ED Staff Research Articles

Separating the wheat from the chaff\u2014COVID-19 in a German emergency department: a case-control study

BackgroundCOVID-19 pandemia is a major challenge to worldwide health care systems. Whereas the majority of disease presents with mild symptoms that can be treated as outpatients, severely ill COVID-19 patients and patients presenting with similar symptoms cross their ways in the emergency department. Especially, the variety of symptoms is challenging with primary triage. Are there parameters to distinguish between proven COVID-19 and without before? How can a safe and efficient management of these inpatients be achieved?MethodsWe conducted a retrospective analysis of 314 consecutive inpatient patients who presented with possible symptoms of COVID-19 in a German emergency department between March and April 2020 and were tested with a SARS-Cov-2 nasopharyngeal swab. Clinical parameters, Manchester Triage System categories, and lab results were compared between patients with positive and negative test results for SARS-Cov-2. Furthermore, we present the existing COVID-19 workflow model of the university hospital in Essen which proved to be efficient during pandemia.ResultsForty-three of the 314 patients (13.7%) were tested positive for COVID-19 by SARS-Cov-2 nasopharyngeal swab. We did not find any laboratory parameter to distinguish safely between patients with COVID-19 and those with similar symptoms. Dysgeusia was the only clinical symptom that was significantly more frequent among COVID-19 patients.ConclusionDysgeusia seems to be a typical symptom for COVID-19, which occurred in 14% of our COVID-19 patients. However, no valid parameters could be found to distinguish clinically between COVID-19 and other diseases with similar symptoms. Therefore, early testing, a strict isolation policy, and proper personal protection are crucial to maintain workflow and safety of patients and ED staff for the months to come.Trial registrationGerman Clinical Trials registry, DRKS00021675

Measuring ‘Need for Recovery’ as an indicator of staff well-being in the emergency department: a survey study

BackgroundThe Need for Recovery (NFR) Scale is an 11-item questionnaire that assesses how work affects intershift recovery. Items are summated to form a score with a maximum value of 100....

Core components of a staff wellness strategy in emergency departments: A clinician-informed nominal group study.

Busy, high-stress EDs prompt many work-based interventions to address staff wellness, with mixed success. The aim of the present study was to enable ED clinicians to systematically identify core components of a work-based strategy to improve their working environment and/or coping. Purposively sampled ED doctors and nurses from one health service were invited to participate in modified nominal group technique. Participants identified, from a pre-defined list, a key ED stressor and then discussed and ratified proposed core components of a work-based strategy to address or ameliorate this stressor. Two nominal group technique sessions were held with a total of 10 participants (n = 7 nurses and n = 3 doctors). Participants proposed several strategies aimed at both individual and organisational levels to address occupational stress and coping, and support staff well-being in the workplace. These included mobile/web-based applications, group counselling sessions, yoga, social activities, team building activities and debriefing. Participants described three key components to promote staff wellness and hence enhance their ability to buffer negative aspects of occupational stress: (i) increased individual and team support; (ii) development of professional resilience; and (iii) maximising opportunities for social connection. Ensuring appropriate systems, services and support for ED staff should be a priority at local departmental, wider organisational and governmental levels. ED clinicians are ideally placed to identify such systems, services and supports. Managers and policy makers can use these findings to inform the implementation of interventions in EDs.

Managing healthcare worker well‐being in an Australian emergency department during the COVID‐19 pandemic

Emergency Medicine staff in Australia and New Zealand are at the forefront of the healthcare response to COVID‐19. This article describes a well‐being plan for ED staff that has been devised to mitigate against the negative psychological impact of the COVID‐19 pandemic.

Study protocol for the ACT response pilot intervention: development, implementation and evaluation of a systems-based Agitation Code Team (ACT) in the emergency department

IntroductionEmergency department (ED) visits for behavioural conditions are rising, with 1.7 million associated episodes of patient agitation occurring annually in acute care settings. When de-escalation techniques fail during agitation management,...

LO56: Rate of delirium recognition by nurses and physicians in a cohort of 1584 older emergency department patients: how many would have been sent home?

Introduction: Unrecognized delirium in the ED remains common despite a 3 fold mortality increase for those discharged home. But previous studies have not assessed delirium recognition rate in a multicenter study nor assessed the management plans of ED staff when they fail to recognize delirium. Objectives: To document 1) the rate of delirium recognition by nurses and MDs in a national sample and 2) the intended management plans for patients with unrecognized delirium. Methods: This is a planned sub-study of a randomized clinical trial at 5 EDs in 4 provinces conducted in English and French. We included people ≥ 65 years old. We excluded those with an ED stay < 4 hours, critical illness, visual impairment or from a nursing home. Research assistants (RAs) assessed delirium using the validated Confusion Assessment Method. RAs then asked ED nurses and physicians if the patient had delirium according to their clinical assessment. RAs also asked how confident they were that the patient could be safely discharged home using a 10 point Likert scale. We report proportions and 95% confidence intervals. RAs notified all ED staff of unrecognized CAM + ve patients prior to actual discharge for safety reasons. Results: We recruited 1584 older people; 1496 (92.5%) had complete data. Mean age was 76.5; 49% were female. Nurses performed 1465 delirium assessments. There were 76 CAM + ve patients in our sample (5.2%, 95% CI 4.2 to 6.5%). Nurses recognized delirium in 34/76 (44.7%, 95% CI: 33.3 to 56.6%). MDs assessed 20 CAM + ve patients and recognized the delirium in 10/20 (50.0%, 95% CI: 27.2 to 72.8). Nurses felt that 11/42 patients with unrecognized delirium could be discharged (26.2% 95% CI: 13.9 to 42.0%). Their median confidence in the safety of their plan was 7.0/10. MDs felt that 2/10 patients with unrecognized delirium could be discharged (20.0% 95% CI: 2.5 to 55.0%). Their median confidence in the safety of their plan was 7.5/10. Conclusion: Despite the potential Hawthorne effect raising initial delirium recognition rates above clinicians’ usual practice outside of a study, delirium recognition by both nurses and MDs remains poor in a national sample of ED patients. We also showed that a significant number of these patients could have been discharged with unrecognized delirium. Further research to find novel ways to improve delirium recognition is needed.

PL02: Double Sequential External Defibrillation for Refractory Ventricular Fibrillation: the DOSE VF pilot randomized controlled trial

Introduction: Despite recent advances in resuscitation, some patients remain in ventricular fibrillation (VF) after multiple defibrillation attempts during out-of-hospital cardiac arrest (OHCA). Vector change defibrillation (VC) and double sequential external defibrillation (DSED) have been proposed as alternate therapeutic strategies for OHCA patients with refractory VF. The primary objective was to determine the feasibility, safety and sample size required for a future cluster randomized controlled trial (RCT) with crossover comparing VC or DSED to standard defibrillation for patients experiencing refractory VF. Secondary objectives were to evaluate the intervention effect on VF termination and return of spontaneous circulation (ROSC). Methods: We conducted a pilot cluster RCT with crossover in four Canadian paramedic services and included all treated adult OHCA patients who presented in VF and received a minimum of three defibrillation attempts. In addition to standard cardiac arrest care, each EMS service was randomly assigned to provide continued standard defibrillation (control), VC or DSED. Services crossed over to an alternate defibrillation strategy after six months. Prior to the launch of the trial, 2,500 paramedics received in-person training for VC and DSED defibrillation using a combination of didactic, video and simulated scenarios. Results: Between March 2018 and September 2019, 152 patients were enrolled. Monthly enrollment varied from 1.4 to 6.1 cases per service. With respect to feasibility, 89.5% of cases received the defibrillation strategy they were randomly allocated to, and 93.1% of cases received a VC or DSED shock prior to the sixth defibrillation attempt. There were no reported cases of defibrillator malfunction, skin burns, difficulty with pad placement or concerns expressed by paramedics, patients, families, or ED staff about the trial. In the standard defibrillation group, 66.6% of cases resulted in VF termination, compared to 82.0% in VC and 76.3% of cases in the DSED group. ROSC was achieved in 25.0%, 39.3% and 40.0% of standard, VC and DSED groups, respectively. Conclusion: Findings from our pilot RCT suggest the DOSE VF protocol is feasible and safe. VF termination and ROSC were higher with VC and DSED compared to standard defibrillation. The results of this pilot trial will allow us to inform a multicenter cluster RCT with crossover to determine if alternate defibrillation strategies for refractory VF may impact patient-centered, clinical outcomes

P061: Barriers to distributing discharge materials in the emergency department

Introduction: An efficient discharging process provides an opportunity for the patient to receive information about their diagnosis, prognosis, treatments, follow-up plan and reasons to return. Even when given complete discharge instructions, studies demonstrate that patients have poor retention of the information due to misunderstandings, language barriers, or poor health literacy. This study sought to identify barriers encountered by healthcare workers in providing discharge handouts to emergency department patients. Methods: A bilingual online survey of fifteen questions was shared with Quebec ED staff physicians and residents at the annual conference, and by email correspondence through the Quebec Emergency Medicine Association (AMUQ - L'Association des médecins d'urgence du Québec). Results: There was a total of 126 responses (96 physicians and 30 residents), with a response rate of 22.7% (126/556) and a completion rate of 84.1%. 85.8% (n = 120) responded that they were aware of discharge instructions available in their ED. Most common discharge handouts were concussion/traumatic brain injury and laceration repair. 58.3% of respondents (n = 120) reported having handed out discharge instructions in the last week, 22.5% in the last month, 10.8% within the last 6 months and 5.8% had not given out discharge instructions in the last 6 months. Respondents indicated that the most common barriers to giving out discharge instructions were their difficulty to access and and the time required. 58% of respondents (n = 65) reported handing out discharge handouts less than 50% of the time for conditions that had a discharge handout available at their hospital. Participants reported they would be more likely to give out discharge instructions if they were easier to print and if there was an automatic prompt from the EMR associated with the diagnosis. When asked to rank based on importance (1 = not important to 10 = very important), the majority of respondents thought discharge instructions were very important for patient comprehension, return to ED instructions and managing expectations of the illness (Median 8, Likert scale 1-10, DI 0.29, n = 119). Conclusion: Despite physicians and residents working in the ED believing discharge instructions are important for patient care, handouts are seldom given to patients. The lack of easy availability such as documents automatically available with the prompt of an electronic medical record would likely increase their distribution.

Delphi assessment of audit and research priorities in an emergency department.

Audit and research projects in the ED are important to improve patient care but can be time and resource consuming. We identified and prioritised audit and research topics among multidisciplinary ED staff to fill perceived knowledge gaps, encourage engagement, reduce duplication and facilitate translation of evidence into clinical practice. A two-stage electronic Delphi survey process was undertaken by senior medical, nursing, education and social work staff at the Royal Children's Hospital, Victoria. Survey 1 collected demographic data and audit and research ideas following a series of open-ended questions. Priority themes were defined as those that had more than four responses. Survey 2 used a 7-point Likert ranking of these themes to generate a departmental audit and research prioritisation list. 72/89 (82%) available senior staff responded to survey 1 and 63/83 (76%) responded to survey 2. Survey 1 yielded 208 audit and 130 research topics. Survey 2 established a prioritised list of 17 audit and 14 research topics. Top audit themes were mental healthcare, patient flow, management of sepsis and delays in ED specialist referrals. Top research priorities were the management of sepsis, mental healthcare, management of patients with autism and the management of severe asthma. This Delphi study has provided departmental audit and research priorities that are perceived to be of importance across the multidisciplinary ED team. This methodology allows strategic allocation of limited resources and may increase staff engagement.

Abstract TMP67: Prehospital Cath Lab Activation Based on EMS Large Vessel Occlusion Screen Cancelled

Background: Current guidelines indicate reduced time to reperfusion with thrombectomy is strongly associated with better outcomes. Validated screening tools for large vessel occlusions are available for the prehospital setting. Objective: To reduce door to access times for patients arriving by EMS to an urban 487 bed quaternary hospital. Methods: Starting in January of 2016, EMS crews screened all stroke patients with the Cincinnati - Stroke Triage Assessment Tool (C-STAT) and communicated results to the ED prior to arrival (PTA). In 2017, a team consisting of Neurology, ED, Cath Lab, Neuro Interventional leadership and stroke coordinator agreed to a 6-month pilot project of activating the Cath Lab when EMS radioed a patient was C-STAT positive. Any ED staff who might take EMS radio report were educated on the new process. Instructions were added to the existing Stroke Patient Checklist. Cath Lab and EMS staff were notified of the pilot project. During the pilot period, feedback was provided to EMS and ED leadership if an issue was identified for a specific case and trends were discussed. Results: During the pilot period, median door to access time for C-STAT positive patients who had Cath Lab activated PTA was 66 minutes compared to the 104 minutes the previous year (37% reduction). Unexpectedly, the median door to needle time for these patients also improved from 45 minutes the previous year to 28 minutes (38% reduction). The Cath Lab was activated PTA 16 times for patients EMS reported as C-STAT positive; Only 5 went on to have a thrombectomy. Overcalls were due to lack of C-STAT specificity (n=6) or C-STAT not scored correctly (n=5). In practice as well as when cases associated with assessment errors are removed, C-STAT demonstrated a low specificity for LVO (37.5% and 40% respectively). Lastly, internal process issues lead to 5 additional PTA Cath Lab activations for patients EMS did not report as being C-STAT positive. Conclusions: It was felt additional education would not be enough to make this initiative sustainable given the low specificity. In conclusion, despite marked improvement in door to access and door to needle times, the overactivation of Cath Lab lead to the initiative being cancelled.

Management of Suicidal Adolescents Presenting to the Emergency Department

Background: Increasingly, adolescents are presented to hospital emergency departments with suicidal ideation (SI) and depression. Even among those who come in with other complaints, depression and SI are common. Emergency personnel are placed in the default position of providing care for these patients, but often lack sufficient knowledge and skills to do this effectively. Objective: The aim of this paper is to offer guidance to emergency personnel and describe goals and strategies for screening and brief interventions. Method: We review risk factors, assessment tools and evidence-based interventions that can be utilized by mental health professionals working in EDs and by ED staff in the absence of mental health professionals. Conclusion: Emergency departments can serve a critical role in risk management and treatment of adolescent depression and suicidal ideation. All patients presenting to the ED should be screened for current and past depression and suicidal ideation or attempts. Brief interventions can be delivered in the ED that can increase the likelihood that patients will receive follow- up care.

Language Assistance for the Care of Limited English Proficiency (LEP) Patients in the Emergency Department: A Survey of Providers and Staff.

Many ED patients have limited English proficiency (LEP). Under Title VI of the 1964 Civil Rights Act, LEP patients are entitled to language assistance, however, multiple studies demonstrate that language assistance is underutilized. We aimed to characterize the knowledge, practice patterns, and preferences of ED providers and staff regarding language assistance for LEP patients. We performed a self-administered, anonymous questionnaire in an urban, public ED where most patients have LEP. Subjects included all ED providers and staff with substantial patient contact. We recorded ED role, knowledge of language assistance policy, prior training on working with interpreters, non-English language skills and bilingual certification. Outcomes included frequency of and comfort level with respondent's own non-English language (NEL) use in the ED, and the preferred and most frequently used modalities of language assistance. Of the 354 total ED employees, 261 were approached and 259 agreed to participate, which represents a 73% response rate (259/354). Respondents were 37% MD/NPs, 34% RNs and 29% other ED staff. Only 50/259 (19%) had prior training on working with interpreters. 171/257 (67%) were "unsure" if the hospital had a policy on language assistance. The most frequent modalities accessed for spoken language assistance were "Other ED staff" 106/259 (41%) or "ad hoc interpreter" 62/259 (24%). Although 227/274 (83%) use a non-English language with patients regularly, comfort levels in using their NEL for clinical care were variable. Most ED providers and staff had little training in the use of language assistance and were unaware of hospital policy. Use of NEL skills by providers for clinical care is common. Dissemination of best practices for the provision of language assistance and the clinical use of NEL skills has the potential to improve communication with LEP patients.

Problem Drinking and Marijuana Use as Risks for Unidirectional and Bidirectional Partner Violence.

Despite evidence that most who perpetrate intimate partner violence (IPV) also report victimization, little is known about bidirectional IPV among Emergency Department (ED) patients and its association with problem drinking and marijuana use. We conducted an observational, cross-sectional survey among low- and moderate-acuity patients at a Northern California safety-net ED. Physical IPV was measured with the Revised Conflict Tactics Scale (CTS2). We recorded patient's frequency of intoxication and marijuana use. Spouse/partner's problem drinking and marijuana use were measured dichotomously. Odds Ratios [ORs] and 95% confidence intervals [CIs] were estimated using multinomial logistic regression models of unidirectional and bidirectional IPV. Among 1,037 patients (53% female), perpetration only, victimization only, and bidirectional IPV were reported by 3.8%, 6.2%, and 13.3% of the sample, respectively. Frequency of intoxication was associated with perpetration (OR 1.50; 95% CI 1.18 to 1.92) and bidirectional IPV (OR=1.34; 95% CI 1.13 to 1.58). Days of marijuana use were associated with bidirectional IPV (OR=1.15; 95% CI 1.03 to 1.28). Patients whose partners were problem drinkers were at risk for victimization (OR=2.56; 95% CI=1.38, 4.76) and bidirectional IPV (OR=1.97; 95% CI 1.18, 3.27). Among patients who reported any past-year IPV, most experienced bidirectional aggression. ED staff should consider asking patients who are married, cohabiting, or in a dating relationship about their experience with past-year IPV and inquire about their substance use patterns and those of their romantic partner, to share information about potential linkages. Medical and recreational marijuana legalization trends underscore the importance of further research on IPV and marijuana.

ICU nurses and ecpr

Introduction: Mortality from refractory cardiac arrest is greater than 90%. Survival may be significantly improved with Extracorporeal Membrane Oxygenation Cardio Pulmonary Resuscitation (ECPR). Objectives: To enable ICU nurses to participate in the ECPR team by preparing the ECPR trolley and/or console. Additional goals: maintain 66% ECPR accreditation following May 2016; plan ECPR nursing training at approximately 2 per month; and maintain ECPR outcomes comparable to reported rates. Methods: Training for nurses commenced May 2015. There were 10 planned sessions employing didactic explanations and simulated demonstrations. From 2016 to 2019 there were approximately two sessions per month booked. Additional hig- fidelity multidisciplinary simulations were provided by the Simulation Coordinator involving ED, Ambulance and Interventional Cardiology staff. Audits of ECMO outcomes were conducted biannually with comparisons made to international registries and literature. Results: By May 2016 greater than 66% of ECMO nurses had been accredited for ECPR. This rate was maintained and is currently 69/84 (82%). Of the planned education sessions from 2015 to 2018; the following were respectively documented as achieved 4/10, 13/23, 10/18 and 13/21. ECPR outcome from 2015-2018 was 39% survival to hospital discharge. Accredited ICU ECPR nurses were assigned every day to the ECPR team and attend ECPR emergency calls as they occurred. Conclusion: It is feasible for ICU nurses to participate as valuable members of the ECPR team. Whilst the potential numbers of patients in NSW who may require ECPR per year for refractory cardiac arrest may remain relatively low (i.e approximately 130/yr) it appears that the possible improvement in survival outcome for this group may be significantly increased from dismal to around 30%. The ICU ECMO ECPR nurse's role in assisting with this survival benefit for the patient is an important part of the function of the team.

Expectations and experiences of women presenting to emergency departments with early pregnancy bleeding.

To explore women's expectations and experiences when presenting to the ED with early pregnancy bleeding. We conducted a qualitative study where women presenting to the ED with early pregnancy bleeding participated in two semi-structured interviews. An initial interview explored expectations of care and was conducted prior to ED treatment. A follow-up interview about experiences with care was conducted after discharge from the ED. Women were recruited from three EDs in suburban Melbourne: one tertiary referral centre and two urban district hospitals. Thirty women with early pregnancy bleeding completed the initial interview and 22 completed the follow-up interview. Eleven participants were primigravid women and 21 participants had never experienced early pregnancy bleeding prior to their ED presentation. Four themes relating to the patient experience were identified: (i) Acknowledgement of patients' concerns by hospital staff, including informing patients of progress and explanation of investigation results; (ii) Early pregnancy bleeding as a distressing experience, with most participants expecting that this would be acknowledged by ED staff, and privacy provided to allow for grieving; (iii) Prolonged waiting time for an urgent medical condition; and (iv) Ongoing care and support, such as providing recommendations of available services to support patients on discharge from the ED. Early pregnancy bleeding is a distressing and anxiety-provoking experience for women attending the ED. Appropriate emotional support is critical to the holistic care for those seeking emergency care.

Abstract 149: Double Sequential External Defibrillation in Refractory Ventricular Fibrillation: The Dose VF Pilot Randomized Controlled Trial

Background: Despite significant advances in resuscitation efforts, there are some patients who remain in ventricular fibrillation (VF) after multiple defibrillation attempts during out-of-hospital cardiac arrest (OHCA). Double sequential external defibrillation (DSED) and vector change defibrillation (VC) have been proposed as alternate therapeutic strategies for OHCA patients in shock-refractory VF. Objective: To determine the feasibility, safety and sample size required for a larger, multicentered, 3-arm, cluster randomized controlled trial (RCT) with 2 crossovers comparing DSED or VC to standard defibrillation (control group) for OHCA patients presenting in shock-refractory VF. Methods: We conducted a pilot cluster randomized controlled trial with crossover including all consecutive treated adult OHCA patients who presented in VF and received a minimum of three successive shocks. In addition to standard cardiac arrest care, each EMS agency was randomly assigned to provide standard defibrillation (control), DSED, or VC, followed by crossover to an alternate defibrillation strategy after 6 months. Results: Prior to the launch of the trial, 2,500 paramedics received in-person training in the techniques of DSED and VC defibrillation using a combination of didactic, video and simulated scenarios. Between March 2018 and June 2019, 113 patients were enrolled in 4 Canadian EMS agencies, with zero missed cases. Monthly enrollment varied from 1 to 6 cases per agency. With respect to feasibility, 96% of cases were compliant with the study protocol, and only five (4.4%) cases received a defibrillation strategy that differed from the allocation schedule. There were no reported cases of defibrillator malfunction, no concerns expressed by paramedics, patients, families, or ED staff about the trial, and no reported cases of skin burns or difficulty with pad placement. Conclusions: Findings from our pilot implementation trial suggest the DOSE VF protocol is feasible and safe. The results of this internal pilot trial will allow us to calculate a sample size for a definitive multicenter cluster RCT with crossovers to determine if these alternate defibrillation strategies for OHCA shock refractory VF will impact patient-centered, clinical outcomes.

Fall-related emergency department visits and hospitalizations among community-dwelling older adults: examination of health problems and injury characteristics

BackgroundFall injuries and related healthcare use among older adults are increasing in the United States. This study examined chronic illnesses, sensory and memory problems, and injury characteristics that were associated with ED visits and hospitalizations among older adults who received medical attention for fall injuries within a 91-day reference period.MethodsData were from the publicly available 2013–2017 US National Health Interview Survey files (unweighted N = 1840 respondents aged > 60 years with fall injuries). We first described socioeconomic, health/mental health, healthcare utilization, and injury characteristics among three groups: those who neither visited an ED nor were hospitalized for their fall injury, those who visited an ED only, and those who were hospitalized. Then, using multinomial logistic regression analysis, we examined associations of healthcare utilization (ED visit only and hospitalization vs. no ED visit/hospitalization) with chronic illnesses, other health problems, and injury characteristics, controlling for socioeconomic factors.ResultsOf older adults who received medical attention for fall injuries, a little more than one-third had an ED visit only and a little less than a fifth had an overnight hospital stay. Multivariable analysis showed that lung disease and memory problems were associated with higher risk of ED visit only; hip and head injuries, facial injuries, and broken bones/fractures (from any type of injury) were more likely to result in hospitalization than other injuries. Fall injuries sustained inside the home, falls from loss of balance/dizziness, and living alone were also more likely to result in hospitalization.ConclusionsThese healthcare utilization findings indicate the significant toll that fall injuries exact on older adults and healthcare systems. Fall prevention should target risk factors that are specific to serious injuries requiring costly care. Strategies for implementing scalable, adaptable, and measurable fall prevention models by primary care and emergency medical service providers and ED staff are needed.

Personalized Care Plans: Are They Effective in Decreasing ED Visits and Health Care Expenditure Among Adult Super-Utilizers?

ProblemSuper-utilizers comprise 4.5% to 8% of all ED patients, but account for 21% to 28% of all ED visits. Excessive use of the emergency department contributes to increased health care costs, recurrent and unnecessary ED workup, decreased emergency readiness, and reduced staff morale. MethodsThe impact of personalized care plan implementation was evaluated using a within-subjects pre-post design. The number of ED visits for each enrolled patient (N = 65) were analyzed before and after personalized care plan enrollment at 90, 180, and 365 days. A post-hoc analysis was completed for each ED visit that resulted in a disposition of discharge. Total and average charges from the ED visits were analyzed to determine the intervention’s effect on health care expenditure. Staff was anonymously surveyed to assess perceived efficacy and level of satisfaction with the intervention before completion of data collection. ResultsMedian ED visits had a statistically significant decrease over 90, 180, and 365 days. There was also a decrease in median, average, and total ED charges for all time points. ED staff perceived the personalized care plans to be an effective intervention and were satisfied with their implementation. DiscussionPersonalized care plans effectively decreased the number of ED visits, reduced health care expenditure, and were well-received by the staff.

Does case management provides support for staff facing frequent users of emergency departments?

Abstract Background Frequent users of emergency departments (FUED; 5 ED visits during the preceding 12 months) account for a disproportionate part of ED visits, causing a wide range of work difficulties to ED staff potentially leading to FUED discrimination. Whereas case management (CM) tailored to FUED leads to a reduction in ED visits, CM impact on ED staff has not been explored yet. This study aimed to compare ED staff perceptions of FUED with and without dedicated CM support. Methods Participants (N = 253) were ED staff (81 physicians; 172 nurses/assistant nurses) of two Swiss university hospitals, one with CM and one without CM support. Perceptions regarding FUED (i.e., knowledge and awareness of the issue extent; related work difficulties; FUEDs’ legitimate use of ED resources) were measured with a 25-item online survey (4 to 10-level Likert scales). Multivariable regression analyses were conducted to 1) explore the associations between CM implementation and FUED perceptions, and 2) test the moderating effect of profession (physician or nurse/nurse assistant) on these associations. All analyses were adjusted by gender and years of practical experience. Results Physicians with CM considered FUED as a less important problem (=.375, R2=.11, p <.05) and rated their knowledge of FUED issue higher (=.245, R2=.077, p <.05) compared to those without CM. In contrast, nurses without CM perceived fewer FUED-related work difficulties (i.e., feeling of failure and helplessness) than nurses with CM. (=-1.01, R2=.06, p <.05) No significant difference was found regarding ED staff’s perceptions of FUEDs’ legitimate use of ED resources and frequentation, nor on nurses’ knowledge of the issue. Conclusions These results suggest that CM intervention for FUED is a potential source of support for ED physicians working with FUED. Further qualitative research is needed to explore why nurses without CM support reported feeling less failure and helplessness regarding FUED. Key messages By highlighting a different impact of CM on nurses’ perception, this study illustrates where CM intervention might be improved. This study supports CM as a promising intervention for FUED by potentially having a positive impact on ED physicians’ perception besides the one previously proved on FUEDs’ number of visits and QOL.

When a health policy cuts both ways: Impact of the National Emergency Access Target policy on staff and emergency department performance.

To explore the impact of the Four-Hour Rule/National Emergency Access Target (4HR/NEAT) on staff and ED performance. A mixed-methods study design was used to link performance data from 16 participating hospitals with the experiences reported by 119 ED staff during policy implementation. Quantitative and qualitative measures were triangulated to identify the staff and organisational effects on hospital performance. An overall score was developed to categorise hospitals into: high, moderate and low performers, then compared with four qualitative themes: social factors, ED management, ED outcomes and 4HR/NEAT compliance. Key factors identified were stress and morale; intergroup dynamics; interaction with patients; resource management; education and training; financial incentives; impact on quality and safety; perceived improvements on access block and overcrowding. High performing hospitals reported increased stress and decreased morale, decreased staff-patient communication and staff shortages; significant changes in ED management and effective use of the whole-of-hospital approach. Moderate performing hospitals reported similar characteristics to a lesser degree, and the perception that 4HR/NEAT did not impact ED practice. Low performing hospitals also reported increased stress and low morale and a less effective whole-of-hospital approach. ED staff also reported a reduction in communication with patients. There was strong evidence of an association between high stress and low morale and the implementation of the 4HR/NEAT across all levels of performance. These adverse consequences of the 4HR/NEAT implementation indicate that a more nuanced approach to efficiency improvements is required. This would balance processes measured by 4HR/NEAT against a range of other clinical and organisational performance measures.