Emergency Department Environment Research Articles

Patterns of Musculoskeletal Disorders among Staff Nurses in the Emergency Department in Saudi Arabia: A Cross-sectional Study

Background: The physically demanding and high-stress environment of Emergency Departments (EDs) significantly contributes to the heightened risk of musculoskeletal disorders (MSDs) among ED nurses. Despite this known association, there is a lack of comprehensive understanding of the prevalence rates and contributing factors within ED settings in Saudi Arabia, necessitating further investigation.Purpose: This study delves into the prevalence and potential predictors of MSDs among nurses in this critical healthcare setting.Methods: A cross-sectional survey was conducted in March 2023 using convenience sampling of 177 ED nurses across 16 public hospitals in Hail, Saudi Arabia. The Nordic Musculoskeletal Questionnaire was employed, with SPSS analyses covering frequency and percentage of pain prevalence via cross-tabulation, and logistic regression to identify risk factors.Results: Over the past year, 68.9% of participants reported lower back pain affecting normal activities in 55.4% of cases. Neck pain was more likely in individuals aged 20-29 and former smokers accounting for 47.6% of the variance (p=0.001). Shorter shifts under 8 hours reduced neck pain risk, whereas a schedule with 50% of night shifts heightened the risk, contributing to 28.4% of the variance (p=0.001). Nurses aged 40-49 and those with significant childcare duties faced higher shoulder pain risk (p=0.024), and adult caregiving duties was linked to upper back pain explaining 40.6% of the variance (p=0.017). No significant links were found for other musculoskeletal pains.Conclusion: The study reveals a significant prevalence of MSDs among the evaluated ED nurses, significantly influenced by specific demographic and work-related factors. Addressing these through ergonomic interventions, optimal scheduling, and wellness programs is crucial for nurse well-being and patient care. Future research should focus on creating holistic wellness programs that support nurses musculoskeletal health.

Academic Detailing as a Health Information Technology Implementation Method: Supporting the Design and Implementation of an Emergency Department-Based Clinical Decision Support Tool to Prevent Future Falls.

Clinical decision support (CDS) tools that incorporate machine learning-derived content have the potential to transform clinical care by augmenting clinicians' expertise. To realize this potential, such tools must be designed to fit the dynamic work systems of the clinicians who use them. We propose the use of academic detailing-personal visits to clinicians by an expert in a specific health IT tool-as a method for both ensuring the correct understanding of that tool and its evidence base and identifying factors influencing the tool's implementation. This study aimed to assess academic detailing as a method for simultaneously ensuring the correct understanding of an emergency department-based CDS tool to prevent future falls and identifying factors impacting clinicians' use of the tool through an analysis of the resultant qualitative data. Previously, our team designed a CDS tool to identify patients aged 65 years and older who are at the highest risk of future falls and prompt an interruptive alert to clinicians, suggesting the patient be referred to a mobility and falls clinic for an evidence-based preventative intervention. We conducted 10-minute academic detailing interviews (n=16) with resident emergency medicine physicians and advanced practice providers who had encountered our CDS tool in practice. We conducted an inductive, team-based content analysis to identify factors that influenced clinicians' use of the CDS tool. The following categories of factors that impacted clinicians' use of the CDS were identified: (1) aspects of the CDS tool's design (2) clinicians' understanding (or misunderstanding) of the CDS or referral process, (3) the busy nature of the emergency department environment, (4) clinicians' perceptions of the patient and their associated fall risk, and (5) the opacity of the referral process. Additionally, clinician education was done to address any misconceptions about the CDS tool or referral process, for example, demonstrating how simple it is to place a referral via the CDS and clarifying which clinic the referral goes to. Our study demonstrates the use of academic detailing for supporting the implementation of health information technologies, allowing us to identify factors that impacted clinicians' use of the CDS while concurrently educating clinicians to ensure the correct understanding of the CDS tool and intervention. Thus, academic detailing can inform both real-time adjustments of a tool's implementation, for example, refinement of the language used to introduce the tool, and larger scale redesign of the CDS tool to better fit the dynamic work environment of clinicians.

Clinical decision-making processes among graduate nurses, specialist nurses and nurse practitioners A collaborative international study.

To explore clinical decision-making by comparing the processes used by three groups of nurses in the emergency departments of three hospitals: in Norway, Finland and Ireland. Clinical decision-making in an emergency department environment is a complex process often occurring in times of crisis. It is an important aspect contributing to the quality of care. However, empirical research is limited regarding the decision-making process in different nursing roles. In accordance with the consolidated criteria for reporting qualitative research, a qualitative and observational study was conducted to explore clinical decision-making by comparing the processes used by three groups of nurses in the emergency departments of three hospitals: in Norway, Finland and Ireland. Six Registered Nurses, six Nurse Specialists and six Nurse Practitioners were observed. A total of 40hours of observation was made at each setting according to a structured observation guideline, followed by clarifying questions. The data material was analysed by means of a qualitative manifest and latent content analysis. Three themes arose: acting in accordance with routines, previous experience and intuition; considering patient experience; and facilitating new alternatives based on critical thinking. The Registered Nurses mainly used the first approach, the Nurse Specialists used the first and the second approaches, and the Nurse Practitioners used all three approaches. The results highlight the differences in decision-making processes between these groups. Nurse Practitioners were the only group that facilitated and evaluated new alternatives using their clinical autonomy, such as stepping up and making independent and collaborative decision-making. The results can be used in countries developing advanced practice nursing education and defining their scope of practice to inform stakeholders.

Healthcare workers’ safety and emotional exhaustion: Exploring the impact of violence and trust in emergency departments

Background In the challenging and often high-stress environment of emergency departments (EDs), healthcare workers (HCWs) frequently encounter a concerning issue of workplace violence (WPV). This study delves into the effects of WPV management and safety on the emotional well-being of ED HCWs. Methods Data collected between 15 March 2023 and 15 May 2023 from 186 HCWs across Obstetrics and Gynecology, Pediatrics, and Adult EDs are analyzed. The survey includes the Safety and Confidence Scale (SCS) to gauge HCWs' perceptions of violence and the Job-Related Emotional Exhaustion Scale (JREES). Results Key findings highlight the prevalence of various forms of WPV in the ED, such as verbal violence (77.4%), threats, and insults (68.8%), with patients and their relatives identified as the primary perpetrators. Male HCWs scored significantly higher on the Violence Management and Safety (VMS) scale compared to their female counterparts. Conclusions In summary, within the demanding ED setting, this study sheds light on the profound impact of WPV on HCWs' emotional exhaustion and their overall sense of safety. It underscores the urgent need to build trust and bolster support mechanisms to alleviate emotional exhaustion among HCWs. Addressing WPV in the ED is paramount for the mental well-being of healthcare workers, particularly when faced with violence from patients and their families.

Assessment of patient’s satisfaction towards Adult Emergency department service at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2021.

Background: The emergency department is the first point of contact for patients to receiveprimary care, and it is considered the first therapeutic unit in the hospital for treatingpatients.Objective:To assess adult Emergency Department service patient satisfaction at theUniversity of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2021.Methods: A cross-sectional study design was employed. A systematic random samplingtechnique was used to select the study participants. The study period was from July 15 toSeptember 15, 2021. Data were collected using a standard Brief Emergency DepartmentPatient Satisfaction Scale. Data was entered in Epidemiological Information version 7.2.1.0and exported to statistical software for Social Science version 20 for further analysis.Descriptive statistics were used to describe the distribution of data.Result: Of the 196 participants approached, 195 completed the questionnaire, with aresponse rate of 99.5%. Of the respondents, 92 (47.2%) with [95% CI: (40.0-54.4)] weresatisfied with the emergency care services provided, whereas 103(52.8%) with [95% CI:(45.6-60.0)]. In the five categories of services, respondents' satisfaction rates with theemergency department staff, emergency department environment, physician care, generalpatient satisfaction, patients’ family satisfaction, and the overall components ofsatisfaction were 50.3%, 42.1%, 48.7%, 57.4%, 65.1%, and 47.2% respectively. The meanwaiting time until seen by a physician in the emergency department was 61 minutes witha standard deviation=75.7 ranging from 2 minutes to 6 hours.Conclusion: According to this study, overall patient satisfaction with adult Emergencydepartment service at the University of Gondar Comprehensive Specialized Hospital waslow. Concerning the five domains of patient satisfaction measurement, the highestsatisfaction level was recorded with the patient's family satisfaction, and the lowestsatisfaction level was documented in the emergency department environment. The meanwaiting time until seen by the doctor was 61 minutes, with a standard deviation of 75.

Investigating the Feasibility of Using a Wearable Device to Measure Physiologic Health Data in Emergency Nurses and Residents: Observational Cohort Study.

Emergency departments play a pivotal role in the US health care system, with high use rates and inherent stress placed on patients, patient care, and clinicians. The impact of the emergency department environment on the health and well-being of emergency residents and nurses can be seen in worsening rates of burnout and cardiovascular health. Research on clinician health has historically been completed outside of clinical areas and not personalized to the individual. The expansion of digital technology, specifically wearable devices, may enhance the ability to understand how health care environments impact clinicians. The primary objective of this pilot study was to assess the feasibility and acceptability of using wearable devices to measure and record physiologic data from emergency nurses and resident physicians. Understanding strategies that are accepted and used by clinicians is critical prior to launching larger investigations aimed at improving outcomes. This was a longitudinal pilot study conducted at an academic, urban, level 1 trauma center. A total of 20 participants, including emergency medicine resident physicians and nurses, were equipped with a wearable device (WHOOP band) and access to a mobile health platform for 6 weeks. Baseline surveys assessed burnout, mental health, and expectations of the device and experience. Participants provided open-ended feedback on the device and platform, contributing to the assessment of acceptance, adoption, and use of the wearable device. Secondary measures explored early signs and variations in heart rate variability, sleep, recovery, burnout, and mental health assessments. Of the 20 participants, 10 consistently used the wearable device. Feedback highlighted varying experiences with the device, with a preference for more common wearables like the Apple Watch or Fitbit. Resident physicians demonstrated higher engagement with the device and platform as compared with nurses. Baseline mental health assessments indicated mild anxiety and depressive symptoms among participants. The Professional Fulfillment Index revealed low professional fulfillment, moderate workplace exhaustion, and interpersonal disengagement. This pilot study underscores the potential of wearable devices in monitoring emergency clinicians' physiologic data but reveals challenges related to device preferences and engagement. The key takeaway is the necessity to optimize device and platform design for clinician use. Larger, randomized trials are recommended to further explore and refine strategies for leveraging wearable technology to support the well-being of the emergency workforce.

Experiences of delivering and receiving mental healthcare in the acute hospital setting: a qualitative study

BackgroundRecent investment in UK liaison psychiatry services has focused on expanding provision for acute and emergency referrals. Little is known about the experiences of users and providers of these services. The aim of this study was to explore the experiences of users of acute liaison mental health services (LMHS) and those of NHS staff working within LMHS or referring to LMHS. A secondary aim was to explore the potential impact of a one-hour service access target on service delivery.MethodsCross-sectional qualitative study. Individual interviews were audio-recorded, transcribed verbatim and interpreted using framework analysis.ResultsService users reported mixed experiences of LMHS, with some reporting positive experiences and some reporting poor care. Most service users described the emergency department (ED) environment as extremely stressful and wished to be seen as quickly as possible. Staff described positive benefits of the one-hour access target but identified unintended consequences and trade-offs that affected other parts of the liaison service.ConclusionsThe assessment and treatment of people who attend ED with mental health problems needs to improve and particular attention should be given to the stressful nature of the ED environment for those who are extremely agitated or distressed.

An exploration of person-centredness among emergency department physiotherapists: a mixed methods study

Purpose There is a growing number of primary contact physiotherapists based in United Kingdom emergency departments (ED) who are expected to deliver person-centred practices. Perceptions of physiotherapists working in these high-pressure environments on person-centredness are currently unknown. A mixed methods exploration of person-centredness among ED physiotherapists targeted this knowledge gap to inform future clinical practice. Methods Online survey and semi-structured interviews followed a convergent mixed methods design with sequential explanatory features. Data sets were analysed separately using descriptive statistics and thematic analysis, respectively, before merged analysis using joint display. Results Twenty-six surveys and 11 in-depth interviews were completed. The three overarching themes of ED patients, ED physiotherapists, and ED environment were generated. Themes were integrated and analysed alongside quantitative survey findings. This produced three novel contributions that further our understanding of person-centred practices among ED physiotherapists. Conclusion ED physiotherapists were mindful of an apparent, yet unspoken struggle between the competing philosophies of biomedicine and person-centredness. The results here support entering a patient’s world as a person-centred approach to help navigate the line between what an ED attender wants and the clinical need of their visit.

A qualitative study of perceived barriers and facilitators to point-of-care ultrasound use among Veterans Affairs Emergency Department providers.

Consistent point-of-care ultrasound (POCUS) use and retention is difficult to achieve, with prior studies citing a lack of provider training, credentialed ultrasound users, and image review as contributing factors. We aimed to assess user feedback on a POCUS implementation intervention by identifying and characterizing the perceived barriers and facilitators at a single Veterans Affairs (VA) hospital using the consolidated framework for implementation research (CFIR). We implemented a co-designed multifaceted training intervention at a VA emergency department (ED) to enhance POCUS usability and sustainability from November 2021-October 2022. We performed semi-structured interviews with 13 attending physicians and 1 Advanced Practice Provider (average of 15 years of clinical practice) in August-October 2022. Interviews were audio-recorded, transcribed, and double-coded using inductive content analysis and mapped to the CFIR, using deductive coding strategies. Through inductive analysis, five major themes emerged: 1) POCUS workflow convenience and efficiency, 2) ED environment and resources, 3) perceptions of high clinical utility of POCUS, 4) perceptions of high educational utility of POCUS, and 5) peer influences, feedback, and teaching. Within these major themes, POCUS facilitator subthemes include: machine availability, use in resident teaching, use in ED procedures, hands-on group training, colleagues' contagiousness and enthusiasm, and support from ultrasound faculty, ED, and hospital leadership. POCUS barrier subthemes were: time constraints, alternative radiology imaging availability, cumbersome steps for image acquisition and documentation/storage, and limited POCUS knowledge and skills comfort. Additional needs identified through CFIR mapping (archiving software, image review process, and faculty credentialing), require development locally to strengthen provider skills and reduce duplicated radiology studies. Our model is a reproducible clinical tool to evaluate barriers and facilitators to POCUS program implementation at any site. Future work should tailor POCUS education to individuals, use momentum from positive peer feedback including "ED clinical champions", and integrate ED/hospital leadership support for program sustainability.

Frailty assessment tools in the emergency department: A geriatric emergency department guidelines 2.0 scoping review.

Given the aging population and growing burden of frailty, we conducted this scoping review to describe the available literature regarding the use and impact of frailty assessment tools in the assessment and care of emergency department (ED) patients older than 60 years. A search was made of the available literature using the Covidence system using various search terms. Inclusion criteria comprised peer-reviewed literature focusing on frailty screening tools used for a geriatric population (60+ years of age) presenting to EDs. An additional search of PubMed, EBSCO, and CINAHL for articles published in the last 5 years was conducted toward the end of the review process (January 2023) to search specifically for literature describing interventions for frailty, yielding additional articles for review. Exclusion criteria comprised articles focusing on an age category other than geriatric and care environments outside the emergency care setting. A total of 135 articles were screened for inclusion and 48 duplicates were removed. Of the 87 remaining articles, 20 were deemed irrelevant, leaving 67 articles for full-text review. Twenty-eight were excluded for not meeting inclusion criteria, leaving 39 full-text studies. Use of frailty screening tools were reported in the triage, care, and discharge decision-making phases of the ED care trajectory, with varying reports of usefulness for clinical decision-making. The literature reports tools, scales, and instruments for identifying frailty in older patients at ED triage; multiple frailty scores or tools exist with varying levels of utilization. Interventions for frailty directed at the ED environment were scant. Further research is needed to determine the usefulness of frailty identification in the context of emergency care, the effects of care delivery interventions or educational initiatives for front-line medical professionalson patient-oriented outcomes, and to ensure these initiatives are acceptable for patients.

Maintaining a safe environment in emergency department waiting rooms.

Increasing demand, overcrowding and insufficient resources have led to situations where patient care is delivered in emergency department (ED) waiting rooms. For nurses undertaking triage in the ED waiting room, overcrowding is challenging, particularly in terms of assessing patients in a timely fashion, monitoring patients for clinical deterioration and ordering investigations. Additionally, long waiting times and a lack of information can lead to communication breakdowns with patients and, at times, patient confrontations with ED staff. This article explores the effects of the busy environment in ED waiting rooms on patients and staff such as triage nurses and waiting room nurses.

GridlockED as an Intervention for Nurses (GAAIN) Study.

GridlockED (The Game Crafter, LLC) is a serious game that was developed to teach challenges that face nursing and medical professionals in the emergency department (ED). However, few studies have explored nurses' perceptions of the utility, fidelity, acceptability, and applicability of the serious game modality. This study examined how ED nurses view GridlockED as a continuing education platform. This single-center observational study explored how nurses engage with and respond to Grid-lockED. The convenience sample included participants recruited from a local continuing nursing education day. Participants completed a presurvey, engaged in a full game play session with the GridlockED game for approximately 45 minutes, and immediately completed a post-game play survey. Of the 48 participants (11 male, 37 female; 44 of 48 were RNs), most (91%) agreed that the workflow reflected in the game was equivalent to the flow in a typical ED. Almost all (96%) found the cases in the game reflective of real ED patients, and most (92%) found the game a useful educational tool to prepare new nurses to transition into the ED environment. The GridlockED game shows potential as a serious game to support nursing education, particularly for new ED nurse orientation and transition to ED practice. [J Contin Educ Nurs. 2024;55(5):231-238.].

Hospital health care workers’ use of facial protective equipment before the COVID-19 pandemic, implications for future policy

Prepandemic routine use of facial (respiratory and eye) protective equipment (FPE) by health care workers was suboptimal. Understanding factors affecting routine use would facilitate escalation to high level use during infectious disease emergencies. This study explored health care workers FPE-related knowledge, attitudes and behaviors. Mixed methods were used in a respiratory ward and adult and pediatric emergency departments (EDs), prior to the COVID-19 pandemic. Study design and thematic analysis were based on the theoretical domains framework. Emergent themes were categorized, using the COM-B behavior model, into capability(C), opportunity(O) and motivation(M), which influence behavior(B). 22 emergent themes, representing factors influencing FPE use, were mapped to theoretical domains framework domains. Personal experience and departmental cultures influenced motivation. Compared with respiratory ward staff, ED clinicians were less knowledgeable about FPE; the unique ED environment and culture inhibited opportunities and motivation for FPE use. Eye protection was infrequently used. Optimal FPE use is challenged by ED care models and settings. Changes are needed to translate pandemic-related improvements into routine care of other respiratory infections. This study identified key determinants of FPE behavior. A review of context-specific FPE guidance for ED by infection prevention and control professionals would help to promote practicable, sustainable compliance.

Abstract 18827: Emergency Department Threat Perceptions and PTSD Symptoms After Suspected Stroke

Introduction: Stroke is a leading cause of death, physical, and psychological disability in the United States. One in four stroke survivors develop significant PTSD symptoms (PTSS), which can influence disease outcomes. It is important to identify factors that increase early psychological distress and subsequent PTSS development, such as threat perceptions in the emergency department (ED). Understanding the relationship between ED threat and PTSS may help identify areas for improving early stroke care. The purpose of this study was to determine whether ED threat perceptions influence PTSS development at 1-, 6- and 12-months after suspected stroke. Methods: The sample consisted of patients (n = 203, 48% female, 59.4 ± 15.5 years) who presented to the ED of an academic medical center for suspected stroke. ED threat was assessed in-hospital using the ED Threat Perceptions questionnaire, and PTSS were assessed at 1-, 6- and 12- months post-stroke using the PCL-5 tool. Linear regression was used to assess the association between ED threat and PTSD symptoms, adjusting for demographics, depression, chronic disease severity (Charlson index), and stroke severity (NIHSS). Results: In unadjusted analyses, ED threat perceptions were associated with higher PTSS at 1- (β=0.42, 95% CI [0.16-0.68] p=0.002), 6- (β=0.32, 95% CI [0.07-0.58], p=0.013), and 12-mo (β=0.44, 95% CI [0.15-0.72], p=0.003), independent of demographics, stroke severity, and depressive symptoms when expressed continuously. In nested models, addition of ED threat perceptions to a model including demographics and stroke severity significantly improved the model (Δ-2 log likelihood = 7.15, df=1; p=0.007), indicating independent effects in the association of ED threat perceptions with PTSD symptoms beyond stroke severity. Conclusions: ED threat perceptions were associated with higher PTSS at 1-, 6-, and 12-months after suspected stroke even after accounting for clinician-measured stroke severity. This suggests that early threat perceptions contribute to PTSD risk above and beyond the physical impact of the event. These results indicate the importance of the ED environment and provide a target for future interventions to minimize the development of PTSD symptoms post-stroke.

An Initiative to Stop Antibiotics Prescribed for Urinary Symptoms When Urine Culture Is Negative.

Urinary symptoms pose frequent diagnostic and management challenges in the emergency department (ED). In our regional health system, we identified the problem of patients started on antibiotics for urinary symptoms in the ED without a process for eventual review or discontinuation if urine culture (UC) later resulted as negative. To address this gap, we implemented a pharmacist-driven follow-up process to discontinue antibiotics after a negative UC. After project implementation, cases reviewed by a pharmacist increased from 0% to 96.7%. Patients contacted to discontinue antibiotics increased from 0% to 40% postintervention. This process improvement is now shared across five rural departments. Our results have broad applicability in any ED environment.

Reducing blood culture contamination in adult patients with cancer presenting to the emergency department.

393 Background: Fever and leukocytosis are among the most common complaints for cancer patients presenting to the Emergency Department (ED). Most patients admitted for fever or infection come through the ED, which is therefore a primary site for blood culture collection. Contamination of these cultures can increase the clinical and financial burdens for the patients, the medical team, and laboratory staff. It may lead to unnecessary removal of central venous access devices or delay of critical therapy or procedures. At our institution, the contamination rate of blood cultures drawn in the ED was more than twice that of the remainder of the hospital (2.8 versus 0.8), prompting this quality improvement project. Unlike on hospital floors, nurses rather than phlebotomists draw the majority of blood cultures due to the urgency of managing suspected sepsis. Our aim was to decrease the contamination rate in the ED by 20 percent after the first PDSA cycle, and ultimately bring it on par with the remainder of the hospital. Methods: First, we compared contamination rates of the ED versus other hospital floors and outpatient centers over three months. We then evaluated the contamination rates of ED nurses versus phlebotomists and peripheral versus central line blood draws. Process mapping and fishbone analysis helped identify practices contributing to higher contamination rates. Key drivers of these practices were diagrammed, and then potential interventions were ranked on a prioritization matrix. Results: We identified the use of alcohol rather than chlorhexidine swabs for peripheral disinfection and inconsistent techniques of blood draw by nurses as the critical contributors to the increased contamination rates in the ED. Our intervention was to create premade blood culture kits that promoted the use of chlorhexidine swabs by ensuring availability and easy access in the fast-paced ED environment. Ten cc syringes in the kits encouraged the withdrawal of adequate blood samples in compliance with the 7-10 cc guideline. Designated nursing team leaders checked off the ED nurses at the bedside, implementing education and adherence to the use of blood culture collection kits. The average number of blood cultures in the emergency department was 1,400. Following two months of these interventions, there was a reduction in blood culture contamination from 2.46 percent to 1.89 percent. Conclusions: A guideline driven, standardized blood culture collection process adhered to by ED nurses is vital to reducing blood culture contamination. Chlorhexidine is necessary to maintain the lowest contamination rates. Readily available and premade blood culture kits improve compliance with the materials and techniques associated with best practices.

How Clinicians Decide? Exploring Complexity of Antibiotic Prescribing in Emergency Departments Using Video-Reflexive Ethnography.

Antibiotic overprescribing is a global issue that significantly contributes to increased antimicrobial resistance. Strengthening antimicrobial prescribing practices should be considered a priority. The emergency department (ED) represents a setting where antibiotics are frequently prescribed, but the determinants that influence prescribing choices are complex and multifaceted. We conducted an exploratory qualitative study to investigate the contextual factors that influence antibiotic prescribing choices among clinicians in the ED. The study employed video-reflexive ethnography (VRE) to capture prospective clinical decision-making in situated practice. Data collection involved fieldwork observations, video observations, and delivery of facilitated group reflexive sessions, where clinicians viewed a selection of recorded video snippets relating to antibiotic prescribing. Study was conducted across two EDs within the same health service in Australia. A total of 29 clinical conversations focusing on antibiotic prescribing were recorded. Additionally, 34 clinicians participated in group reflexive sessions. Thematic analysis from the transcribed data yielded four themes: 'importance of clinical judgment', 'usability of prescribing guidelines', 'managing patient expectations', and 'context-dependent disruptions'. Our findings provide insights into the challenges faced by clinicians in navigating complex ED environment, utilising electronic decision-support tools and engaging in discussions about patient treatments with senior clinicians. The findings also indicate that VRE is useful in visualising full complexity of the ED setting, and in initiating meaningful discussions among clinical teams. Integrating the use of VRE in everyday clinical settings can potentially facilitate the implementation of pragmatic solutions for delivering effective antibiotic stewardship practices.

A Lethal Combination of Delirium and Overcrowding in the Emergency Department.

Delirium is a common public health concern that significantly impacts older patients admitted to the Emergency Department (ED). This condition is linked to adverse outcomes such as reduced long-term functionality, higher mortality rates, extended hospital stays, and increased medical costs. The identification of risk factors is crucial for the early recognition and management of delirium in ED patients. Aging, cognitive decline, polypharmacy, and sensory impairment are some of the most common general risk factors described in the literature. Although validated delirium assessment tools already exist, they are not practical for the fast-paced ED environment because of their extended evaluation period or specialized training request. Moreover, clear guidance is needed to select the most suitable tool for detecting delirium, balancing between the accuracy and the swiftness required in an overcrowded, high-stress, and understaffed healthcare setting. This narrative review aims to analyze the updated literature on delirium risk factors in older ED patients and focuses on the methods for better screening, managing, and treating this condition in the ED.

Older patients referred for geriatric consultation in the emergency department: characteristics and healthcare utilization

BackgroundComprehensive geriatric assessment (CGA) is difficult to perform in the emergency department (ED) environment and performance of screening tools in identifying vulnerable older ED patients who are best candidates for a geriatric consultation remain questionable.AimTo determine the characteristics of older patients referred for a geriatric consultation by ED staff and to investigate these patients’ subsequent healthcare utilization.MethodsSecondary analysis of data previously collected for a prospective observational study of patients aged 75 + years visiting the ED of an academic hospital in Switzerland over four months (Michalski-Monnerat et al., J Am Geriatr Soc 68(12):2914–20, 2020). Socio-demographic, health, functional (basic activities of daily living; BADL), cognitive, and affective status data were collected at admission by a research nurse using a standardized brief geriatric assessment. Information on geriatric consultations, hospitalization, discharge destination, and 30-day readmission were retrieved from hospital database. Bivariable and multivariable analyses were performed using this data set collected previously.ResultsThirty-two (15.8%) of the 202 enrolled patients were referred for a geriatric consultation. Compared to the others, they were older (84.9 ± 5.4 vs 82.9 ± 5.4 years, p = .03), more impaired in BADL (4.8 ± 1.6 vs 5.5 ± 1.0, p = .01), with more comorbid conditions (5.3 ± 1.5 vs 4.5 ± 1.9, p = .03), more frequently admitted after a fall (43.7% vs 19.4%, p = .01), and hospitalized over the previous 6-month period (53.1% vs 30.6%, p = .02). Multivariable analyses that adjusted for variables significantly associated with outcomes in bivariable analysis found that being admitted after a fall (AdjOR 4.0, 95%CI 1.7–9.4, p < .01) and previously hospitalized (AdjOR 2.7, 95% CI 1.2–6.2, p = .02) remained associated with increased odds of consultation, whereas the inverse association with BADL performance remained (AdjOR 0.7, 95%CI 0.5–0.9, p = .01).Patients referred for geriatric consultation had higher odds of hospitalization (84.4% vs 49.4%; AdjOR 5.9, 95%CI 2.1–16.8, p < .01), but similar odds of home discharge when admitted, and of 30-day readmission.ConclusionAbout one in six older ED patients were referred for a geriatric consultation who appeared to be those most vulnerable, as suggested by their increased hospitalization rate. Alternative strategies are needed to enhance access to geriatric consultation in the ED.

Expanding Role of Dual-Energy CT for Genitourinary Tract Assessment in the Emergency Department, From the AJR Special Series on Emergency Radiology.

Among explored applications of dual-energy CT (DECT) in the abdomen and pelvis, the genitourinary (GU) tract represents an area where accumulated evidence has established the role of DECT to provide useful information that may change management. This review discusses established applications of DECT for GU tract assessment in the emergency department (ED) setting, including characterization of renal stones, evaluation of traumatic injuries and hemorrhage, and characterization of incidental renal and adrenal findings. Use of DECT for such applications can reduce the need for additional multiphase CT or MRI examinations and reduce follow-up imaging recommendations. Emerging applications are also highlighted, including use of low-energy virtual monoenergetic images (VMIs) to improve image quality and potentially reduce contrast media doses and use of high-energy VMIs to mitigate renal mass pseudoenhancement. Finally, implementation of DECT into busy ED radiology practices is presented, weighing the trade-off of additional image acquisition, processing time, and interpretation time against potential additional useful clinical information. Automatic generation of DECT-derived images with direct PACS transfer can facilitate radiologists' adoption of DECT in busy ED environments and minimize impact on interpretation times. Using the described approaches, radiologists can apply DECT technology to improve the quality and efficiency of care in the ED.