What next for the Australian Atlas of Healthcare Variation series? Focusing the system on appropriate and sustainable health care.

Mapping, identifying and reducing unwarranted healthcare variation is integral to improving the appropriateness of care - minimising wasteful or unnecessary care and redirecting care to those who could benefit most (J Eval Clin Pract 26: 687-696, 2020). The Australian Atlas of Healthcare Variation series has examined variation in healthcare use since 2015. The findings reported in the Atlas series have led to important system changes.

Persisting gaps in dementia carer wellbeing and education: A qualitative exploration of dementia carer experiences.

Aims: To explore the emotional wellbeing of dementia carers in the lead up to and during transition of a person living with dementia to a residential aged care facility.

Design: An interpretative qualitative study.

Methods: Semi-structured interviews were conducted with informal carers of person living with dementia between February and June 2023.

Person-centred decisions in emergency care for older people living with frailty: principles and practice.

Older people living with frailty are frequent users of emergency care and have multiple and complex problems. Typical evidence-based guidelines and protocols provide guidance for the management of single and simple acute issues. Meanwhile, person-centred care orientates interventions around the perspectives of the individual.

Understanding Dementia Carer Experiences Before Admission to a Residential Aged Care Facility: Implications for Integrated Care.

In-depth understanding of dementia carer experience can assist clinicians by providing insight into dementia onset, symptoms and management, and help conceptualize and understand the pattern of dementia progress over time and what help is needed. We undertook a qualitative study to understand dementia carers experiences of providing care and reasons for admission to a residential aged care facility (RACF). Three themes were identified: (1) Challenges in the path to diagnosis and care, leading to delays accessing support; (2) Carer role impacted by living circumstances; and (3) Variation in decision support prior to admission to a RACF.

Implementation and evaluation of a nurse-led intervention to augment an existing residential aged care facility outreach service with a visual telehealth consultation: stepped-wedge cluster randomised controlled trial.

Background: Up to 75% of residents from residential aged care facilities (RACF) are transferred to emergency departments (ED) annually to access assessment and care for unplanned or acute health events. Emergency department presentations of RACF residents can be both expensive and risky, and many are unnecessary and preventable. Processes or triage systems to assess residents with a health event, prior to transfer, may reduce unnecessary ED transfer.

Optimal care of people with brain cancer in the emergency department: A cross-sectional survey of outpatient perceptions.

Objective: People diagnosed with brain cancer commonly present to the emergency department (ED). There is uncertainty about essential components and processes of optimal care from the perspective of consumers, and few guidelines exist to inform practice. This study examined the perceptions of outpatients and their support persons regarding what constitutes optimal care for people with brain cancer presenting to the ED.

Junior Medical Officers' knowledge of advance care directives and substitute decision making for people without decision making capacity: a cross sectional survey.

Background: For the benefits of advance care planning to be realised during a hospital admission, the treating team must have accurate knowledge of the law pertaining to implementation of advance care directives (ACDs) and substitute decision making.

Aims: To determine in a sample of Junior Medical Officers (JMOs): (1) knowledge of the correct order to approach people as substitute decision makers if a patient does not have capacity to consent to treatment; (2) knowledge of the legal validity of ACDs when making healthcare decisions for persons without capacity to consent to treatment, including the characteristics associated with higher knowledge; and (3) barriers to enacting ACDs.

Methods: A cross-sectional survey was conducted at five public hospitals in New South Wales, Australia.

Junior medical doctors' decision making when using advance care directives to guide treatment for people with dementia: a cross-sectional vignette study.

Background: Junior medical doctors have a key role in discussions and decisions about treatment and end-of-life care for people with dementia in hospital. Little is known about junior doctors' decision-making processes when treating people with dementia who have advance care directives (ACDs), or the factors that influence their decisions. To describe among junior doctors in relation to two hypothetical vignettes involving patients with dementia: (1) their legal compliance and decision-making process related to treatment decisions; (2) the factors influencing their clinical decision-making; and (3) the factors associated with accurate responses to one hypothetical vignette.

Video-telehealth to support clinical assessment and management of acutely unwell older people in Residential Aged Care: a pre-post intervention study.

Background: Older people living in Residential Aged Care (RAC) are at high risk of clinical deterioration. Telehealth has the potential to provide timely, patient-centred care where transfer to hospital can be a burden and avoided. The extent to which video telehealth is superior to other forms of telecommunication and its impact on management of acutely unwell residents in aged care facilities has not been explored previously.

Supporting residential aged care through a Community of Practice.

Transfers to emergency departments and hospitalizations are common for older people living in residential aged care who experience acute deterioration. This paper shares reflections from 10 years of work across a region in New South Wales, Australia, to develop a new model of care in 141 residential aged care homes. The model successfully reduced emergency department transfers and admissions to hospital.

Silver Book II: an international framework for urgent care of older people in the first 72 hours from illness or injury.

The new edition of the Silver Book, Silver Book II, provides a framework for the urgent care of older people in the first 72 hours from illness or injury. It incorporates principles of geriatric medicine, quality improvement (including patient reported outcome measures) and interdisciplinary care in a balanced, practical and evidence-rich manual on unscheduled and emergent care for older adults. Silver Book II shows how frailty, comprehensive geriatric assessment and shared decision-making can be locally adapted according to national practice and policy across the world.

A purple patch for evidence-based health policy?

The global focus on nation states' responses to the COVID-19 pandemic has rightly highlighted the importance of science and evidence as the basis for policy action. Those with a lifelong passion for evidence-based policy (EBP) have lauded Australia's and other nations' policy responses to COVID-19 as a breakthrough moment for the cause. This article reflects on the complexity of the public policy process, the perspectives of its various actors, and draws on Alford's work on the Blue, Red and Purple zones to propose a more nuanced approach to advocacy for EBP in health.

Assessment of advance care planning documentation for residents of residential aged care facilities presenting to the emergency department.

Objective This study assessed the availability and quality of advance care planning (ACP) documentation among older residential aged care facility (RACF) residents who presented to the emergency department (ED). Methods A prospective review of the medical records of RACF residents aged ≥75 years who presented to the ED from May to June 2018 was conducted. Availability of ACP was determined based on the presence of an ACP document inclusive of an advance care directive (ACD) in the medical record.

Evaluation of a safe medication strategy intervention for people with dementia with an unplanned admission: Results from the Safe Medication Strategy Dementia Study.

Objective: To evaluate whether a safe medication strategy compared with usual care, provided to people with dementia during an unplanned admission, reduces readmissions to hospital and re-presentation to emergency departments within three months.

Methods: A prospective, controlled pre-/post-trial conducted at two regional hospitals in New South Wales, Australia.

Results: No treatment effect was seen for time to first re-presentation or readmission within three months (P = .

Reducing Hospital Transfers from Aged Care Facilities: A Large-Scale Stepped Wedge Evaluation.

Background/objectives: Older people living in residential aged care facilities (RACFs) experience acute deterioration requiring assessment and decision making. We evaluated the impact of a large-scale regional Aged Care Emergency (ACE) program in reducing hospital admissions and emergency department (ED) transfers.

Design: A stepped wedge nonrandomized cluster trial with 11 steps, implemented from May 2013 to August 2016.

Evaluation of Carer Strain and Carer Coping with Medications for People with Dementia after Discharge: Results from the SMS Dementia Study.

This study reports carer strain and coping with medications for people with dementia with an unplanned admission to hospital, and it evaluates the impact of a safe medication intervention on carer coping and carer strain. This was a quasi-experimental pre/post-controlled trial that included a survey of carers about managing medications for people with dementia after discharge. For 88 carers who completed surveys, 33% were concerned about managing medications, and 40% reported difficulties with medication management, including resistive behaviours by people with dementia.

Knowledge and confidence of junior medical doctors in discussing and documenting resuscitation plans: a cross-sectional survey.

Background: A resuscitation plan is a medically authorised order to use or withhold resuscitation interventions. Absence of appropriate resuscitation orders exposes patients to the risk of invasive medical interventions that may be of questionable benefit depending on individual circumstances.

Aims: To describe among junior doctors: (i) self-reported confidence discussing and completing resuscitation plans; (ii) knowledge of resuscitation policy including whether resuscitation plans are legally enforceable and key triggers for completion; and (iii) the factors associated with higher knowledge of triggers for completing resuscitation plans.

Diagnosis of urinary tract infection in older persons in the emergency department: To pee or not to pee, that is the question.

Doreen is a 79-year-old woman referred by her general practitioner to the ED for intravenous antibiotics for a urinary tract infection (UTI). She lives in a residential aged care facility (RACF) and staff report malodourous and cloudy urine. She denies dysuria or frequency.