Emergency Department Care Providers Research Articles

Postpandemic Evaluation of the Eco-Efficiency of Personal Protective Equipment Against COVID-19 in Emergency Departments: Proposal for a Mixed Methods Study.

The COVID-19 pandemic has had a profound impact on emergency department (ED) care in Canada and around the world. To prevent transmission of COVID-19, personal protective equipment (PPE) was required for all ED care providers in contact with suspected cases. With mass vaccination and improvements in several infection prevention components, our hypothesis is that the risks of transmission of COVID-19 will be significantly reduced and that current PPE use will have economic and ecological consequences that exceed its anticipated benefits. Evidence is needed to evaluate PPE use so that recommendations can ensure the clinical, economic, and environmental efficiency (ie, eco-efficiency) of its use. To support the development of recommendations for the eco-efficient use of PPE, our research objectives are to (1) estimate the clinical effectiveness (reduced transmission, hospitalizations, mortality, and work absenteeism) of PPE against COVID-19 for health care workers; (2) estimate the financial cost of using PPE in the ED for the management of suspected or confirmed COVID-19 patients; and (3) estimate the ecological footprint of PPE use against COVID-19 in the ED. We will conduct a mixed method study to evaluate the eco-efficiency of PPE use in the 5 EDs of the CHU de Québec-Université Laval (Québec, Canada). To achieve our goals, the project will include four phases: systematic review of the literature to assess the clinical effectiveness of PPE (objective1; phase 1); cost estimation of PPE use in the ED using a time-driven activity-based costing method (objective2; phase 2); ecological footprint estimation of PPE use using a life cycle assessment approach (objective3; phase 3); and cost-consequence analysis and focus groups (integration of objectives1to3; phase 4). The first 3 phases have started. The results of these phases will be available in 2023. Phase 4 will begin in 2023 and results will be available in 2024. While the benefits of PPE use are likely to diminish as health care workers' immunity increases, it is important to assess its economic and ecological impacts to develop recommendations to guide its eco-efficient use. PROSPERO CRD42022302598; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=302598. DERR1-10.2196/50682.

Swift role negotiations: Communicative strategies for enabling rapid role shifts in cross-functional teaming

ABSTRACT This field study of a hospital emergency department (ED) examined role negotiations among ED care providers in teaming (i.e., the process of bringing individuals in distinct roles to collaborate as a temporary unit). A grounded qualitative analysis revealed that although a prescriptive role structure enables teaming through role-based coordination, ED providers negotiated one another’s role shifts via brief communicative acts to work through novel situations. Whereas role negotiation has traditionally been theorized as individuals’ attempts to (re)shape their roles throughout their organizational membership, this study showed how roles are negotiated in action quickly and as needed to adapt to emergent needs. Based on the findings, we reconceptualized role negotiation as swift communication situated in short-lived moments of collaboration.

Implicit Bias in Pediatrics: An Emerging Focus in Health Equity Research.

* Abbreviation: ED — : emergency department Despite large-scale investments in research, health policy, care delivery models, and medical school curricula, inequities along the continuum of child health care and health persist.1,2 The study “Racial and Ethnic Differences in Emergency Department Pain Management of Children with Fractures”3 in this issue of Pediatrics contributes new insights into the field of pediatric health equity research with a focus on pain in the emergency department (ED) setting. Goyal et al3 find that although racial and/or ethnic minority children were more likely to receive analgesics and achieve a ≥2-point reduction in pain, they were less likely to receive opioids and experience optimal pain reduction. This work builds on a well-established body of literature in adult care and an emerging evidence base in pediatrics demonstrating inequities in analgesic administration.4 Studies in pediatric EDs have demonstrated racial and/or ethnic disparities in analgesic management for children presenting with acute abdominal pain and appendicitis.5,6 The current study adds to the field by combining process and outcome measures in assessing analgesic management. As the authors and other researchers in the field have highlighted, there … Address correspondence to Jean L. Raphael, MD, MPH, Texas Children’s Hospital, 6701 Fannin St, Suite D.1540.00, Houston, TX 77030. E-mail: raphael{at}bcm.edu

P017: A time-driven activity-based costing method to estimate health care costs in the emergency department

Introduction: Poor physicians’ knowledge of health care costs has been identified as an important barrier to improving efficiency and reducing overuse in care delivery. Moreover, costs of tests and treatments estimated with traditional costing methods have been shown to be imprecise and unreliable. We estimated the cost of frequent care activities in the emergency department (ED) using the time-driven activity-based costing (TDABC) method. Methods: We conducted a TDABC study in the ED of the CHUL, Québec city (77000 visits/year). We estimated the cost of all potential care activities (e.g. triage) provided to adult patients with selected urgent (e.g. pulmonary sepsis) and non urgent (e.g. urinary tract infection) conditions frequently encountered in the ED. Following Lean management principles, process maps were developed by a group of ED care providers for each care activity to identify human resources, supplies and equipment involved, and to estimate the time required to complete each process. Resource unit cost (e.g. cost per minute of a nurse) and overhead rate were calculated using financial information from fiscal year 2015-16. Estimated cost of each care activity (e.g. chest X-ray) including physicians’ charges was calculated by summing overhead allocation and the cost of each process (e.g. disinfection of the X-ray machine) as obtained by multiplying the resource unit cost by the time for process completion. Results: Process maps were developed for 14 conditions and 68 ED care activities. We estimated the costs of activities (CAN$) related to nursing (e.g. urinalysis and culture triage ordering $14.70), clerk tasks (e.g. patient registration $3.40), physicians (e.g. FAST scan $20.90), laboratory testing (e.g. CBC $6.30), diagnostic imaging (e.g. abdominal CT scan $146.50), therapy (e.g. 5 mg of iv morphine $20.40), and resuscitation (rapid sequence intubation with ketamine and succinylcholine $146.40). Overall, emergency physicians’ charges, personnel salaries and overheads accounted for 38%, 22% and 16% of all ED care costs, respectively. Conclusion: Our results represent an important step toward increasing emergency physicians’ awareness on the real cost of their interventions and empowering them to adopt more cost-effective practice patterns.

The Role of Bias by Emergency Department Providers in Care for American Indian Children.

American Indian children have high rates of emergency department (ED) use and face potential discrimination in health care settings. Our goal was to assess both implicit and explicit racial bias and examine their relationship with clinical care. We performed a cross-sectional survey of care providers at 5 hospitals in the Upper Midwest. Questions included American Indian stereotypes (explicit attitudes), clinical vignettes, and the Implicit Association Test. Two Implicit Association Tests were created to assess implicit bias toward the child or the parent/caregiver. Differences were assessed using linear and logistic regression models with a random effect for study site. A total of 154 care providers completed the survey. Agreement with negative American Indian stereotypes was 22%-32%. Overall, 84% of providers had an implicit preference for non-Hispanic white adults or children. Older providers (50 y and above) had lower implicit bias than those middle aged (30-49 y) (P=0.01). American Indian children were seen as increasingly challenging (P=0.04) and parents/caregivers less compliant (P=0.002) as the proportion of American Indian children seen in the ED increased. Responses to the vignettes were not related to implicit or explicit bias. The majority of ED care providers had an implicit preference for non-Hispanic white children or adults compared with those who were American Indian. Provider agreement with negative American Indian stereotypes differed by practice and respondents' characteristics. These findings require additional study to determine how these implicit and explicit biases influence health care or outcomes disparities.

Emergency Department Discharge Prescription Interventions by Emergency Medicine Pharmacists

We determine the rate and details of interventions associated with emergency medicine pharmacist review of discharge prescriptions for patients discharged from the emergency department (ED). Additionally, we evaluate care providers' satisfaction with such services provided by emergency medicine pharmacists. This was a prospective observational study in the ED of an academic medical center that serves both adult and pediatric patients. Details of emergency medicine pharmacist interventions on discharge prescriptions were compiled with a standardized form. Interventions were categorized as error prevention or optimization of therapy. The staff of the ED was surveyed related to the influence and satisfaction of this new emergency medicine pharmacist-provided service. The 674 discharge prescriptions reviewed by emergency medicine pharmacists during the study period included 602 (89.3%) for adult patients and 72 (10.7%) for pediatric patients. Emergency medicine pharmacists intervened on 68 prescriptions, resulting in an intervention rate of 10.1% (95% confidence interval [CI] 8.0% to 12.7%). The intervention rate was 8.5% (95% CI 6.4% to 11.1%) for adult prescriptions and 23.6% for pediatric prescriptions (95% CI 14.7% to 35.3%) (difference 15.1%; 95% CI 5.1% to 25.2%). There were a similar number of interventions categorized as error prevention and optimization of medication therapy, 37 (54%) and 31 (46%), respectively. More than 95% of survey respondents believed that the new pharmacist services improved patient safety, optimized medication regimens, and improved patient satisfaction. Emergency medicine pharmacist review of discharge prescriptions for discharged ED patients has the potential to significantly improve patient care associated with suboptimal prescriptions and is highly valued by ED care providers.

443 Emergency Department Care Provider Perception of Department-Based Pharmacist Services

443 Emergency Department Care Provider Perception of Department-Based Pharmacist Services

151: Development of a Novel Communication Tool Using Patient Focus Group Input

Emergency care involves rapid sharing of information between patients and care providers under stressful circumstances in a setting where no previous therapeutic relationship exists. Communication of critical medical information to patients and their families is essential to providing comprehensive emergency care that benefits the patient.. Despite efforts by staff to communicate effectively, emergency department (ED) patients often have difficulty understanding their care in the department and the follow-up care needed. Our goal is to identify specific points in the patient encounter that serve as barriers to communication and to develop a communication instrument to overcome those barriers. Rather than develop a provider-driven instrument, we started with a patient-driven discussion of recent ED care and the communication that occurred during that care. A focus group of patients taken from recent ED visits discussed communication strategies and gave feedback on an instrument in development to help address communication barriers. Investigators approached all triage level 2 and 3 patients seen in a 44-bed, level II trauma ED, serving a 537-bed teaching hospital during a contiguous period until 40 consents were obtained. Consenting patients were contacted 1 week later by phone and asked to participate in focus group discussion. Those available to participate attended one of two focus groups. The moderators led focus group discussions about experiences related to communication during the patient's recent emergency department visit and then asked participants to evaluate a draft communication tool proposed to improve ED communication. Discussion was transcribed in written form by the moderators, confirmed with participants prior to the end of the group discussion, then debriefed between the moderators after each group. Transcribed focus group discussions were then reviewed by the investigators and themes identified. Concrete suggestions for improvement in the communication instrument will be incorporated in future pilot trials of the communication instrument. At the point of phone contact, 25% of patients indicated willingness to participate, and 15% actually attended a focus group. Scheduling conflicts, ongoing medical problems or fatigue with medical contact were most frequently cited as reasons for not attending. Patients over age 70 were more likely to attend. The primary theme that emerged was the need for more frequent updates to the plan of care and the need for clear identification of team members. The triage process was the most confusing and dissatisfying aspect of care identified by patients in the focus group. Specific suggestions to improve a future communication instrument were provided by several participants and were distinct from those designed by providers. These included having an area for patients to write down their questions and a clear designation of the patient's per os (PO) status. This focus group study of communication between ED care providers and their patients identifies common themes across a variety of patient ages and chief complaints. The clarity of a plan of care that is known to the patient and family member emerged as a significant request. Patient feedback, on a communication tool in development, led to significant additions and alteration in the tool from the provider developed version.

Time Motion Study in a Pediatric Emergency Department Before and After Computer Physician Order Entry

To determine the effect of computer physician order entry on pediatric emergency department (ED) care providers allocation of time. We seek to determine whether the increase in time by ED care providers on the computer will decrease time spent with patients. This was a before-and-after observational time-and-motion study conducted at an urban pediatric ED. Observers recorded how caregivers allocated their time during 180-minute observation periods at 30-second increments the summers before after computer physician order entry introduction. Time on the computer was recorded in seconds. Observations were placed into 3 categories (direct patient care, indirect patient care, other), each with its own subcategories. For attending physicians, median computer time increased from 5.0 minutes before computer physician order entry to 9.5 minutes after computer physician order entry (P=.01). For resident physicians, median computer time increased from 5.5 minutes before computer physician order entry to 14.3 minutes after computer physician order entry (P=.001). For nurses, time on the computer was not significantly different before and after computer physician order entry (P=.15), although it appears there was still some change in time allocation. After computer physician order entry, nurses' talking with staff about patient care decreased from 24.5 minutes to 13.3 minutes (P=.01). Computer physician order entry did not decrease time with patients for any of the caregiver types. The addition of computer physician order entry to a pediatric ED increases time spent on the computer by both attending and resident physicians but not for emergency nurses. This additional time on the computer is allocated from nonpatient care activities. The addition of computer physician order entry decreases nurses' time talking with other staff for patient care.

Introducing a nurse practitioner into an urban Canadian emergency department

Our objective was to compare the emergency care provided by a nurse practitioner (NP) with that provided by emergency physicians (EPs), to identify emergency department (ED) patients appropriate for autonomous NP practice and to acquire data to facilitate the development of the clinical scope of practice recommendations for ED practice for NPs. Using a comprehensive 3-part process, we selected and hired the best NP from 12 applicants. The NP was oriented to the operations of our free-standing community ED and incorporated in the care team, working in real time with EP preceptors during a 6-month, prospective clinical assessment comparing NP care with EP care. ED preceptors reviewed every case in real time with the NP and completed an explicit evaluation form to determine whether NP assessment, investigation, treatment and disposition were "all equivalent to emergency physician care" (AEEPC) or whether they differed. The proportion of AEEPC interactions was determined for 23 patient presentation categories. Our a priori assumption was that a patient presentation category might be suitable for autonomous NP practice if 50% of NP encounters in that category were rated as AEEPC. Descriptive data were presented for patient case mix, teaching domains and time criteria. Eighty-three NP shifts and 711 patient encounters were evaluated by 21 EP preceptors. The NP saw a median of 8 patients per shift. In 43% of encounters, NP care was AEEPC. Highest AEEPC rates were found in the patient follow-up categories general follow-up (55.4%), diagnostic imaging (91.7%) and microbiology laboratory results (87.6%). NP scores over 50% were also seen for lacerations (63.6%) and isolated sore throats (53%). With teaching, NP performance improved over time. With the exception of follow up-related complaints, simple lacerations and isolated sore throats, NP care differed substantially from EP care. Although NPs with extensive emergency experience and training might ultimately be able to function as autonomous ED care providers, Canadian EDs currently developing job descriptions for emergency NPs should focus on a model of collaborative practice with EPs.

Support for Emergency Department Screening for Intimate Partner Violence Depends on Perceived Risk

Emergency department (ED) screening for intimate partner violence (IPV) faces logistic difficulties and has uncertain efficacy. We surveyed 146 ED visitors and 108 ED care providers to compare their support for ED IPV screening in three hypothetical scenarios of varying IPV risk. Visitor support for screening was 5 times higher for the high-risk (86%) than for the low-risk (17%) scenario. Providers showed significantly more support for the need for ED IPV screening than visitors. Controlling for confounding by gender, race, experience with IPV, hospital, and marital status did not affect comparisons between groups. These responses indicate greater support for IPV screening in the ED for high-risk than for low-risk cases, particularly among visitors.

T HE C HALLENGES OF R ESPONDING TO “H IGH-TECH ” C ARDIAC I MPLANT P ATIENTS IN C RISIS

Complex new technologies are frequently added to the palate of modern cardiac care, and numerous potential technologies are poised for patient availability upon successful clinical trials. Some cardiac implants, while thoroughly understood by many cardiologists and most cardiac surgeons, are poorly understood by prehospital (e.g., paramedic, emergency medical technician) and emergency department care providers (e.g., physicians, nurses, respiratory therapists), potentially facilitating improper or inadequate patient care. Exploring the technologies of coronary stents, left ventricular assist devices, and the currently experimental total artificial heart, it is offered that prehospital and emergency department care providers (and ultimately their patients) would benefit by formal training regarding these devices.