Patient Care In Emergency Department Research Articles

Optimizing older patient care in emergency departments: a comprehensive survey of current practices and challenges in Northern Italy.

The progressive aging of the population and the increasing complexity of health issues contribute to a growing number of older individuals seeking emergency care. This study aims to assess the state of the art of care provided to older people in the Emergency Departments of Lombardy, the most populous region in Italy, counting over 2million people aged 65 years and older. An online cross-sectional survey was developed and disseminated among emergency medicine physicians and physicians affiliated to the Lombardy section of the Italian Society of Geriatrics and Gerontology (SIGG), during June and July 2023. The questionnaire covered hospital profiles, geriatric consultation practices, risk assessment tools, discharge processes and perspectives on geriatric emergency care. In this mixed method research, 219 structured interviews were collected. The majority of physicians were employed in hospitals, with 54.7% being geriatricians. Critical gaps in older patient's care were identified, including the absence of dedicated care pathways, insufficient awareness of screening tools, and a need for enhanced professional training. Tailored protocols and geriatric educational programs are crucial for improving the quality of emergency care provided to older individuals. These measures might also help relieve the burden on the Emergency Departments, thereby potentially enhancing overall efficiency and ensuring better outcomes.

Towards normalizing emergency department care of patients with COVID-19

Towards normalizing emergency department care of patients with COVID-19

Behavioural ‘nudging’ interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial

IntroductionOpioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and...

RAFF-5 Study to Improve the Quality and Safety of Care for Patients Seen in the Emergency Department With Acute Atrial Fibrillation and Flutter

BackgroundWe sought to improve the immediate and subsequent care of emergency department (ED) patients with acute atrial fibrillation (AF) and flutter (AFL) by implementing the principles of the Canadian Association of Emergency Physicians AF/AFL Best Practices Checklist. MethodsThis cohort study included 3 periods: before (7 months), intervention introduction (1 month), and after (7 months), and was conducted at a major academic centre. We included patients who presented with an episode of acute AF or AFL and used multiple strategies to support ED adoption of the Canadian Association of Emergency Physicians checklist. We developed new cardiology rapid-access follow-up processes. The main outcomes were unsafe and suboptimal treatments in the ED. ResultsWe included 1108 patient visits, with 559 in the before and 549 in the after period. In a comparison of the periods, there was an increase in use of chemical cardioversion (20.6% vs 25.0%; absolute difference [AD], 4.4%) and in electrical cardioversion (39.2% vs 51.2%; AD, 12.0%). More patients were discharged with sinus rhythm restored (66.9% vs 75.0%; AD, 8.1%). The proportion seen in a follow-up cardiology clinic increased from 24.2% to 39.9% (AD, 15.7%) and the mean time until seen decreased substantially (103.3 vs 49.0 days; AD, -54.3 days). There were very few unsafe cases (0.4% vs 0.7%) and, although there was an increase in suboptimal care (19.5% vs 23.1%), overall patient outcomes were excellent. ConclusionsWe successfully improved the care for ED patients with acute AF/AFL and achieved more frequent and more rapid cardiology follow-up. Although cases of unsafe management were uncommon and patient outcomes were excellent, there are opportunities for physicians to improve their care of acute AF/AFL patients. ClinicalTrials.gov IdentifierNCT05468281

Emergency Nursing Didactics – Opinions, Resource, and Skill Exchange (E.N.D.O.R.S.E) – A collaborative academic initiative in the Emergency Department

Introduction: Emergency Physicians and Nurses often work together as the two most prominent figures at the patient bedside, involved in clinical decision making, procedures, and medication administration. However, they are not afforded many opportunities to debrief and share educational knowledge and resources surrounding decisions, implementation, and protocols. After preliminary discussions on interest and knowledge gaps, a collaboration between Emergency Physicians and nurses was established under an academic initiative entitled ‘Emergency Nursing Didactics – Opinions, Resource, and Skill Exchange (E.N.D.O.R.S.E.)' at Mediclinic City Hospital, Dubai. Aims/Objectives: We aimed to provide a platform within the Emergency Department (ED) to promote interpersonal communication and feedback between healthcare providers. The initiative sought to improve skills, confidence, and standardize workflows around essential procedures/protocols. Materials/Methods: A structured 30-minute session break-down was created and customized information handouts were prepared, with evidence-based references. Sessions were conducted once a month, with in-person teaching within the ED alongside a video conference set up. Post-session questionnaires were utilized to determine knowledge reception, ideas on improvement, and future direction of E.N.D.O.R.S.E. sessions. Results: Topics included waveform capnography, Inotropes and infusion settings, SVT management, Right/posterior ECG placement, high-risk pattern recognition, and Intubation workflow. Sessions lasted 30 minutes, did not interfere with actual patient care, and were attended in-person, online, with recordings viewed later by all department members. Post-session questionnaires revealed that 92.3% of participants found the sessions provided them with new information, with approximately 88% of them ‘Very confident' (5/5) in using the skills taught thereafter. 77% of participants rated the quality of the sessions as ‘Excellent' (5/5), and 88% indicated they would like for the topics to be repeated in future sessions. Participants also reported that sessions offered them a safe, structured environment within which to ask questions and improve knowledge. Discussion: Creation of a safe, structured learning environment allows ED healthcare providers to identify knowledge and skill gaps that may otherwise not be unmasked. While Nursing education is ubiquitous, this is often delivered amongst nurses and by nurses. E.N.D.O.R.S.E. is a first-of-its-kind platform where physicians and nurses work together to develop soft skills. What seemed to be trivial tasks became optimized through collaborative learning and idea exchange. Conclusion: Collaborative learning allows for ‘practiced proficiency' of skills and offers an opportunity to enhance ED workflow and patient care.

Factor First: An Assessment of Emergency Department Care of Patients with Hemophilia

Background: With the establishment of hemophilia treatment centres (HTCs) and home infusion programs for factor replacement therapy, emergency department use among patients with hemophilia occurs less frequently, with patients often presenting for significant bleeding events only. As a result, the management of patients with hemophilia can represent a challenge to emergency department (ED) physicians and staff. Both delays in diagnosis of a bleeding event, and timely administration of hemostatic therapy have been associated with patient morbidity and mortality. The World Federation of Hemophilia, in addition to other organizations, emphasize the importance of timely receipt of clotting factor replacement therapy, providing treatment at the time a bleed is suspected. If a patient with hemophilia is registered with a HTC, they often carry a wallet card, or have a formalized treatment plan, outlining their diagnosis and emergency treatment of bleeding recommendations to ensure timely access to hemostatic therapy. The aim of this study was to describe ED management of patients with hemophilia at a single Canadian HTC, with a focus on use of individualized emergency bleeding management protocols, and time to receipt of hemostatic therapy within the ED. Methods: Adult patients with hemophilia A or B (FVIII or FIX ≤40%), of any severity, followed at the Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, were identified for inclusion. ED health utilization and ED encounter management data for each of the four hospital sites in Calgary, AB was obtained from the electronic health record for the cohort, through to 2022. Results: A total of 191 patients with hemophilia A and B were identified for study inclusion. 153 patients with hemophilia A (mild 64.7%; moderate 5.9%; severe 28.8%) and 38 patients with hemophilia B (mild 44.7%; moderate 36.8%; severe 18.4%). Males comprised 77.5% of the patient cohort. A total of 393 ED visits occurred over the study period. Less than a third of ED visits were associated with receipt of hemostatic therapy (either desmopressin or clotting factor concentrate). The median time from triage to ordering of hemostatic therapy was 2.9 hrs (IQR 2.3-3.2), and median time from triage to administration of hemostatic therapy was 4.2 hrs (IQR 3.1-4.2). For ED visits due to suspected bleeds, the proportion of patients who received either coagulation factor replacement or desmopressin within two hours of ED triage is depicted in Figure 1. Time to receipt of hemostatic therapy did not significantly differ whether desmopressin or clotting factor concentrate was administered. The number of ED visits in which the individualized emergency bleeding management protocol was accessed is depicted in Figure 2. Among those accessed in 2022, the proportion of protocols that were updated within the last 365 days was 86.8%. Less than 20% of ED visits were associated with a hematology consultation. Conclusions: Increasing utilization of individualized emergency bleeding management protocols for patients with hemophilia was observed; however, significant delays in timely receipt of hemostatic therapy remains, with infrequent involvement of hematology in consultation. Time to receipt of potentially life-saving hemostatic therapy for our cohort falls outside of hemophilia care standards. This data provides a better understanding of the experience of patients with hemophilia in the ED and provides an opportunity to define further quality improvement interventions to ensure quality care metrics in this population are met.

284 Nationwide Capabilities Assessment of Emergency Department Care of Patients With Opioid Use Disorder: 2022 to 2023

284 Nationwide Capabilities Assessment of Emergency Department Care of Patients With Opioid Use Disorder: 2022 to 2023

Hospital Development of a Hybrid Emergency Department—Inpatient Care Observation Unit

IntroductionThis project aimed to design and implement an emergency department-managed observation unit that improves inpatient bed and emergency department stretcher capacity, decreases observation patient length of stay, earns high patient satisfaction scores, and generates a positive fiscal impact on the organization. MethodsThis quality improvement project followed a 1-group, pre- and postprogram implementation design. ResultsIn the first year of operations, 40% of the total observation patients treated in this hospital were managed in the new observation unit. Emergency department observation unit length of stay across all patient complaints was half of the average length of stay for observation patients located on hospital inpatient units. In most cases, the emergency department observation unit was in the top 25 percentile of hospital Press Ganey inpatient satisfaction categories. The hospital estimates a contribution margin of three-quarters of a million dollars in the first year. DiscussionThis effective and efficient hybrid observation unit possessed specific aspects of inpatient and emergency department patient care models. Placing providers and nurses at the workstation for faster communication expedited care. Prioritizing all observation patient testing, transportation, phlebotomy, and intravenous (IV) services shortened disposition times. Emergency nurses transitioning to the observation unit were challenged to acquire inpatient care knowledge. Observation unit management struggled to maintain staffing while under an inpatient productivity model managed by the inpatient house supervisor. Reducing patient disposition time required clear communication between observation unit and inpatient staffing managers, between physician consultants and advanced practice nursing providers, and among nurses, patients, and providers. Observation units are 1 solution to decrease observation patient length of stay and improve emergency department capacity.

Pain and Satisfaction Perceptions of Ultrasound-Guided Versus Conventional Peripheral Intravenous Catheterization: A Randomized Controlled Trial

BackgroundWhile many emergency department (ED) patients need peripheral vascular catheterization, diagnosis and treatment are often delayed by difficult intravenous access (DIVA). AimsThis study of ED patients with DIVA was designed to evaluate ultrasound (US)-guided peripheral intravenous (IV) catheterization, compare it with conventional catheterization, and analyse patient pain and satisfaction regarding catheterization. DesignRandomized controlled clinical trial. MethodsAdult patients treated in the ED who scored >3 on the Adult-Difficult Venous Catheterization scale were randomly assigned to either US-guided or conventional peripheral IV catheterization. Data were collected from April to December 2016. Study variables were catheter insertion success, number of catheterization attempts, time required to perform the procedure, catheter length and calibre, puncture site, complications, and catheter functioning. Pain and patient satisfaction were also analysed for each group and the full sample. Results120 and 138 patients were recruited for the US-guided and conventional peripheral IV catheterization groups, respectively. For the US-guided compared to the conventional procedure, insertion success was greater (91.75% versus 89.9%; p=0.04), the mean (SD) number of attempts was lower (1.29 (0.59) versus 1.81 (1.28); p<0.001), mean (SD) satisfaction was greater (7.59 (2.04) versus 6.69 (2.28); p=0.03), and the mean (SD) required time in minutes was greater (7.89 (7.13) versus 5.1 (3.69); p=0.045). Mean (SD) pain was moderate in both groups (4.6 (2.75) versus 4.33 (2.91) (p=0.32). Logistic regression for the full sample indicated that more attempts and greater pain were both associated with reduced satisfaction, while use of higher-calibre catheters was associated with greater satisfaction. ConclusionUS-guided compared to conventional peripheral IV catheterization in patients with DIVA was more successful, required fewer attempts, enabled use of longer and higher-calibre catheters, and led to greater patient satisfaction. Patients who underwent US-guided intravenous catheterization reported moderate pain, similar to that reported for the conventional procedure. Clinical implicationsUS-guided peripheral intravenous catheterization improves ED patient care, as it requires fewer catheterization attempts. It is especially recommended for patients with DIVA.

Pharmacist involvement in blood culture follow up for patients discharged from the emergency department

Study objectiveThis study evaluates the time to attempted patient contact for positive blood cultures in patients discharged from the Emergency Department (ED) resulting when an Emergency Medicine (EM) pharmacist is on-duty compared to off-duty. MethodsThis single center, retrospective study included patients who were discharged from the ED and had subsequent positive blood cultures. Blood cultures were reviewed utilizing an algorithm previously approved and implemented by an interdisciplinary team in 2016. Standard practice was for the microbiology lab to notify the ED charge nurse of the positive blood culture, however, the algorithm placed the pharmacist as the responsible reviewer when on duty, leaving charge nurses and physicians as the responsible reviewers when a pharmacist was off duty and not on site. The primary outcome was time from ED notification of the positive gram stain of the blood culture to first attempted patient contact; we compared this outcome for cultures resulting when an EM pharmacist was on duty to those resulting when an EM pharmacist was off duty. Despite being off duty, a pharmacist may have reviewed these cultures if they remained unaddressed when the pharmacist returned on-site. In this case, the blood culture review was included in the off-duty cohort. Secondary outcomes included evaluation for appropriateness of the recommendation made to the patient during contact, 30-day infection-related readmission rates, patient's adherence to the recommendations, and barriers to patient contact. An infectious disease attending physician independently reviewed cases where the algorithm was not followed. ResultsA total of 127 patients identified by a query of our institution's database were screened against inclusion/exclusion criteria and 56 were excluded, leaving 71 patients for final analysis (54 and 17 in the on- and off-duty cohorts, respectively). Baseline demographics with respect to sex, age and risk factors for bacteremia were not different between groups, except there were more immunocompromised patients in the on-duty cohort (35.2%) compared to off-duty cohort (5.9%) [p = 0.01]. Median [IQR] time to first attempted patient contact was significantly shorter in the on-duty cohort at 0.8 h [0.4–2.8] vs 5.6 h [1.4–11.7] (p = 0.025). A pharmacist acted upon 93% of all cultures, including several resulting during off-duty hours. Secondary outcomes did not differ. Fourteen (25.9%) of on-duty cultures and six (35.3%) of off-duty cultures were deemed contaminants. Two recommendations in the off-duty group were inappropriate based on the infectious disease attending physician review. The lack of active voicemail was the main barrier to contacting a patient. ConclusionsIn patients discharged from the ED with subsequent positive blood cultures, time to attempted patient contact was significantly shorter when a pharmacist was on-duty. Our data emphasizes the importance of having a standardized practice in place to optimize ED patient care and outcomes and the benefit of a pharmacist's involvement in the process.

We’re Open: Caring for the Walking Well in a Rural Emergency Department

Emergency departments (EDs) are increasingly unable to cope with patient volume, leading staff to question the arrival of those seeking non-urgent care. However, these patients ideally should be afforded appropriate management and treatment. In 2014, the Carbonear General Hospital ED in Newfoundland and Labrador took decisive action, engaging front-line staff and shifting the focus of care away from why patients were visiting to prioritize how best to treat those who did. By 2019, the ED had not needed to resort to hallway medicine, despite a visit volume that increased to 30,000 patients over five years, and staff grew into a close-knit, quality improvement and community force. From this experience, it is evident that small investments in education and system redesign can shift attitudes toward ED care for patients, and provide support for primary care in the community. It has already started in one hospital — we’re open for assistance with primary and non-urgent care.

Effect of ED-based transitional care interventions by healthcare professionals providing transitional care in the emergency department on clinical, process and service use outcomes: a systematic review

ObjectiveSuboptimal transitional care (ie, needs assessment and coordination of follow-up care) in the emergency department (ED) is an important cause of ED revisits and hospital admissions and may potentially harm...

Protocol for a multi-site randomized controlled trial of a stepped-care intervention for emergency department patients with panic-related anxiety

BackgroundApproximately 40% of Emergency Department (ED) patients with chest pain meet diagnostic criteria for panic-related anxiety, but only 1–2% are correctly diagnosed and appropriately managed in the ED. A stepped-care model, which focuses on providing evidence-based interventions in a resource-efficient manner, is the state-of-the art for treating panic disorder patients in medical settings such as primary care. Stepped-care has yet to be tested in the ED setting, which is the first point of contact with the healthcare system for most patients with panic symptoms.MethodsThis multi-site randomized controlled trial (RCT) aims to evaluate the clinical, patient-centred, and economic effectiveness of a stepped-care intervention in a sample of 212 patients with panic-related anxiety presenting to the ED of Singapore’s largest public healthcare group. Participants will be randomly assigned to either: 1) an enhanced care arm consisting of a stepped-care intervention for panic-related anxiety; or 2) a control arm consisting of screening for panic attacks and panic disorder. Screening will be followed by baseline assessments and blocked randomization in a 1:1 ratio. Masked follow-up assessments will be conducted at 1, 3, 6, and 12 months. Clinical outcomes will be panic symptom severity and rates of panic disorder. Patient-centred outcomes will be health-related quality of life, daily functioning, psychiatric comorbidity, and health services utilization. Economic effectiveness outcomes will be the incremental cost-effectiveness ratio of the stepped-care intervention relative to screening alone.DiscussionThis trial will examine the impact of early intervention for patients with panic-related anxiety in the ED setting. The results will be used to propose a clinically-meaningful and cost-effective model of care for ED patients with panic-related anxiety.Trial registrationClinicalTrials.gov NCT03632356. Retrospectively registered 15 August 2018.

A critical appraisal of delirium clinical practice guidelines relevant to the care of older adults in the emergency department with a synthesis of recommendations: an umbrella review protocol

BackgroundUp to 35% of older adults present to the emergency department (ED) with delirium or develop the condition during their ED stay. Delirium associated with an ED visit is independently linked to poorer outcomes such as loss of independence, increased length of hospital stay, and mortality. Improving the quality of delirium care for older ED patients is hindered by a lack of knowledge and standards to guide best practice. High-quality clinical practice guidelines (CPGs) have the power to translate the complexity of scientific evidence into recommendations to improve and standardize practice. This study will identify and synthesize recommendations from high-quality delirium CPGs relevant to the care of older ED patients.MethodsWe will conduct a multi-phase umbrella review to retrieve relevant CPGs. Quality of the CPGs and their recommendations will be critically appraised using the Appraisal of Guidelines, Research, and Evaluation (AGREE)-II; and Appraisal of Guidelines Research and Evaluation – Recommendations Excellence (AGREE-REX) instruments, respectively. We will also synthesize and conduct a narrative analysis of high-quality CPG recommendations.DiscussionThis review will be the first known evidence synthesis of delirium CPGs including a critical appraisal and synthesis of recommendations. Recommendations will be categorized according to target population and setting as a means to define the bredth of knowledge in this area. Future research will use consensus building methods to identify which are most relevant to older ED patients.Trial registrationThis study has been registered in the Open Science Framework registries: https://doi.org/10.17605/OSF.IO/TG7S6.

Assessment of Emergency Department Care for Patients with Acute Pain Crisis after the Formation of a Multidisciplinary Team

Introduction:American Society of Hematology (ASH) guidelines recommend the rapid evaluation and treatment of patients presenting to the Emergency Department (ED) with pain from an acute vaso-occlusive episode (VOE) related to sickle cell disease (SCD). The treatment of severe pain from VOE in SCD is time dependent and time sensitive. Guidelines recommend that treatment for acute VOE with parental opioid analgesia occurs within 60 minutes of ED registration. With respect to the five-level Emergency Severity Index (ESI) triage tool, in which lower numbers indicate higher acuity, patients with SCD are to be assigned an Emergency Severity Index (ESI) of 2 indicating (a) greater disease burden, and (b) the need for high priority bed assignment. Objectives: We aimed to create a multidisciplinary team of providers to assess and address the existing barriers and facilitators to improving guideline adherence for the management of acute crises in our large academic health system. The primary outcome of this initiative was to improve guideline adherence by ensuring 90% or greater adherence to ESI 2 assignment to acknowledge illness severity as well as timely, within 60-minute opioid analgesia. Methods: In March 2020, we convened a multidisciplinary team of stakeholders to discuss the ED care of patients with SCD presenting with an acute VOE. The group comprises ED and infusion center nurse champions, nurse educators, nurse leaders, hematologists, palliative care specialists, primary care physicians, psychologists, advanced practice providers and other allied health professionals including social work and spiritual care. Initial monthly meetings established recommendations based on national guidelines and discussed interventions to improve guideline adherence including 1. a nursing driven pain management orderset with subcutaneous and intranasal opioids, 2. a best practice alert with the recommended guidelines. We conducted a retrospective review of ED visit data including all patients with a known diagnosis of sickle cell disease presenting to the ED with a chief complaint of acute pain related to VOE from January 2018-February 2020 and March 2020 to March 2022. We compared the before and after intervention using descriptive statistics. Results: Of the 760 unique encounters for acute pain related to sickle cell disease from 2018-2022, 406 visits occurred before the group formation and 354 visits occurred after the group formed. Mean age was 30.5 years (+/- 19.5) in the pre-intervention period compared to the 29.5 years (+/- 18.9) in the post intervention period. The time to the first opioid order placed pre-intervention averaged 53.3 mins (+/- 64.9) was not significantly different compared to the post period 75.2 mins (+/- 125.8; p =0.17). The proportion of patients assigned an ESI 2 changed from 49.3% to 50.5%. Conclusion: While there was a marginal increase in the ESI 2 assignment among SCD patients presenting in acute VOE, there was no significant change in the ED time to first opioid after the formation of a multidisciplinary team.

Redirecting Nonurgent Patients From the Pediatric Emergency Department to Their Pediatrician Office for a Same-Day Visit-A Quality Improvement Initiative.

Providing high-quality care in the appropriate setting to optimize value is a worthy goal of an efficient health system. Consequences of managing nonurgent complaints in the emergency department (ED) have been described including inefficiency, loss of the primary care-patient relationship, and delayed care for other ED patients. The purpose of this initiative was to redirect nonurgent patients arriving in the ED to their primary care office for a same-day visit, and the SMART AIM was to increase redirected patients from 0% of those eligible to 30% in a 12-month period. The setting was a pediatric ED (PED) and primary care office of a tertiary care pediatric medical system. The initiative utilized the electronic health record to identify and mediate the redirection of patients to the patient's primary care office after ED triage. The primary measurement was the percentage of eligible patients redirected. Additional measures included health benefits during the primary care visit (vaccines, well-visits) and a balancing measure of patients returned to the PED. The SMART AIM of >30% redirection was achieved and sustained with a final redirection rate of 46%. In total, 216 of 518 eligible patients were redirected, with zero untoward outcomes. The encounter time for redirected patients was similar for those who remained in the PED, and additional health benefits were appreciated for redirected patients. This initiative redirected nonurgent patients efficiently from a PED setting to their primary care office. The process is beneficial to patients and families and supports the patient-centered medical home. The balancing measure of no harm done to patients who accepted redirect reinforced the reliability of PED triage. The benefits achieved through the project highlight the value of the primary care-patient relationship and the continued need to improve access for patients and families.

Expressions of Compassion Fatigue by Emergency Department Nurses Caring for Patients With Opioid and Substance Use Disorders

IntroductionThe misuse of and addiction to opioids are a national public health crisis. The complexity of delivering patient care in emergency departments exposes nurses to stressful work situations with complex patient loads and increasing levels of compassion fatigue. Emergency nurses were asked about their feelings of compassion fatigue while caring for patients with opioid use and/or substance use disorders. MethodsTwenty-four focus groups with emergency nurses (N = 53) at a level I trauma center were conducted in late 2019 and early 2020 are used in this qualitative study using thematic analysis that identified 1 main theme of compassion fatigue with 3 subthemes (nurse frustration with addicted patients, emotional responses, and job satisfaction). ResultsFindings highlight that emergency nurses working with patients with opioid use and/or substance use disorders are dealing with a number of negative emotional stressors and frustrations, which in turn has increased their levels of compassion fatigue. These nurses repeatedly expressed feelings of increasing frustration with addicted patients, negative emotional responses, and decreasing levels of job satisfaction as components of their compassion fatigue. DiscussionThese emergency nurses identified 3 areas to improve their compassion: improved management support with encouragement across all work shifts, debriefing opportunities, and more education. Fostering a high level of self-awareness and understanding of how the work environment influences personal well-being are necessary strategies to avoid the frustrations and negative emotional responses associated with compassion fatigue.

Sustainability of a Clinical Decision Support Intervention for Outpatient Care for Emergency Department Patients With Acute Pulmonary Embolism

Physicians commonly hospitalize patients presenting to the emergency department (ED) with acute pulmonary embolism (PE), despite eligibility for safe outpatient management. Risk stratification using electronic health record-embedded clinical decision support systems can aid physician site-of-care decision-making and increase safe outpatient management. The long-term sustainability of early improvements after the cessation of trial-based, champion-led promotion is uncertain. To evaluate the sustainability of recommended site-of-care decision-making support 4 years after initial physician champion-led interventions to increase outpatient management for patients with acute PE. This retrospective cohort study was conducted in 21 US community hospitals in an integrated health system. Participants included adult patients presenting to the ED with acute PE. Study sites had participated in an original decision-support intervention trial 4 years prior to the current study period: 10 sites were intervention sites, 11 sites were controls. In that trial, decision support with champion promotion resulted in significantly higher outpatient management at intervention sites compared with controls. After trial completion, all study sites were given continued access to a modified decision-support tool without further champion-led outreach. Data were analyzed from January 2019 to February 2020. ED treatment with a modified clinical decision support tool. The main outcome was frequency of outpatient management, defined as discharge home directly from the ED, stratified by the PE Severity Index. The safety measure of outpatient care was 7-day PE-related hospitalization. This study included 1039 patients, including 533 (51.3%) women, with a median (IQR) age of 65 (52-74) years. Nearly half (474 patients [45.6%]) were rated lower risk on the PE Severity Index. Overall, 278 patients (26.8%) were treated as outpatients, with only four 7-day PE-related hospitalizations (1.4%; 95% CI, 0.4%-3.6%). The practice gap in outpatient management created by the earlier trial persisted in the outpatient management for patients with lower risk: 109 of 236 patients (46.2%) at former intervention sites vs 81 of 238 patients (34.0%) at former control sites (difference, 12.2; [95% CI, 3.4-20.9] percentage points; P = .007), with wide interfacility variation (range, 7.1%-47.1%). In this cohort study, a champion-led, decision-support intervention to increase outpatient management for patients presenting to the ED with acute pulmonary embolism was associated with sustained higher rates of outpatient management 4 years later. The application of our findings to improving sustainability of practice change for other clinical conditions warrants further study.

Fallacy of Median Door-to-ECG Time: Hidden Opportunities for STEMI Screening Improvement.

BackgroundST‐segment elevation myocardial infarction (STEMI) guidelines recommend screening arriving emergency department (ED) patients for an early ECG in those with symptoms concerning for myocardial ischemia. Process measures target median door‐to‐ECG (D2E) time of 10 minutes.Methods and ResultsThis 3‐year descriptive retrospective cohort study, including 676 ED‐diagnosed patients with STEMI from 10 geographically diverse facilities across the United States, examines an alternative approach to quantifying performance: proportion of patients meeting the goal of D2E≤10 minutes. We also identified characteristics associated with D2E>10 minutes and estimated the proportion of patients with screening ECG occurring during intake, triage, and main ED care periods. We found overall median D2E was 7 minutes (IQR:4–16; range: 0–1407 minutes; range of ED medians: 5–11 minutes). Proportion of patients with D2E>10 minutes was 37.9% (ED range: 21.5%–57.1%). Patients with D2E>10 minutes, compared to those with D2E≤10 minutes, were more likely female (32.8% versus 22.6%, P=0.005), Black (23.4% versus 12.4%, P=0.005), non‐English speaking (24.6% versus 19.5%, P=0.032), diabetic (40.2% versus 30.2%, P=0.010), and less frequently reported chest pain (63.3% versus 87.4%, P<0.001). ECGs were performed during ED intake in 62.1% of visits, ED triage in 25.3%, and main ED care in 12.6%.ConclusionsExamining D2E>10 minutes can identify opportunities to improve care for more ED patients with STEMI. Our findings suggest sex, race, language, and diabetes are associated with STEMI diagnostic delays. Moving the acquisition of ECGs completed during triage to intake could achieve the D2E≤10 minutes goal for 87.4% of ED patients with STEMI. Sophisticated screening, accounting for differential risk and diversity in STEMI presentations, may further improve timely detection.

The effect of display size on ultrasound interpretation

Ultrasound (US) is an essential component of emergency department patient care. US machines have become smaller and more affordable. Handheld ultrasound (HUS) machines are even more portable and easy to use at the patient's bedside. However, miniaturization may come with consequences. The ability to accurately interpret ultrasound on a smaller screen is unknown. This pilot study aims to assess how screen size affects the ability of emergency medicine clinicians to accurately interpret US videos. This pilot study enrolled a prospective convenience sample of emergency medicine physicians. Participants completed a survey and were randomized to interpret US videos starting with either a phone-sized screen or a laptop-sized screen, switching to the other device at the halfway point. 50 unique US videos depicting right upper quadrant (RUQ) views of the Focused Assessment with Sonography in Trauma (FAST) examination were chosen for inclusion in the study. There were 25 US videos per device. All of the images were previously obtained on a cart-based machine (Mindray M9) and preselected by the study authors. Participants answered "Yes" or "No" in response to whether they identified free fluid. The time that each participant took to interpret each video was also recorded. Following the assessment, participants completed a post-interpretation survey. The goal of the pilot was to determine the accuracy of image interpretation on a small screen as compared to a laptop-sized screen. Statistical analyses were performed using MATLAB (The MathWorks, Inc., Natick, MA). Nonparametric statistical tests were utilized to compare subgroups, with a Wilcoxon signed rank test used for paired data and a Wilcoxon rank sum test for unpaired data. 52 emergency medicine physicians were enrolled in the study. The median accuracy of US interpretation for phone versus laptop image screen was 88.0% and 87.6% (p=0.67). The mean time to interpret with phone versus laptop screen was 293 and 290s (p=0.66). The study found no statistically significant difference in the accuracy of US interpretation nor time spent interpreting when the pre-selected RUQ videos generated on a cart-based ultrasound machine were reviewed on a phone-sized versus a laptop-sized screen. This pilot study suggests that the accuracy of US interpretation may not be dependent upon the size of the screen utilized.