Life In The Slower Lane

Build for emergent problems

nashte
10–14 minutes

The following is the information for my presentation at the Gold Coast Research Symposium – June 2026.

Build for emergent problems – how did I build this talk
GCUH_Research_DesignForFrailty_v1.0DownloaD

Quadruple Aim Keynote Map

A slide-by-slide map of visual direction, on-slide wording, audience-facing content and supporting references.

Slide 1

Title + QR + listening styles

Visual direction

Clean title slide; QR code on the right; subtle Metro South / ED texture only

On-slide phrase / quote
Built for emergent problems
Frailty at the front door and the Quadruple Aim in EDs
Measuring what matters for older people, clinicians and system performance

Audience-facing checklist

  • Title, topic, and scope were introduced.
  • Multiple valid listening styles were normalised, including attentive listening, note-taking, scrolling, fact-checking, and following links in real time.
  • A QR code was provided to a public resource list for the talk.
  • The formal beginning of the keynote was signposted clearly.

References / fact-checking

  1. Brief bio: Dr Terry Nash — Senior Staff Specialist Emergency Physician, Princess Alexandra Hospital Emergency Department; CAREPACT Clinical Lead; PhD candidate, University of Queensland School of Medicine.
  2. Role and candidature verification were drawn from the current keynote deck and HDR progress review source pack (internal project documents; no DOI).
  3. No scholarly literature was assigned to this slide because it carried orientation and access information rather than substantive research claims.
Slide 2

Population ageing as a success story

Visual direction

Official ageing graph already selected from ABS/AIHW; full-width if possible

On-slide phrase / quote
This is a success story

Audience-facing checklist

  • Population ageing was framed as evidence of longer life, better health care, and improved social and economic conditions.
  • Older age was separated from assumptions of severe illness, dependency, or imminent death.
  • Emergency medicine was positioned as the acute interface where the consequences of demographic success become visible.
  • College-level policy and education work on ageing, access block and emergency system design was acknowledged, including ACEM emergency geriatrics activity.

References / fact-checking

  1. Burkett E. Emergency medicine and population ageing: a call to action. Emerg Med Australas. 2024. Open DOI
  2. Burkett E, et al. Trends and predicted trends in presentations of older people to Australian emergency departments: effects of demand growth, population aging and climate change. Aust Health Rev. 2016. Open DOI
  3. Buckinx F, et al. Burden of frailty in the elderly population: perspectives for a public health challenge. Arch Public Health. 2015. Open DOI
  4. Reid J, et al. The Australian Frailty Network: development of a consumer-focussed national response to frailty. Australas J Ageing. 2024. Open DOI
Slide 3

Frailty is at the front door

Visual direction

Older person at threshold / ambulance ramp / bold frailty diagram

On-slide phrase / quote
Frailty is at the front door

Audience-facing checklist

  • Ageing was distinguished from frailty; more older people by number and proportion did not imply that most older people were frail.
  • Frailty was presented as the acute phenotype increasingly visible in emergency demand.
  • The Clegg definition was used to explain vulnerability to disproportionate deterioration after minor stressors.
  • Frail older people were framed not as “breaking” the ED, but as revealing where the system was already brittle.
  • Frailty was framed as dynamic rather than fixed, with opportunities for prevention, remediation and reversal depending on stage and context.

References / fact-checking

  1. Clegg A, et al. Frailty in older people. Lancet. 2013. Open DOI
  2. Gill TM, et al. Transitions between frailty states among community-living older persons. Arch Intern Med. 2006. Open DOI
  3. Travers C, et al. Building resilience and reversing frailty: a randomised controlled trial of a primary care intervention for older adults. Age Ageing. 2023. Open DOI
  4. Sison CP, et al. Rethinking emergency care for older adults living with frailty. Lancet Healthy Longev. 2024. Open DOI
Slide 4

Lean into the tension

Visual direction

Abseiling climber leaning back into rope, or bridge cable under load, or loom under tension

On-slide phrase / quote
Lean into the tension

Audience-facing checklist

  • Constraint, uncertainty, pressure, incompleteness, and competing goods were identified as ordinary conditions of emergency medicine rather than deviations from ideal care.
  • Tension was framed as something that can sharpen thinking, not only something to be resolved.
  • The cognitive literature on emergency decision-making under pressure was used as the evidentiary anchor for this section.
  • The Quadruple Aim was foreshadowed as a frame that reveals tension rather than resolving it, with the move from triple to quadruple framing noted conceptually.

References / fact-checking

  1. Pines JM, et al. Cognitive biases in emergency physicians: a pilot study. J Emerg Med. 2019. Open DOI
  2. Kunitomo K, et al. Cognitive biases encountered by physicians in the emergency room. BMC Emerg Med. 2022. Open DOI
  3. Egoda Kapuralalage R, et al. Clinical decision-making: cognitive biases and heuristics in triage decisions in the emergency department. Am J Emerg Med. 2025. Open DOI
  4. Schubert CC, et al. Characterizing novice-expert differences in macrocognition: an exploratory study of cognitive work in the emergency department. Ann Emerg Med. 2013. Open DOI
Slide 5

Quadruple Aim image / framing slide

Visual direction

The Quadruple Aim diagram from the current deck/blog or a cleaned equivalent from literature/policy

On-slide phrase / quote
The Quadruple Aim is an improved framing

Audience-facing checklist

  • The Quadruple Aim image was displayed as a framing device rather than as a performance measure.
  • Each aim was introduced as containing internal tension rather than a single stable objective.
  • The four domains were identified as patient experience, population health, system performance, and provider well-being.
  • The next four slides were signposted as one slide per aim.

References / fact-checking

  1. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014. Open DOI
  2. Samadbeik M, et al. Patient flow in emergency departments: a comprehensive umbrella review of solutions and challenges across the health system. BMC Health Serv Res. 2024. Open DOI
  3. Carpenter CR, et al. Adapting emergency care for persons living with dementia: results of the Geriatric Emergency Care Applied Research Network scoping review and consensus conference. JAMDA. 2022. Open DOI
  4. Rosenberg MS, et al. Geriatric emergency department guidelines. Ann Emerg Med. 2014. Open DOI
Slide 6

Aim 1 — patient experience

Visual direction

Bedside conversation; frail older person plus family/supporter; symbolic split-image of “the person you can see / the queue behind them”

On-slide phrase / quote
The individual encounter ↔ the queue

Audience-facing checklist

  • Patient experience was framed as a tension inside the aim itself.
  • A good individual encounter for a frail older person was identified as time-intensive by definition: 5Ms, baseline cognition, supporter involvement, supported decision-making, and “what matters most”.
  • That same time was identified as impacting every other person waiting to be seen, or the department’s capacity to respond elsewhere.
  • Person-centred care was complicated by the recognition of fluid, ongoing selfhood rather than a fixed identity in dementia.
  • Dignity of risk and supported decision-making were introduced as emerging but under-explored priorities for emergency care.

References / fact-checking

  1. Chary AN, et al. Emergency department communication with diverse caregivers and persons living with dementia: a qualitative study. J Am Geriatr Soc. 2024. Open DOI
  2. Gettel CJ, et al. A qualitative study of “what matters” to older adults in the emergency department. West J Emerg Med. 2022. Open DOI
  3. Chapman M, Philip J, Komesaroff P. A person-centred problem. Humanit Soc Sci Commun. 2022. Open DOI
  4. Donnelly M. Deciding in dementia: the possibilities and limits of supported decision-making. Int J Law Psychiatry. 2019. Open DOI
  5. Foundas M. Dignity of risk in residential aged care: a call to reframe understandings of risk. Med J Aust. 2025. Open DOI
Slide 7

Aim 2 — population health

Visual direction

ED as safety net / upstream-downstream flow / RACF, GP, ambulance, ED

On-slide phrase / quote
The ED is the revelation, not the delivery point

Audience-facing checklist

  • Population health was framed as what the ED sees when upstream systems have already failed or thinned.
  • Primary care gaps, aged care gaps, after-hours resource gaps, social support gaps and fragmented care were identified as part of emergency demand.
  • Injurious falls were presented as rising before and around dementia diagnosis, making the fall potentially already a conversation about cognition.
  • “Mechanical falls” language was identified as a source of anchoring bias that obscures frailty, cognition, polypharmacy and accumulated vulnerability.
  • Prevention was placed in tension with proportionate care, especially in advanced dementia and severe frailty.

References / fact-checking

  1. Zhang L, et al. Injurious falls before, during and after dementia diagnosis: a population-based study. Age Ageing. 2022. Open DOI
  2. Nagaraj G, et al. Avoiding anchoring bias by moving beyond “mechanical falls” in geriatric emergency medicine. Emerg Med Australas. 2018. Open DOI
  3. Iaboni A, et al. A palliative approach to falls in advanced dementia. Am J Geriatr Psychiatry. 2018. Open DOI
  4. Brennan F, et al. Our dementia challenge: arise palliative care. Intern Med J. 2023. Open DOI
Slide 8

Aim 3 — system performance

Visual direction

Blocked patient flow / ramping / corridor / ward-discharge graphic / hospital dashboard

On-slide phrase / quote
The ED performance is the “emergency system fault alert indicator”, but the hospital engine is the bit that’s failing.

Audience-facing checklist

  • Throughput-only thinking was identified as too narrow for frailty-informed emergency care.
  • Access block, ambulance ramping and bed occupancy were framed as whole-of-system problems rather than ED process failures alone. The recent MJA work especially “banana in the tail pipe” is a direct challenge – the banana that’s in the tailpipe is disproportionately made up of older people and people with disabilities needing accommodation that matches their needs.
  • Throughput was placed in tension with thoroughness, with explicit attention to collateral history “what is this person like at their baseline”, cognition, family involvement, and “what matters most”.
  • Queensland older-person exemplars such as GEDI, CAREPACT and RaSS were referenced as whole-of-continuum models rather than isolated ED interventions – but they assist in providing the additional elements to improve the quality of care in the ED – as well as attempting to alleviate demand.
  • Implementation success was framed as dependent on context, leadership, capability, and knowledge exchange rather than intervention content alone.

References / fact-checking

  1. Yoon H-J, et al. The association between access block and ambulance ramping, and the impact of COVID-19: a retrospective observational cohort study of 25 Queensland hospitals. Med J Aust. 2026. Open DOI
  2. Riahi V, et al. The impact of hospital bed occupancy on patient flow and emergency department access: a 25-hospital cohort study. Med J Aust. 2026. Open DOI
  3. Hassanzadeh H, et al. Strategies for reducing access block and waiting time for patients seeking emergency hospital care: results of a ward-level discrete event simulation at Queensland’s largest public hospitals. Med J Aust. 2026. Open DOI
  4. Wallis M, et al. The Geriatric Emergency Department Intervention model of care: a pragmatic trial. BMC Geriatr. 2018. Open DOI
  5. Koerner J, et al. Context and mechanisms that enable implementation of specialist palliative care Needs Rounds in care homes: results from a qualitative interview study. BMC Palliat Care. 2021. Open DOI
Slide 9

Aim 4 — provider well-being

Visual direction

Fatigued clinician at workstation / humane but strained ED image / cognitive load visual

On-slide phrase / quote
Care of the patient requires care of the provider

Audience-facing checklist

  • Provider well-being was framed as the aim added last and measured least.
  • It was positioned as a necessary precondition of better care rather than an optional extra.
  • Burnout was framed not only as a morale issue, but as a cognitive and clinical problem.
  • Reduced safety-related quality, impaired attention, working memory and executive function were identified as especially relevant to older-person emergency care.
  • Endurance was placed in tension with sustainability, with the claim that older-person care often erodes first when workforce condition erodes.

References / fact-checking

  1. Dewa CS, et al. The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: a systematic review. BMJ Open. 2017. Open DOI
  2. Gavelin HM, et al. Clinical burnout and cognitive functioning: a systematic review and meta-analysis. Work Stress. 2022. Open DOI
  3. Wolfshohl JA, et al. Association between empathy and burnout among emergency medicine physicians. J Clin Med Res. 2019. Open DOI
  4. Persico N, et al. Influence of shift duration on cognitive performance of emergency physicians: a prospective cross-sectional study. Ann Emerg Med. 2018. Open DOI
Slide 10

Final challenge — ageist language, burnout, and the close

Visual direction

Reflective image: empty staff room after shift / clinician silhouette / speech bubble / quiet return to Quadruple Aim image in background

On-slide phrase / quote
Ageist language is behaviour — not identity

Audience-facing checklist

  • Off-the-cuff ageist language was framed as behaviour that should not be collapsed into the whole identity of the clinician who used it.
  • A distinction was made between explanation and excuse: the behaviour was not defended, but its conditions of emergence were treated as worthy of study.
  • The age-positive language literature was used to argue that words matter for older-person outcomes.
  • Burnout, cognitive strain and empathy erosion were introduced as plausible contributors to depersonalising or dismissive language in ED settings.
  • A final research challenge was posed: the direction and strength of association between burnout and ageist language in emergency care remains to be measured.
  • The close returned to the central claim that the frail older person makes all four tensions visible at once, and that designing for this cohort designs a better ED for everyone.

References / fact-checking

  1. Alsaba N, et al. Words and language matter: improving older person’s healthcare outcomes through use of age-positive language. Emerg Med Australas. 2026. Open DOI
  2. Goodwin J, et al. How do emergency department staff respond to behaviour that challenges displayed by people living with dementia? A mixed-methods study. BMJ Open. 2023. Open DOI
  3. Oliveira D, et al. Experiences of stigma and discrimination among people living with dementia and family carers in Brazil: qualitative study. Ageing Soc. 2021. Open DOI
  4. Kane M, et al. Assessing implicit and explicit dementia stigma in young adults and care-workers. Dementia. 2020. Open DOI
  5. Ting HH, et al. Biased language in simulated handoffs and clinician recall and attitudes. JAMA Netw Open. 2024. Open DOI