Thesis structure

Chapter two,Methodology: This research used a multiphase, emergent mixed methods, quantitative-dominant, explanatory sequential design. Chapter two presents an overview of the growth of mixed methods research as a distinct research paradigm, the pragmatic assumptions associated with mixed methods research, and the development of mixed methods typologies and designs, as well as a rationale for the choice of research design in this study.

Chapter three, Emergency department crowding: a systematic review of causes, consequences and solutions: Chapter three contains the final Word document of a systematic review titled ‘Emergency department crowding: a systematic review of

causes, consequences and solutions’, published in PLOS ONE in August 2018. A key finding of this review was a dearth in the published research investigating the causes of ED crowding. Due to the different formatting styles of many academic journals, it was decided to include the final Microsoft Word version of all published papers to ensure consistent formatting throughout this thesis.

Chapter four, Characteristics of longitudinal patterns of emergency department presentations in Tasmania: Chapter four contains the final Word document of a

published manuscript titled ‘Planning for the future: emergency department

presentation patterns in Tasmania, Australia’, published online in International Emergency Nursing in September 2017. This paper describes the findings of a detailed analysis of four-years of ED presentations in Tasmania, the smallest of Australia’s six

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states. A key finding of the analysis was a significant per capita increase in ED presentations in the South of the state by those aged ≥ 75 years.

Chapter five, Access to healthcare and how it is measured: As patient-perceived access to care has been proposed as a potential driver of ED presentations by the elderly, Chapter five presents an overview of the literature into access to healthcare. A group of conditions called PPHs have been identified as an acceptable measure of patient- perceived access to care. Therefore, the second half of Chapter five details the processes involved in identifying the conditions considered to be potentially preventable, the development of the term PPHs, and the research evidence to support PPHs as an indicator of patient-perceived access to care.

Chapter six, Emergency department crowding in Tasmanian: the role of potentially avoidable admissions: Chapter six contains the final Word document of a peer-reviewed manuscript accepted for an oral presentation at the 6th Annual International Conference on Worldwide Nursing, in Singapore in July 2018 titled ‘Patient-perceived access to care is a driver of increased emergency department presentations by the

elderly’. This paper describes the findings of a retrospective data analysis of six-years of hospital admissions to one Australian hospital, specifically looking at PPHs. Key findings of the analysis were a 10% per capita increase in PPHs, and a 174% increase in short- stay hospitalisations for CCF, over the six years, by patients aged ≥ 75 years.

Chapter seven, Factors driving the increase in emergency department presentations and short-stay hospital admissions for elderly patients with congestive cardiac failure: Chapter seven provides the methods and results of a DMR audit to compare the experiences of the 175 individuals aged ≥ 75 years who experienced a short-stay hospital admission for CCF at the RHH in the years 2010-11 and 2015-16. A key finding of the audit was that, although the profile of these patients had not changed appreciably over the six years, there were 142 more ED presentations and 116 more hospital admissions by patients in this demographic in 2015-16 than in 2010-11, placing a significant burden on health system resources.

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Chapter eight, The role of patient-perceived access to care in emergency department presentations and short-stay hospital admissions: Chapter eight details the methods and results of phase four of the research project, which involved undertaking semi- structured interviews to qualitatively explore the role of patient-perceived access to care in ED presentations in Tasmania. A key finding of the analysis was that, although the participants perceived that they had good access to care when they required it, when viewed through the lens of the domains of access to care, their actual access was less than ideal. The main areas of concern included a lack of person-centred care, poor continuity of care with a preferred GP and inadequate levels of health literacy, leading to a limited ability of the participants to be involved in self-management of their chronic condition.

Chapter nine, Discussion: Chapter nine provides a discussion of the study findings, with reference to the study aims and in the context of the broader literature in the field of ED crowding and its relationship to patient-perceived access to care. Limitations of the study are discussed and recommendations for clinicians, policy makers and future research provided.