Emergency Department Staff Members Research Articles

Coordinating a Team Response to Behavioral Emergencies in the Emergency Department: A Simulation-Enhanced Interprofessional Curriculum.

IntroductionWhile treating potentially violent patients in the emergency department (ED), both patients and staff may be subject to unintentional injury. Emergency healthcare providers are at the greatest risk of experiencing physical and verbal assault from patients. Preliminary studies have shown that a team-based approach with targeted staff training has significant positive outcomes in mitigating violence in healthcare settings. Staff attitudes toward patient aggression have also been linked to workplace safety, but current literature suggests that providers experience fear and anxiety while caring for potentially violent patients. The objectives of the study were (1) to develop an interprofessional curriculum focusing on improving teamwork and staff attitudes toward patient violence using simulation-enhanced education for ED staff, and (2) to assess attitudes towards patient aggression both at pre- and post-curriculum implementation stages using a survey-based study design.MethodsFormal roles and responsibilities for each member of the care team, including positioning during restraint placement, were predefined in conjunction with ED leadership. Emergency medicine residents, nurses and hospital police officers were assigned to interprofessional teams. The curriculum started with an introductory lecture discussing de-escalation techniques and restraint placement as well as core tenets of interprofessional collaboration. Next, we conducted two simulation scenarios using standardized participants (SPs) and structured debriefing. The study consisted of a survey-based design comparing pre- and post-intervention responses via a paired Student t-test to assess changes in staff attitudes. We used the validated Management of Aggression and Violence Attitude Scale (MAVAS) consisting of 30 Likert-scale questions grouped into four themed constructs.ResultsOne hundred sixty-two ED staff members completed the course with >95% staff participation, generating a total of 106 paired surveys. Constructs for internal/biomedical factors, external/staff factors and situational/interactional perspectives on patient aggression significantly improved (p<0.0001, p<0.002, p<0.0001 respectively). Staff attitudes toward management of patient aggression did not significantly change (p=0.542). Multiple quality improvement initiatives were successfully implemented, including the creation of an interprofessional crisis management alert and response protocol. Staff members described appreciation for our simulation-based curriculum and welcomed the interaction with SPs during their training.ConclusionA structured simulation-enhanced interprofessional intervention was successful in improving multiple facets of ED staff attitudes toward behavioral emergency care.

Visite de services d’urgences en Californie. Rapport d’un groupe d’urgentistes français

Improving the quality of care in Emergency Departments (ED) is a priority. Benchmarking and qualitative methods have been applied as health quality improvement tools. Our goal is to describe the application of these methods. University EDs located in California were visited. Semi-structured questionnaires were used for interviews with ED managers and staff members, on the organizational aspects, including triage and care pathways; human resources; equipment; quality and performance indicators; transverse links between ED and hospital wards; bed management; and patients-centered care. District health officials were also interviewed. Three adult and two pediatric EDs were visited; 56 ED leaders and staff members were interviewed. We have identified many innovative organizational and management aspects such as the role of nurse-practitioners, the importance of fast-track in the organization of ED, and the critical care area project. The architecture, organization, and care projects are at the service of the ED quality project. Security has emerged as a priority in reducing waiting times. Bed management and ED–hospital culture reflect a growing priority and provided the through-ED pathway. Visit to the EDs abroad as a part of structured visits by managerial and scientific methods allows us to find new quality development paths of care and to improve the working conditions of our ED teams.

Aged care residents in the emergency department: the experiences of relatives.

The aim of this study was to investigate the experiences of relatives who had a family member in an aged care facility subsequently transferred to an emergency department. The provision of timely and relevant patient information is vital for assessment and management of older patients presenting to the emergency department from aged care facilities. Older people are commonly accompanied by relatives who are an important resource for emergency department staff, providing medical information and assisting with treatment decisions. Investigating the experiences of relatives may provide key information to enable improvements in the delivery of emergency department care. This study used a descriptive qualitative design. Semi-structured interviews were undertaken with 24 relatives of residents who were transferred from an aged care facility to an emergency department in Victoria, Australia in the previous three years. Inductive content analysis was used to analyse the transcripts. Relatives reflected on four main themes following their emergency department visit: The need for clear communication; The role of relatives in emergency department care; How older people are perceived in the health care system and an Ability to provide specialised care. Many people link their emergency department experience to the quality of communication with emergency department staff, and participants in this study felt satisfied with their visit when they were included in discussions about treatment, and their role was recognised by staff members. In contrast, participants were dissatisfied with the care provided to their family member when staff members failed to communicate with them, or recognise their role in the care of the family member. The findings of this study emphasise the importance of effective communication between emergency department staff and family members, in relation to treatment and end-of-life care.

Evaluation of an ultra-brief psycho-education and referral intervention provided to patients presenting to a hospital emergency department with symptoms of panic attack

People who experience panic attacks are frequent utilisers of hospital Emergency Departments (EDs). The ED setting provides an opportunity to provide ultra-brief interventions, specifically by referring these patients to specialist mental health care. This study attempted to evaluate the effectiveness of an ultra-brief psycho-education and referral intervention, a panic information card (PIC), currently distributed at three Victorian EDs. Participants were a convenience sample of 72 individuals (20 males and 51 females, 1 unspecified) who had presented to an ED for panic symptoms in the past 12 months. Individuals self-identified as either a card receiver (CR) or a non-card receiver (NCR). Two senior ED staff members were interviewed regarding their evaluation of the effectiveness of the PIC. It was hypothesised that CRs would; (1) review the PIC favourably; (2) be more likely to seek help for PA than NCRs; (3) seek help sooner than NCRs; and (4) seek help on fewer occasions post-intervention than NCRs. Staff were hypothesised to review the card favourably and as a simple addition to ED practice. Both CRs and staff reviewed the PIC favourably, though there were no significant differences in help-seeking behaviour or time taken to access help between groups. CRs sought help on significantly fewer occasions than NCRs. Despite limitations of non-randomisation and modest sample size, this study contributes to evidence on the utility of ultra-brief interventions and supports the potential of ultra-brief ED-based interventions to expedite mental health referral, decrease utilisation of ED by panickers, reduce financial costs for the medical system, and increase psycho-education of sufferers.

Satisfaction of health professionals after implementation of a primary care hospital emergency centre in Switzerland: A prospective before–after study

Background and aimThe increasing number of patients requiring emergency care is a challenge and leads to decreased satisfaction of health professionals at emergency departments (EDs). Thus, a Swiss hospital implemented a hospital-associated primary care centre at the ED.The study aim was to investigate changes in job satisfaction of ED staff before and after the implementation of this new service model and to measure hospital GPs' (HGPs) satisfaction at the hospital-associated primary care centre. MethodThis study was embedded in a large prospective before–after study over two years. We examined changes in job satisfaction with a questionnaire followed by selected interviews approaching all of the involved 25 ED staff members and 38 HGPs. ResultsThe new emergency care model increased job satisfaction of ED staff and HGPs in all measured dimensions. The overall job satisfaction of ED employees improved from 76.5 to 83.9 points (visual analogue scale 0–100; difference 7.4 points [95% CI: 1.3 to 13.5, p = 0.02]). 86% of 29 HGPs preferred to provide their out-of-hours service at the new hospital-associated primary care centre. ConclusionsThe hospital-associated primary care centre is a promising option to improve job satisfaction of different health professionals in emergency care.

Burnout in emergency department healthcare professionals is associated with coping style: a cross-sectional survey

IntroductionIneffective coping may lead to impaired job performance and burnout, with adverse consequences to staff well-being and patient outcomes. We examined the relationship between coping styles and burnout in emergency...

Becoming a Doctor: One Physician's Journey Beyond Competence.

Becoming a Doctor: One Physician's Journey Beyond Competence.

ED staff knowledge and attitudes towards the paramedic profession in Israel

Objective: To examine the level of knowledge and attitudes of emergency department (ED) personnel towards the paramedic profession in Israel, and to examine opinions of the ED staff regarding integration of paramedics into the ED work staff. Study design: Cross-sectional survey conducted among health care workers. Sample and setting: The research population was physicians and nurses in four level 1 hospitals in Israel. The sample population includes 92 physicians (approximately 61%) and 102 nurses (approximately 34%). Methods: The questionnaire, distributed from November 2011 to February 2012, was composed of five parts: demographics, questions examining interactions with paramedics, knowledge about the paramedics’ work, their assessment of paramedics’ skills, and their attitudes about expanding the paramedic's scope of practice. The questionnaire was sent to 150 personal emails of ED staff members (physicians and nurses). 68 additional questionnaires were filled in EDs. Results: About one fifth of the physicians (21.7%) reported encountering a paramedic on a daily basis, while 87.3% of the nurses reported encountering a paramedic on a daily basis. 72% of the physicians and 77.5% of the nurses knew how to distinguish between a paramedic and a basic or intermediate EMT based on differences in their uniforms. Only 31.5% of the physicians and 43.1% of the nurses knew that the majority of MICUs (Mobile Intensive Care Unit) in Israel have no physician on board. Most physicians and nurses had a high degree of knowledge of the scope of practice of paramedics and a high regard for their clinical skills. Although both physicians and nurses agreed that paramedics can expand their scope of practice to EDs, physicians supported such a measure more than nurses.

Effect of Troponin I Point-of-Care Testing on Emergency Department Throughput Measures and Staff Satisfaction

Emergency departments (EDs) are challenged to provide rapid triage and evaluation to make appropriate patient disposition and timely treatment decisions. Cardiac troponin is the preferred biomarker for evaluation of patients with chest pain. The objective of this before-and-after study was to determine the impact of Point-of-Care (POC) troponin testing on turnaround times, door-to-troponin result times, ED length of stay (LOS) in patients with chest pain, and staff satisfaction with POC testing. After POC implementation, the average door-to-troponin result time significantly decreased from 105 to 51 min (p < 0.000). The average LOS decreased from 290 to 255 min; however, the change was not significant (p = 0.082). The majority of nurses (81%) felt that POC testing encouraged communication among patient care team members, and satisfaction was high with 82% of all ED staff members rating their satisfaction as excellent.

Inefficiencies and vulnerabilities of telephone-based communication between U. S. poison control centers and emergency departments

Context. Poison control centers (PCCs) and emergency departments (EDs) rely upon telephone communication to collaborate. PCCs and EDs each create electronic records for the same patient during the course of collaboration, but those electronic records are not shared. Objective. The purpose of this study was to describe the current, telephone based process of PCC–ED communication as the basis for potential process improvement. Materials and methods. This study was conducted at one PCC and two tertiary care EDs. We developed workflow diagrams to depict clinician descriptions of the current process, descriptions obtained through interviews of key informants. We also analyzed transcripts of phone calls between emergency departments and the poison control center, corresponding to a random sample of 120 PCC cases occurring January 1–December 31, 2011. Results. Collaboration between the ED and PCC takes place during multiple telephone calls, and the process is unsupported by shared documentation. The process occurs in three phases: notification, collaborative care, and ongoing consultation. In the ED, multiple care providers may communicate with the PCC, but only one ED care provider communicates with the poison control center specialist at a time. Handoffs occur for both ED and PCC. Collaborative care planning is common and most cases involve some type of request for information, whether vital signs, laboratory results, or verification that a treatment was administered. We found evidence of inefficiencies and safety vulnerabilities, including the inability of PCC specialists to reach ED care providers, telephone calls routed through multiple ED staff members in an attempt to reach the appropriate care provider, and exchange of clinical information with non-clinical staff. In 55% of cases, the patient was discharged prior to any synchronous telephone communication between the ED care provider and a PCC specialist. Ambiguous communication of information was observed in 22% of cases. In 12% of cases, a PCC specialist was unable to obtain requested information from the ED. Discussion and conclusion. Inefficiencies and vulnerabilities occur in telephone-based PCC–ED communication. Prudence begs consideration of alternative processes and models of ED–PCC communication and information sharing, including a process that supports collaboration with health information exchange.

“Bath Salts”–Induced Psychosis in a Young Woman

“Bath Salts”–Induced Psychosis in a Young Woman

An Observation Tool for Studying Patient-oriented Workflow in Hospital Emergency Departments

Studying workflow is a critical step in designing, implementing and evaluating informatics interventions in complex sociotechnical settings, such as hospital emergency departments (EDs). Known approaches to studying workflow in clinical settings attend to the activities of individual clinicians, thus being inadequate to characterize patient care as a cooperative work. The purpose of this paper is twofold. First, we introduce a novel, theory-driven patient-oriented workflow methodology, which better addresses the complex, multiple-provider nature of patient care. Second, we report the development of an observational tool and protocol for use in studies of this type, and the results of an evaluation study. We created a tablet computer implementation of an instrument to efficiently capture patient-oriented workflow, and evaluated it through a field study in three EDs. We focused on activities occurring over time during a single patient care episode as well as the roles of the ED staff members who conducted the activities. The evidence generated supports the validity, viability, and reliability of the tool. The coverage of the tool in terms of activities and roles was satisfactory. The tool was able to capture the sequence of activity-role pairs for 108 patient care episodes. The inter-rater reliability assessment yielded a high kappa value (0.79). The patient-oriented workflow methodology has the potential to facilitate modeling patient care in EDs by characterizing both roles and activities in sequence. The methodology also provides researchers and practitioners a more realistic and comprehensive workflow perspective that can inform the design, implementation and evaluation of health information technology interventions.

1557 Implementation of a Procedural Sedation Programme in a Tertiary Paediatric Emergency Department

Background and AimsIn the conduct of Paediatric Procedural Sedation (PPS) within the Emergency Department (ED) the combination of powerful drugs, variable competency levels and high staff turnover carry the potential...

Evaluation of an Emergency Department Educational Campaign for Recognition of Suicidal Patients

IntroductionTo evaluate the impact of a simple emergency department (ED)–based educational intervention designed to assist ED providers in detecting occult suicidal behavior in patients who present with complaints that are not related to behavioral health.MethodsStaff from 5 ED sites participated in the study. Four ED staff members were exposed to a poster and clinical guide for the recognition and management of suicidal patients. Staff members in 1 ED were not exposed to training material and served as a comparator group.ResultsAt baseline, only 36% of providers reported that they had sufficient training in how to assess level of suicide risk in patients. Greater than two thirds of providers agreed that additional training would be helpful in assessing the level of patient suicide risk. More than half of respondents who were exposed to the intervention (51.6%) endorsed increased knowledge of suicide risk during the study period, while 41% indicated that the intervention resulted in improved skills in managing suicidal patients.ConclusionThis brief, free intervention appeared to have a beneficial impact on providers' perceptions of how well suicidality was recognized and managed in the ED.

Introducing Medical Students to Radiology as Paid Emergency Department Triage Assistants

The aim of this report is to provide a detailed description of a program employing medical students to assist with triaging off-hour diagnostic imaging studies at a major academic medical center. Current and former participants of the Medical student Emergency Department (ED) Radiology Triage Program were interviewed regarding the inception, development, and impact of this program. Student participation and triage activities were compiled and tabulated from scheduling records and triage assistant call logs. Opportunities for medical students to obtain an intensive, well-organized experience in radiology are often absent or occur relatively late during medical school, which can be problematic for developing basic imaging literacy and for making timely, well-informed decisions regarding radiology as a career path. The authors describe a program that provides students with a rigorous, hands-on experience in radiology relatively early in their training by employing medical students to assist the emergency department radiology staff with managing off-hour radiology workflow. Students work with the off-hour emergency department radiologists and staff members answering phone calls and help to facilitate the ordering and protocoling of studies and the dissemination of results to clinicians. The employment of medical student triage assistants provides in-depth exposure to clinical radiology relatively early in medical school, while providing an effective system to help streamline the off-hour workflow for attending radiologists, residents, technicians, and support staff members.

Konfliktherd Notaufnahme

Workplace violence in the emergency department is an concerning worldwide hazard with serious individual and organisational consequences. Up to now, scientific research analysing this issue is limited to non-European countries. In the present article, we seek to describe the phenomenon of violence against emergency department staff members and to report on various methods of violence prevention and de-escalation with regard to their proven effectiveness.

Examination of staphylococcal stethoscope contamination in the emergency department (pilot) study (EXSSCITED pilot study)

The objective of this study was to determine the prevalence of Staphylococcus-contaminated stethoscopes belonging to emergency department (ED) staff and to identify the proportion of these that were Staphylococcus aureus or methicillin-resistant Staphylococcus aureus (MRSA). We conducted a prospective observational cohort study of bacterial cultures from 100 ED staff members' stethoscopes at three EDs. Study participants were asked to complete a questionnaire. Fifty-four specimens grew coagulase-negative staphylococci and one grew methicillin-susceptible S. aureus. No MRSA was cultured. Only 8% of participants, all of whom were nurses, reported cleaning their stethoscope before or after each patient assessment. Alcohol-based wipes were most commonly used to clean stethoscopes. A lack of time, being too busy, and forgetfulness were the most frequently reported reasons for not cleaning the stethoscope in the ED. This study indicates that although stethoscope contamination rates in these EDs are high, the prevalence of S. aureus or MRSA on stethoscopes is low.

Incidence and Impact of Physician and Nurse Disruptive Behaviors in the Emergency Department

BackgroundDisruptive behaviors have been shown to have a significant negative impact on staff collaboration and clinical outcomes of patient care. Disruptive episodes are more likely to occur in high stress areas such as the Emergency Department (ED). Having the structure, process, and skills in place to effectively address this issue will lower the likelihood of preventable adverse events. ObjectivesTo assess the status of disruptive behaviors and staff relationships in the ED setting. MethodsA 23-question survey tool was distributed to a regional group of ED physicians, nurses, and staff members to assess their perceptions as to the incidence of discipline-specific occurrences, types and impact of disruptive behaviors on staff behaviors, communication efficiency, and patient outcomes of care. ResultsA total of 370 surveys were received. Fifty-seven percent witnessed the disruptive behaviors by physicians, 52% witnessed the disruptive behaviors by nurses; 32.8% of the respondents felt that disruptive behavior could be linked to the occurrence of adverse events, 35.4% to medical errors, 24.7% to compromises in patient safety, 35.8% to poor quality, and 12.3% to patient mortality. Eighteen percent reported that they were aware of a specific adverse event that occurred as a direct result of disruptive behavior. ConclusionDisruptive behaviors in the ED have a significant impact on team dynamics, communication efficiency, information flow, and task accountability, all of which can adversely impact patient care. EDs need to recognize the significance of disruptive behaviors and implement appropriate policies and protocols to address this issue.

Pediatric Patient Safety in Emergency Departments: Unit Characteristics and Staff Perceptions

The goals were (1) to describe emergency department (ED) characteristics thought to be related to patient safety within the Pediatric Emergency Care Applied Research Network, (2) to measure staff perceptions of the climate of safety in EDs, and (3) to measure associations between ED characteristics and a climate of safety. Twenty-one EDs were surveyed to assess physical structure, staffing patterns, overcrowding, medication administration, teamwork, and methods for promoting patient safety. A validated survey on the climate of safety was administered to all emergency department staff members. Safety climate scores were compared to evaluate associations with ED characteristics. A total of 1747 staff members (49%) responded to the survey on the climate of safety. A minority of EDs had organized safety activities such as safety committees (48%) or walk-rounds (38%), used computerized physician order entry (38%), had ED pharmacists (19%), or had formal physician/registered nurse teams (38%). The majority (67%) treated patients in hallways. Most (67%) varied staffing on the basis of seasonal patient volume. Of the 1747 ED staff members (49%) responding to the survey, there was a wide range (28%-82%) in the proportion reporting a positive safety climate. Physicians' ratings of the climate of safety were higher than nurses' ratings, and perceptions varied according to work experience. Characteristics associated with an improved climate of safety were a lack of ED overcrowding, a sick call back-up plan for physicians, and the presence of an ED safety committee. Large variability existed among EDs in structures and processes thought to be associated with patient safety and in staff perception of the safety climate. Several ED characteristics were associated with a positive climate of safety.

Unanticipated Influence of Coordination Mechanisms on Physician Workstyles and ED Operational Efficiency

The coordination of activities in a work context has been examined by many disciplines and in recent years the role of information systems and other artifacts has become increasingly prominent. The emergency department (ED) of a hospital in a large US city is used to study how information systems and other coordinating mechanisms affect how physicians choose to perform their work and how such choices can impact the operational performance of the ED as a whole. The study used direct observation of the work performed in the ED, interviews of physicians, nurses and other ED staff members, and the analysis of historical performance data. The key findings were that the workstyles adopted by physicians were shaped by incidental characteristics of coordination mechanisms. Some workstyles appear to have adverse, albeit unintended, effects on aspects of the department's operational performance.