Emergency Department Placement Research Articles

Accuracy of colour Doppler ultrasound for nasogastric tube placement in emergency department: A prospective observational study.

Nasogastric tube (NGT) placement is a common procedure in EDs. Successful NGT placement reduces complications such as aspiration pneumonia, pneumothorax and mortality. While chest radiography is the gold standard for confirmation, colour Doppler ultrasonography (CDU) has demonstrated high accuracy. As its applicability in the ED remains underexplored, the present study evaluates the accuracy of CDU in confirming NGT placement in the ED. A prospective observational study was conducted in a tertiary hospital ED from October 2022 to October 2023. Adult patients requiring NGT insertion were eligible. NGT placement was performed using a standardised protocol and confirmed with CDU and chest radiography. Accuracy of CDU was assessed against chest radiography, and procedural times for confirmation were compared using the Kruskal-Wallis H test. Of 157 patients screened, 144 were included. CDU demonstrated 92.45% (95% confidence interval 85.67-96.69) sensitivity, 80.56% (63.98-91.81) specificity, positive predictive value 0.93 (0.88-0.96), negative predictive value 0.78 (0.64-0.88), positive likelihood ratio 4.75 (2.44-9.27) and negative likelihood ratio 0.09 (0.05-0.19). The median (interquartile range) confirmation times were 3.0 min (2.0-3.0) for CDU and 42.0 min (30.0-55.0) for radiography (P < 0.001). CDU should not currently be used as a standalone method for confirming NGT placement due to its limitations and risk of false-positive results. Further research is required to address these challenges before considering its clinical implementation.

Experiences of Physiotherapy Students, Health Care Providers, and Patients with a Role-Emerging Student Clinical Placement in an Emergency Department: A Qualitative Study.

Purpose: To understand the experiences and perspectives of physiotherapy (PT) students, their clinical instructor, nurses, physicians, and patients with a role-emerging student clinical placement in an emergency department (ED) and to identify barriers and facilitators in implementing this placement model. Method: We conducted qualitative semi-structured interviews with 6 PT students, 1 PT clinical instructor, 15 nurses, 12 physicians, and 17 patients. Five researchers independently coded the transcribed interviews and performed thematic analysis in an interpretive description tradition with frequent peer debriefing and reflexive discussions. Results: Students and their clinical instructor reported that the placement setting provided a unique learning opportunity. Patients and ED staff noted that involving the PT students in patient care delivery improved the musculoskeletal assessments and self-management advice provided to patients. Identified barriers included students' inability to chart in the electronic medical record, lack of bed space, and lack of clarity about students' scope and abilities. Reported facilitators included positive perceptions of the students' supervision and a perceived positive impact on patient care and the health care team. Conclusions: Participants reported positive experiences with the student ED placement and recommended similar placements in the future. Understanding barriers and facilitators in implementing PT student clinical placements in an ED can inform future placements.

The accuracy of ultrasonography in confirming endotracheal tube placement in emergency department

The accuracy of ultrasonography in confirming endotracheal tube placement in emergency department

The evaluation of compliance with iRefer guidelines for abdominal imaging and the impact of the normal abdominal radiograph on the clinical confidence and decision making of emergency clinicians

The evaluation of compliance with iRefer guidelines for abdominal imaging and the impact of the normal abdominal radiograph on the clinical confidence and decision making of emergency clinicians

Saline Flush versus Chest x ray in Confirmation of Central Venous Catheter Placement; a Diagnostic Accuracy Study.

Central venous catheterization (CVC) is a commonly performed procedure in critically ill patients of emergency department. This study was designed to compare the diagnostic accuracy of saline flush with CXR in confirmation of above-the-diaphragm CVC placement. This prospective cross sectional study was conducted on adult patients in need of CVC placement in emergency department. Placement Confirmation was performed with saline flush method and CXR, then chest computed tomography (CT) was performed as the gold standard. The screening performance characteristics of the two methods were calculated and compared using SPSS 21 and STATA 11. 103 cases with the mean age of 57.18±9.3 (35 -80) years were studied (52.4% male). The mean duration of procedure was 2.5±1.24 in saline flush and 32.11±5.52 minutes in CXR method (P<0.001(. The area under the ROC curves for saline flush and CXR in confirmation of CVC placement were 0.90 (95%CI: 0.70 - 0.100) and 0.80 (95%CI: 0.55 - 0.100), respectively (p = 0.317). The sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio of saline flush were 80%, 100%, 100, 98.9%, Infinity, and 0.01, respectively. These measures were 60%, 100%, 100%, 98%, Infinity, and 0.02 for CXR, respectively. It seems that saline flush method could be considered as a safe, rapid, and accurate bedside method for CVC placement confirmation in emergency department.

Teaching bedside ultrasound to medical students.

Point-of-care ultrasound (POCUS) assists in the rapid diagnosis of conditions in the Emergency Department (ED). POCUS has been introduced to international medical curricula; however, there is no described implementation of clinically focused POCUS education in Australian medical schools. We wanted to investigate whether a formal curriculum can be effective and feasible in an Australian medical school. Pre-post intervention study of a focused curriculum based on the Extended Focused Assessment with Sonography in Trauma (E-FAST) examination, consisting of online and practical teaching, was implemented for Year-4 and -5 medical students. An online questionnaire was used to measure knowledge, image interpretation and confidence prior to the intervention. After the intervention and ED placement, the questionnaire was repeated and students were assessed performing the E-FAST examination on a healthy volunteer. Twenty-seven students participated in both the pre-intervention and post-intervention questionnaires. There was a significant improvement in confidence in performing the E-FAST after the intervention [p<0.001]. There was also a significant improvement in ultrasound knowledge and image interpretation skills. For the formative assessment, the mean score was 31.8 out of 33 and 22 of 27 students (82%) passed the assessment. There is no described implementation of clinically focused point-of-care ultrasound education in Australian medical schools CONCLUSIONS: We have demonstrated that a focused curriculum can improve POCUS knowledge and skills. The curriculum was feasible and well received. With global trends to include POCUS in medical education, Australian institutions should consider upskilling their medical graduates.

A longitudinal study of well-being, confidence and competence in junior doctors and the impact of emergency medicine placements

ObjectivesTo measure levels of, and change in junior doctor well-being, confidence and self-reported competence over their second postgraduate training year and the impact of emergency department (ED) placements on these...

Emergency Department Placement and Management of Indwelling Urinary Catheters in Older Adults: Knowledge, Attitudes, and Practice

Emergency Department Placement and Management of Indwelling Urinary Catheters in Older Adults: Knowledge, Attitudes, and Practice

310 Outcome of Emergency Department Placement of Transvenous Pacemakers

310 Outcome of Emergency Department Placement of Transvenous Pacemakers

An evaluation of foundation doctor training: a mixed-methods study of the impact on workforce well-being and patient care [the Evaluating the Impact of Doctors in Training (EDiT) study

BackgroundA major reform of junior doctor training was undertaken in 2004–5, with the introduction of foundation training (FT) to address perceived problems with work structure, conditions and training opportunities for postgraduate doctors. The well-being and motivation of junior doctors within the context of this change to training (and other changes such as restrictions in working hours of junior doctors and increasing demand for health care) and the consequent impact upon the quality of care provided is not well understood.ObjectivesThis study aimed to evaluate the well-being of foundation year 2 (F2) doctors in training. Phase 1 describes the aims of delivering foundation training with a focus on the role of training in supporting the well-being of F2 doctors and assesses how FT is implemented on a regional basis, particularly in emergency medicine (EM). Phase 2 identifies how F2 doctor well-being and motivation are influenced over F2 and specifically in relation to EM placements and quality of care provided to patients.MethodsPhase 1 used semistructured interviews and focus groups with postgraduate deanery leads, training leads (TLs) and F2 doctors to explore the strategic aims and implementation of FT, focusing on the specialty of EM. Phase 2 was a 12-month online longitudinal study of F2 doctors measuring levels of and changes in well-being and motivation. In a range of specialties, one of which was EM, data from measures of well-being, motivation, intention to quit, confidence and competence and job-related characteristics (e.g. work demands, task feedback, role clarity) were collected at four time points. In addition, we examined F2 doctor well-being in relation to quality of care by reviewing clinical records (criterion-based and holistic reviews) during the emergency department (ED) placement relating to head injury and chronic obstructive pulmonary disease (COPD).ResultsPhase 1 of the study found that variation exists in how successfully FT is implemented locally; F2 lacks a clearly defined end point; there is a minimal focus on the well-being of F2 doctors (only on the few already shown to be ‘in difficulty’); the ED presented a challenging but worthwhile learning environment requiring a significant amount of support from senior ED staff; and disagreement existed about the performance and confidence levels of F2 doctors. A total of 30 EDs in nine postgraduate medical deaneries participated in phase 2 with 217 foundation doctors completing the longitudinal study. F2 doctors reported significantly increased confidence in managing common acute conditions and undertaking practical procedures over their second foundation year, with the biggest increase in confidence and competence associated with their ED placement. F2 doctors had levels of job satisfaction and anxiety/depression that were comparable to or better than those of other NHS workers, and adequate quality and safety of care are being provided for head injury and COPD.ConclusionsThere are ongoing challenges in delivering high-quality FT at the local level, especially in time-pressured specialties such as EM. There are also challenges in how FT detects and manages doctors who are struggling with their work. The survey was the first to document the well-being of foundation doctors over the course of their second year, and average scores compared well with those of other doctors and health-care workers. F2 doctors are benefiting from the training provided as we found improvements in perceived confidence and competence over the year, with the ED placement being of most value to F2 doctors in this respect. Although adequate quality of care was demonstrated, we found no significant relationships between well-being of foundation doctors and the quality of care they provided to patients, suggesting the need for further work in this area.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

What You See (Sonographically) Is What You Get: Vein and Patient Characteristics Associated With Successful Ultrasound‐guided Peripheral Intravenous Placement in Patients With Difficult Access

Ultrasound (US) has been shown to facilitate peripheral intravenous (IV) placement in emergency department (ED) patients with difficult IV access (DIVA). This study sought to define patient and vein characteristics that affect successful US-guided peripheral IV placement. This was a prospective observational study of US-guided IV placement in a convenience sample of DIVA patients in an urban, tertiary care ED. DIVA patients were defined as having any of the following: at least two failed IV attempts or a history of difficult access plus the inability to visualize or palpate any veins on physical exam. Patient characteristics (demographic information, vital signs, and medical history) were collected on enrolled patients. The relationships between patient characteristics, vein depth and diameter, US probe orientation, and successful IV placement were analyzed. A total of 169 patients were enrolled, with 236 attempts at access. Increasing vessel diameter was associated with a higher likelihood of success (odds ratio [OR] = 1.79 per 0.1-cm increase in vessel diameter, 95% confidence interval [CI] = 1.37 to 2.34). Increasing vessel depth did not affect success rates (OR = 0.96 per 0.1-cm increase of depth, 95% CI = 0.89 to 1.04) until a threshold depth of 1.6 cm, beyond which no vessels were successfully cannulated. Probe orientation and patient characteristics were unrelated to success. Success was solely related to vessel characteristics detected with US and not influenced by patient characteristics or probe orientation. Successful DIVA was primarily associated with larger vessel, while vessel depth up to >1.6 cm and patient characteristics were unrelated to success. Clinically, if two vessels are identified at a depth of <1.6 cm, the larger diameter vessel, even if comparatively deeper, should yield the greatest likelihood of success.