BackgroundThe recognition of patient deterioration depends largely on identifying abnormal vital signs, yet little is known about the daily pattern of vital signs measurement and charting.MethodsWe compared the pattern of vital signs and VitalPAC Early Warning Score (ViEWS) data collected from admissions to all adult inpatient areas (except high care areas, such as critical care units) of a NHS district general hospital from 1 May 2010 to 30 April 2011, to the hospital's clinical escalation protocol. Main outcome measures were hourly and daily patterns of vital signs and ViEWS value documentation; numbers of vital signs in the periods 08:00–11:59 and 20:00–23:59 with subsequent vital signs recorded in the following 6 h; and time to next observation (TTNO) for vital signs recorded in the periods 08:00–11:59 and 20:00–23:59.Results950 043 vital sign datasets were recorded. The daily pattern of observation documentation was not uniform; there were large morning and evening peaks, and lower night-time documentation. The pattern was identical on all days. 23.84% of vital sign datasets with ViEWS ≥ 9 were measured at night compared with 10.12–19.97% for other ViEWS values. 47.42% of patients with ViEWS=7–8 and 31.22% of those with ViEWS ≥ 9 in the period 20:00–23:59 did not have vital signs recorded in the following 6 h. TTNO decreased with increasing ViEWS value, but less than expected by the monitoring protocol.ConclusionsThere was only partial adherence to the vital signs monitoring protocol. Sicker patients appear more likely to have vital signs measured overnight, but even their observations were often not followed by timely repeat assessments. The observed pattern of monitoring may reflect the impact of competing clinical priorities.

IntroductionOf the 40 million people globally in need of palliative care (PC), just 14% receive it, predominantly in high-income countries. Within fragile health systems that lack PC, incurable illness is often marked by pain and suffering, as well as burdensome costs. In high-income settings, PC decreases healthcare utilisation, thus enhancing value. Similar cost-effectiveness models are lacking in low-income and middle-income countries and with them, the impetus and funding to expand PC delivery.MethodsWe conducted a systematic search of seven databases to gather evidence of the cost-effectiveness of PC in low-income and middle-income countries. We extracted and synthesised palliative outcomes and economic data from original research studies occurring in low-income and middle-income countries. This review adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and includes a quality appraisal.ResultsOur search identified 10 eligible papers that included palliative and economic outcomes in low-income and middle-income countries. Four provided true cost-effectiveness analyses in comparing the costs of PC versus alternative care, with PC offering cost savings, favourable palliative outcomes and positive patient-reported and family-reported outcomes.ConclusionsDespite the small number of included studies, wide variety of study types and lack of high-quality studies, several patterns emerged: (1) low-cost PC delivery in low-income and middle-income countries is possible, (2) patient-reported outcomes are favourable and (3) PC is less costly than the alternative. This review highlights the extraordinary need for robust cost-effectiveness analysis of PC in low-income and middle-income countries in order to develop health economic models for the delivery of PC, direct resource allocation and guide healthcare policy for PC delivery in low-income and middle-income countries.

There are extensive unmet palliative care needs in Ethiopia. Untreated pain and high costs of illness are the major contributors to psychosocial distress and financial crisis in this Ethiopian population.

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Introduction: The “4Ms” model – What Matters, Medication, Mentation, and Mobility – is increasingly gaining attention in age-friendly health systems, yet a feasible approach to identifying what matters to older adults in the emergency department (ED) is lacking. Adapting the “What Matters” questions to the ED setting, we sought to describe the concerns and desired outcomes of both older adult patients seeking ED care and their treating clinicians. Methods: We conducted 46 dyadic semi-structured interviews of cognitively intact older adults and their treating clinicians. We used the “What Matters” conversation guide to explore patients’ 1) concerns and 2) desired outcomes. We then asked analogous questions to each patient’s treating clinician regarding the patient’s priorities. Interviews were professionally transcribed and coded using an inductive approach of thematic analysis to identify emergent themes. Results: Interviews with older adults lasted a mean of three minutes, with a range of 1–8 minutes. Regarding patients’ concerns, five themes emerged from older adults: 1) concern through a family member or outpatient clinician recommendation; 2) no concern, with a high degree of trust in the healthcare system; 3) concerns regarding symptom cause identification; 4) concerns regarding symptom resolution; and 5) concerns regarding preservation of their current status. Regarding desired outcomes, five priority themes emerged among older adults: 1) obtaining a diagnosis; 2) returning to their home environment; 3) reducing or resolving symptoms; 4) maintaining self-care and independence; and 5) gaining reassurance. Responding to what they believed mattered most to older adult patients, ED clinicians believed that older adults were concerned primarily about symptom cause identification and resolution and primarily desired a return to the home environment and symptom reduction. Conclusion: This work identifies concerns and desired outcomes of both older adult patients seeking ED care and their treating clinicians as well as the feasibility of incorporating the “What Matters” questions within ED clinical practice.