin assay introduction on patients presenting to the emergency department.

Abstract: Objective Biomarkers are a critical component in the investigation of patients with potential ischaemic heart disease. The proposed benefits of a high-sensitivity troponin (hs-Tn) assay include earlier diagnosis of myocardial infarction. However, the decreased specificity may adversely affect clinical practice. The present study aims to investigate the impact that the introduction of a hs-Tn assay had on patients presenting to the ED. Methods A pre- and post-interventional analysis was performed on all patients presenting to the Royal Melbourne Hospital ED, and had a troponin, in the 12 months before and after the introduction of the hs-Tn assay. The main outcome measures were ED length of stay, admission rates, proportion of patients undergoing interventional cardiac procedures and proportion diagnosed with myocardial infarction. Results There were 6557 patients who had a conventional assay and 7335 patients who had a hs-Tn assay. The introduction of a hs-Tn assay was associated with an increased abnormal troponin rate (23.4% vs 28.1%, P < 0.001). The median length of ED stay decreased by 9.1% (P < 0.001). The proportion admitted to hospital increased (60.9% vs 65.9%, P < 0.001); however, there was no difference in the proportion undergoing revascularisation or the proportion diagnosed with myocardial infarction. Conclusions Although the introduction of a hs-Tn assay led to an increase in hospital admissions, the unchanged rate of cardiac procedures or final diagnoses of acute myocardial infarction and ischaemic heart disease suggests that the hs-Tn did not improve the detection of these conditions. It remains unclear whether there was a benefit admitting the additional cohort of patients.

Estimation of the potential eye and tissue donor pool in an Australian emergency department.

Abstract: Objective EDs have long been considered a potential source of eye and tissue donors, but no specific evidence to support this was identified in the Australian setting. The present study aims to bridge that knowledge gap, by analysing medical and social histories of those who have died over a 5 year period so as to determine donation eligibility in this population. Methods A retrospective audit was undertaken of all patients who died within the Royal Melbourne Hospital ED between 2010 and 2014. ED records, pharmacy records and electronic medical histories were audited for the presence of eye and tissue donation exclusion criteria and the distribution of these criteria within the target population. Results Over the 5 year period, of 326 deaths that occurred in the ED, one third was suitable for eye donation (n = 106) and one in seven (n = 45) for tissue donation. Of the age appropriate patients, five criteria were identified that excluded up to 85% of the population not eligible to donate. These were: haematological malignancies, neurodegenerative conditions, non-haematological malignancies, chronic renal failure and eye disease. Conclusion The present study has identified a large pool of potential eye and tissue donors; a pool mostly unrecognised by emergency clinicians. An extensive list of exclusion criteria restricts donor potential. However, the present study has identified that only five fundamentally limit donation in the ED population. Utilisation of this knowledge will allow for the development of clinical triggers that will improve identification, and increase realisation, of potential donors.

Intravenous Midazolam-Droperidol (combination), Droperidol (only) or Olanzapine (only) for the acutely agitated patient: A multi-centred, randomised, double-blind, triple-dummy, clinical trial

Abstract: Intravenous Midazolam-Droperidol (combination), Droperidol (only) or Olanzapine (only) for the acutely agitated patient: A multi-centred, randomised, double-blind, triple-dummy, clinical trial Author(s) Taylor, DMCD; Yap, CYL; Knott, JC; Taylor, SE; Phillips, GA; Karro, J; Chan, EW; Kong, DCM; Castle, DJ Citation The 16th International Conference on Emergency Medicine (ICEM 2016), Cape Town, South Africa, 18-21 April 2016.