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Start date: 2020Subject: search.filters.subject.Hospitals

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    Exploring solutions : addressing non-urgent emergency department presentations : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing, Massey University, Albany, New Zealand
    (Massey University, 2025-07-30) Alderson, Amber
    Background: The Emergency Department (ED) plays a crucial role in delivering healthcare, focusing on the rapid assessment and treatment of serious illnesses or injuries, often providing life-saving resuscitation and stabilisation. However, EDs face increasing pressure from rising patient volumes, increased acuity and limited resources. This growing demand highlights the need for innovative strategies to optimise ED operations and improve patient outcomes. Patients presenting to the ED with non-urgent concerns need to be managed through more appropriate pathways. Aim: This study aims to analyse the characteristics of non-urgent ED presentations and propose a novel care pathway to address the healthcare needs of this patient group effectively. Methods: A mixed-methods approach was employed, combining qualitative and quantitative data. Five focus groups with healthcare professionals provided qualitative insights into non-urgent presentations. A quantitative patient database review spanning eight years (65,000-90,000 annual ED presentations) was conducted to identify trends and inform the new pathway development. The stage-gate process was used to guide the development and refinement of the proposed care pathway, ensuring systematic evaluation and iteration at each stage based on stakeholder feedback and data insights. Findings: Analysis revealed a priority non-urgent patient group defined by specific criteria: ‘walk-ins’ to the ED, self-referred, Australasian Triage Scale (ATS) four or five, not redirected to urgent care and presenting within six months of a prior ED visit. These individuals predominantly resided in high-deprivation areas, were aged 20–69 years, had low-acuity diagnoses and high ED attrition rates. Using these findings, the Coordination, Assessment, Treatment and Community Hauora (CATCH) model was developed. This pathway integrates ED based nurse practitioners undertaking assessment and treatment alongside patient navigators who empower patients and connect them with appropriate healthcare services. Unlike the conventional ED model, grounded in critical care and triage principles, the CATCH model is tailored to address non-urgent care needs. Conclusion: This research identifies a distinct non-urgent patient group presenting to the ED and introduces a targeted care pathway leveraging nurse practitioners and patient navigators. Future studies could implement the CATCH model to evaluate its real-world effectiveness in improving care and reducing ED demand.
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    Respiratory Support of Adults in the Emergency Department : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, [Auckland], New Zealand
    (Massey University, 2024-11) O'Donnell, Jane Frances
    Introduction: Adult emergency department (ED) patients frequently require respiratory support (RS), yet limited research on RS, particularly nasal high-flow (NHF) therapy, is available in this setting. This doctoral research aimed to analyse the nature of ED-based RS and its impact on adult patient outcomes, focusing on NHF therapy. Grounded in an evidence-based practice (EBP) framework, this research proposes to bridge a theory-practice gap and inform NHF clinical decision-making in the ED. Methodology: This thesis was informed by a positivist philosophical paradigm and methodology underpinned by an EBP theoretical framework. The research approach was quantitative, the research strategy was non-experimental, the design was multi-method, and the time horizon was cross-sectional, using two methods. The two methods were a systematic review (SR) with meta-analysis (MA) and a point prevalence study (PPS). Each method was conducted in parallel and as per the multi-method design, and the results were integrated to form the thesis findings and answer the research questions. Results: In the first method, the SR provided five MAs involving 18 ED RCTs reporting on 1874 participants. A 45% reduction in escalation relative risk (RR) was seen for NHF vs conventional oxygen therapy (COT) (RR 0.55; 95% CI, 0.33 to 0.92; p = 0.02), with no difference in mortality or adverse event risk. For NHF vs non-invasive ventilation (NIV), NHF increased escalation risk by 81% (RR 1.81; 95% CI, 1.19 to 2.75; p < 0.01). Mortality risk was not different for NHF vs NIV. In the second method, the PPS characterised 76 patients receiving RS from a total of 898 ED-presenting patients. The PPS was underpowered and unable to support its planned inferential analyses. The mean age of the participants was 67.38 years (SD ± 17.4); 52% (n = 40) were male, 48.6% (n = 37) had greater than three comorbidities, and 44% (n = 34) had primary respiratory diagnoses. By ethnicity, the Indigenous New Zealand Māori were overrepresented in the data (n = 18, 23%). Of those receiving RS, the minority (n = 12, 15.7%) received NHF; however, all these required subsequent hospitalisation. The absolute prevalence of the requirement for escalation of RS was n = 22 (28.9%). The hospitalisation rate was 22% higher, and the hospital length of stay was 42% longer for those requiring RS escalation in the ED. Māori demonstrated a 5.8% higher risk of requiring escalation of care on an absolute scale (n = 6, 33.3%) vs (n = 16, 27.5%), and a 22% increased risk on a relative scale (RR 1.22; 95% CI 0.56 to 2.67; p = 0.60) than non-Māori. Conclusions: When the results from the two methods were integrated, the main finding was that nearly a third of those receiving RS required escalation of their RS, with those receiving NHF requiring less escalation than those receiving all other forms of RS combined. These findings align with the meta-analysis of studies for the comparison of NHF compared to COT but not the comparison of NHF compared to NIV.
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    Slow and steady-small, but insufficient, changes in food and drink availability after four years of implementing a healthy food policy in New Zealand hospitals
    (BioMed Central Ltd, 2024-12) Mackay S; Rosin M; Kidd B; Gerritsen S; Shen S; Jiang Y; Te Morenga L; Ni Mhurchu C
    BACKGROUND: A voluntary National Healthy Food and Drink Policy (the Policy) was introduced in public hospitals in New Zealand in 2016. This study assessed the changes in implementation of the Policy and its impact on providing healthier food and drinks for staff and visitors in four district health boards between 1 and 5 years after the initial Policy introduction. METHODS: Repeat, cross-sectional audits were undertaken at the same eight sites in four district health boards between April and August 2017 and again between January and September 2021. In 2017, there were 74 retail settings audited (and 99 in 2021), comprising 27 (34 in 2021) serviced food outlets and 47 (65 in 2021) vending machines. The Policy's traffic light criteria were used to classify 2652 items in 2017 and 3928 items in 2021. The primary outcome was alignment with the Policy guidance on the proportions of red, amber and green foods and drinks (≥ 55% green 'healthy' items and 0% red 'unhealthy' items). RESULTS: The distribution of the classification of items as red, amber and green changed from 2017 to 2021 (p < 0.001) overall and in serviced food outlets (p < 0.001) and vending machines (p < 0.001). In 2021, green items were a higher proportion of available items (20.7%, n = 815) compared to 2017 (14.0%, n = 371), as were amber items (49.8%, n = 1957) compared to 2017 (29.2%, n = 775). Fewer items were classified as red in 2021 (29.4%, n = 1156) than in 2017 (56.8%, n = 1506). Mixed dishes were the most prevalent green items in both years, representing 11.4% (n = 446) of all items in 2021 and 5.5% (n = 145) in 2017. Fewer red packaged snacks (11.6%, n = 457 vs 22.5%, n = 598) and red cold drinks (5.2%, n = 205 vs 12.5%, n = 331) were available in 2021 compared to 2017. However, at either time, no organisation or setting met the criteria for alignment with the Policy (≥ 55% green items, 0% red items). CONCLUSIONS: Introduction of the Policy improved the relative healthiness of food and drinks available, but the proportion of red items remained high. More dedicated support is required to fully implement the Policy.
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    Effectiveness of hospital transfer payments under a prospective payment system: An analysis of a policy change in New Zealand
    (John Wiley and Sons Ltd, 2022-07) Schumacher C
    Prospective payment systems reimburse hospitals based on diagnosis-specific flat fees, which are generally based on average costs. While this encourages cost-consciousness on the part of hospitals, it introduces undesirable incentives for patient transfers. Hospitals might feel encouraged to transfer patients if the expected treatment costs exceed the diagnosis-related flat fee. A transfer fee would discourage such behavior and, therefore, could be welfare enhancing. In 2003, New Zealand introduced a fee to cover situations of patient transfers between hospitals. We investigate the effects of this fee by analyzing 4,020,796 healthcare events from 2000 to 2007 and find a significant reduction in overall transfers after the policy change. Looking at transfer types, we observe a relative reduction in transfers to non-specialist hospitals but a relative increase in transfers to specialist facilities. It suggests that the policy change created a focusing effect that encourages public health care providers to transfer patients only when necessary to specialized providers and retain those patients they can treat. We also find no evidence that the transfer fee harmed the quality of care, measured by mortality, readmission and length of stay. The broader policy recommendation of this research is the introduction or reassessment of transfer payments to improve funding efficiency.
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    The use of telephone communication between nurse navigators and their patients
    (Public Library of Science (PLoS), 2020) Heritage B; Harvey C; Brown J; Hegney D; Willis E; Baldwin A; Heard D; Mclellan S; Clayton V; Claes J; Lang M; Curnow V
    Background Hospitals and other health care providers frequently experience difficulties contacting patients and their carers who live remotely from the town where the health service is located. In 2016 Nurse Navigator positions were introduced into the health services by Queensland Health, to support and navigate the care of people with chronic and complex conditions. One hospital in Far North Queensland initiated an additional free telephone service to provide another means of communication for patients and carers with the NNs and for off-campus health professionals to obtain details about a patient utilising the service. Calls made between 7am and 10pm, seven days per week are answered by a nurse navigator. Aim To report utilisation of the service by navigated clients and remotely located clinicians compared to use of navigators’ individual work numbers and direct health service numbers. We report the reason for calls to the free number and examine features of these calls. Methods Statistical analysis examined the call reason, duration of calls, setting from where calls originated and stream of calls. Interactions between the reasons for calls and the features of calls, such as contact method, were examined. Results The major reason for calls was clinical issues and the source of calls was primarily patients and carers. Clinical calls were longer in duration. Shorter calls were mainly non-clinical, made by a health professional. Setting for calls was not related to the reason. The most frequent number used was the individual mobile number of the NN, followed by the hospital landline. Although the free number was utilised by patients and carers, it was not the preferred option. Conclusion As patients and carers preferred to access their NN directly than via the 1800 number, further research should explore options best suited to this group of patients outside normal business hours.