Emergency Department Health Care Research Articles

318 Use of Telemedicine Physicians for Telephone Triage of Head Injury Patients

Telehealth utilization continues to grow as an emergency medicine resource with the potential to improve both quality of care and resource utilization. In 2019 our academic emergency department (ED) instituted an emergency medicine telehealth program for our large community health system, including physician support for nurse line triage calls. The telehealth provider is available to the triage line nurse and may modify the triage recommendation, including downgrading a recommendation for ED care. The objective of this study was to evaluate nurse triage line calls for head injury and describe the outcomes of patients whose triage recommendation was downgraded by the telehealth physician from ED care. We conducted an observational study of patients who received care recommendations from a nurse triage line after sustaining a head injury from January 8, 2019 to April 2, 2020. The electronic health records of all cases where an emergency medicine telehealth physician was consulted and downgraded the initial triage recommendation of “ED care,” were reviewed and evaluated for adverse outcomes, defined as: 1 subsequent identification of an intracranial hemorrhage, 2 -hospitalization or 3 -death related to the index head injury within 30 days. We summarized data using descriptive statistics with 95% confidence intervals. During the study period the nurse triage line received 1,793 calls for head injury; for 1,214 (67.7%) of these calls, the initial recommendation based on the triage nurse protocol was for “ED care.” A total of 298 (25%) of calls with an initial triage recommendation of ED care were referred to the telemedicine provider for further review, of which 146 (49%, 95% CI 43%-55%) were downgraded from referral to the ED to non-emergency department outpatient evaluation or home care. Among the patients with a downgraded triage recommendation, 9 (6%) sought emergency care within the next 30 days related to the index injury, and no patients had an adverse outcome as previous defined. Nearly half of the head injury calls referred to the telehealth physician were subsequently triaged away from ED care without any identified adverse outcomes. These findings suggest that telehealth involvement in nursing triage recommendations resulted in a reduction of unnecessary ED visits, potential imaging and health care costs.

Use of World Health Organization Guidelines to Improve Hand Washing Efficacy.

Hand washing continues to be the number one most effective way to prevent the spread of germs. This quality improvement project examines whether a hands-on soap and water hand washing tutorial increases the quality of hand washing technique. The Glow Team developed and presented an evidence-based hands-on teaching tutorial demonstrating proper hand washing technique as recommended by the World Health Organization to 100 emergency department health care workers. The efficacy of the technique was evaluated by applying black light-sensitive lotion. Participants washed their hands before and after the education session. Participants completed a posttest to evaluate their gained knowledge of hand washing. Hand washing efficacy improved from 60% preeducation to 82% posteducation. Each individual step noted improvement posteducation. Of 100 participants, 98 reported this education was helpful and suggested yearly competencies, posted fliers, and repeated demonstrations to improve compliance among self and peers. [J Contin Educ Nurs. 2020;51(10):453-456.].

Including Social and Behavioral Determinants in Predictive Models: Trends, Challenges, and Opportunities.

In an era of accelerated health information technology capability, health care organizations increasingly use digital data to predict outcomes such as emergency department use, hospitalizations, and health care costs. This trend occurs alongside a growing recognition that social and behavioral determinants of health (SBDH) influence health and medical care use. Consequently, health providers and insurers are starting to incorporate new SBDH data sources into a wide range of health care prediction models, although existing models that use SBDH variables have not been shown to improve health care predictions more than models that use exclusively clinical variables. In this viewpoint, we review the rationale behind the push to integrate SBDH data into health care predictive models and explore the technical, strategic, and ethical challenges faced as this process unfolds across the United States. We also offer several recommendations to overcome these challenges to reach the promise of SBDH predictive analytics to improve health and reduce health care disparities.

Examining emergency department inequities between Māori and non-Māori: do they exist?

Abstract Despite Māori (Indigenous population of New Zealand, NZ) having high Emergency Department (ED) use, few studies have explored for ethnic inequities in ED within NZ. ED healthcare can be time-pressured, complex and demanding. Clinical decision-making in this context may facilitate provider prejudice, stereotyping and bias. The Examining Emergency Department Inequities (EEDI) is a retrospective observational study, designed from a Kaupapa Māori Research position, examining ED admissions in NZ between 2006 and 2012 using the existing Shorter Stays in Emergency Department National Research Project dataset combined with clinical information extracted from NZ’s National Minimum Dataset. The key predictor variable is patient ethnicity with covariates: sex, age-group, area deprivation, mode of presentation, referral method, Australasian Triage Scale and the Multimorbidity Measure (M3 Index) for co-morbidities. Generalised linear regression models investigated the associations between pre-admission variables and the measures of ED care, and mortality. There were a total of 5,972,102 ED events (1,168,944 Māori, 4,803,158 non-Māori). We found an increasing proportion of ED events/year, a higher proportion of Māori ED events from younger age groups and areas of high deprivation compared to non-Māori. Māori had a higher proportion of self-referral and were triaged to be seen within a longer timeframe compared to non-Māori. After controlling for year of ED event, gender, triage category, age at presentation, NZ Deprivation decile and M3 Comorbidity score: Māori had shorter ED arrival to assessment time; shorter ED Length of Stay and less Access Block (>8 hour ED LOS before ward admission). Despite this, Māori mortality within ED or within 10 days of discharge was higher than non-Māori. These findings suggest different patterns in ED usage between Māori and non-Māori. Of concern, inequities in mortality exist despite positive indicators of ED care. Key messages There is evidence of different patterns in emergency department use between Māori and non-Māori in New Zealand. Māori:non-Māori inequities in mortality exist despite positive indicators of emergency department care.

48 Paediatric intubation in an adult-based community hospital emergency department (ED)

Abstract Background Airway intubation is a high-risk procedure, especially in the paediatric population. Training ED healthcare providers is challenging because it is rare. Success and adverse events (AEs) could be due to patients’ illness, the health professional intubating, and hospital factors. Objectives Describe paediatric intubations in an adult community-based hospital, with primary outcomes being first-pass success and AEs. The secondary objective is to determine what factors are association with intubation success and related AEs. Design/Methods Retrospective chart review of patients < 18 years intubated in the ED between Jan 1, 2006 and Mar 31, 2017 (demographics, intubation details, physiologic outcomes). Analysis: descriptive and comparative statistics (intubations with vs. without AEs), p<0.05 significant. Results n=121 intubations occurred in the ED over the 10-year period. Mean (standard deviation) age 6.9 (6.8) years. First pass success occurred in n=76 (62.8%), and 33 (27.3%) second pass success. There was n=22 (18.2) minor AEs, n=3 (2.5) major AEs. There were no significant differences between profession intubating and first pass success (p=0.384), or AEs (p=0.472), Table 1. Indications for intubation included respiratory and/or oxygenation failure n=54 (44.6%), airway protection n=51 (42.2%), airway obstruction n=4 (3.3%), cardiopulmonary arrest n=2 (1.7%) [n=9 missing]. Use of specialized equipment was used in n=19 of the intubations, n=12 on first attempt, 8 second attempt, 4 third attempt. No accidental extubations occurred, but the ETT was repositioned in n=33 (27%) after first intubation. Conclusion Pediatric intubation in an adult community-based hospital is rare. Success rate of intubation on first attempt is low with minor AEs. There was no significant difference between the type of health professional intubating. These results will inform the development of tools and education for paediatric advanced airway management in adult community-based hospitals, and enhance patient outcomes in the ED.

Prevalence of methicillin-resistant Staphylococcus aureus colonization in the emergency department health care workers

Introduction: AThe aim of this study was to evaluate the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization in the health care workers of emergency department of Imam Reza hospital, Tabriz, Iran Methods: In a total of 63 physicians and nurses in the emergency department of Imam Reza hospital, after obtaining written consent and completing a checklist, a sample of nasal mucosa was collected for microbiological examination and isolation of Staphylococcus aureus (SA) strain. Determination of resistance patterns (by diffusion method) was performed according to the standard methods of methicillin. Results: Out of 63 participants, 8 subjects (12.7%) had colonization of S. aureus; 4 of them were physicians (17.3% of the participated physicians) and 4 were nurses (10% of the participated nurses). Out of 8 isolated SA, 2 cases (25%) and overall 3.1% were methicillin-resistant. In our study, there was a significant relationship between co-employment in other hospitals and patient care at home with SA colonization, but there was not a significant relationship with specialty, work experience, sinusitis, history of antibiotic use, history of skin disease, hand washing habits and use of personal protective equipment. Conclusion: Prevalence of MRSA was not high among health workers of emergency department.

Determinants of healthcare use by homeless people with schizophrenia or bipolar disorder: results from the French Housing First Study

ObjectivesThere is limited evidence available on the health-seeking behaviours of individuals in relation to determinants of healthcare use. This study aimed to analyse the determinants of healthcare use (including both hospital and outpatient services) among homeless people with severe mental health illnesses. Study designThe study used data from a multicentre, randomised, controlled trial conducted in four large French cities (the French Housing First Study). MethodsData were drawn from 671 homeless people enrolled in the study between August 2011 and April 2014. Mobile mental health outreach teams recruited homeless individuals with severe mental health illnesses who were living on the street or in emergency shelters, hospitals or prisons. Data collection was performed during face-to-face interviews. Healthcare service use included hospitalisations, mental health and regular emergency department (ED) visits and outpatient visits to healthcare facilities or physicians’ offices over a 6-month follow-up period. The data were analysed with zero-inflated (ZI) two-part models. ResultsIn total, 61.1% of participants had at least one hospitalisation stay over the previous 6 months, with a mean of 25 (+/− 39.2) hospital days, and the majority (51%) had visited the ED (either for regular or mental health issues) during the same time period. The results confirmed the role of financial barriers (resources and health insurance) in seeking hospital care (P < 0.05). The main predictors for hospital use in the study population were a better social functioning score (odds ratio [OR]: 1.03; P < 0.001) and having schizophrenia (OR: 1.39; P < 0.01). Higher mental health scores (assessed by the Medical Outcomes Study 36-item Short Form Health Survey) (OR: 1.03, P < 0.01) and alcohol dependence (OR: 2.13; P < 0.01) were associated with not using ED healthcare services. Being ‘absolutely homeless’ predicted an increased use of the ED and a zero use of outpatient services. Inversely, no association with factors related to the homelessness trajectory was found in hospital ZI negative binomial models. ConclusionThis study is important because a comprehensive understanding of the determinants of healthcare use enables healthcare systems to adapt and develop. The efficiency of medicosocial interventions targeting the homeless population with mental health illnesses must also be assessed. Clinical trial numberNCT01570712.

Understanding the Impacts of Caregiver Stress.

Identifying risk factors associated with caregiver stress and suggesting methods for systematic caregiver screening for caregiver strain, depression, and anxiety. Emergency department, primary care, and other health care settings. Caregiver stress can lead to multiple negative outcomes including declines in physical health, increased mental health concerns, and overall decreased quality of life. Caregiver stress also leads to increased financial costs to the person, family, and health care systems, making it a public health issue. Recognizing caregiver stress is the initial step to identifying those in need of support and to providing quality care. Fortunately, caregiver stress can be prevented or reduced using a culturally competent multidimensional approach to addressing social determinants of health and unmet physical, psychological, and social/emotional needs of caregivers. Case management plays a critical role in assessing, educating, advocating, creating care plans, and advocating for both the caregiver and the care recipient.

Quality Improvement in a Pandemic.

Quality Improvement in a Pandemic.

Rapid responses in the emergency department of Linkou Chang Gung Memorial Hospital, Taiwan effectively prevent spread of COVID-19 among healthcare workers of emergency department during outbreak: Lessons learnt from SARS

sLinkou Chang Gung Memorial Hospital, Taiwan has been on the forefront of efforts to manage and mitigate the Coronavirus Disease 2019 (COVID-19) pandemic since 20th January 2020. Despite having one of the largest and busiest emergency departments (EDs) in the world, we have managed to maintain a “zero-infection” rate among our ED healthcare workers through various systematic approaches. The measures implemented include establishing a clear flowchart with route planning, strict infection control policies and regulation of medical equipment, and team-based segregation in the workplace. These strategies, borne of our experience during the severe acute respiratory syndrome (SARS) outbreak, can complement a network of well-trained personnel to enable EDs around the world in successfully mounting an effective defense against new airborne illness while minimizing healthcare personnel casualties.

COVID-19 During the Opioid Epidemic - Exacerbation of Stigma and Vulnerabilities.

COVID-19 During the Opioid Epidemic - Exacerbation of Stigma and Vulnerabilities.

The provision of emergency healthcare for women who experience intimate partner violence: part 2. Strategies to address knowledge deficits and negative attitudes.

The first article in this two-part series evaluated healthcare professionals' approaches to the care of women who present to the emergency department (ED) with injuries related to intimate partner violence (IPV). It identified barriers to appropriate care provision, which included a lack of knowledge on the part of healthcare professionals and negative professional attitudes. This second article details the findings of a literature review of three databases that aimed to evaluate strategies to address the lack of knowledge of healthcare professionals and negative attitudes concerning IPV. A total of 11 articles were included in the review. Two main strategies to address ED healthcare professionals' knowledge deficits and negative attitudes about IPV were identified. These were developed into the themes of IPV/domestic violence specialists, and education and training.

Non-COVID and COVID emergency department healthcare workers’ perception of COVID-19 at Patan Hospital, Nepal

Introduction: Patan Hospital (PH), Patan Academy of Health Sciences (PAHS) has separated non COVID and COVID emergencies for the safety of health care workers (HCWs). This study was conducted to assess the safety perception of healthcare workers working in emergency departments during the outbreak of COVID-19.&#x0D; Method: A cross sectional descriptive study was conducted among HCWs in non COVID and COVID emergency departments at PH, PAHS, Nepal, in April 2020 during COVID-19 outbreak. Questionnaires containing open and closed questions were used. Ethical approval was obtained.&#x0D; Result: Out of 72 HCWs, 58 (80.5%) responded, 47 (81%) felt need to have separate non COVID and COVID emergencies, 27 (46.6%) answered they were not comfortable working with the partial PPE (masks, gloves), 29 (50%) felt the need of having primary and secondary triaging.&#x0D; Conclusion: Emergency staff expressed need of having separate non COVID and COVID emergencies, and importance of primary and secondary triage.

Stone Care Triage During COVID-19 at the University of Washington.

Stone Care Triage During COVID-19 at the University of Washington.

LO53: Emergency department visits for hyperglycemia: through the eyes of the patient

Introduction: Patients with poorly-controlled diabetes often visit the emergency department (ED) for treatment of hyperglycemia. While previous qualitative studies have examined the patient experience of diabetes as a chronic illness, there are no studies describing patients’ perceptions of ED care for hyperglycemia. The objective of this study was to explore the patient experience regarding ED hyperglycemia visits, and to characterize perceived barriers to adequate glycemic control post-discharge. Methods: This study was conducted at a tertiary care academic centre in London, Ontario. A qualitative constructivist grounded theory methodology was used to understand the experience of adult patient partners who have had an ED hyperglycemia visit. Patient partners, purposively sampled to capture a breadth of age, sex, disease and presentation frequency were invited to participate in a semi-structured individual interview to probe their experiences. Sampling continued until a theoretical framework representing key experiences and expectations reached sufficiency. Data were collected and analyzed iteratively using a constant comparative approach. Results: 22 patients with type 1 or 2 diabetes were interviewed. Participants sought care in the ED over other options because of their concern of having a potentially life-threatening condition, advice from a healthcare provider or family member, or a perceived lack of convenient alternatives to the ED based on time and location. Participants’ care expectations centred around symptom relief, glycemic control, reassurance and education, and seeking referral to specialist diabetes care post-discharge. Finally, perceived system barriers that challenged participants’ glycemic control included affordability of medical supplies and medications, access to follow-up and, in some cases, the transition from pediatric to adult diabetes care. Conclusion: Patients with diabetes utilize the ED for a variety of urgent and emergent hyperglycemic concerns. In addition to providing excellent medical treatment, ED healthcare providers should consider patients’ expectations when caring for those presenting with hyperglycemia. Future studies will focus on developing strategies to help patients navigate some of the barriers that exist within our current limited healthcare system, enhance follow-up care, and improve short- and long-term health outcomes.

Codesigning discharge communication interventions with healthcare providers, youth and parents for emergency practice settings: EDUCATE study protocol

IntroductionDischarge communication is an important aspect of patient care but frequently has shortcomings in emergency departments (EDs). In a paediatric context, youth or parents with young children often leave the...

Are loose-fitting powered air-purifying respirators safe during chest compression? A simulation study.

BackgroundThe application of appropriate personal protective equipment for respiratory protection to health care workers is a cornerstone for providing safe healthcare in emergency departments. We investigated the protective effect and usefulness of loose-fitting powered air-purifying respirators (PAPRs) during chest compression.MethodsThis was a single-center simulation study performed from May 2019 to July 2019 in a tertiary hospital. We measured the concentrations of ambient aerosol and particles inside the loose-fitting PAPR during chest compression, and this ratio was set as the simulated workplace protecting factor (SWPF). According to the National Institute for Occupational Safety and Health regulations, the assigned protection factor (APF) of loose-fitting PAPRs is 25. Thus, the loose-fitting PAPRs were assumed to have a protective effect when the SWPF were ≥ 250 (APF × 10). We measured the SWPF of PAPR in real time during chest compression and also investigated the problems encountered during its use.ResultsNinety-one participants (median age 29 [interquartile range (IQR): 26–32] years; 74% female) completed the simulation. None of the participants failed with SWPF below 250 during three sessions of chest compression. The median (IQR) values of SWPF at three cycles were 17,063 (10,145-26,373), 15,683 (9477-32,394), and 16,960 (7695-27,279). There was no disconnection of equipment or mechanical failures during chest compression. In addition, most participants (83%) replied that they rarely or never experienced difficulty in verbal communication and felt that the loose-fitting PAPR was comfortable.ConclusionsThe loose-fitting PAPRs provided sufficient respiratory protection without disturbances during chest compression.

Knowledge and Preparedness of Healthcare Providers Towards Bioterrorism

Introduction: Several emergent circumstances require healthcare providers to be able to recognize the dangerous and uncommon pathogenic agents. An in-depth literature review showed that studies about bioterrorism preparedness amongst healthcare providers from the Middle East, including Saudi Arabia, are lacking. Therefore, we conducted this study to investigate the knowledge and preparedness level of first emergency respondents towards bioterrorism events, which are the emergency department (ED) healthcare providers and the poison control center/clinical laboratory staff. Methods: A cross-sectional study was conducted between at the Emergency departments and poison control centers/clinical laboratories three in major tertiary care hospitals in Riyadh city, Saudi Arabia. The subjects were randomly selected to complete the self-administered questionnaire to collect study outcomes. Results: A total of 1030 participants were included in the final data analysis. The majority were nurses, 516 (50.1%) and doctors 351 (34.1%), and females 550 (53.6%). Overall, the findings revealed a mean knowledge score of 4.92 ± 1.86 out of 12 in the basic concepts of bioterrorism and basic clinical presentations of bioterrorism-related agents. Moreover, the findings showed a mean knowledge score of 22.80 ± 3.92 out of 38 in the bioterrorism preparedness and governing policies and procedures. Respondents who received previous training in bioterrorism preparedness had a significantly higher number of perceived benefits than those not sure and without prior training (z = -2.67, p = 0.008) and (z = - 4.4, p < 0.0001), respectively. About 79.4% of participants did not have previous training in bioterrorism preparedness, but 68.7% expressed willingness in the institution's response and control to assist in the event of a bioterrorist attack. Conclusion: Although healthcare professionals have reported their willingness to assist in bioterrorism events, they need to enhance their knowledge towards bioterrorism preparedness. Funding Statement: The study was funded by King Fahad Medical City, Riyadh, Saudi Arabia. Declaration of Interests: Authors have no conflict of interests. Ethics Approval Statement: The study was reviewed and approved by the institutional review boards at the study site. Participants’ completion of the questionnaire implied their consent to take part in the study.

Real-time display of laboratory testing status improves satisfaction levels in an emergency department: A pilot study.

BackgroundClinicians need to know timelines of requested laboratory tests to provide effective patient management. We developed a real‐time laboratory progress checking system and measured its effectiveness using appropriate indicators in an emergency room setting.MethodsIn our original in‐house health information system display, blank spaces, which were generated for test results when tests were ordered, remained empty until the final results reported. We upgraded the laboratory reporting system to show real‐time testing information. The stages included requests for test, label printing, sampling, laboratory receipts, performance of tests, verification of results, and interpretation of results and final report by laboratory physician. To assess the usefulness of the function, we measured the emergency department healthcare workers' satisfaction and compared the number of phone calls about test status before and after implementation.ResultsAfter the system upgrade, the healthcare workers' understanding of the testing process increased significantly as follows. More clinicians could estimate the time of final test results through the real‐time testing status information (61.9% and 85.7%, P = .002), and respondents reported that the upgraded system was more convenient than the original system (41.3% and 22.2%, respectively, P = .022). The number of phone calls about the test status decreased after implementation of the upgrade; however, the difference was not statistically significant (before, 0.13% [63 calls/48 637 tests] and after, 0.09% [42/46 666]; P = .066).ConclusionsThe real‐time display of laboratory testing status increased understanding of testing process among healthcare workers in emergency room, which ultimately may increase the usefulness and efficiency of the laboratory service use.

Identification of emergency department patients for referral to rapid-access addiction services.

Substance-related emergency department (ED) visits are rapidly increasing. Despite this finding, many EDs do not have access to on-site addiction services. This study characterized substance-related ED presentations and assessed the ED health care team's perceived need for an on-site rapid-access addiction clinic for direct patient referral from the ED. This prospectively enrolled cohort study was conducted at an urban tertiary care ED from June to August 2018. Adult ED patients with problematic or high-risk substance use were enrolled by ED staff using a one-page form. The electronic and paper records from the index ED visit were reviewed. The primary outcome evaluated whether the ED health care team would have referred the patient to an on-site rapid-access addiction clinic, if one were available. We received 557 enrolment forms and 458 were included in the analysis. Median age was 35 years, and 64% of included patients were male. Alcohol was the most commonly reported substance of problematic or high-risk use (60%). Previous ED visits within 7 days of the index visit were made by 28% of patients. The ED health care team indicated "Yes" for rapid-access addiction clinic referral from the ED for 66% of patients, with a mean of 4.3 patients referred per day during the study period. At least four patients per day would have been referred to an on-site rapid-access addiction clinic from the ED, had one been available. This indicates a gap in care and collaborating with other sites that have successfully implemented this clinic model is an important next step.