Emergency Department Health Care Research Articles

Remote Biometric Monitoring of Patients With COVID-19 With Exertional Hypoxia Treated With Supplemental Oxygen

Remote Biometric Monitoring of Patients With COVID-19 With Exertional Hypoxia Treated With Supplemental Oxygen

Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings.

Debriefing is increasingly used in clinical environments. Surveys indicate staff support for debriefing clinical events, but little is known about the specific effects of debriefing on healthcare workers in the workplace. INFO (Immediate, Not for personal assessment, Fast facilitated feedback, and Opportunity to support and ask questions) is a charge nurse facilitated clinical event debriefing program implemented in 2016 and currently used in five Emergency Departments (ED) in Calgary, Alberta, Canada. There have been more than 840 documented INFO debriefings. Thirty interprofessional ED healthcare workers were recruited through posters and email to take part in voluntary one-on-one interviews using a standardized question script that asked participants about their experience with INFO debriefing assessments. Specifically, participants were asked to provide demographic information, give feedback about their involvement in INFO clinical debriefings, impact of debriefings on their clinical practice, stress levels and wellbeing. Interviews were transcribed and analysed using NVivo software. Forty-five healthcare workers replied to the initial recruitment methods with fifteen not responding to follow-up communication. Overall, staff satisfaction with INFO debriefing was highly rated. A qualitative thematic analysis to saturation approach was used to analyse the data. Five main themes were identified: 1.Effect of debriefing on clinical practice and patient care. 2. Psychological safety and teamwork. 3. Emotional acknowledgment after critical events. 4. Managing work stress in the ED. 5. Barriers to debriefing. In this study, debriefing in the ED helped interprofessional healthcare workers manage stress, provide improved patient care and teamwork while acknowledging emotions. This study specifically involved INFO, however, there are similarities that make our findings applicable to other clinical event debriefing programs. We believe this study provides further evidence supporting debriefing in clinical care areas.

Seroprevalence of SARS-CoV-2 in Emergency Department Healthcare Workers at Sírio-Libanês Hospital, Brazil.

COVID-19 has spread rapidly worldwide. Information on its prevalence and factors associated with infection are important for protecting both professionals and patients in healthcare centers. This study evaluated the seroprevalence of antibodies against SARS-CoV-2 and its association with the degree of exposure and use of personal protective equipment by healthcare professionals dedicated to the treatment of patients with flu-like illnesses in the emergency room. The research team included an analysis of healthcare professionals who underwent enzyme-linked immunosorbent assay serological testing for SARS-CoV-2 between May 28 and June 26, 2020, in the emergency room of Sírio-Libanês Hospital in São Paulo, Brazil. Participants answered individual questionnaires on occupational information, medical health history, and factors associated with exposure to the novel coronavirus. The questionnaire variables were compared based on the serological results. Of the 164 study participants, 96 (58.54%) reported at least 1 flu-like symptom and 42 (25.61%) presented serology results that were compatible with SARS-CoV-2 infection. The asymptomatic declared group accounted for 62 participants; of these, 8 (12.90%) had positive serology results (neutralizing antibody and IgG) for SARS-CoV-2. Data analysis showed a positive correlation with duration of work, safety in wearing and reusing personal protective equipment, and presence of anosmia, and showed a negative relationship with duration of mask use. Our findings suggest that the perception of symptoms by healthcare professionals is not a good screening parameter for the diagnosis of an infectious disease with respiratory symptoms, such as COVID-19. The main influencing factor for the control of infection is the elaboration of workflows and safety protocols based on simple and clear rules as well as investments in team training.

Analysis of self-initiated visits for cervical trauma at urgent care centers and subsequent emergency department referral

BackgroundFollowing trauma involving the cervical spine (c-spine), patients often seek care at urgent care centers (UCCs) or emergency departments (EDs). PurposeThe purpose was to assess whether UCCs could effectively image acute self-selected c-spine trauma without referral to the ED as well as to estimate costs differences between UCC and ED imaging assessment. Materials and methodsThis retrospective study identified patients receiving c-spine imaging at UCCs affiliated with a large academic hospital system from 5/1/-8/31/2021. Patients receiving c-spine X-rays with an indication of trauma following low acuity injury, at UCCs were compared to patients receiving any c-spine imaging in the main campus ED. Medical record numbers were cross-referenced to identify patients receiving imaging at both a UCC and ED within 24 h and within 7 days. Work relative value units (wRVUs) for each UCC and ED imaging type were calculated. For the hypothetical scenario of patients presenting to the ED in the absence of UCC, patients were assumed to receive c-spine computed tomography (CT) without contrast per “usually appropriate” designation by the American College of Radiology Appropriateness Criteria®. ResultsAmong 143 self-selected, low acuity, patients who received c-spine X-rays at UCCs with an indication of trauma, one required referral to the ED within 24 h and two required referrals to the ED within 7 days. During the 4-month study period, 105.94 wRVUs ($3696.25) were saved by performing a c-spine X-ray in an UCC instead of a CT in the ED, extrapolated to 317.82 wRVUs ($11,088.74) per year. Using the average total costs of an UCC visit versus an ED visit, a total $145,976 was estimated to be saved during the study period or $437,928 per year. ConclusionOffering access for patient-initiated visits at UCCs for low-acuity c-spine trauma may help reduce the need for an ED visit, reducing imaging and healthcare visit costs. Summary statementUrgent Care Centers (UCCs) reduced the need for an Emergency Department (ED) referral visit in nearly 100% of self-selected, low acuity, patients with cervical trauma. Key results•Only 1.4% of patients required referral to an ED after a UCC visit for acute cervical trauma in this specific population.•In our system, UCCs are estimated to result in a savings of $437,928 over the course of a year in reduced ED visit costs, and $11,088.74 in wRVUs for this specific population.

Rural health disparities in health care utilization for dementia in Minnesota.

We visualized rural-urban differences in inpatient hospitalization and emergency department (ED) health care utilization (HCU) for older adults with dementia to understand the HCU of rural versus urban older adults in Minnesota and to examine in greater detail the variability of HCU in rural areas. For 3 older adult age groups, we utilized Healthcare Cost and Utilization Project (H-CUP) datasets from 2016 to 2018 to profile hospital admission rates, and ED visit rates related to dementia stratified by rurality and regions. Rates were visualized by spatial interpolation method. We then used logistic regression analysis adjusted by multiple covariates to evaluate rural-urban differences of the chance of having a dementia diagnosis in HCU. Minnesota rural areas showed 17.6% lower age-adjusted rate (AAR) of dementia mortality than urban areas. AARs of ED visits for dementia were 12.4% higher in rural ZIP codes, whereas AARs of hospitalization were 24.7% lower. After controlling for neighborhood-level risk factors, such as income, education, health behaviors, and provider access, the odds ratios of having dementia diagnosis are 12% lower if an ED visit patient lives in rural as opposed to an urban area (OR = 0.88, P<.0001). In comparison to AAR, the fully adjusted data showed larger rural-urban predictors of having dementia diagnoses in hospitalizations and ED utilizations and demonstrated differences between AAR of ED visit and odds ratios of having dementia diagnosis. A regional comparison revealed that dementia ED visits were higher for Northeast MN compared to Minnesota's largest metropolitan region.

Participatory Action Research on perceptions, concerns and needs of health professionals in an emergency department from Argentina

To explore perceptions, concerns and needs of healthcare professionals in an emergency department (ED) from Argentina. Participatory action research, coordinated and carried out by ED healthcare professionals, which included physicians, nurses and administrative staff who actively engaged in both data collection and analysis. Mixed methodologies were used: documentary analysis of complaints and written claims by patients, 10 individual interviews, and two reflective focus groups of 10 healthcare professionals (who differed in occupation, seniority and experience, including residents in training). The topics that emerged were work factors that lead to errors and threaten patient-centered clinical encounters: work overload and lack of time, the overuse of resources for defensive medicine purposes and technology that replaces physical contact. Healthcare professionals reported episodes of aggression by patients or their families, when long waits and structural insufficiencies (such as lack of beds, saturation of the waiting room, discomfort) threaten patience and tolerance. From these insights, improvements were generated in various areas of the ED. The identification of problems by the ED stakeholders l was a relevant approach that led to a process of collective management change, promoted reflection and raised awareness, allowing the identification of areas for improvement, design strategies and concrete feasible proposals.

Designing a Sensory Kit to Improve the Environment for Children with Autism Spectrum Disorder in the Pediatric Emergency Department.

Children with autism spectrum disorder (ASD) have more frequent use of healthcare services, including visits to the emergency department (ED). Medical care for children with ASD can be adversely affected by the highly stimulating environment of the ED. In this study, we gained insights from stakeholders with lived experience (parents of children with ASD, children with ASD, and ED healthcare providers) to create and implement a sensory equipment kit. The kit was evaluated and iteratively improved based on observations of children using the sensory equipment, satisfaction surveys from their parents, and interviews with healthcare providers in the ED. Findings from this study can be used to guide other EDs in creating their own ASD sensory kit.

Patient and Provider Perspectives on Emergency Department Care Experiences among People with Mental Health Concerns.

Emergency departments (EDs) are an important source of care for people with mental health (MH) concerns. It can be challenging to treat MH in EDs, and there is little research capturing both patient and provider perspectives of these experiences. We sought to summarize the evidence on ED care experiences for people with MH concerns in North America, from both patient and provider perspectives. Medline and EMBASE were searched using PRISMA guidelines to identify primary studies. Two reviewers conducted a qualitative assessment of included papers and inductive thematic analysis to identify common emerging themes from patient and provider perspectives. Seventeen papers were included. Thematic analysis revealed barriers and facilitators to optimal ED care, which were organized into three themes each with sub-themes: (1) interpersonal factors, including communication, patient–staff interactions, and attitudes and behaviours; (2) environmental factors, including accommodations, wait times, and restraint use; and (3) system-level factors, including discharge planning, resources and policies, and knowledge and expertise. People with MH concerns and ED healthcare providers (HCPs) share converging perspectives on improving ED connections with community resources and diverging perspectives on the interplay between system-level and interpersonal factors. Examining both perspectives simultaneously can inform improvements in ED care for people with MH concerns.

Intravenous medication errors in the emergency department, knowledge, tendency to make errors and affecting factors: An observational study

BackgroundIntravenous medication errors are common in hospital settings particularly emergency department. This study aimed to determine intravenous medication preparation and administration errors, contributing factors, tendency towards making errors and knowledge level of emergency department healthcare workers. MethodsA cross-sectional study using a structured, direct observation method was conducted. It was conducted with 23 emergency healthcare workers working in the emergency department of a university hospital in Turkey. Data were collected by questionnaires: Knowledge Test on Intravenous Medication Administration, Intravenous Drug Administration Standard Observation Form, Drug and Transfusion Administration Sub-Dimension scale, Perceived Stress Scale and Pittsburgh Sleep Quality Index. ResultsIt was determined that the knowledge level of the emergency healthcare workers about intravenous medication administration was moderate, and the tendency mistakes regarding drug and transfusion applications was very low. There was no relationship between education level, years of work, years of work in the emergency department, perceived stress level and sleep quality, and the tendency of making mistakes in drug and transfusion applications. ConclusionIt is important for patient safety to prevent medication errors by determining the factors affecting intravenous medication administration, tendency to make mistakes and knowledge levels, which are frequently used in emergency department.

Development of the use of primary health care emergency departments after interventions aimed at decreasing overcrowding: a longitudinal follow-up study

BackgroundThis study, conducted in a Finnish city, examined whether decreasing emergency department (ED) services in an overcrowded primary care ED and corresponding direction to office-hours primary care would modify service usage for specific gender, age or diagnosis groups.MethodsThis was an observational retrospective study carried out by gradually decreasing ED services in primary care. The interventions aimed at decreasing use of EDs were a) application of ABCDE-triage combined with public guidance on the proper use of EDs, b) closure of a minor supplementary ED, and finally, c) application of “reverse triage” with enhanced direction of the public to office-hours services and away from the remaining ED The annual number of visits to office-hours primary care GPs in different gender, age and diagnosis groups (International Classification of Diseases (ICD − 10) were recorded during a 13-year follow-up period.ResultsThe total number of monthly visits to EDs decreased slowly over the whole study period. This decrease was similar in women and men. The decrease was stronger in the youngest age groups (0–19 years). GPs treated decreasing proportions of ICD-10 groups. Recorded infectious diseases (Groups A and J, and especially diagnoses related to infections of respiratory airways) tended to decrease. However, visits due to injuries and symptomatic diagnoses increased.ConclusionDecreasing services in a primary health care ED with the described interventions seemed to reduce the use of services by young people. The three interventions mentioned above had the effect of making the primary care ED under study appear to function more like a standard ED driven by specialized health care.

Understanding Emergency Department Healthcare Professionals' Perspectives of Caring for Individuals in Suicidal Crisis: A Qualitative Study

Help seekers regularly present to Emergency Departments (EDs) when in suicidal crisis for intervention to ensure their immediate safety, which may assist in reducing future attempts. The emergency health workforce have unique insights that can inform suicide prevention efforts during this critical junction in an individual's experience with suicide. This paper explores the treatment and care delivery experiences of 54 health professionals working in EDs within one of the LifeSpan suicide prevention trial sites in Australia. Data was collected via six focus groups and six interviews. Thematic analysis resulted in three themes: (1) physicality of the emergency department, (2) juggling it all–the bureaucracy, practicalities, and human approach to care, and (3) impact of care delivery on ED staff. Findings highlight the need for workplace training that incorporates responding to the uncertainty of suicidal crisis, to compliment the solution-focused medical model of care. Broader policy changes to the ED system are also considered to ensure better outcomes for health professionals and help-seekers alike.

Did Personality Type Influence Burn Out Syndrome Manifestations During Covid-19 Pandemic?

IntroductionEmergency department (ED) health care providers had one of the highest incidences of burnout just before the pandemic. Personality type influences the way we communicate and relate to others, as well as our reaction to stress. In evaluating the causes of burnout, we take into account several factors, the most important of which being the conditions of the professional environment, interpersonal relationships and personality traits. This study aims to identify and analyze the relationships between personality traits and burnout syndrome in medical staff in the Emergency Department.Material and MethodsA descriptive, multicenter cross-sectional study project was used to collect data from 60 physicians and nurses from the Emergency Department of the County Emergency Clinical Hospital Galati. The tools used, distributed to participants to collect socio-demographic details, included the Eysenck Personality Inventory (EPI), and a pilot questionnaire. The questionnaire consisted of 11 questions, concerning exhaustion level, and focused on stress-generating elements and emotional management in the Emergency Department during the pandemic.ResultsA large percentage of doctors in ED (45.8%) (n = 24) indicated a high level of exhaustion, while only 30.6% (n = 36) of nurses indicated a high level of exhaustion. Physicians displayed a higher level of stress than nurses, with 66.6% (n = 24) of physicians indicating an increased level of stress, compared to only 36.1% (n = 36) of nurses. A large percentage of nurses indicated a high level of depression (36.1%), whereas only 25% of Emergency Department physicians indicated a high level of depression.DiscussionThe individuals with a melancholic and choleric temperament, as rated by the EPI, appeared more susceptible to developing burnout syndrome. The indication of instability or neuroticism appears to enhance the occurrence of burnout syndrome. There was also a correlation between extraversion and a high level of burnout, with extraverted individuals more easily reaching a high level of burnout.ConclusionThe results indicate a greater occurrence of exhaustion and stress in Emergency Department physicians compared to nurses in the Emergency Department. From the results, we can propose that there is a relationship between the personality traits as measured by the EPI and the occurrence of burnout syndrome. These findings may help to understand the vulnerability of medical staff to burnout, and to pre-emptively support them to deal effectively with stressors in the work environment.

Investigating the Components of Virtual Emergency Department.

The prediction of the demography of Spain shows that Spain will experience an aging population soon. Aging is a condition of chronic disease resulting in overcrowding Emergency Department. Despite chronic diseases, Covid-19 became a serious issue for emergency Department staff and health care providers. All of these matters emphasized the importance of the Virtual Emergency Department which can provide faster and more affordable medical services while everyone can keep the social distance as much as possible. In this chapter, we investigated the role of IT in the healthcare system and the possible suggested solutions. We have studied the existing telemedicine, e-health, machine learning algorithms and in the end, their combination to built an integrated virtual emergency department to cover all the aspects. We have proposed a model for this integrated model and studied the possibility of success in each step including admission, triage, diagnoses, and clinical advice based on literature.

Investigation of usability problems of electronic medical record systems in the emergency department.

Despite the benefits of using electronic medical record (EMR) systems, existing studies show that many healthcare providers are uncertain regarding their usability. The usability issues of these systems decrease their efficiency, discourage clinicians, and cause dissatisfaction among patients, which may result in safety risks and harm. The aim of this study was to collect and analyze EMR system usability problems from actual users. Practical user interface guidelines were presented based on the medical practices of these users. Employing an online questionnaire with a seven-point Likert scale, usability issues of EMR systems were collected from 200 emergency department healthcare providers (103 physicians (medical doctors) and 97 nurses) from South Korea. The most common usability problem among the physicians and nurses was generating in-patient selection. This pertained to the difficulty in finding the required information on-screen because of poor visibility and a lack of distinctiveness. The major problems of EMR systems and their causes were identified. It is recommended that intensive visual enhancement of EMR system interfaces should be implemented to support user tasks. By providing a better understanding of the current usability problems among medical practitioners, the results of this study can be useful for developing EMR systems with increased effectiveness and efficiency.

Associations of Healthcare Utilization and Costs with Increasing Pain and Treatment Intensity Levels in Osteoarthritis Patients: An 18-Year Retrospective Study

IntroductionOsteoarthritis (OA) is a complex disease, and prior studies have documented the health and economic burdens of patients with OA compared to those without OA. Our goal was to use two strategies to further stratify OA patients based on both pain and treatment intensity to examine healthcare utilization and costs using electronic records from 2001 to 2018 at a large integrated health system.MethodsAdult patients with ≥1 pain numerical rating scale (NRS) and diagnosis of OA were included. Pain episodes of ≥90 days were defined as mild (0–3), moderate (4–6), or severe (7–10) based on initial NRS. Patients were initially classified as mild and moved to moderate-severe OA if any of eight treatment-based criteria were met. Outpatient visits (OP), emergency department visits (ED), inpatient days, and healthcare costs (both all-cause and OA-specific) were compared among pain levels and OA severity levels as frequencies and per-member-per-year rates, using generalized linear regression models adjusting for age, sex, and body mass index, with contrasts of p < 0.05 considered significant.ResultsWe identified 127,656 patients, 92,576 with pain scores. Moderate and severe pain were associated with significantly higher rates of OA-related utilization and costs, and all-cause ED visits and pharmacy costs. Moderate-severe OA patients had significantly higher OA-related utilization and costs, and all-cause OP, ED and pharmacy costs.ConclusionsPain and treatment intensity were both strongly associated with OA-related utilization but not consistently with all-cause utilization. Our results provide promising evidence of better criteria and approaches for predicting disease burden and costs in the future.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40744-022-00448-7.

Immediate Interventions After Surgery to Reduce Readmission for Upper Extremity Infections.

Upper extremity infections (UEIs), commonly caused by intravenous drug use and direct trauma to the hand, can be devastating. Many studies support hand therapy postoperatively to improve outcomes. This population of patients often experience increased returns to the emergency department (ED) for treatment, repeat surgery, poor function, and increased hospital expenditure.This is a 2-phase study to investigate and intervene on the care pathway for patients undergoing surgery for UEI at a single urban university hospital. For the first 6-month phase, all patients with UEI requiring surgery received the standard of care, including written discharge instructions, a scheduled follow-up, and a determination for hand therapy based on evaluation. During the second phase, over the following 6 months, all patients with UEI requiring surgery received an intervention before discharge, in addition to standard of care, including a scripted educational session on the importance of hand therapy by a resident physician, home exercise program instructions, and a referral to hand therapy before discharge. Outcome measures were assessed for 6 months. Outcome measures included follow-up, hand therapy attendance, ED visits for the same complaint, readmissions, and reoperations.Forty-seven patients were in the first control group without intervention and 41 patients were in the second intervention group. Of the control group, 43% attended a follow-up appointment, 2% attended hand therapy, and 45% presented to the ED, resulting in a total of 167 visits. Eleven presented to the ED and were readmitted for complications from surgery, all 11 required a second operation. In the intervention group, 54% attended a follow-up appointment (P = 0.044), more patients attended hand therapy (22% P = 0.013), and 24% presented to the ED (P = 0.047), resulting in 40 ED visits.Seven were readmitted for complications from surgery and 4 required a second operation (P = 0.1). Early, simple intervention and education prove to be an effective method to decrease emergency department burden and healthcare expenditure for treatment of a challenging population. Although additional education and referral to hand therapy utilization do not change operation rates, it decreased returns to the ED, readmissions, and increased follow-up.

Professional quality of life and resilience in emergency department healthcare professionals during COVID‐19 in Hong Kong: A cross‐sectional study

Background:The professional quality of life of healthcare professionals in emergency departments may be compromised during the COVID‐19 pandemic.Objectives:This study aims to examine professional quality of life and resilience as well as their relationships among emergency department healthcare professionals in Hong Kong during the COVID‐19 outbreak.Methods:This study employed a cross‐sectional design. Healthcare professionals (doctors and nurses) working in emergency departments in Hong Kong were recruited via snowball sampling. The Professional Quality of Life Scale, version 5, and the 10‐item Connor‐Davidson Resilience Scale were used to assess their positive (compassion satisfaction) and negative (secondary traumatic stress and burnout) aspects of professional quality of life and self‐reported resilience. Socio‐demographics and work‐related characteristics were also analysed.Results:A total of 106 participants provided valid responses. The results showed an overall moderate level of compassion satisfaction, secondary traumatic stress and burnout among emergency department healthcare professionals. The mean score of the 10‐item Connor‐Davidson Resilience Scale was 23.8. Backward linear regression analyses revealed self‐reported resilience was the only significant predictor of compassion satisfaction (regression coefficient B = 0.875; p &lt; 0.001), secondary traumatic stress (B = −0.294, p &lt; 0.001) and burnout (B = −0.670; p &lt; 0.001), explaining 70.6%, 18.5% and 59.8% of total variance, respectively.Conclusion:Emergency department healthcare professionals in Hong Kong experienced an overall moderate level of professional quality of life during the COVID‐19 outbreak. Those with a higher level of self‐reported resilience had better compassion satisfaction and lower levels of secondary traumatic stress and burnout. The results support the importance of developing interventions that foster resilience among this group of emergency department healthcare professionals to combat COVID‐19.

Predicting Areas with High Concentration of the Long-Term Uninsured and Their Association with Emergency Department Usage by Uninsured Patients in South Carolina.

Background: To predict areas with a high concentration of long-term uninsured (LTU) and Emergency Department (ED) usage by uninsured patients in South Carolina. Methods: American Community Survey data was used to predict the concentration of LTU at the ZIP Code Tabulation Area (ZCTA) level. In a multivariate regression model, the LTU concentration was then modeled to predict ED visits by uninsured patients. ED data came from the restricted South Carolina Patient Encounter data with patients’ billing zip codes. A simulation was conducted to predict changes in the ED visit numbers and rates by uninsured patients if the LTU concentration was reduced to a lower level. Results: Overall, there was a positive relationship between ED visit rates by the uninsured patients and areas with higher concentrations of LTU. Our simulation model predicted that if the LTU concentration for each ZCTA was reduced to the lowest quintile, the ED visit rates by the uninsured would decrease significantly. The greatest reduction in the number of ED visits by the uninsured over a two-year period was for the following primary diagnoses: abdominal pain (15,751 visits), cellulitis and abscess (11,260 visits) and diseases for the teeth and supporting structures (10,525 visits). Conclusions: The provision of primary healthcare services to the LTU could help cut back inappropriate uses of ED resources and healthcare costs.

The effect of N95 respirators on vital parameters, PETCO2, among healthcare providers at the pandemic clinics.

BackgroundWearing face shields and masks, which used to have very limited public use before the COVID-19 outbreak, has been highly recommended by organizations, such as CDC and WHO, during this pandemic period.AimsThe aim of this prospective study is to scrutinize the dynamic changes in vital parameters, change in end tidal CO2 (PETCO2) levels, the relationship of these changes with taking a break, and the subjective complaints caused by respiratory protection, while healthcare providers are performing their duties with the N95 mask.MethodsThe prospective cohort included 54 healthcare workers (doctors, nurses, paramedics) who worked in the respiratory unit of the emergency department (ED) and performed their duties by wearing valved N95 masks and face shields. The vital parameters and PETCO2 levels were measured at 0–4th–5th and 9th hours of the work-shift.ResultsOnly the decrease in diastolic BP between 0 and 9 h was statistically significant (p = 0.038). Besides, mean arterial pressure (MAP) values indicated a significant decrease between 0–9 h and 5–9 h (p = 0.024 and p = 0.049, respectively). In terms of the vital parameters of the subjects working with and without breaks, only PETCO2 levels of those working uninterruptedly increased significantly at the 4th hour in comparison to the beginning-of-shift baseline levels (p = 0.003).ConclusionAlthough the decrease in systolic blood pressure (SBP) and MAP values is assumed to be caused by increased fatigue due to workload and work pace as well as increase in muscle activity, the increase in PETCO2 levels in the ED healthcare staff working with no breaks between 0 and 4 h should be noted in terms of PPE-induced hypoventilation.

Implementation analysis of case management interventions for frequent users of healthcare services: A multiple-case study.

Context. Case management interventions (CMIs) are recognized to improve patients' experience of integrated care, to promote better utilization of healthcare resources, and to reduce emergency department visits, hospitalizations and health care costs. However, contextual factors influencing implementation of CMIs in primary care settings in Canada still need to be studied. Objective. To examine facilitators and barriers influencing implementation planning, engagement of key actors and the start-up phases of a CMI led by nurse case managers for frequent users of healthcare services with chronic diseases and complex care needs. Study design. Qualitative multiple case study design. Setting. Six primary care clinics across four provinces in Canada. Population studied. Frequent users of healthcare services with chronic diseases and complex care needs. Intervention. A CMI led by nurse case managers that included four main components: 1) patient needs assessment; 2) care planning, including an individual services plan (ISP); 3) coordination of services among health and social services partners; 4) self-management support for patients and families. Methods. Data collection: in-depth interviews with nurse case managers (n=10), clinic managers (n=5), and other healthcare professionals (n=5); six focus groups with family physicians (n=20), and other healthcare professionals (n=8); and field notes by research coordinators. Analysis: Mixed descriptive thematic analysis; intra-case histories; systematic comparison among cases by means of a descriptive and interpretative matrix; investigator and patient partners triangulation. Outcome Measures. Factors influencing the implementation of the CMI in primary care settings. Results. Difficulty of access to patient hospital information is a common barrier to all cases, as well as identification and recruitment of patients with the greatest needs of a CMI. Nurse case managers need extra time in the short term, especially when preparing and conducting the ISP. On the other hand, a culture of patient-centredness and collaboration; managerial and clinical leadership and support; and a positive perception of the CMI alongside provider engagement helps to overcome these barriers. Conclusions. This study may help researchers, decision-makers and clinicians plan the implementation of CMIs in primary care settings for frequent users of healthcare services with chronic diseases and complex care needs.