Critical care nursing policy, practice, and research priorities: An international cross-sectional study.

PURPOSE: To examine the status of critical care nursing internationally, assess the impact of the COVID-19 pandemic, and identify research priorities by surveying professional critical care nursing organizations (CCNOs) worldwide. DESIGN: A descriptive survey methodology was used. This study is the sixth worldwide quadrennial review to assess international critical care nursing needs and provide evidence to inform critical care nursing policy, practice and research priorities globally. METHODS: The sixth World Federation of Critical Care Nurses survey of CCNOs was emailed to potential participants from countries with CCNOs or known critical care nurse leaders. Data were collected online using Survey Monkey™. Responses were entered into SPSS version 28 software (IBM Corp.) and analyzed by geographical region and national wealth group. FINDINGS: Ninety-nine national representative respondents participated in the survey (70.7% response rate). The most important issues identified were working conditions, teamwork, staffing levels, formal practice guidelines, wages, and access to quality education programs. The top five CCNO services that were of most importance were providing national conferences, local conferences, workshops and education forums, practice standards and guidelines, and professional representation. Important pandemic-related services and activities provided by CCNOs included addressing emotional and mental well-being of nurses, providing guidance related to nurse staffing/workforce needs, assisting to coordinate efforts to obtain personal protective equipment supplies, serving as a country liaison with the World Health Organization's COVID-19 response activities, and assisting in the development and implementation of policies regarding standards of care. The most important contributions expected from the World Federation of Critical Care Nurses were standards for professional practice, standards for clinical practice, website resources, professional representation, and providing online education and training materials. The top five research priority areas were: stress levels (inclusive of burnout, emotional exhaustion and compassion fatigue); critical care nursing shortage, skill mix and workforce planning; recruitment, retention, turnover, working conditions; critical care nursing education and patient outcomes; and adverse events, staffing levels, patient outcomes. CONCLUSIONS: The results highlight priority areas for critical care nursing internationally. The COVID-19 pandemic impacted critical care nurses as direct care providers. As a result, addressing the ongoing needs of critical care nurses remains a priority area of focus. The results also highlight important policy and research priorities for critical care nursing globally. Results of this survey should be incorporated into strategic action plans at the national and international levels. CLINICAL RELEVANCE: Issues of importance to critical care nurses including research and policy priorities during and following COVID-19 are now clarified through this survey. The impact and importance that COVID-19 has had on critical care nurses and their preferences and priorities are provided. Clear guidance to leaders and policy makers on where critical care nurses would like to see greater focus and attention to help strengthen the contribution of critical care nursing practice to the global healthcare agenda.

A practical approach to establishing a critical care outreach service: An expert panel research design.

BACKGROUND: For over two decades, nurse-led critical care outreach services have improved the recognition, response, and management of deteriorating patients in general hospital wards, yet variation in terms, design, implementation, and evaluation of such services continue. For those establishing a critical care outreach service, these factors make the literature difficult to interpret and translate to the real-world setting. AIM: The aim of this study was to provide a practical approach to establishing a critical care outreach service in the hospital setting. METHOD: An international expert panel of clinicians, managers, and academics with experience in implementing, developing, operationalising, educating, and evaluating critical care outreach services collaborated to synthesise evidence, experience, and clinical judgment to develop a practical approach for those establishing a critical care outreach service. A rapid review of the literature identified publications relevant to the study. A modified Delphi technique was used to achieve expert panel consensus particularly in areas where insufficient published literature or ambiguities existed. FINDINGS: There were 502 publications sourced from the rapid review, of which 104 were relevant and reviewed. Using the modified Delphi technique, the expert panel identified five key components needed to establish a critical care outreach service: (i) approaches to service delivery, (ii) education and training, (iii) organisational engagement, (iv) clinical governance, and (v) monitoring and evaluation. CONCLUSION: An expert panel research design successfully synthesised evidence, experience, and clinical judgement to provide a practical approach for those establishing a critical care outreach service. This method of research will likely be valuable in other areas of practice where terms are used interchangeably, and the literature is diverse and lacking a single approach to practice.

Work climate in emergency health services during COVID-19 pandemic-An international multicenter study.

Introduction: A good working climate increases the chances of adequate care. The employees of Emergency in Hospitals are particularly exposed to work-related stress. Support from management is very important in order to avoid stressful situations and conflicts that are not conducive to good work organization. The aim of the study was to assess the work climate of Emergency Health Services during COVID-19 Pandemic using the Abridged Version of the Work Climate Scale in Emergency Health Services. Design: A prospective descriptive international study was conducted. Methods: The 24-item Abridged Version of the Work Climate Scale in Emergency Health Services was used for the study. The questionnaire was posted on the internet portal of scientific societies. In the study participated 217 women (74.5%) and 74 men (25.4%). The age of the respondents ranged from 23 to 60 years (SD = 8.62). Among the re-spondents, the largest group were Emergency technicians (85.57%), followed by nurses (9.62%), doctors (2.75%) and Service assistants (2.06%). The study was conducted in 14 countries. Results: The study of the climate at work shows that countries have different priorities at work, but not all of them. By answering the research questions one by one, we can say that the average climate score at work was 33.41 min 27.0 and max 36.0 (SD = 1.52). Conclusion: The working climate depends on many factors such as interpersonal relationships, remuneration or the will to achieve the same selector. In the absence of any of the elements, a proper working climate is not possible.

Evaluation of an Intensive Care Outreach Nurse Program in 4 UAE Hospitals.

BACKGROUND: Intensive care outreach nurses (ICONs) can reduce deterioration and death of patients in hospitals. PURPOSE: Evaluate outcomes associated with implementation of the ICON role across 4 UAE hospitals. METHODS: Trend analyses and χ 2 tests were used to measure changes before ICON program, during ICON year 1, ICON year 2, when the service coverage extended 24/7, and until the end of 2019. RESULTS: From year 1 to year 2, failures to escalate decreased from a rate of 14.8 to 5.6 episodes per 1000 admissions for all sites combined ( P < .001). The cardiac arrest rate went from 4.04 to 1.42 per 1000 admissions in year 2 and continued downward to 0.72 per 1000 ( P < .001). Transfer from ward or readmission to intensive care unit/high dependency unit varied by site, although there was a statistically significant trend for all hospitals combined. CONCLUSION: The ICON role contributed to fewer failure to escalate incidents and lower cardiac arrest rates.

Epidemiology and outcome of pressure injuries in critically ill patients with chronic obstructive pulmonary disease: A propensity score adjusted analysis.

BACKGROUND: Pressure injuries are a frequent complication in intensive care unit (ICU) patients, especially in those with comorbid conditions such as chronic obstructive pulmonary disease (COPD). Yet no epidemiological data on pressure injuries in critically ill COPD patients are available. OBJECTIVE: To assess the prevalence of ICU-acquired pressure injuries in critically ill COPD patients and to investigate associations between COPD status, presence of ICU-acquired pressure injury, and mortality. STUDY DESIGN AND METHODS: This is a secondary analysis of prospectively collected data from DecubICUs, a multinational one-day point-prevalence study of pressure injuries in adult ICU patients. We generated a propensity score summarizing risk for COPD and ICU-acquired pressure injury. The propensity score was used as matching criterion (1:1-ratio) to assess the proportion of ICU-acquired pressure injury attributable to COPD. The propensity score was then used in regression modeling assessing the association of COPD with risk of ICU-acquired pressure injury, and examining variables associated with mortality (Cox proportional-hazard regression). RESULTS: Of the 13,254 patients recruited to DecubICUs, 1663 (12.5%) had documented COPD. ICU-acquired pressure injury prevalence was higher in COPD patients: 22.1% (95% confidence interval [CI] 20.2 to 24.2) vs. 15.3% (95% CI 14.7 to 16.0). COPD was independently associated with developing ICU-acquired pressure injury (odds ratio 1.40, 95% CI 1.23 to 1.61); the proportion attributable to COPD was 6.4% (95% CI 5.2 to 7.6). Compared with non-COPD patients without pressure injury, mortality was no different among patients without COPD but with pressure injury (hazard ratio [HR] 1.07, 95% CI 0.97 to 1.17) or COPD patients without pressure injury (HR 1.13, 95% CI 1.00 to 1.27). Mortality was higher among COPD patients with pressure injury (HR 1.35, 95% CI 1.15 to 1.58). CONCLUSION AND IMPLICATIONS: Critically ill COPD patients have a statistically significant higher risk of pressure injury. Moreover, those that develop pressure injury are at higher risk of mortality. As such, pressure injury may serve as a surrogate for poor prognostic status to help clinicians identify patients at high risk of death. Also, delivery of interventions to prevent pressure injury are paramount in critically ill COPD patients. Further studies should determine if early intervention in critically ill COPD patients can modify development of pressure injury and improve prognosis.

Critical care nursing role in low and lower middle-income settings: a scoping review.

OBJECTIVES: A scoping review was conducted to answer the question: How is critical care nursing (CCN) performed in low-income countries and lower middle-income countries (LICs/LMICs)? DESIGN: Scoping review guided by the JBI Manual for Evidence Synthesis. DATA SOURCES: Six electronic databases and five web-based resources were systematically searched to identify relevant literature published between 2010 and April 2021. REVIEW METHODS: The search results received two-stage screening: (1) title and abstract (2) full-text screening. For sources of evidence to progress, agreement needed to be reached by two reviewers. Data were extracted and cross-checked. Data were analysed, sorted by themes and mapped to region and country. RESULTS: Literature was reported across five georegions. Nurses with a range formal and informal training were identified as providing critical care. Availability of staff was frequently reported as a problem. No reports provided a comprehensive description of CCN in LICs/LMICs. However, a variety of nursing practices and non-clinical responsibilities were highlighted. Availability of equipment to fulfil the nursing role was widely discussed. Perceptions of inadequate resourcing were common. Undergraduate and postgraduate-level preparation was poorly described but frequently reported. The delivery of short format critical care courses was more fully described. There were reports of educational evaluation, especially regarding internationally supported initiatives. CONCLUSIONS: Despite commonalities, CCN is unique to regional and socioeconomic contexts. Nurses work within a complex team, yet the structure and skill levels of such teams will vary according to patient population, resources and treatments available. Therefore, a universal definition of the CCN role in LIC/LMIC health systems is likely unhelpful. Research to elucidate current assets, capacity and needs of nurses providing critical care in specific LIC/LMIC contexts is needed. Outputs from such research would be invaluable in supporting contextually appropriate capacity development programmes.

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study.

PURPOSE: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. METHODS: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. RESULTS: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9-27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6-16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score < 19, ICU stay > 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2-1.8), stage II (OR 1.6; 95% CI 1.4-1.9), and stage III or worse (OR 2.8; 95% CI 2.3-3.3). CONCLUSION: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat.

The Fifth International Survey of Critical Care Nursing Organizations: Implications for Policy.

PURPOSE: To examine the activities, concerns, and expectations of critical care nurses and professional critical care nursing organizations worldwide. DESIGN: A descriptive survey methodology was used. This study is the fifth worldwide quadrennial review of its type to monitor variations in critical care nursing needs and provide robust evidence to inform policy related to critical care nursing practice. METHODS: The fifth World Federation of Critical Care Nurses international survey of critical care nursing organizations was emailed to potential participants from countries with critical care nursing organizations or known critical care nurse leaders. Data were collected online. Responses were entered into SPSS version 23 software (IBM Corp., Armonk, NY, USA) and analyzed by geographical region and national wealth group. FINDINGS: Eighty-two national representative respondents participated in the survey, of whom two thirds (n = 56, 68%) had an established critical care nursing organization in their country. The five most important issues identified were working conditions, teamwork, staffing levels, the need for formal practice guidelines and competencies, and wages. The top five critical care nursing organization services that were considered to be of most importance were professional representation, as well as provision of workshops and education forums, national conferences, practice standards and guidelines, and local conferences. The most important contributions expected from the World Federation of Critical Care Nurses were standards for clinical practice and professional practice, international conferences, professional representation, and study and education grants. CONCLUSIONS: The results highlight priority areas for critical care nursing and reinforce the need to address factors that can inform critical care nursing policy and practice. Results of this survey should be incorporated into strategic action plans at the national and international levels. CLINICAL RELEVANCE: Nursing leaders, policymakers, and other interested stakeholders should consider these findings when planning critical care workforce requirements. Interested parties should work collaboratively to inform recommendations for further policy and action.

COVID-19: What we've learned so far / COVID-19: Lo que hemos aprendido hasta ahora / COVID-19: O que aprendemos até agora

Coronavirus disease 2019 (COVID-19) has dominated almost every aspect of human life on planet Earth since it was first discovered in Wuhan, Hubei province, China, in December 20191. A quick google search of the expression COVID-19 reveals more than 3.22 billion results. In order to understand the importance of this type of virus, we need to carry out two extremely important epidemiological issues: the basic reproduction number (Ro) and the effective infection number (R). Ro is used to measure the transmission potential of a virus. This number is an average of how many people to whom an infected patient is able to transmit the pathogen, assuming that people close to the patient are not immune to it. Now let's understand R. A population will rarely be completely susceptible to infection in the real world. Some contacts will be immune due to a previous infection that conferred immunity or as a result of previous immunization, due to the action of vaccines. Therefore, not all contacts will be infected and the average number of secondary cases per infectious case will be less than Ro. In this calculation, we take into account susceptible and non-susceptible people. With this information presented, we can conclude that if the value of R is >1, the number of cases will increase, starting an epidemic. For a virus to stop spreading, R must be <1. To estimate R, we multiply the value of Ro by the susceptible fraction of a population2.

La enfermedad por coronavirus 2019 (COVID-19) ha dominado casi todos los aspectos de la vida humana en el planeta Tierra desde que se descubrió por primera vez en Wuhan, provincia de Hubei, China, en diciembre de 20191. Una búsqueda rápida en Google de la expresión COVID-19 revela más de 3,22 billones de resultados. Para comprender la importancia de este tipo de virus, necesitamos conocer dos conceptos epidemiológicos extremadamente importantes: el número de reproducción básico (Ro) y el número de infección efectivo (R). Ro se usa para medir el potencial de transmisión de un virus. Este número es un promedio de la cantidad de personas a las que un paciente infectado puede transmitir el patógeno, suponiendo que las personas cercanas al paciente no sean inmunes a él. Ahora comprendamos R. Una población rara vez será completamente susceptible a la infección en el mundo real. Algunos contactos serán inmunes debido a una infección previa que confirió inmunidad o como resultado de una inmunización previa, por la acción de las vacunas. Por lo tanto, no todos los contactos se infectarán y el número promedio de casos secundarios por caso infeccioso será menor que Ro. En este cálculo, tenemos en cuenta a las personas susceptibles y no susceptibles. Con esta información presentada, podemos concluir que si el valor de R es >1, el número de casos aumentará, comenzando una epidemia. Para que un virus deje de propagarse, R debe ser <1. Para estimar R, multiplicamos el valor de Ro por la fracción susceptible de una población2.

A doença de coronavírus 2019 (COVID-19) dominou quase todos os aspectos da vida humana no planeta Terra desde que foi descoberta pela primeira vez em Wuhan, província de Hubei, China, em dezembro de 20191. Uma rápida pesquisa no Google pela expressão COVID-19 revela mais de 3,22 bilhões de resultados. Para entender a importância desse tipo de vírus, precisamos conhecer dois conceitos epidemiológicos extremamente importantes: o número de reprodução básico (Ro) e o número de infecção efetivo (R). Ro é usado para medir o potencial de transmissão de um vírus. Esse número de para quantas pessoas um paciente infectado é capaz de transmitir o patógeno, assumindo que as pessoas próximas ao paciente não são imunes a ele. Agora vamos entender R. Uma população raramente será completamente suscetível a infecções no mundo real. Alguns contatos ficam imunes devido a uma infecção previa que conferiu imunidade ou como resultado de imunização anterior, devido à ação de vacinas. Portanto, nem todos os contatos serão infectados e o número médio de casos secundários por caso infeccioso será menor que Ro. Nesse cálculo, consideramos pessoas suscetíveis e não suscetíveis. Com essas informações apresentadas, podemos concluir que, se o valor de R for >1, o número de casos aumentará, iniciando uma epidemia. Para que um vírus pare de se espalhar, R deve ser <1. Para estimar R, multiplicamos o valor de Ro pela fração suscetível de uma população2

Staff's Perception of the Intensive Care Outreach Nurse Role: A Multisite Cross-sectional Study.

BACKGROUND: Rapid Response Systems are emerging internationally to provide a patient-focused approach to prevent potentially avoidable deaths and serious adverse events. LOCAL PROBLEM: This study focused on ward nurses in the United Arab Emirates (UAE) government hospitals who were perceived to lack the confidence and knowledge to detect and/or respond to deteriorating patients. METHOD: A cross-sectional study design was used to evaluate the Intensive Care Outreach Nurse (ICON) role from the perspectives of the ICONs, their managers/educators, and ward-based physicians and nurses. ICONs are intensive care experienced nurses with additional education in the role of rapid responder to the deteriorating patient. INTERVENTIONS: An ICON role was implemented across 4 hospitals to respond to and support clinicians in the recognition and management of the deteriorating patient on general inpatient wards. RESULTS: ICON skills perceived as most beneficial by respondents included staff education, respiratory therapy, medication administration, and intravenous access. CONCLUSIONS: The ICON role is able to support recognition and management of the deteriorating patients.

Emergency department models of care in Queensland: a multisite cross-sectional study.

Objective The acuity and number of presentations being made to emergency departments (EDs) is increasing. In an effort to safely and efficiently manage this increase and optimise patient outcomes, innovative models of care (MOC) have been implemented. What is not clear is how these MOC reflect the needs of patients or relate to each other or to ED performance. The aim of this study was to describe ED MOC in Queensland, Australia. Methods Situated within a larger mixed-methods study, the present study was a cross-sectional study. In early 2015, leaders (medical directors and nurse managers) from public hospital EDs in Queensland were invited to complete a survey detailing ED activity, staffing profiles, treatment space, MOC and National Emergency Access Target (NEAT) performance. Routinely collected ED information system data was also used. Results Twenty of the 27 EDs invited participated in the study (response rate 74%). An extensive array of MOC were identified that were categorised into those that facilitate input, throughput and output from the ED. There was no consistent evidence as to the relative effectiveness of these MOC in achieving ED performance benchmarks, such as NEAT performance. Conclusion There is considerable variability in the MOC used throughout EDs in Queensland. A more complete analysis of the relative effectiveness of different MOC either in isolation or as part of a comprehensive approach would help inform more consistent MOC in Queensland EDs. What is known about the topic? MOC in any given ED are implemented in response to factors such as the geographical location of the hospital, hospital-specific characteristics and service profile, staffing profile and patient demographic profile. In the era of time-based targets, they may also serve to address a particular aspect of flow in the face of rising ED demand. Although many of the MOC attempt to deal with flow in a linear fashion, target specific phases of the ED journey or address particular patient cohorts, what is clear is that not all EDs are shaped and formed the same. What does this paper add? The study provides a comprehensive description of the varied models of care operating within Queensland public hospital EDs and how they relate to ED performance. A basic taxonomy of contemporary ED MOC is necessary to allow comparison between departments and inform decisions regarding safety, efficiency and cost-effectiveness. What are the implications to practitioners? A contemporary understanding of the presence and profile of ED MOC that currently exist within a network of hospitals and health services is important for managers, clinicians and patients to inform decision-making regarding the safety, clinical effectiveness and cost-effectiveness of these models. This understanding can also inform where and how further improvements in care delivery can progress.

Nurse participation in legal executions: An ethics round-table discussion.

A paper was published in 2003 discussing the ethics of nurses participating in executions by inserting the intravenous line for lethal injections and providing care until death. This paper was circulated on an international email list of senior nurses and academics to engender discussion. From that discussion, several people agreed to contribute to a paper expressing their own thoughts and feelings about the ethics of nurses participating in executions in countries where capital punishment is legal. While a range of opinions were presented, these opinions fell into two main themes. The first of these included reflections on the philosophical obligations of nurses as caregivers who support those in times of great need, including condemned prisoners at the end of life. The second theme encompassed the notion that no nurse ever should participate in the active taking of life, in line with the codes of ethics of various nursing organisations. This range of opinions suggests the complexity of this issue and the need for further public discussion.

Understanding ED performance after the implementation of activity-based funding.

OBJECTIVE: The aim of this study was to describe emergency department (ED) activities and staffing after the introduction of activity-based funding (ABF) to highlight the challenges of new funding arrangements and their implementation. METHODS: A retrospective study of public hospital EDs in Queensland, Australia, was undertaken for 2013-2014. The ED and hospital characteristics are described to evaluate the alignment between activity and resourcing levels and their impact on performance. RESULTS: Twenty EDs participated (74% response rate). Weighted activity units (WAUs) and nursing staff varied based on hospital type and size. Larger hospital EDs had on average 9076 WAUs and 13 full time equivalent (FTE) nursing staff per 1000 WAUs; smaller EDs had on average 4587 WAUs and 10.3 FTE nursing staff per 1000 WAUs. Medical staff was relatively consistent (8.1-8.7 FTE per 1000 WAUs). The proportion of patients admitted, discharged, or transferred within 4 hours ranged from 73% to 79%. The ED medical and nursing staffing numbers did not correlate with the 4-hour performance. CONCLUSION: Substantial variation exists across Queensland EDs when resourcing service delivery in an activity-based funding environment. Historical inequity persists in the staffing profiles for regional and outer metropolitan departments. The lack of association between resourcing and performance metrics provides opportunity for further investigation of efficient models of care.

Systematic review of gender- dependent outcomes in sepsis.

BACKGROUND: Men and women appear to exhibit different susceptibilities to sepsis and possibly divergent outcomes. However, the effect of sex and gender in critical illness outcomes is still controversial and the underlying mechanisms appear to be complex. OBJECTIVES: We aimed to systematically review and synthesize evidence on the influence of sex on outcomes in critically ill adult patients with sepsis, as reported in published studies specifically including investigation of the effect of sex among their aims. Primary outcome measures include in-hospital mortality, intensive care unit (ICU) mortality and length of stay (LOS) in the ICU. SEARCH STRATEGY: The review was based on focused literature searches (CINAHL, PUBMED, EMBASE and COCHRANE). Methodological quality was assessed through the STROBE checklist and the Cochrane Tool for Bias in Cohort Studies. Meta-analysis was performed using STATA. Published observational studies addressing outcomes of sepsis among their primary aims and having included gender comparisons among primary outcomes in critically ill adult patients were included. RESULTS: A total of eight eligible studies were included. With the exception of mortality, it was not possible to perform meta-analysis for other outcomes. Included studies reported data on 25,619 patients with sepsis (14 309 male/11 310 female). There is a paucity of well-designed studies addressing the effect of sex on mortality among patients with sepsis, and absence of studies addressing the effects of sex on multiple organ dysfunction of non-infectious origin. There was significant heterogeneity among study estimates (p = 0·001; I2 =78·1%). CONCLUSIONS: Although results of data syntheses appear to point towards a small disadvantage for survival among women, our results suggest that data on the impact of sex on sepsis outcomes remain equivocal. Implications for future research include approaches to adjustment for confounders and prospective designs. RELEVANCE TO CLINICAL PRACTICE: Clarifying sex-related differences in sepsis, if any, is crucial for informing evidence-based care.

Review article: Emergency department models of care in the context of care quality and cost: a systematic review.

To identify current ED models of care and their impact on care quality, care effectiveness, and cost. A systematic search of key health databases (Medline, CINAHL, Cochrane, EMbase) was conducted to identify literature on ED models of care. Additionally, a focused review of the contents of 11 international and national emergency medicine, nursing and health economic journals (published between 2010 and 2013) was undertaken with snowball identification of references of the most recent and relevant papers. Articles published between 1998 and 2013 in the English language were included for initial review by three of the authors. Studies in underdeveloped countries and not addressing the objectives of the present study were excluded. Relevant details were extracted from the retrieved literature, and analysed for relevance and impact. The literature was synthesised around the study's main themes. Models described within the literature mainly focused on addressing issues at the input, throughput or output stages of ED care delivery. Models often varied to account for site specific characteristics (e.g. onsite inpatient units) or to suit staffing profiles (e.g. extended scope physiotherapist), ED geographical location (e.g. metropolitan or rural site), and patient demographic profile (e.g. paediatrics, older persons, ethnicity). Only a few studies conducted cost-effectiveness analysis of service models. Although various models of delivering emergency healthcare exist, further research is required in order to make accurate and reliable assessments of their safety, clinical effectiveness and cost-effectiveness.

Funding emergency care: Australian style.

The ongoing challenge for ED leaders is to remain abreast of system-wide changes that impact on the day-to-day management of their departments. Changes to the funding model creates another layer of complexity and this introductory paper serves as the beginning of a discussion about the way in which EDs are funded and how this can and will impact on business decisions, models of care and resource allocation within Australian EDs. Furthermore it is evident that any funding model today will mature and change with time, and moves are afoot to refine and contextualise ED funding over the medium term. This perspective seeks to provide a basis of understanding for our current and future funding arrangements in Australian EDs.