Provision of healthcare within short-term custody settings such as police watch-houses presents a complex public health challenge. This area has received limited attention in the literature, particularly the viewpoints of paramedics, who are a key link in the chain of healthcare. This study aimed to describe paramedics' decision-making practices and procedures regarding the transport of patients from the watch-house to the emergency department. A qualitative descriptive study was undertaken utilizing semi-structured interviews with paramedics in Queensland, Australia. A full thematic analysis was not completed due to the small sample and limited data sufficiency. However, interview data were grouped into similar categories with the goal of reporting these novel findings. Six paramedics from five metropolitan, regional, and rural/remote regions participated. Interviews were analysed into four main categories: paramedic's role, challenges, enablers, and suggestions. Paramedics described their role as being autonomous with decision-making, especially regarding transport to hospital. Reported challenges revolved around the complexity of the patient, environment, and competing health/security needs. A key issue identified by paramedics was perceived dissatisfaction from police when their assessment resulted in a recommendation to transport the patient to hospital. Enablers included the controlled environment of the watch-house and access to watch-house embedded healthcare providers. Suggestions related to improving structures (e.g. paperwork, education, hours of on-site healthcare providers) and processes (e.g. communication, transport). This study provides a unique perspective on the key role that paramedics have in the delivery of the healthcare to patients in short-term custody and accords with findings from previous studies with emergency doctors.

ObjectiveGlobally, the social and economic costs of alcohol-related disorders are considerable. The aim of this study was to determine the characteristics, clinical care requirements and outcomes of alcohol-related presentations (ARPs) to emergency departments (EDs).MethodsA multi-site observational study was undertaken in Queensland, Australia. We selected a random sample of 2720 presentations to four public hospital EDs between April 2016 and August 2017, in which the treating clinician perceived that alcohol contributed to the presentation. Routinely collected demographic, clinical, outcomes and costings data were analysed. Additional data about clinical care delivery in the ED (bedside tests, radiology, pathology and referrals) were extracted by manual medical record review.ResultsThe ARPs predominantly involved young men: 62% arrived by ambulance and 61% arrived between 6pm and 6am. Most (>83%) ARPs had at least one vital observation (i.e. heart rate, blood pressure, respiratory rate) recorded, 46% had pathology, and 41% had radiology. Some form of medication (e.g. paracetamol, diazepam, thiamine) was ordered in 65% of ARPs and 20% involved intravenous fluid treatment. Referrals to a specialist team (e.g. mental health, alcohol and other drug services) were documented for 42% of patients. The median ED length of stay was 194min (IQR: 122-292 min); the admission rate was 38%; and the median cost of ED episodes of care (in Australian dollars) was A$651 (IQR: A$422-961).ConclusionsThe ED resource utilisation and costs due to the use of alcohol are considerable. Public health measures that reduce alcohol-related harm have the potential to reduce ED occupancy, workloads and costs.

OBJECTIVE:People detained in short-term police custody often have complex health conditions that may necessitate emergency care, yet little is known about their management in EDs. The present study aimed to understand ED doctors' experiences and perceptions regarding the appropriateness and management of detainee transfers from police watch-houses to the EDs. METHODS:A qualitative descriptive study, using semi-structured interviews undertaken with ED doctors working in five purposively sampled EDs across Queensland, Australia. Data were analysed using inductive content analysis. RESULTS:Fifteen ED specialists and trainees participated. Participants reported that their overarching approach was to provide equitable care for watch-house detainees, as they would for any patient. This equitable approach needed to be responsive to complicating factors common to this population, including presence of police guards; restraints; complexity (physical/mental/social) of presentation; reliance on police to transport; ED doctors' often limited understanding of the watch-house environment; justice processes and uncertain legal disposition; communication with the watch-house; and detainees misreporting symptoms. Thresholds for assessment and treatment of detainees were contextualised to the needs of the patient, ED environment, and imperatives of other relevant agencies (e.g. police). Participants often relied on existing strategies to deliver quality care despite challenges, but also identified a need for additional strategies, including education for ED staff; improved communication with watch-houses; standardised paperwork; extended models of watch-house healthcare; and integrated medical records. CONCLUSIONS:Providing equitable healthcare to patients transported from watch-houses to the EDs is challenging but essential. Numerous opportunities exist to enhance the delivery of optimal care for this underserved population.

Background Identifying factors predictive of hospital admission can be useful to prospectively inform bed management and patient flow strategies and decrease emergency department (ED) crowding. It is largely unknown if admission rate or factors predictive of admission vary based on the population to which the ED served (i.e., children only, or both adults and children). This study aimed to describe the profile and identify factors predictive of hospital admission for children who presented to four EDs in Australia and one ED in Sweden. Methods A multi-site observational cross-sectional study using routinely collected data pertaining to ED presentations made by children < 18 years of age between July 1, 2011 and October 31, 2012. Univariate and multivariate analysis were undertaken to determine factors predictive of hospital admission. Results Of the 151,647 ED presentations made during the study period, 22% resulted in hospital admission. Admission rate varied by site; the children’s EDs in Australia had higher admission rates (South Australia: 26%, Queensland: 23%) than the mixed (adult and children’s) EDs (South Australia: 13%, Queensland: 17%, Sweden: 18%). Factors most predictive of hospital admission for children, after controlling for triage category, included hospital type (children’s only) adjusted odds ratio (aOR):2.3 (95%CI: 2.2–2.4), arrival by ambulance aOR:2.8 (95%CI: 2.7–2.9), referral from primary health aOR:1.5 (95%CI: 1.4–1.6) and presentation with a respiratory or gastrointestinal condition (aOR:2.6, 95%CI: 2.5–2.8 and aOR:1.5, 95%CI: 1.4–1.6, respectively). Predictors were similar when each site was considered separately. Conclusions Although the characteristics of children varied by site, factors predictive of hospital admission were mostly similar. The awareness of these factors predicting the need for hospital admission can support the development of clinical pathways.

Providing appropriate healthcare to people in short-term police custody settings (i.e. watch-houses) is challenging due to the complexity of detainee health needs and the limitations of the custodial environment. However, little is known about how detainee healthcare is managed in Australia, including economic considerations. This study had two aims: (1) to understand police perspectives on the costs associated with the delivery of healthcare to watch-house detainees in Queensland, Australia and (2) to scope the applicability of the Prison Healthcare Expenditure Reporting Checklist (PHERC) tool for the Australian watch-house context. The study employed an exploratory qualitative descriptive approach. A purposive sample comprised 16 watch-house staff from six regions in Queensland, Australia, interviewed between April and November 2021. A key finding was that police viewed healthcare expenditure as a major, but largely unavoidable cost for Australian watch-houses. Participants reported that direct expenditure comprised mostly of in-house healthcare services (of which there were a variety of models), but also costs of medication and health-related consumables. Indirect costs included costs of escorting and guarding detainees requiring transfer to hospital for health assessment and treatment. Participants reported that the PHERC was not applicable to the Australian watch-house context. Future research should explore the cost-effectiveness of different watch-house healthcare delivery models and how best to measure this.

Objective. The harmful use of alcohol is a global issue. This study aimed to describe and compare the profiles, emergency department (ED) clinical characteristics, and outcomes of alcohol-related ED presentations (ARPs) and non-alcohol-related ED presentations (NARPs).Methods. A multi-site observational study of all presentations to four EDs between 4 April 2016 and 31 August 2017, was conducted. Routinely collected ED clinical, administrative and costings data were used. Classification of ARPs were prospectively recorded by clinicians. Analysis was performed at the presentation, rather than person level. Univariate tests were undertaken to compare demographics, ED clinical characteristics and outcomes between ARPs and NARPs.Results. A total of 418 051 ED presentations occurred within the 17-month study period; 5% (n = 19 875) were ARPs. Presentations made by people classified as ARPs were younger, more likely to be male, present on weekends or at night, and arrive by ambulance or police compared to NARPs. Compared with NARPs, ARPs had a longer median ED length of stay of over 20 min (95% CI 18-22, median 196 min vs 177 min, P < 0.001), a 5.5% (95% CI 4.9-5.3) lower admission rate (36% vs 42%, P < 0.001), and a AUD69 (95% CI 64-75) more expensive ED episode-of-care (AUD689 vs AUD622, P < 0.001).Conclusion. Clinically meaningful differences were noted between alcohol-related and non-alcohol-related ED presentations. The higher cost of care for ARPs likely reflects their longer time in the ED. The healthcare and economic implications of incidents of alcohol-related harm extend beyond the ED, with ARPs having higher rates of ambulance and police use than NARPs.

Medical Journal of AustraliaVolume 217, Issue 6 p. 287-289 PerspectivesOpen Access Health care in police watch-houses: a challenge and an opportunity Julia L Crilly, Corresponding Author Julia L Crilly julia.crilly@health.qld.gov.au Gold Coast Hospital and Health Service, Gold Coast, QLD Griffith University, Gold Coast, QLDE-mail: julia.crilly@health.qld.gov.auSearch for more papers by this authorCaitlin Brandenburg, Caitlin Brandenburg orcid.org/0000-0002-6992-7790 Griffith University, Gold Coast, QLDSearch for more papers by this authorStuart A Kinner, Stuart A Kinner Curtin University, Perth, WA University of Melbourne, Melbourne, VICSearch for more papers by this authorEd Heffernan, Ed Heffernan Queensland Health, Brisbane, QLDSearch for more papers by this authorJoshua Byrnes, Joshua Byrnes Griffith University, Gold Coast, QLDSearch for more papers by this authorCathy Lincoln, Cathy Lincoln Gold Coast Hospital and Health Service, Gold Coast, QLDSearch for more papers by this authorPaul Gardiner, Paul Gardiner Queensland Police Service, Brisbane, QLDSearch for more papers by this authorPeter Davidson, Peter Davidson University of California San Diego, San Diego, CA, USASearch for more papers by this authorAnnabel Somerville, Annabel Somerville Cairns Hospital and Health Service, Cairns, QLDSearch for more papers by this authorDaniel Wilson, Daniel Wilson Queensland Ambulance Service, Brisbane, QLDSearch for more papers by this authorDavid Green, David Green Gold Coast Hospital and Health Service, Gold Coast, QLDSearch for more papers by this authorStuart Thomas, Stuart Thomas RMIT University, Melbourne, VICSearch for more papers by this author Julia L Crilly, Corresponding Author Julia L Crilly julia.crilly@health.qld.gov.au Gold Coast Hospital and Health Service, Gold Coast, QLD Griffith University, Gold Coast, QLDE-mail: julia.crilly@health.qld.gov.auSearch for more papers by this authorCaitlin Brandenburg, Caitlin Brandenburg orcid.org/0000-0002-6992-7790 Griffith University, Gold Coast, QLDSearch for more papers by this authorStuart A Kinner, Stuart A Kinner Curtin University, Perth, WA University of Melbourne, Melbourne, VICSearch for more papers by this authorEd Heffernan, Ed Heffernan Queensland Health, Brisbane, QLDSearch for more papers by this authorJoshua Byrnes, Joshua Byrnes Griffith University, Gold Coast, QLDSearch for more papers by this authorCathy Lincoln, Cathy Lincoln Gold Coast Hospital and Health Service, Gold Coast, QLDSearch for more papers by this authorPaul Gardiner, Paul Gardiner Queensland Police Service, Brisbane, QLDSearch for more papers by this authorPeter Davidson, Peter Davidson University of California San Diego, San Diego, CA, USASearch for more papers by this authorAnnabel Somerville, Annabel Somerville Cairns Hospital and Health Service, Cairns, QLDSearch for more papers by this authorDaniel Wilson, Daniel Wilson Queensland Ambulance Service, Brisbane, QLDSearch for more papers by this authorDavid Green, David Green Gold Coast Hospital and Health Service, Gold Coast, QLDSearch for more papers by this authorStuart Thomas, Stuart Thomas RMIT University, Melbourne, VICSearch for more papers by this author First published: 28 August 2022 https://doi.org/10.5694/mja2.51688AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Police watch-house detainees have complex health needs that involve multiple agencies and require coordinated, interagency solutions Police watch-houses (Queensland term) are buildings designed "for the temporary holding of prisoners before prisoners are released or transferred to a corrective services facility or detention centre".1 They may also be used to hold people who are intoxicated, appear mentally ill, or are awaiting trial.2 Watch-houses are also referred to as police cells, station cells, lock-ups, holding cells, jails, and custody suites in other Australian jurisdictions and countries. "Temporary" means "overnight or for 24 hours or longer",1 and can be as long as 4 weeks.2, 3 In Queensland, watch-houses are staffed primarily by police officers, in some cases assisted by civilian watch-house officers. Common problems faced in prison health care include vulnerability, physical and mental stress, and associated social determinants of poor health.4 These are reflected among watch-house detainees.5, 6 A review of 505 coroners' reports pertaining to deaths in police custody in Australia between 1991 and 2016 revealed that 43 (9%) occurred in a police station, police vehicle, police cell, or watch-house;7 of these, 15 occurred in Queensland, and 17 were Aboriginal or Torres Strait Islander people. The primary cause of those 43 deaths was medical (49%), followed by suicide (33%), accident (2%), intentionally killed (2%), and other (14%).7 As a group, detainees are largely disconnected from health services, so beyond their immediate, untreated health problems, comparatively little is known about underlying and unaddressed social determinants (eg, homelessness, unemployment, poor education, low incomes). United Nations Mandela Rule 24.1 stipulates that prisoners are entitled to medical care that is equivalent to that which they could access in the community.8 While complying with the Mandela Rule has challenged Australian prisons,9 the extent to which this includes the watch-house setting is unclear. A study of detainee experiences in Victoria indicates significant challenges, with reports of deprivation of material comfort, dignity and respect, and exposure to harsh, hostile, overcrowded and degrading environments.2 Access to health care in short term custody settings can be hampered by a range of underlying contexts, structures and processes of health care delivery.10 Evidence predominates from the United States and United Kingdom.10 To further advance reform in this neglected area, our group has been investigating strategies used at several geographically diverse police watch-houses across Queensland. This follows on from single-site research reporting that situating an emergency trained nurse within a watch-house yielded multiple positive impacts,11 including reducing unnecessary detainee transfers to the emergency department (ED) and associated costs. This article highlights key challenges for the people and systems responsible for the health and safety of detainees in Queensland, and identifies potential opportunities to reduce the burden on these systems and improve access to appropriate health care. Challenges Overseas, the health needs of detainees in police custody represent challenges at individual, system, and inter-agency levels.12 It is important to understand these challenges in the Queensland context to inform opportunities to drive equitable, cost-effective strategies for this population. Challenges relating to individuals ▪ Detainees have significant health complexities with higher rates of mental illness, substance dependence and communicable diseases11 than the broader community.13 In addition, they commonly present with acute exacerbations of chronic conditions such as diabetes mellitus, hypertension, asthma, substance dependence, and mental illness.12-14 They may also be acutely injured, intoxicated and/or distressed owing to the circumstances surrounding their detention, which may mask symptoms or hinder timely health assessment. ▪ Detainees commonly have complex social needs. They often belong to multiple categories of vulnerable populations.15 This is especially evident for Aboriginal and Torres Strait Islander people, who represent 30% of the custodial population16 despite comprising only 3.3% of the Australian population.17 The prevalence of mental disorder among Indigenous adults in Queensland custody is very high (males, 73%; females, 86%) compared with community estimates,18 highlighting both layered vulnerability and the need for culturally appropriate responses. ▪ Autonomous decision making is limited for detainees. Detainees have little autonomy in decisions about their own health care and rely on police assistance to access services. Some may be motivated to under-report or over-report health issues, either because they are mistrustful of those responsible for their health care access (eg, the police), or in an effort to leave the watch-house environment to receive care.19 This has led to recommendations for alternative approaches enabling medically trained staff to be on-site to assess, monitor and reassess detainees.20 Challenges relating to systems ▪ Watch-houses are not health care settings and are not necessarily well equipped to manage health care delivery. Similarly, health care settings such as EDs are not custodial settings. Hence there are inherent risks when transferring detainees out of a secure setting and into a health care setting, including the risk of absconding, risks to staff safety, and risks to the health of the detainee while in transit. The remoteness of some watch-houses and police cells, especially in Queensland, can mean slower coordination with health services, placing more burden on watch-house staff to correctly identify and respond to acute medical needs. ▪ Watch-houses are not prisons. Unlike prisons and youth detention facilities, watch-houses may have both children and adults of different genders, all requiring segregation. Managing such segregation during a pandemic, and where detainees may be a particular risk to themselves or others, can add extra complexities to an often already crowded and challenging environment. ▪ Police staff are not health care professionals but are expected to have a role in health screening of detainees10, 19 and delivering some minor care (eg, medication administration).19 Many watch-house detainees have health problems which necessitate a rapid and effective response that may include forensic medical officer, general practitioner, government medical officer or nurse consultation (via phone or in person), ambulance service call-out, and ED transfer. Common reasons requiring an ED transfer pertain to trauma and toxicology related problems.11 Given the duty of care owed to detainees by police, a risk mitigation approach often guides decision making for transportation. Although evidence-based guidelines exist to inform health care delivery in prison settings,21, 22 there is limited evidence to guide health care management for detainees in police watch-houses.10 Challenges relating to connections between agencies United Nations Mandela Rule 24.2 requires continuity of care between custodial and community health care services.8 This is complicated by the wide range of providers involved in the health care of detainees. These agencies may have different communication preferences, organisational cultures, professional terminology, procedures, and sometimes different objectives. Adding to this, privacy issues surrounding sharing of health information are complex, and health care providers in watch-house settings may have difficulty accessing necessary health information in a timely fashion. Understanding of contextual capabilities between agencies is required. Re-engaging detainees who were previously disengaged from health services before watch-house entry13 may be hampered by uncertainty regarding their discharge destination. Furthermore, processes in one system can affect another. Health care services therefore need to plan care around criminal justice processes and outcomes that may not yet be determined (eg, bail, release, imprisonment), leading to uncertainty regarding provision of ongoing or follow-up care. There are considerable costs of health care for watch-house detainees. Such costs relate to in-watch-house health care covering health care personnel (with varying models noted in the literature),10 medications, and general medical supplies; and police escort and guard costs for transfer to and treatment in external health care settings. Opportunities and a way forward Despite the myriad challenges, watch-house detention provides a unique opportunity to intercept a vulnerable, complex and otherwise hard-to-reach population, and identify unmet health needs.23 As has been suggested for prisons, health training for all staff working in watch-houses should include social determinants of health.4 Given the high rates of Indigenous Australians in custody,16 further investment in resourcing for culturally capable care, especially mental health services, is also needed.18 The short term nature of watch-house detention limits the potential to achieve sustained health improvements for detainees, although brief interventions for some health needs24 (eg, substance use, sexual health screening, vaccination) may be effective. Increased access to health care providers in watch-houses would improve assessment, triage and management of some health problems. This could help minimise adverse outcomes, and potentially reduce unnecessary and resource-intensive transfers to EDs. Consistent with World Health Organization recommendations for prisons,21 models of health care in watch-houses should be closely linked with public health services and, ideally, administered by a health care agency rather than the police service. Consistent with this, understanding the expected roles of the health team and those of the police watch-house would be imperative. Further investment in interagency strategies is needed to reduce the burden on police and EDs, and ensure appropriate care for detainees. Potential strategies should balance the risk of unnecessary transport to hospital with the imperative to address the entrenched social, security and health challenges25 at play in this especially vulnerable population. Continuity of care should be a key consideration in this context,9 capitalising on the opportunity to link this population to ongoing services to support sustained improvements in health. A shared electronic medical record would be optimal; however, a broader governance framework that promotes integration between watch-house and community health care providers is needed to facilitate effective information sharing and continuity of care. These goals will require a sustained, coordinated investment in intersectoral collaboration. The overlap of health and law enforcement offers important opportunities to support health care delivery to detainees. It is time to capitalise on these opportunities. Acknowledgements This work was supported by funding from the Emergency Medicine Foundation. Open access Open access publishing facilitated by Griffith University, as part of the Wiley - Griffith University agreement via the Council of Australian University Librarians. Competing interests No relevant disclosures. Provenance Not commissioned; externally peer reviewed. References 1 Queensland Police Service. Operating Procedure Manual. Chapter 16 – Custody. https://www.police.qld.gov.au/sites/default/files/2022-01/OPM%20-%20Chapter%2016%20-%20Custody.pdf (viewed June 2022). 2Walker S, Higgs P, Stoové M, Wilson M. "That's the lowest place on earth!" Experiences of the carceral spaces of Australian police custody for marginalized young men. Qual Health Res 2020; 30: 880- 893. 3Zeng Z. Jail inmates in 2017. US Department of Justice Bureau of Justice Statistics (NCJ 251774). April 2019. https://www.bjs.gov/index.cfm?ty=pbdetail&iid=6547 (viewed May 2022). 4World Health Organization. Prisons and health. https://www.who.int/europe/health-topics/prisons-and-health (viewed June 2022). 5Ogloff J, Warren L, Tye C, Blaher F, Thomas S. Psychiatric symptoms and histories among people detained in police cells. Soc Psychiatry Psychiatr Epidemiol 2011; 46: 871- 880. 6Walker S, Higgs, P, Stoove M, Wilson M. "They just don't care about us!": Police custody experiences for young men with histories of injecting drug use. Aust NZ J Criminol 2020; 53: 102- 120. 7Walsh T, Counter A. Deaths in custody in Australia: a quantitative analysis of coroners' reports. Curr Issues Crim Justice 2019, 31: 143- 163. 8 United Nations Office on Drugs and Crime. The United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules). https://www.unodc.org/documents/justice-and-prison-reform/Nelson_Mandela_Rules-E-ebook.pdf (viewed June 2022). 9Mackay A. The relevance of the United Nations Mandela rules for Australian prisons. Altern Law J 2017; 42: 279- 285. 10Wardrop R, Ranse J, Chaboyer W, Crilly J. Structures, processes and outcomes of health care for people detained in short-term police custody settings: a scoping review. J Forensic Leg Med 2021; 81: 102198. 11Crilly J, Lincoln C, Scuffham P, et al. Effect of a 24/7 nursing presence in a police watch house on police presentations to the emergency department. Aust Health Rev 2020; 44: 924- 930. 12Rekrut-Lapa T, Lapa A. Health needs of detainees in police custody in England and Wales. Literature review. J Forensic Leg Med 2014; 27: 69- 75. 13Ceelen M, Dorn T, Buster M, et al. Health-care issues and health-care use among detainees in police custody. J Forensic Leg Med 2012; 19: 324- 331. 14Ogloff JR., Thomas SD, Luebbers S, et al. Policing services with mentally ill people: developing greater understanding and best practice. Aust Psychol 2012; 48: 57- 68. 15McKinnon I, Grubin D. Health screening in police custody. J Forensic Leg Med 2010; 17: 209- 212. 16 Australian Bureau of Statistics. Prisoners in Australia. 9 Dec 2021. https://www.abs.gov.au/statistics/people/crime-and-justice/prisoners-australia/latest-release#:~:text=From%2030%20June%202020%20to,prisoners%20per%20100%2C000%20adult%20population (viewed June 2022). 17 Australian Institute of Health and Welfare. Profile of Indigenous Australians. 7 July 2022. https://www.aihw.gov.au/reports/australias-health/profile-of-indigenous-australians (viewed July 2022). 18Heffernan EB, Andersen KC, Dev A, Kinner S. Prevalence of mental illness among Aboriginal and Torres Strait Islander people in Queensland prisons. Med J Australas 2012, 197: 37- 41. 19McKinnon I, Finch TL. Contextualising health screening risk assessments in police custody suites – qualitative evaluation from the HELP-PC study in London, UK. BMC Public Health 2018; 18: 393. 20 Office of the State Coroner, Queensland Courts. Findings of Inquest: Inquest into the death of Herbert John Mitchell. 14 Dec 2012. https://www.courts.qld.gov.au/__data/assets/pdf_file/0008/170774/cif-mitchell-hj-20121214.pdf (viewed June 2022). 21Møller L, Stöver H, Jürgens R, et al, editors. Health in prisons: a WHO guide to the essentials in prison health. Copenhagen: WHO Regional Office for Europe, 2007. https://www.euro.who.int/__data/assets/pdf_file/0009/99018/E90174.pdf (viewed June 2022). 22 Royal Australian College of General Practitioners (RACGP). Standard for health services in Australian Prisons ( 1st edition). Victoria, Australia: RACGP. 2011. https://www.racgp.org.au/FSDEDEV/media/documents/Running%20a%20practice/Practice%20standards/Health-services-in-Australian-prisons.pdf (viewed June 2022). 23Lord Bradley. The Bradley Report: Lord Bradley's review of people with mental health problems or learning disabilities in the criminal justice system. London: Department of Health, 2009. https://webarchive.nationalarchives.gov.uk/ukgwa/20130123195930/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_098694 (viewed June 2022). 24Addison M, Mcgovern R, Angus C, et al. Alcohol screening and brief intervention in police custody suites: pilot cluster randomised controlled trial (AcCePT). Alcohol Alcohol 2018; 53: 548- 559. 25van Dijk AJ, Herrington V, Crofts N, et al. Law enforcement and public health: recognition and enhancement of joined-up solutions. Lancet 2019; 393: 287- 294. Volume217, Issue6September 2022Pages 287-289 ReferencesRelatedInformation

Objective People detained in police custody are a vulnerable population with complex health needs, sometimes requiring emergency care. This study evaluated the effect of a 24/7 nursing presence in a police watch house on police presentations to the emergency department (ED). Methods This was a retrospective observational study conducted in a regional ED in Queensland. Equal time periods of 66 days before (T1), during (T2) and after (T3) the pilot service was trialled in 2013 were compared to determine changes in patient and service delivery outcomes. The time to see a doctor in the ED, ED length of stay, hospital admission rate, number of transfers from the watch house to the ED and associated costs were measured. The nature of health care delivered by nurses to detainees in the watch house during the pilot was also examined. Results Fewer detainees were transferred from the police watch house to the ED during the pilot period (T1, n=40; T2, n=29; T3, n=34). Cost reductions associated with reduced police and ambulance attendance, as well as hospitalisations, outweighed the watch house nursing costs, with cost savings estimated at AUD7800 per week (60% benefiting police; 40% benefiting the health service). The most common health problems addressed during the 1313 healthcare delivery episodes provided to 351 detainees in the watch house during the pilot related to substance misuse, chronic disease and mental health problems. Conclusion Fewer transfers from the police watch house to the ED were noted when there was a 24/7 nursing presence in the watch house. This model appears to be economically efficient, but further research is required. What is known about the topic? People detained in police custody are a vulnerable population with complex health needs, sometimes requiring emergency care. What does this paper add? Transfers from the police watch house to the ED were fewer when there was a 24/7 nursing presence in the police watch house (an economically efficient model). Nursing care provided to detainees in the watch house setting predominantly related to substance misuse, chronic disease and mental health problems. What are the implications for practitioners? With a 24/7 nursing presence in the police watch house, transfer to the ED was avoided for some detainees. Similar strategies that respond to coronial recommendations advocating for enhancements in police-health collaboration warrant evaluation.

Background: Emergency department (ED) triage is the process of prioritising patients by medical urgency. Delays in intensive care unit (ICU) admission can adversely affect patients. Objectives: This study aimed to identify characteristics associated with ICU admission for patients triaged as Australasian Triage Scale (ATS) 3 but subsequently admitted to the ICU within 24 h of triage. Methods: This retrospective, observational cohort study was conducted in a public teaching hospital in Queensland, Australia. Patients older than 18 y triaged with an ATS 3 and admitted to the ICU within 24 h of triage or admitted to the ward between January 1, 2012, and December 31, 2012, were included. The demographic and clinical profiles of ICU admissions vs. all other ward admissions for patients triaged an ATS of 3 were compared. Multivariable regression analysis compared characteristics of patients triaged with an ATS of 3 who did and did not require ICU transfer. Descriptive data are reported as n (%) and median and interquartile range (IQR). Regression analysis is reported as adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs). Results: Of the 27 454 adult ED presentations triaged with an ATS of 3, 22.4% (n = 6138) required hospital admission, comprising 5302 individuals, 2.1% of whom (n = 110) were admitted to the ICU within 24 h of triage. Age- and sex-adjusted predictors of ICU admission for patients triaged with an ATS of 3 included infectious (aOR: 3.7; 95% CI: 2.0-6.9), neurological (aOR: 2.8; 95% CI: 1.6-5.0), and gastrointestinal disorders (aOR: 2.2; 95% CI 1.2-3.5); arriving by ambulance; arriving after hours; or arriving on weekends. Regardless of diagnosis or sex, persons older than 80 y were less likely to be admitted to the ICU (aOR: 0.4; 95% CI: 0.2-0.8). Conclusions: Patients triaged as ATS 3 presenting on weekends or after hours, and those with infectious, gastrointestinal, or neurological conditions warrant careful attention as these factors were associated with higher odds of ICU admission. Ongoing staff education regarding triage and signs of deterioration are important to prevent avoidable outcomes. ? 2020 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

Extended delays in the transfer of patients from ambulance to ED can compromise patient flow. The present study aimed to describe the relationship between the use of an Emergency Department Ambulance Off‐Load Nurse (EDAOLN) role, ED processes of care and cost effectiveness.

To describe and compare characteristics and outcomes of patient presentations brought in by police (BIBP) with those not BIBP (NBIBP) to one Australian ED.

BACKGROUND:Increasing presentations to the Emergency Department (ED) via police (which include detainees, prisoners and community residing persons) and the increase in chronic and mental health illness in detainee and prisoner populations has prompted an increased requirement for healthcare delivery within the custodial environment. This study aimed to describe the Watch House Emergency Nurse (WHEN) role, focusing on structures and processes underpinning the role.METHODS:In this qualitative, descriptive study, semi-structured interviews were undertaken in 2015 with 14 key stakeholders from health, police, and ambulance services. Interviews were analysed using content analysis to inform the findings.FINDINGS:Important structural elements of the WHEN role included an ED triage competent registered nurse, a 2-day integrated training program, and clear guidelines to provide a framework for identifying, prioritising and managing healthcare needs. Important process elements were clear communication between nurses, police, and medical staff, and a clear understanding of roles and responsibilities to facilitate continuity of care and appropriate referral. The underpinning perceived benefit of the WHEN role was 'safety'. This was in terms of personal, professional, and detainee safety.CONCLUSION:The structures and processes underpinning the innovative WHEN role provides a valuable foundation for guiding evaluations of other nursing roles in other early custody settings.

OBJECTIVE:Timely and appropriate assessment and management within the ED impacts patient outcomes including in-hospital mortality and length of stay (LOS). Within the ED, several processes facilitate timely recognition of the need for intensive care unit (ICU) admission. This study describes characteristics and outcomes for patient presentations admitted to ICU from ED, categorised by Australasian Triage Score (ATS), ICU admission time and ICU admission source.METHODS:A retrospective observational cohort study with linked health data of adult ICU admissions during 2012. Outcomes measured included: ED, ICU and hospital LOS, time to see ED clinician, ICU readmission and ICU and hospital mortality rates.RESULTS:In total, 423 ICU admissions occurred within 24 h of ED arrival; 395 were admitted directly to ICU; 28 were admitted to the ward before ICU admission. ATS 3/4/5 patients comprised 26.7% of ICU admissions and experienced longer waits to be seen, longer total ED LOS, shorter ICU LOS and a lower mortality rate than those triaged ATS 1/2. Compared to ICU admissions during business hours, admissions outside hours did not differ significantly for any outcome measured. Patients admitted to the ward before ICU experienced longer waits to be seen and longer ED LOS.CONCLUSION:Most patients are appropriately identified in ED as requiring ICU admission, although around one in four were triaged ATS 3/4. Patients admitted to the ward first tended to have poorer outcomes than those directly admitted to ICU. Factors predicting the need for ICU admission should be identified to support clinical decision-making.

The safety and benefits of restrictive transfusion strategies have been demonstrated by research studies, but whether transfusions are being restricted

Emergency department overcrowding is an increasing issue impacting patients, staff and quality of care, resulting in poor patient and system outcomes. In order to facilitate better management of emergency department resources, a patient admission predictive tool was developed and implemented. Evaluation of the tool's accuracy and efficacy was complemented with a qualitative component that explicated the experiences of users and its impact upon their management strategies, and is the focus of this article. Semi-structured interviews were conducted with 15 pertinent users, including bed managers, after-hours managers, specialty department heads, nurse unit managers and hospital executives. Analysis realised dynamics of accuracy, facilitating communication and enabling group decision-making Users generally welcomed the enhanced potential to predict and plan following the incorporation of the patient admission predictive tool into their daily and weekly decision-making processes. They offered astute feedback with regard to their responses when faced with issues of capacity and communication. Participants reported an growing confidence in making informed decisions in a cultural context that is continually moving from reactive to proactive. This information will inform further patient admission predictive tool development specifically and implementation processes generally.

Financial distress and shrinking police candidate pools have diminished cities' abilities to protect the public. In this Viewpoints video, David Green, Lieutenant for the San Bernardino Police Department, discusses his CHDS Master's thesis, which examines the manner in which cities have adapted by using civilians to perform the duties of sworn detectives. Specifically, he looks at whether this practice enhances cities' contributions to public safety. Nine law enforcement organizations across the country that applied this policy were analyzed. It focused on cost implications, impacts on investigative and emergency response capabilities, job qualifications, training standards, scope of duties, and overall efficacy. Similar themes include the ability of cities to reduce costs and to achieve equivalent work output from civilian personnel. Dissimilar themes surrounded the reasons cities adopted the policy and how they trained the personnel. From the analysis, this thesis determined that the use of civilian personnel does enhance cities' contributions to public safety. This thesis also identified a need for a uniform national framework for policy adoption and for state peace officer accrediting commissions to develop guidelines for training and certification.

Study Objectives: To evaluate the implementation of a Patient Admission Prediction Tool (PAPT) in terms of patient flow outcomes and decision-making strategies. Methods: Setting: The PAPT was implemented in 2 Australian public teaching hospitals during October-December 2010 (hospital A) and October-December 2011 (hospital B). Design: A multisite prospective, comparative (before and after) design was used. Patient flow outcomes measured included access block and hospital occupancy. Daily and weekly data were collected from patient flow reports and routinely collected emergency department information by the site champion and researchers. Results: Daily decision-making strategies ranged from business as usual to use of overcensus beds. Weekly strategies included advanced approval to use of overcensus beds and prebooking nursing staff. These strategies resulted in improved weekend discharges to manage incoming demand for the following week. Following the introduction of the PAPT and workflow guidelines, patient access and hospital occupancy levels could be maintained despite increases in patient presentations (hospital A). Conclusions: The use of a PAPT, embedded in patient flow management processes and championed by a manager, can benefit bed and staff management. Further research that incorporates wider evaluation of the use of the tool at other sites is warranted.

Public health funerals are provided where the deceased has no living relatives to carry out a funeral.

ED overcrowding in Australia has been, and in many cases still is, a major public healthcare issue. I have been a Fellow of the Australasian College for Emergency Medicine (FACEM) since I passed the second ever Fellowship exam in 1987 and have been the Director of Emergency Medicine at Gold Coast Hospital (now Gold Coast University Hospital) for over 27 years. I have been a member of the Australasian College for Emergency Medicine (ACEM) court of examiners for most of this period and have been extensively involved in registrar training for all of this time. Over this long passage of time I have watched strong systems of specialist emergency care develop, and seen the expertise and quality of care improve for the community accessing ED care. I have also seen ED overcrowding evolve as over time an increasing demand for care collided with relative decreases in inpatient bed stocks per head of population as Australia got older with an increasing burden of chronic disease. The ACEM has been at the forefront in efforts to resolve the issue of ED overcrowding. Through the research of Drew Richardson, Peter Sprivulis and others it was clearly shown that ED overcrowding is associated with poor outcomes for those patients who spend more than 8 h in an ED waiting for an inpatient bed. We have all made huge efforts to reduce waiting times and improve patient flow in our departments with considerable success in some states. But over the past few years I’ve noticed changes in our practice, time clocks on patients and disposition become more of an ED mantra than diagnosis. I feel this has also been reflected generally when it comes to the relatively poor pass rates in the Short Answer Questions (SAQs) and other parts of the FACEM Fellowship Examination. The key question as I see it is ‘has National Emergency Access Target (NEAT) dumbed down emergency physicians?’. Have we become the masters of moving patients through complex systems, and by that deflecting much of the diagnostic workup to other areas such as Medical Admission Units (MAUs), Clinical Decision Units (CDUs) and Rapid Admission and Planning Units (RAPUs)? Clearly, for most emergency physicians NEAT has radically changed our business. Diagnostic workups have changed from ‘fine dining’ to ‘fast food’. We see more patients faster and spend less time with them. We have even set up ‘drive through’ service in some centres with ‘see and treat’ models. NEAT measures when you arrive and when you leave and nothing in between. While seen as a ‘quality’ access target, it in no way measures what actually happens in this time gap or after. As the tragedy of the Mid Staffordshire disaster shows, target-driven systems that run under ‘command control’ management systems can have diabolical consequences for patients and their families. But that is not to say that NEAT has not improved access to care. Clearly great strides have been made in offloading ambulances, reducing waiting times and improving the efficiency of admission processes. Every emergency physician in this country has been told time and time again ‘NEAT is a whole of hospital problem’, yet the engagements of inpatient teams is often patchy and only tacitly acknowledged within the NEAT process. Nationally we are driving hard towards a 90% target for 2015, yet there is little evidence base for the exact percentage of NEAT that delivers optimal care. We have made great strides to improve the ‘non-admitted’ part of NEAT but in manystates the ‘admittedNEAT’figures hover between 30 and 40%. Despite this, we have made improvements in access block. Prior to NEAT the previous access block targets (that required less than 20% of admitted patients waited for a bed for more than 8 h) were never met in Queensland. This target has been achieved in Queensland across the board on 2013 data, a very significant feat. As Geelhoed and de Klerk showed in Western Australia reducing access block reduces inpatient mortality. This is the key evidence base that relates improvement in quality to a time target for our admitted patients. Yet under NEAT we never celebrated this historic milestone. We forgot what we were originally trying to solve! While considerable time improvements have been made we are still well below the proposed 90% 2015 NEAT in every state, and the stretching target has seen us pushed harder to get patients through the system faster. What is the evidence base for a 90% target? The answer is sadly lacking. The key part of the NEAT equation is ‘admitted NEAT’, as improvements in admitted NEAT reduce access block and therefore reduce ED overcrowding and inpatient mortality, and we have a considerable evidence base for this. I was marking some trial SAQs for a group of ED registrars last week. I have done this type of thing for over 20 years now. The group, in preparation for their upcoming Fellowship exam prepare one of the old FACEM David Green, MD, FACEM, Director. bs_bs_banner

OBJECTIVE:To develop and validate models to predict emergency department (ED) presentations and hospital admissions for time and day of the year.METHODS:Initial model development and validation was based on 5 years of historical data from two dissimilar hospitals, followed by subsequent validation on 27 hospitals representing 95% of the ED presentations across the state. Forecast accuracy was assessed using the mean average percentage error (MAPE) between forecasts and observed data. The study also determined a daily sample size threshold for forecasting subgroups within the data.RESULTS:Presentations to the ED and subsequent admissions to hospital beds are not random and can be predicted. Forecast accuracy worsened as the forecast time intervals became smaller: when forecasting monthly admissions, the best MAPE was approximately 2%, for daily admissions, 11%; for 4-hourly admissions, 38%; and for hourly admissions, 50%. Presentations were more easily forecast than admissions (daily MAPE ∼7%). When validating accuracy at additional hospitals, forecasts for urban facilities were generally more accurate than regional forecasts (accuracy is related to sample size). Subgroups within the data with more than 10 admissions or presentations per day had forecast errors statistically similar to the entire dataset. The study also included a software implementation of the models, resulting in a data dashboard for bed managers.CONCLUSIONS:Valid ED prediction tools can be generated from access to de-identified historic data, which may be used to assist elective surgery scheduling and bed management. The paper provides forecasting performance levels to guide similar studies.