Emergency Department Registrar Research Articles

124 Administration of Fascia Iliaca Block to Patients Who Have Suffered a Neck of Femur Fracture

Abstract Aim Hip fractures are the most common serious injury affecting elderly people and are associated with a total cost to the health and social services over £1 billion per year. This injury takes approximately 1% of the NHS budget. Furthermore current 30-day mortality rate is 6.5% so has serious implications for patients. NICE recommend that nerve blocks should be used to help perioperative pain and limit the use of opioids. We audited our use of analgesia, especially fascia iliaca blocks (FIB), to see whether training could improve the management of these patients. Method We conducted a retrospective cohort study in which a total of 188 patients, who had sustained a hip fracture, were audited during 4 discrete periods between March 2021-July 2021. The primary outcome assessed was whether they had received a FIB preoperatively. Improvements were implemented between audit cycles to see if they achieved desired outcomes. Results Implementation of good quality teaching to orthopaedic juniors and emergency department registrars and juniors successfully improved rate of FIB from 2.5% to 47%. The rate of FIB was not sustained over time and declined to 22%. Factors thought to influence this decline included regular rotation of junior doctors and increasing time pressures in the emergency department. Conclusions Our data suggested that low rates of FIB resulted in high opioid use in the emergency department. Allocated teaching sessions on administration of FIB were a successful way to improve use of blocks and reduce opioid use.

Simulation-based medical education can be used to improve the mental health competency of emergency physicians.

We explored the feasibility of developing, running and evaluating a simulation-based medical education (SBME) workshop to improve the knowledge, skills and attitudes of emergency department (ED) doctors when called on to assess patients in psychiatric crisis. We designed a four-hour workshop incorporating SBME and a blend of pre-reading, short didactic elements and multiple-choice questions (MCQs). Emergency department nurses (operating as SBME faculty) used prepared scripts to portray patients presenting in psychiatric crisis. They were interviewed in front of, and by, ED doctors. We collected structured course evaluations, Debriefing Assessment for Simulation in Healthcare (DASH) scores, and pre- and post-course MCQs. The pilot workshop was delivered to 12 ED registrars using only existing resources of the Psychiatry and Emergency Departments. Participants highly valued both 'level of appropriateness' (Likert rating μ = 4.8/5.0) and 'overall usefulness' (μ = 4.7/5.0) of the programme. They reported an improved understanding of the mental state and of relevant legal issues and rated the debriefings highly (participant DASH rating: n = 193; score μ = 6.3/7.0). Median MCQ scores improved non-significantly pre- and post-course (7.5/12 vs 10/12, p = 0.261). An SBME workshop with these aims could be delivered and evaluated using the existing resources of the Psychiatry and Emergency Departments.

Emergency department revisits within 72 hours to a tertiary care referral hospital in South India

Introduction: Emergency department (ED) revisits are an important indication of health-care quality provided by a hospital. In the West, ED revisits rate range from 2.9% to 4.9%. However, data from India are lacking, and hence. this study was done. Methodology: This retrospective observational study was done in a 45-bedded ED of a teaching hospital in South India. All the patients who revisited the ED within 72 hours over a 1-year period were considered. The revisit was categorized as unavoidable if the patient was diagnosed correctly and managed appropriately during the first visit or if the patient presented with an unrelated illness within 72 hours. Results: The ED revisit rate was 0.8% (549/65,900). The monthly revisit rates ranged from 0.50% to 1.91%. About 57.9% were initially categorized as priority 3, 33.9% as priority 2, and 8.3% as priority 1 patients. During the revisit, 41.6% were priority 3 patients, 44.3% were priority 2 patients, and 13.7% were priority 1 patients. Gastrointestinal symptoms such as abdominal pain, vomiting, diarrhea, and constipation were the most common initial presenting complaints seen in 36% of the patients followed by fever (15.3%). A majority (75%) of these patients were initially discharged by the ED registrars. More than half (55.2%) of the revisits were avoidable. During the second visit, 58% were discharged in a stable condition, 31.7% were admitted to the hospital, and 4.8% died in the ED. Conclusion: ED revisits are associated with significant distress to the patients and more than half of them can be avoided.

Emergency department registrar transformation: It is not all about the medicine.

Emergency department registrar transformation: It is not all about the medicine.

Assessment of Patient-Centered Approaches to Collect Sexual Orientation and Gender Identity Information in the Emergency Department

Health care and government organizations call for routine collection of sexual orientation and gender identity (SOGI) information in the clinical setting, yet patient preferences for collection methods remain unknown. To assess of the optimal patient-centered approach for SOGI collection in the emergency department (ED) setting. This matched cohort study (Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity [EQUALITY] Study) of 4 EDs on the east coast of the United States sequentially tested 2 different SOGI collection approaches between February 2016 and March 2017. Multivariable ordered logistic regression was used to assess whether either SOGI collection method was associated with higher patient satisfaction with their ED experience. Eligible adults older than 18 years who identified as a sexual or gender minority (SGM) were enrolled and then matched 1 to 1 by age (aged ≥5 years) and illness severity (Emergency Severity Index score ±1) to patients who identified as heterosexual and cisgender (non-SGM), and to patients whose SOGI information was missing (blank field). Patients who identified as SGM, non-SGM, or had a blank field were invited to complete surveys about their ED visit. Data analysis was conducted from April 2017 to November 2017. Two SOGI collection approaches were tested: nurse verbal collection during the clinical encounter vs nonverbal collection during patient registration. The ED physicians, physician assistants, nurses, and registrars received education and training on sexual or gender minority health disparities and terminology prior to and throughout the intervention period. A detailed survey, developed with input of a stakeholder advisory board, which included a modified Communication Climate Assessment Toolkit score and additional patient satisfaction measures. A total of 540 enrolled patients were analyzed; the mean age was 36.4 years and 66.5% of those who identified their gender were female. Sexual or gender minority patients had significantly better Communication Climate Assessment Toolkit scores with nonverbal registrar form collection compared with nurse verbal collection (mean [SD], 95.6 [11.9] vs 89.5 [20.5]; P = .03). No significant differences between the 2 approaches were found among non-SGM patients (mean [SD], 91.8 [18.9] vs 93.2 [13.6]; P = .59) or those with a blank field (92.7 [15.9] vs 93.6 [14.7]; P = .70). After adjusting for age, race, illness severity, and site, SGM patients had 2.57 (95% CI, 1.13-5.82) increased odds of a better Communication Climate Assessment Toolkit score category during form collection compared with verbal collection. Sexual or gender minority patients reported greater comfort and improved communication when SOGI was collected via nonverbal self-report. Registrar form collection was the optimal patient-centered method for collecting SOGI information in the ED.

Experience of a tutor centric model for sonography training of emergency department registrars in an Australian urban emergency department 2009-2012.

Purpose: To assess the impact of a regular sonographer proctored training program for emergency medicine trainees in the use of Emergency Department bedside ultrasound Methods: Emergency Department (ED) Registrars in the Swan District Hospital ED were provided with proctored instruction in bedside ultrasound in performance of extended focused assessment sonography in trauma (eFAST) and abdominal aortic aneurysm (AAA) detection. Training was conducted by credentialed sonographers for individual trainees in a 1:1 or 1:2 setting for 1 hour on a weekly basis. Registrars who trained in the Department between Jan 2009 to Dec 2012 were invited to participate in a survey conducted between June–August 2013 designed to assess the impact of training on their confidence and use of bedside sonography. Results: Registrars reported increased perception of their skill level in AAA and eFAST post‐training. High levels of confidence in their ability to adjust machine settings for image optimisation, recognition of free fluid in the abdomen and ability to recognise an AAA were also reported. The participants who completed at least 10 hours of training and at least 20 scans showed significantly greater improvement in their perception of skill and confidence levels than those with less time. Registrars reported training was of significant benefit, improving their confidence in obtaining good quality images and their understanding of the equipment, which contributed to them obtaining accreditation. Benefits were ongoing and 50% of participants reported using ultrasound in clinical practice at least 3 times per week and a further 30% at least weekly after leaving ED. Conclusion: Proctored training in the clinical context for ED registrars resulted in improvement in skills, confidence and willingness to maintain skills through practice in the clinical context over the long‐term.

Computed tomography in acute abdominal pain: an overused investigation?

The use of computed tomography (CT) for the evaluation of patients presenting to the emergency department (ED) with acute abdominal pain has increased. We set out to investigate its effectiveness. A prospective study conducted at a tertiary referral centre between August and September 2012, utilizing a questionnaire completed by the ordering doctors. Patients with acute abdominal pain who underwent an abdominal CT scan were included in the study, excluding those with a history of recent abdominal trauma or abdominal, pelvic, groin or scrotal surgery. Of the 260 patients undergoing an abdominal CT scan for the investigation of acute abdominal pain, 60 had questionnaires completed. Fifty-seven per cent of abdominal CT scans were ordered by an ED registrar or consultant. Sixty-five per cent of patients were not discussed with the surgical team prior to ED staff ordering the CT scan. 'To confirm clinical suspicion' and 'to rule out sinister aetiology' were the most important reasons for ordering an abdominal CT. In 54% of cases, there was a change in primary diagnosis post CT scan and in 50% of patients, a change in disposition. Diagnostic confidence in the primary diagnosis did not change significantly post-CT scan. There was no significant difference between which group ordered a CT scan and the probability that the scan showed nil acute pathology. Abdominal CT scans frequently changed the clinical diagnosis and patient disposition. Twenty-three per cent of patients had no identifiable cause on CT scan for their acute abdominal pain.

A pain in the neck

A 75-year-old man presented to the emergency department with dizziness. He had been in good health until 5 weeks before admission, when his ladder slipped while he was cutting branches...

PB6 Antimicrobial stewardship education and effect on prescribing in the emergency department of an irish teaching hospital

Objectives and BackgroundCareful selection of antimicrobials is imperative in preventing adverse events and resistant organisms. Guidelines and their availability encourage appropriate prescribing. In our centre, the microbiology team present bi-annually...

Training and competency in rapid sequence intubation: the perspective from a Scottish teaching hospital emergency department

BackgroundRapid sequence intubation (RSI) is an established core competency for emergency medicine trainees. The training and experience required to achieve competency is unclear.AimsTo illustrate the RSI training and experience attained...

Prospective evaluation of a two-tiered trauma activation protocol in an Australian major trauma referral hospital

Objective To evaluate a two-tiered trauma activation protocol in a major trauma referral hospital in Australia. Methods A prospective study performed over a 12-month period of all consecutive trauma activations in a major trauma referral hospital. The triage tool assigned patients into two tiers of trauma activation. The full trauma activation was initiated where physiological or anatomical criteria were present. These patients were assessed by a multispecialty trauma team. A consult trauma activation was initiated where only mechanism of injury criteria was present. These patients were assessed by the Emergency Department Registrar and Surgical Registrar. The primary endpoint was major trauma outcome defined as either injury severity score (ISS) greater than 15, requirement for High Dependency Unit or Intensive Care Unit (HDU/ICU) admission, need for urgent operative intervention, or in hospital mortality. Results Of 1144 trauma activations, 468 (41%) were full trauma and 676 (59%) were consult trauma activations. The full trauma activation group had a significantly higher proportion of the major trauma outcome (34% vs. 5%, p < 0.01) and all 18 patients (2%) who died were in the full trauma activation group. Sensitivity of the triage tool for the major trauma outcome was 83%, specificity was 68%, undertriage was 3% and overtriage was 27%. Conclusions The two-tiered trauma activation protocol is effective in identifying patients with major trauma from those with minor trauma. There were no deaths in undertriaged patients.