Hamad General Hospital Emergency Department Research Articles

Qatar Prediction Rule Using ED Indicators of COVID-19 at Triage.

Introduction: The presence of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) and its associated disease, COVID-19 has had an enormous impact on the operations of the emergency department (ED), particularly the triage area. The aim of the study was to derive and validate a prediction rule that would be applicable to Qatar’s adult ED population to predict COVID-19-positive patients.Methods: This is a retrospective study including adult patients. The data were obtained from the electronic medical records (EMR) of the Hamad Medical Corporation (HMC) for three EDs. Data from the Hamad General Hospital ED were used to derive and internally validate a prediction rule (Q-PREDICT). The Al Wakra Hospital ED and Al Khor Hospital ED data formed an external validation set consisting of the same time frame. The variables in the model included the weekly ED COVID-19-positivity rate and the following patient characteristics: region (nationality), age, acuity, cough, fever, tachypnea, hypoxemia, and hypotension. All statistical analyses were executed with Stata 16.1 (Stata Corp). The study team obtained appropriate institutional approval.Results: The study included 45,663 adult patients who were tested for COVID-19. Out of these, 47% (n = 21461) were COVID-19 positive. The derivation-set model had very good discrimination (c = 0.855, 95% Confidence intervals (CI) 0.847–0.861). Cross-validation of the model demonstrated that the validation-set model (c = 0.857, 95% CI 0.849–0.863) retained high discrimination.A high Q-PREDICT score ( ≥ 13) is associated with a nearly 6-fold increase in the likelihood of being COVID-19 positive (likelihood ratio 5.9, 95% CI 5.6–6.2), with a sensitivity of 84.7% (95% CI, 84.0%–85.4%). A low Q-PREDICT ( ≤ 6) is associated with a nearly 20-fold increase in the likelihood of being COVID-19 negative (likelihood ratio 19.3, 95% CI 16.7–22.1), with a specificity of 98.7% (95% CI 98.5%–98.9%).Conclusion: The Q-PREDICT is a simple scoring system based on information readily collected from patients at the front desk of the ED and helps to predict COVID-19 status at triage. The scoring system performed well in the internal and external validation on datasets obtained from the state of Qatar.

Evaluating preparedness of emergency trainees to triage victims of mass casualty incidents

Background: Triage of victims in mass casualty incidents (MCI) is crucial in prioritizing care and allocating resources1. Triage skills are important to be evaluated for training and better preparedness. Using clinical vignettes is a well-known approach to evaluate clinicians’ knowledge and decision-making2. This study aims to evaluate preparedness of emergency residents and fellows to triage victims of MCI. Methods: Emergency Medicine (EM) residents and fellows at Hamad General Hospital, Emergency Department (HGH-ED) were invited to the study. Each participant filled a questionnaire followed by triaging of 15 vignette-based victims of MCI. Descriptive statistics elaborated on participants’ training and relevant exposures (Table 1). It also showed the degree of agreement in their triage results and rates of under-triage and over-triage. Cohen's kappa coefficient showed inter-rater agreement and internal consistency in triage results. Results: Participants included 63 emergency trainees, 27 residents, and 36 fellows. Only 28.3% (n = 17) of them participated in an MCI drill over the past two years. 51.7% (n = 31) attended training on triage in MCI. 73.3% (n = 44) indicated that they have rarely or never triaged victims in a real MCI or a drill. Only 3.3% (n = 2) perceived themselves as highly confident in triaging victims of MCI. A total of 904 triage outcomes resulted from this exercise (Table 2). The overall rate of agreement among the triage outcomes is 73% (660 times in 904 triage outcomes). The rate of over-triage was 36.8% and 23% under-triage. Conclusion: Better triage results was associated with previous triage training. The rate of over-triage was as the literature recommends. However, the rate of under triage was alarmingly higher than the literature recommendation as < 5%3. The higher rate of under-triage imposes a risk of missing seriously injured victims, which may lead to higher mortality or poor patients’ outcomes. Further training and exercises may be the key to saving more lives and resources.

A comparative, epidemiological study of acute renal colic presentations to emergency departments in Doha, Qatar, and Melbourne, Australia

BackgroundThis study aimed to compare the epidemiology, clinical presentations, management, and outcomes of renal colic presentations in two major academic centers from geographically diverse populations: Qatar (a country in the Afro-Asian stone belt) and South-Eastern Australia (not within a stone belt).MethodsWe undertook a retrospective cohort study of patients with renal colic who presented to the Hamad General Hospital Emergency Department (HGH-ED), Qatar, and The Alfred ED, Melbourne, Australia, during a period of 1 year from August 1, 2012, to July 31, 2013. Cases were identified using ICD-9-CM codes, and an electronic template was used to record the data on predefined clinical variables.ResultsA total of 12,223 from the HGH-ED and 384 from The Alfred ED were identified as renal colic presentations during the study period. The rate of renal colic presentations at the HGH-ED was 27.9 per 1000 ED visits compared to 6.7 per 1000 ED visits at The Alfred ED. Patients presenting to the HGH-ED were significantly younger [34.9 years (29.0–43.4) than The Alfred ED [48 years (37–60); P < 0.001].The median stone size was larger in the HGH-ED group [6 (4–8) mm] versus The Alfred ED group [4 (3–6) mm, P < 0.001]. The intervention rate in the stone-positive population was significantly higher in the HGH-ED group as opposed to The Alfred ED group (38.7 versus 11.9%, P < 0.001). At the time of discharge, The Alfred ED group received fewer analgesic prescriptions (55.8 versus 83.5%, P < 0.001) and more tamsulosin prescriptions (25.3 versus 11.7%, P < 0.001).ConclusionsRenal colic presentations to the HGH-ED, Qatar, were younger, with larger stone size mostly located in the lower ureter, compared to The Alfred ED, Melbourne, Australia. The findings suggest that the benefits of treatment including medical expulsion therapy will vary between the two populations. Differences in epidemiology and patient mix should be considered while tailoring strategies for effective management of patients with renal colic in a given setting.

Tabletop Exercise on Mass Casualty Incident Triage, Does it Work?

Background: The triage is the first step in medical hierarchy for better management before treatment and transport in mass casualty incident (MCI). Therefore, an accurate, valid and timely triage will safe life and limbs, especially, when done by expert and experienced staff in MCI triage. This study planned to evaluate the MCI triage skills of the medical staff like doctors and nurses at Hamad General Hospital Emergency Department (HGH ED). They were provided a table top exercise (TTX) about MCI triage to improve the skills and knowledge followed by impact assessment. The study trial was planned and performed at emergency department of (tertiary hospital) Hamad general hospital at Doha Qatar. Methods: The study includes both intervention and control groups. The selected sample of ED medical and nursing staff was randomly divided into two groups. The intervention group performed the table top exercise and the control group followed written paper based instructions about MCI triage. The both groups were asked to triage 20 standardized cases as per simple triage and rapid treatment (START) triage. The study evaluated the triage accuracy and time to triage as primary outcome as well as over and under triaging for both groups as secondary outcomes. Results: The study results report 90% triage accuracy in the intervention group and 70% in control group with a difference of 20% to 30%. The time to triage for 20 standardized cases was 5.4 minutes in intervention group and 8.2 minutes in control group, so participants in the intervention group triaged their patients more quickly than participants in the control group mean difference 2.8 minutes 98.5% confident interval 5.4 to 8.2 minutes. The over and under triaging were 5% for both in the intervention side but 20%, 10% respectively in the control side. The reliability was also found better at intervention side due to repeated training. The validity is not measured because the nature of work is simulation and only one triage system is used. Conclusion: The table top exercise (TTX) on triage for one hour improved the triaging skills of the ED medical staff up to 20% to 30% in comparison to written paper based instruction technique as well as the time to triage was also near to the half. The study suggests future studies to validate these findings which may also confirm other triage related findings like accuracy, over and under triage, validity, reliability and time to triage.

Forty-eight hours return visits at Hamad General Hospital Emergency Department on January 2015

Background: Hamad General Hospital (HGH) Emergency Department (ED) provided 465,942 patient visits in 2014. (ED) use has increased annually resulting in overcrowding, longer wait periods for service and increased stress on health care workers. Much attention has been paid to factors contributing to this increased usage such as the return visit of an (ED) patient within 48 hours of the initial visit. 48 hours is the benchmark time period used in measuring (ED) return visits utilized by many countries and it became a mandatory quality indicator of performance by the Supreme Council of Health in Qatar on April 2015. This study was conducted to identify factors associated with scheduled and unscheduled 48 hours return visits to serve as a basis for a Quality Improvement Project (QIP) for development of interventions to decrease unscheduled returns. Methods: An exploratory quantitative study using a descriptive correlational design was performed. The sample consisted of all patients had a return visits to (ED) within 48 hours from the discharge time during January 2015 at the study facility. Data were abstracted from electronic patients’ records utilizing the data collection tool, all electronic records was reviewed by experienced emergency physicians. Results: For the study month of January 2015 there were 1023 return visits within 48 hours from the discharge time (2%) out of 42981 (ED) patients. 906 visits (89%) was unplanned out of them 102 visits (11%) was clinically significant. 85 cases(9%) were admitted on the return visit and we had no mortality cases. Abdominal pain was the main presenting complaint (28%) of all revisits followed by musculoskeletal pain (13%) for patients whom presenting with the same complaint. Conclusion: Abdominal pain is the most frequent complaint associated with unscheduled return visits. Further Study is important to design and implement interventions to decrease the frequency of unscheduled returns.

Save kids, not all children with minor head injury need CT head, QIP in Hamad General Hospital Emergency Department, Qatar

Background: Whilst Head CT scanning carries an important role in the identification of clinically significant intracranial injuries, there are associated risks of radiation. Our initial audit of clinical notes and survey of EM physicians revealed a rate of 45% CT scans for pediatric minor head injuries with around half of requests not indicated. In 36% there were issues with documentation. The aim is to achieve a sustained compliance with Internationally acceptable guidelines of Head CT scanning for pediatric minor head trauma at Hamad General Hospital Emergency Department (ED). Intervention: We conducted staff education through weekly program of Continuing Medical Education for emergency physicians, prominent display and availability of handouts of the International clinical decision rules (NICE guidelines, PECARN) in all clinical areas within the ED, encourage proper documentation for all head injury cases to meet JCI standards of documentation, and formulate a revised pediatric head injury guideline based on the international clinical decision rules. Methods and results: The audit in August 2014 showed that 62 CT head were done, 45% of them were deemed unnecessary when measured against NICE guidelines. Also there was deficient documentation in 36% of cases due to the unavailability and difficulty accessing the guidelines. We supplied all areas in the ED with handouts of the guidelines, and conducted shop floor education for ED physicians. Regular sessions were conducted during educational activities and emergency seminars. The re-audit in January 2015 showed decreasing rate of CT scans at the rate of 22% achieving a reduction by 33% and improvement in the documentation by 31%. The overall reduction of and decreasing the percentage of unindicated CT head by around 30%. Conclusion and recommendation: Managing minor head injury in pediatric age group becomes more safe by increasing the physician awareness about the evidence based updated guidelines.

A security survey of Emergency Department Hamad General Hospital

A security Survey of Emergency Department Hamad General Hospital Background The problem of Emergency Department (ED) violence is a worldwide issue, and a systematic approach to mitigating the threat to our colleagues and patients is fundamental to the advancement of Emergency Medicine (EM). One of the important step to this is to assess and improve knowledge of the staff on workplace violence and how to react to it. Aim of this survey was to assess staff knowledge about measures against workplace violence. Methods: We conducted a survey between, July 2015 to August 2015, in Hamad General Hospital Emergency Department (HGH-ED). Doctors and non-doctors health professionals working in the HGH-ED were asked to fill a paper survey. Data was collected and analyzed anonymously. The categorical outcomes are presented in proportions and continuous outcomes as mean with SD. Results: A total of 180 staffs were approached to fill this survey. 61.1% was the response rate. Of 110 who completed the survey, 68 (61.8%) were doctors working as ED physicians, and 42 (38.2%) were nurses and clerks. The male proportion was 62.27%. Median age category was 30-39 years with work experience less than five years. Only 24 out of 110 responders (21.8%) were aware about HMC policy dealing with workplace violence. 56 (50.9%) of the staff members were not sure about how to deal with if the incidence happen involving them or their colleague. Non-doctor staff was found to have higher percentage of feeling unsafe at work. Conclusion: We found poor knowledge about workplace violence policy and how to deal with it in the ED staff. Dedicated efforts are needed to make the staff aware and prepare for such situations.

Organophosphorus toxicity awareness among Emergency Department healthcare providers in Tertiary Care Hospital, Qatar

Background: Organophosphorus poisoning is a global public health problem. Annually, approximately 200,000–300,000 individuals die worldwide from Organophosphorus poisoning with the majority of deaths occurring in developing countries. In many countries in the Middle East, legislation is inflexible and unable to cope with new challenges. Often standards are not consistent with international and national needs. Hamad General Hospital (HGH) is the main tertiary care hospital in Qatar with its Emergency Department (ED) sees in access of 1500 patients in a 24 hour period. Anecdotally, there is a wide variation in practice of Organophosphorus toxicity management at HGH ED. The aim of this study is to check the knowledge and practice of the healthcare workers involved in managing such cases regarding decontamination, use of PPE and management. Methods: This is a cross sectional survey using a pre developed questionnaire collected from a representative sample of 280 physicians of different grades and nurses in HGH ED. Results: Till date collected data from 156 nurses and 66 emergency physicians showed failure of recognition of correct indication of atropine use in 47% of nurses (73 out of 156) and in (15%) of physicians (10 out of 66). Wearing appropriate respiratory and skin protective equipment while attending to patients with suspected Organophosphorus poisoning was up to the desired standard in 54% of nurses (85 out of 156) and 97 % of physicians (64 out of 66). The more years of experience the more safety awareness. Conclusion: Junior staff knowledge about anti dote indications and diagnosis is the best. However the seniors are more aware about protective measures. We recommend the introduction of standardized Evidence based clinical algorithm and developing of educational sessions aiming to increase awareness about organophosphorus toxicity management. A secondary audit is necessary following the above intervention to measure the awareness improvement.

Hamad General Hospital-Emergency Department (HGH-ED) staff with mass casualty incident/disaster involving children

Introduction: A mass casualty incident (MCI) or disaster can happen at any time. People at the extremes of ages are affected more especially children. Working in the nation's biggest Emergency Department (ED), Hamad General Hospital (HGH)-ED, staff preparedness is crucial to handle such unfortunate event or events. This study aims to assess the preparedness level, knowledge and the willingness of the HGH-ED staff to deal with MCI/Disaster involving children. Methods: A prospective descriptive study design-using questionnaire to gather data. The study included a 21-item Questionnaire examining preparedness level, knowledge and the willingness of HGH-ED staff dealing with MCI/Disaster involving children. The questionnaire was send to 720 HGH-ED staff, descriptive statistics were used to describe study variables. Results: Out of the total responders, 73.5% were ED nurse and 26.4% ED physician the average work experience was 7.81 ± 4.94 years. 74% reported that they have never been involved in disaster/MCI involving children's and 82% of the total responders they don't have any formal training in regard of dealing with pediatric victims of disaster. 64% where either unaware or uncertain about the existence of HGH-ED pediatric specific disaster plan. Conclusion: The result of our study showed that the preparedness level and the knowledge to deal with disaster/MCI involving children in our ED staff were found to be low due to lack of knowledge of children special needs and lack of experience to deal with children involved in MCI and low level of training that ED staff had.

Wait a minute: Not all cases of paracetamol overdose need N-acetylcysteine, quality improvement project in Hamad General Hospital Emergency Department

Background: Management of serious paracetamol overdose with N-acetylcysteine (NAC) is an effective strategy. Early treatment with NAC prevents the formation of a toxic metabolite that leads to hepatic injury. However, inappropriate treatment with NAC and overtreatment with NAC can lead to potential adverse side effects and unnecessary hospital admission. The aim of the study was to assess the administration of NAC in the setting of paracetamol overdose and determine whether the institutional use of this antidote is consistent with the international standards. We hypothesize that some patients receive antidotal NAC unnecessarily after paracetamol exposure, and that a simple quality improvement intervention in educational activity may improve the administration of this antidote. Methods: A retrospective quality improvement chart review evaluated charts of patients who were treated with NAC for paracetamol exposure over a 2-month period in the Emergency Department of Hamad General Hospital. The quality improvement intervention consisted of establishing a paracetamol clinical practice guideline, providing access to a treatment nomogram for NAC use, enhancing educational activities to improve the clinician's understanding of appropriate NAC use, and establishing a clinical toxicology service for all paracetamol exposures. Results: NAC administration to 67% of the cases after paracetamol exposure were found to be medically unnecessary according to the established international guidelines for management of paracetamol overdose. Post-intervention measurement showed significant improvement by decreasing unnecessary NAC administration to only 33%. Conclusion: In our institution, NAC treatment after paracetamol exposure is usually administered unnecessarily. Inappropriate administration of this antidote results in a significant waste of resources and unnecessarily prolonged hospital stay. Adherence to the clinical practice guidelines may lead to a significant improvement in this antidote use after paracetamol exposure. Given that this antidote is used inappropriately despite widespread knowledge that guidelines for paracetamol exposure exist, we believe that continuous education on the topic, chart audits and feedback, and use of a clinical toxicology service may improve the knowledge and appropriate use of this antidote and will improve patient care.

Improving patients' flow in a busy emergency department by DPR (dedicated phlebotomy room) technique

Background: This study is a quality improvement project that aimed at improving patient flow in Male Urgent Area (MUA), one of the busiest areas in the largest emergency department in the state of Qatar. Methods: The baseline process was designed by mapping and drawing a cause-and-effect diagram. Pre- and post-auditing was done after careful intervention of introducing a phlebotomy room in Male See and Treat area, the main feeder to MUA. The feeding areas to MUA and the daily flow of patients were studied in detail. Points of interest in the baseline process map were identified and targeted. Supporting data of about 398 patients helped in designing the process map and identifying the point of interest. Results: Post-intervention analysis showed a remarkable improvement in time to phlebotomy in Hamad General Hospital Emergency Department. The proportion of patients moving to MUA and receiving phlebotomy increased from 48.6% to 84.1% in the first hour. Patients' hematological laboratory workup that helps MUA's physicians in decision making was readily available. Conclusion: Patient flow and phlebotomy time can be significantly improved by introducing a dedicated phlebotomy room in a busy emergency department. It is concluded that identification and targeting of the main point of interest in baseline process mapping is crucial and of considerable importance in a quality improvement project. Keywords: Emergency department, phlebotomy time, patient flow

Qatar ambulance service and Hamad General Hospital Emergency Department staff's perception of current patient handover practice

Background: The handover process is meant to ensure patient safety and maintain continuity of care through endorsement of critical patient information. This study evaluates staff's perceptions about the current patient handover process effectiveness between Ambulance Service (AS) and Emergency Department (ED) clinicians. It may help identify barriers and contributing factors to an effective patient handover. Methods: An electronic questionnaire was circulated to all ED doctors/nurses and AS staff (Estimated N = 1,000). 400 questionnaires were completed of which 92 did not meet the inclusion criteria. Respondents were 43% AS staff, 29% ED nurses, and 28% ED doctors. A 4-point Likert scale (1 = strongly disagree-4 = strongly agree) was used. The mean was calculated for every variable to determine each group perception. One-way ANOVA tested the relationship between demographics and perceptions’ variables. Results: Although 62% of respondents believe the current handover process is safe and 65% believe AS staff report all critical information, 70% of respondents think that it causes AS/ED staff conflicts, and 72% believe the current handover process needs changing. ANOVA test revealed significant differences in the mean between study groups’ handover safety perceptions. Interestingly, ED nurses expressed more safety concern (2.43) than ED doctors (2.58) and AS staff (2.82) with p-value &lt; 0.05. The main perceived barriers to effective handover were: Lack of handover protocol (89%); Lack of a standardized handover tool (89%); Fragmented communication (85%); and Frequent interruptions (82%). 93% of the respondents believe the use of a standardized handover tool will improve the patient handover process despite 67% of them not knowing any standardized handover tool. Conclusion: The lack of handover protocol and a standardized tool leads to significant variation and is a patient safety concern due to potential loss of critical information. We believe that a mutually agreed standardized handover tool such as ISBAR would reduce handover variation and ensure quality.