The evaluation of compliance with iRefer guidelines for abdominal imaging and the impact of the normal abdominal radiograph on the clinical confidence and decision making of emergency clinicians

Background: Attendance of adult patients to the emergency department (ED) with acute abdominal pain is a frequent event. Abdominal X-ray (AXR) imaging is commonly the choice of investigation but previous studies have suggested that AXR plays a small role in assessment because of its low diagnostic yield and limited contribution to direct clinical decision making. As per iRefer radiology guideline, there are four indications of requesting an X-ray that are shown to be clinically relevant and thus minimizing the unnecessary radiation in non-indicated tests: Clinical suspicion of bowel obstruction, foreign body ingestion, renal colic and acute exacerbation of inflammatory bowel disease.

It has been estimated that around 31% of children will experience a traumatic event during childhood, most commonly serious accidents that lead to hospitalisation. Around 15% of children who experience such events go onto develop post-traumatic stress disorder. Emergency department (ED) clinicians have a unique opportunity to intervene during the early peri-trauma period, which can involve incorporating a trauma-informed approach within their care. The available evidence indicates that clinicians internationally need further education and training to enhance their knowledge and confidence in providing trauma-informed psychosocial care. However, UK/Ireland specific knowledge is limited. The current study analysed the UK and Irish subset of data (N=434) that was collected as part of an international survey of ED clinicians. Questionnaires indexed clinician confidence in providing psychosocial care, and a range of potential barriers to providing that care. Hierarchical linear regression was used to identify predictors of clinician confidence. Clinicians reported moderate levels of confidence in providing psychosocial care to injured children and families (M=3.19, SD=0.46). Regression analyses identified negative predictors of clinical confidence, including a lack of training, worrying about further upsetting children and parents, and low levels of perceived departmental performance in providing psychosocial care (R 2=0.389). The findings highlight the need for further training in psychosocial care for ED clinicians. Future research must identify nationally relevant pathways to implement training programmes for clinicians, in order to improve their skills in relation to paediatric traumatic stress and to reduce the perception of barriers identified in the present study.

Patients with undifferentiated acute abdominal pain (AAP) frequently present to the Emergency Department (ED). The most common diagnosis is the nonspecific abdominal pain although missed occult surgical pathology in the haemodynamically stable patient with equivocal symptoms and signs is a potential source of morbidity. The objectives of this study were two-fold. Firstly, to ascertain the accuracy of ED clinicians in the diagnosis of AAP, and to delineate if there was a population of patients who would normally require admission to hospital that would be suitable to be managed on a Clinical Decision Unit (CDU) protocol. Secondly, to prospectively evaluate such a strategy by way of a pilot study. An initial retrospective cohort study of consecutive patients presenting to the ED with undifferentiated AAP were analysed. Data were extracted on admission, length of stay and the correlation between initial ED clinical diagnosis and final discharge diagnosis. Following this, a protocol was developed within our institution for the management of patients with stable AAP on a CDU pathway. This was then formally evaluated over a period of 25 months as part of a quality improvement exercise. A total of 501 patients were analysed of whom 48% were admitted from the ED. The initial ED diagnosis was correct in 57% of patients, and 28% of admitted patients were discharged within 48 h with no specific intervention. During the period of the pilot study, 189 patients were entered on to the AAP CDU pathway, of which 85% were safely discharged directly from the CDU and 67% within 24 h. Of the 28 patients admitted only four required an operation. Use of the protocol in this population resulted in the initial ED assessment being correct in 69% of cases. The management of stable AAP within the ED environment on a well-defined CDU pathway is feasible and can facilitate safe, efficient and effective care with early discharge and an increase in the accuracy of the final diagnosis.

Aim Epistaxis is a common, potentially life-threatening presentation in the Emergency Department (ED) with an incidence of 108/100 000 population per year. 85% of all patients presenting with epistaxis are managed by ED clinicians without specialist input or admission. Guidelines exist from ENT UK on epistaxis management, however awareness of these guidelines, nuances in techniques and levels of confidence by ED clinicians is not known. This quality improvement study aims to assess the confidence of ED clinicians in managing epistaxis, and investigate whether this could be improved through educational intervention. Method A single-centre, prospective, baseline audit was conducted following local approval. An initial questionnaire assessed knowledge of appropriate Hippocratic first aid method for epistaxis, alongside individual confidence in providing epistaxis prevention advice. The educational intervention included a 30 minute interactive tutorial on epistaxis during the local department teaching for ED clinicians. The audit loop was then closed by repeating the questionnaire. Results Pre- (n = 20) and post- (n = 8) intervention questions were completed by ED clinicians. Knowledge scores of appropriate epistaxis first aid provision increased from 53% pre-intervention to 88% post-intervention. Reported confidence in providing epistaxis prevention advice also increased from a mean score of 2.7 pre-intervention to 4.1 post-intervention on a 5-point Likert scale. Conclusions ED clinicians generally lack knowledge on appropriate first aid techniques on managing epistaxis and confidence in providing epistaxis prevention advice. Both of these parameters may be improved by simple educational interventions which may be implemented nationally.

BackgroundA major reform of junior doctor training was undertaken in 2004–5, with the introduction of foundation training (FT) to address perceived problems with work structure, conditions and training opportunities for postgraduate doctors. The well-being and motivation of junior doctors within the context of this change to training (and other changes such as restrictions in working hours of junior doctors and increasing demand for health care) and the consequent impact upon the quality of care provided is not well understood.ObjectivesThis study aimed to evaluate the well-being of foundation year 2 (F2) doctors in training. Phase 1 describes the aims of delivering foundation training with a focus on the role of training in supporting the well-being of F2 doctors and assesses how FT is implemented on a regional basis, particularly in emergency medicine (EM). Phase 2 identifies how F2 doctor well-being and motivation are influenced over F2 and specifically in relation to EM placements and quality of care provided to patients.MethodsPhase 1 used semistructured interviews and focus groups with postgraduate deanery leads, training leads (TLs) and F2 doctors to explore the strategic aims and implementation of FT, focusing on the specialty of EM. Phase 2 was a 12-month online longitudinal study of F2 doctors measuring levels of and changes in well-being and motivation. In a range of specialties, one of which was EM, data from measures of well-being, motivation, intention to quit, confidence and competence and job-related characteristics (e.g. work demands, task feedback, role clarity) were collected at four time points. In addition, we examined F2 doctor well-being in relation to quality of care by reviewing clinical records (criterion-based and holistic reviews) during the emergency department (ED) placement relating to head injury and chronic obstructive pulmonary disease (COPD).ResultsPhase 1 of the study found that variation exists in how successfully FT is implemented locally; F2 lacks a clearly defined end point; there is a minimal focus on the well-being of F2 doctors (only on the few already shown to be ‘in difficulty’); the ED presented a challenging but worthwhile learning environment requiring a significant amount of support from senior ED staff; and disagreement existed about the performance and confidence levels of F2 doctors. A total of 30 EDs in nine postgraduate medical deaneries participated in phase 2 with 217 foundation doctors completing the longitudinal study. F2 doctors reported significantly increased confidence in managing common acute conditions and undertaking practical procedures over their second foundation year, with the biggest increase in confidence and competence associated with their ED placement. F2 doctors had levels of job satisfaction and anxiety/depression that were comparable to or better than those of other NHS workers, and adequate quality and safety of care are being provided for head injury and COPD.ConclusionsThere are ongoing challenges in delivering high-quality FT at the local level, especially in time-pressured specialties such as EM. There are also challenges in how FT detects and manages doctors who are struggling with their work. The survey was the first to document the well-being of foundation doctors over the course of their second year, and average scores compared well with those of other doctors and health-care workers. F2 doctors are benefiting from the training provided as we found improvements in perceived confidence and competence over the year, with the ED placement being of most value to F2 doctors in this respect. Although adequate quality of care was demonstrated, we found no significant relationships between well-being of foundation doctors and the quality of care they provided to patients, suggesting the need for further work in this area.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

To explore and describe patients' expectations, perceptions and experiences of having a pelvic examination (PV) in the emergency department (ED) and to describe ED clinicians' attitudes and perceptions regarding PVs. A mixed methods study using questionnaires and semi-structured interviews with patients and clinicians at two EDs in the same health service (tertiary ED and urban district ED) between May 2023 and February 2024. Quantitative data are reported descriptively using means and proportions. A qualitative descriptive approach and thematic analysis were used to develop themes from interviews and gather granular insights from participants' first-hand experiences. Clinicians completed 84 questionnaires and nine interviews. Patients completed 63 questionnaires and eight interviews. Quantitative and qualitative data were merged to form four themes: (1) the variable clinical utility of the PV in ED, (2) lack of ED clinician confidence and training, (3) bedside manner as primary influence on patient experience, and (4) the inadequate ED setting for performing intimate exams. The utility of PVs in ED remains ambiguous and it is vital to avoid unnecessary invasive exams. However, urgent PVs will sometimes be needed and participants have made actionable suggestions to improve the clinical care delivered when performing PVs in ED. The four themes can inform future strategies to advance clinicians' training, confidence and skill level when performing PVs. This will lead to overall enhanced patient experience and satisfaction and reduce downstream negative consequences of having an inadequate PV experience in ED.

Virtual reality distraction during pediatric intravenous line placement in the emergency department: A prospective randomized comparison study.

BackgroundThe Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian C-Spine Rule—together known as The Ottawa Rules—are a set of internationally validated clinical decision rules developed to decrease unnecessary diagnostic imaging in the emergency department. In this study, we sought to develop and evaluate the use of a mobile app version of The Ottawa Rules.ObjectiveThe primary objective of this study was to determine acceptability of The Ottawa Rules app among emergency department clinicians. The secondary objective was to evaluate the effect of publicity efforts on uptake of The Ottawa Rules app.MethodsThe Ottawa Rules app was developed and publicly released for free on iOS and Android operating systems in April 2016. Local and national news and academic media coverage coincided with app release. This study was conducted at a large tertiary trauma care center in Ottawa, Canada. The study was advertised through posters and electronically by email. Emergency department clinicians were approached in person to enroll via in-app consent for a 1-month study during which time they were encouraged to use the app when evaluating patients with suspected knee, foot, or neck injuries. A 23-question survey was administered at the end of the study period via email to determine self-reported frequency, perceived ease of use of the app, and participant Technology Readiness Index scores.ResultsA total of 108 emergency department clinicians completed the study including 42 nurses, 33 residents, 20 attending physicians, and 13 medical students completing emergency department rotations. The median Technology Readiness Index for this group was 3.56, indicating a moderate degree of openness for technological adoption. The majority of survey respondents indicated favorable receptivity to the app including finding it helpful to applying the rules (73/108, 67.6%), that they would recommend the app to colleagues (81/108, 75.0%), and that they would continue using the app (73/108, 67.6%). Feedback from study participants highlighted a desire for access to more clinical decision rules and a higher degree of interactivity of the app. Between April 21, 2016, and June 1, 2017, The Ottawa Rules app was downloaded approximately 4000 times across 89 countries.ConclusionsWe have found The Ottawa Rules app to be an effective means to disseminate the Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian C-Spine Rule among all levels of emergency department clinicians. We have been successful in monitoring uptake and access of the rules in the app as a result of our publicity efforts. Mobile technology can be leveraged to improve the accessibility of clinical decision tools to health professionals.

As part of a larger multi-site translational research project this study explored patient and staff experiences, perspectives, and recommendations in relation to a mental health liaison nursing (MHLN) team established in the emergency department (ED) of a metropolitan hospital in New South Wales, Australia. Semi-structured interviews were conducted with a sample of ED patients (n=26), ED nurses (n=10), ED consultants (n=9), and members of the consultation-liaison psychiatry team (n=5). Data were analysed thematically. Patients emphasized the numerous therapeutic qualities of the MHLN role, the promptness with which they were seen and the value of follow-up. Privacy was identified as important, and some negative experiences were reported. Staff identified that the MHLN team are able to respond to a variety of ED presentations in a timely manner. There was recognition that the MHLN team needs to be integrated within the ED as a specialist resource that builds ED capacity. Consistent staffing of the MHLN team with designated clinicians was also considered essential. Integrating a nurse practitioner-led MHLN team within the ED has demonstrated multiple benefits for patients, ED staff, and overall service provision. Incorporating a specialist mental health nursing service within the ED builds confidence in ED clinicians. Members of the psychiatry team also acknowledge the value of aligning the clinical governance of the MHLN team within the ED and the reduced workload this model of care has on their service provision to ED, freeing them up to concentrate on their broader general hospital role.

Previous studies have suggested that child abuse and neglect (CAN) is under recognised and under reported. Our aims were to examine and compare child protection (CP) knowledge, confidence and practice of frontline clinicians in general practice and hospital settings in South Western Sydney (SWS). We surveyed doctors and nurses in general practice and in the emergency department (ED) in a district in SWS using a validated questionnaire. Of the 113 responses, 62 were general practitioners (GPs), 9 practice nurses, 26 ED nurses and 16 ED doctors. The confidence level with identifying CAN was moderate, with a significant difference between groups. The majority (59%) had made previous CP reports, few suspected but decided not to report; reporting rates differed significantly. A majority (80%) reported some CP training; of the 22 with no training, 21 were GPs and practice nurses. Of those reporting some training, more than 70 per cent of ED nurses, GPs and practice nurses felt their training was inadequate, compared with 19 per cent of ED doctors. There are significant differences in confidence and practice between frontline clinicians in primary care and ED. Targeted CP training should be provided for all frontline clinicians with particular emphasis on primary care GPs. Copyright © 2011 John Wiley & Sons, Ltd.‘We surveyed doctors and nurses in general practice and in the emergency department’‘There are significant differences in confidence and practice between front‐line clinicians in primary care and ED’

377 The Association Between Post-Assault Physical Appearance and Behaviors in the Emergency Department and Assault Types

Prospective evaluation of the MET-AP system providing triage plans for acute pediatric abdominal pain

Commentary

Introduction Evidence shows that 20 minutes of cool running water applied within 3 hours of burn injury (20CRW) improves patient outcomes including reduced odds of requiring skin grafting or hospitalisation. Study investigators are undertaking an implementation research to translate 20CRW into clinical practices of County Fire and Emergency Medical Services (EMS) and the Burn Center’s Emergency Department (ED). As part of this research, we undertook a sub-project, with local EMS and ED clinical champions. to identify barriers and enablers to 20CRW practice change and co-design implementation strategies to address them. Methods Online surveys were developed and disseminated to EMS and ED clinicians and focus groups involving EMS and ED clinician champions were conducted. Results were deductively coded using the Consolidated Framework for Implementation Research (CFIR) and then mapped to the Expert Recommendations for Implementing Change (ERIC) matching tool to identify potential implementation strategies. Findings from the surveys, focus groups and CFIR-ERIC mapped strategies were then fedback to clinical champions to achieve consensus and inform the subsequent co-design of tailored implementation strategies to address them. Results A total of 204 EMS and 96 ED clinicians completed the survey, and 10 EMS and 9 ED clinical champions participated in four focus group sessions. Multiple interrelated barriers and enablers related to clinicians, patients, the 20CRW intervention, organisations and environment were identified that covered four of the CFIR domains. Most clinicians were unaware of 20CRW (>80%). Whilst 82% of ED and 56% of EMS clinicians considered 20CRW an acceptable practice change, 60% and 65% of ED and EMS clinicians respectively, deemed it different to current practices. The relative advantage of delivering 20CRW to patients with large burns with risks of hypothermia and/or other urgent care needs was raised; access to water was a logistical challenge in the variable pre-hospital environment and the structural design of the ED and ED cubicles; contaminated water in the prehospital environment and the risk of wound contamination were also raised. Development of multiple tailored implementation strategies are underway including guidelines with patient exclusion criteria and advice regarding water sources, recruitment and training of implementation champions, educational resources and fact sheets, and purchasing of equipment for cooling enroute to hospital and in ED cubicles. Conclusions Translating evidence into sustainable clinical practice change is complex and requires more than new guidelines, knowledge and skills. Validated implementation science methodologies can assist in identifying barriers and enablers to sustainable practice changes. Applicability of Research to Practice Findings of this research will inform the translation of 20CRW evidence into County EMS and ED guidelines and clinical practices.

Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients.