Emergency Department patient perceptions of privacy and confidentiality

The study objective was to determine if Emergency Department (ED) patients experience breaches of privacy and confidentiality during their ED stay and to determine if the type of room in which the patient is placed affects privacy. We surveyed a convenience sample of ED patients at the conclusion of their ED stay regarding their privacy and confidentiality. Overall, 36% of patients overheard conversations with similar frequencies in walled and curtained rooms. The location of conversations overheard varied depending on the type of patient room, as curtained rooms allowed conversations from adjacent rooms to be overheard and walled rooms allowed more conversations from the hallway or nursing station to be overheard. Patients felt more comfortable giving their history and having physical examinations performed in walled vs. curtained rooms. Inappropriate or unprofessional comments by staff were heard by 1.6% of patients. Health care providers in the ED need to be aware of breaches in confidentiality and privacy, as our patients deserve respect of their privacy and confidentiality during their ED visit.     

Improving patient privacy and confidentiality in one regional Emergency Department – A quality project

Background

Patient privacy and confidentiality (PPaC) is an important consideration for nurses and other members of the health care team. Can a patient expect to have confidentiality and in particular privacy in the current climate of emergency health care? Do staff who work in the Emergency Department (ED) see confidentiality as an important factor when providing emergency care? These questions are important to consider.

Methods

This is a two phased quality improvement project, developed and implemented over a six month period in a busy regional, tertiary referral ED.

Results

Issues identified for this department included department design and layout, overcrowding due to patient flow and access block, staff practices and department policies which were also impacted upon by culture of the team, and use of space.

Conclusions

Changes successful in improving this issue include increased staff awareness about PPaC, intercom paging prior to nursing handover to remove visitors during handover, one visitor per patient policy, designated places for handover, allocated bed space for patient reviews/assessment and a strategy to temporarily move the patient if procedures would have been undertaken in shared bed space. These are important issues when considering policy, practice and department design in the ED.     

Emergency department design and patient perceptions of privacy and confidentiality

The study objective was to determine if Emergency Department (ED) patients experience fewer breaches of privacy and confidentiality in a larger, renovated ED compared to a similar patient population before renovation. We surveyed a convenience sample of patients regarding their privacy and confidentiality at the conclusion of their ED stay. In the post-renovation ED, 14% of patients overheard conversations about themselves or other patients, compared to 36% of patients in the ED before renovation. This was likely a result of both an increase in the department size (564 square feet per treatment space post-renovation vs. 375 square feet per treatment space pre-renovation) and the elimination of rooms separated only by curtains. Issues of privacy and confidentiality should be taken into consideration in the design of new departments and those to be renovated.     

Confidentiality and Privacy Breaches in a University Hospital Emergency Department

Objective : To determine the frequency of visual and auditory confidentiality and privacy breaches in a university ED.
Methods : A prospective, observational study of medical personnel behavior was performed using participant and direct observation techniques. Observations were made in a university tertiary referral and trauma center emergency facility. Observers recorded auditory and visual confidentiality and privacy breaches in various patient care areas during 1-hour periods. Information collected included patient name or room number, complaint/diagnosis, diagnostic tests, past medical history, and personal information. It was then determined whether a clear identification of the patient's name or face and/or an association to his or her clinical course could be made.
Results : All members of the health care team committed confidentiality and privacy breaches. Frequency of breaches was dependent on room location and design. Breaches in the triage/waiting area occurred for >53% of the patients. Breaches near the physician/nursing station ranged from 3 to 24 per hour and 1.5 to 3.4 per patient hour. Other inappropriate comments also were noted. One hundred consecutive patients and family members were interviewed at ED release, with only 2/100 having noticed the status board, although neither could recall any specific details.
Conclusion : Confidentiality and privacy breaches occur in a university ED by all members of the health care team. The ED architecture and floor plan affect patient confidentiality and privacy.     

An interdisciplinary mock trial involving pharmacy, law, and ethics.

OBJECTIVE: To describe an innovative, interdisciplinary approach to illustrate the relationship between healthcare ethics and law. METHODS: A mock trial was created for students enrolled in the Samford University McWhorter School of Pharmacy and Department of Paralegal Education. The trial served as the starting point to discuss confidentiality in health care in general and pharmacy in particular. Students from both programs served on the jury and rendered a verdict after the case had been presented. The Alabama statute concerning exceptions to confidentiality is reviewed. The students' assignment and lessons learned are also described. SUMMARY: Students thoroughly enjoyed this method of teaching and learning. The mock trial provided an interesting way to exemplify the often complex relationship between healthcare ethics and law.     

Isolated Adrenal Hematoma Presenting as Acute Right Upper Quadrant Pain

Background: Adrenal hematoma is an infrequent occurrence in the setting of adult trauma care. It is typically associated with diffuse abdominal injury, and its presence is commonly correlated with high injury severity and mortality. Objectives: To discuss the recognition of adrenal hematoma as a cause of right upper quadrant pain. Case Report: We present the case of a 23-year-old man who presented to the Emergency Department (ED) with acute right upper quadrant pain after blunt trauma to the area; he was initially diagnosed with an abdominal contusion with an incidental adrenal adenoma. After experiencing continued pain for 2 days, the patient returned to the ED for re-evaluation. Subsequent imaging revealed that the adrenal mass had enlarged, and it was determined that this patient had suffered an acute adrenal hematoma. The lesion was determined to be self-limited and the patient was treated with supportive care. Follow-up images 8 weeks later revealed resolution of the hematoma and the patient reported complete resolution of symptoms. We also discuss adrenal hematoma in the trauma setting and explain that in our patient, given the clinical scenario and statistical evidence, an initial diagnosis of adrenal hematoma should be favored over abdominal contusion with incidental adenoma. Conclusion: We describe a case of a traumatic isolated adrenal hematoma that presents acutely as right upper quadrant pain. This unusual presentation highlights the need for recognition of the adrenal gland as a potential cause of right upper quadrant pain in the trauma setting.     

Ketamine-induced Catalepsy during Adult Sedation in the Emergency Department

Background

Ketamine continues to rise in popularity for procedural sedation in the Emergency Department (ED) for both adult and pediatric patients. The medication has a good safety profile and is well tolerated in the majority of patients. However, the Emergency Physician should be aware of the full range of side-effects that may be encountered, so as to best anticipate and prepare for potential complications.

Objectives

We describe two cases of catalepsy (muscle hypertonia with dissociation) in patients undergoing sedation with ketamine.

Case Report

In the first case, a patient presented to the ED after a prehospital awake nasal intubation for an exacerbation of chronic obstructive pulmonary disease. After sedation with ketamine, he was extubated and transitioned to bi-level positive pressure ventilation. Shortly after receiving ketamine, he exhibited severe muscular hypertonia of the upper extremities with facial grimacing. A second patient underwent ketamine sedation for reduction of a shoulder dislocation. After medication administration, he exhibited full body muscular hypertonicity, interfering briefly with the procedure. In both patients, catalepsy resolved spontaneously.

Conclusions

Ketamine-induced catalepsy is a self-limited side-effect that has the potential to interfere with procedures performed under sedation.     

Legal aspects of continence: disclosure of a medical condition

This article explores the issue of patient confidentiality and the exceptions to that duty. Even if a health professional considers that there would be a public interest in a patient's condition being made known, the patient is entitled to have his confidential information kept secret. There are recognized exceptions in law to the duty of confidentiality, and the guidance issued by the health professional registration bodies should be followed.     

Confidentiality. 1: Nurses' duty to respect patient confidentiality

Trust is at the heart of the nurse/patient relationship, yet many nurses find themselves in situations where they are tom between their duty of confidentiality to the patient and other duties. This series of articles seeks to analyse the source of the duty of confidentiality and discusses individual situations giving rise to conflict within the statutory law context.     

Legal principles of confidentiality and other public interests: Part 1

The principles of confidentiality are of paramount importance to nurses and all health professionals. This is explicitly so as the Common Law recognizes confidentiality and supports its importance. However, current practice must take cognizance of the realities of 21st century healthcare delivery - we live in an age of electronic data that is potentially very difficult to keep secret. New rules, protocols and guidelines are being formulated, and regulatory bodies such as the Nursing and Midwifery Council (NMC) reflect such rules in their codes of professional conduct. There is, however, a debate that is suggesting that the rules that relate to confidentiality may need to expand or even bend a little as innovate ways of obtaining, storing, utilizing and communicating data continue to occupy the minds of government and those who formulate legal principles (British Medical Association, 2005). This series of three articles will explore these issues. The first part is a review of case law that explores the fundamental legal principles that underpin confidentiality. The second will concentrate on a review of the guidelines that are to be found in professional regulatory documentation - the NMC and the General Medical Council as they relate to the legal principles. The third and last part will review and reflect on issues that relate expressly to the implementation of electronic patient records, with a review of appropriate statutory legislation and principles of common law.     

Infective endocarditis of native valve after anterior nasal packing

We present a case report of a patient who was previously treated for spontaneous epistaxis with a petroleum jelly gauze (0.5 in x 72 in) anterior nasal packing filled with an antibiotic ointment, along with prophylactic oral clindamycin. The patient presented with fever and hypotension 3 days after the nasal packing. Her blood cultures grew methicillin-resistant Staphylococcus aureus and the transesophageal echocardiography showed vegetation on the atrial surface of the posterior mitral valve leaflet, confirming the diagnosis of bacterial endocarditis attributable to nasal packing. Several case reports discuss toxic shock syndrome after nasal packing, but none describe endocarditis of the native heart valves subsequent to anterior nasal packing. Current guidelines on endocarditis prophylaxis produced by the American Heart Association, European Cardiac Society, and British Cardiac Society together with published evidence do not recommend endocarditis prophylaxis for patients with native heart valves undergoing anterior nasal packing.     

Emergency Department Vancomycin Use: Dosing Practices and Associated Outcomes

Background

Emergency Department (ED) dosing of vancomycin and its effect on outcomes has not been examined.

Study Objective

To describe current vancomycin dosing practices for ED patients, focusing on patient factors associated with administration, dosing accuracy based on patient body weight, and clinical outcomes.

Methods

Single-center, retrospective cohort study of vancomycin administered in the ED over 18 months in an academic, tertiary care ED. Data were collected on 4656 patients. Data were analyzed using a generalized estimating equations model to account for multiple doses being administered to the same patient.

Results

The ED dose was continued, unchanged, in 2560 admitted patients (83.8%). The correct dose was given 980 times (22.1%), 3143 doses (70.7%) were underdosed, and 318 were overdosed (7.2%). Increasing weight was associated with underdosing (adjusted odds ratio 1.52 per 10 kg body weight, p < 0.001). Patients who received doses of vancomycin > 20 mg/kg had longer hospital length of stay (p = 0.005); were more likely to spend ≥ 3 days in the hospital (odds ratio [OR] 1.49; 95% confidence interval [CI] 1.12–1.98, p = 0.006); and more likely to die (OR 1.88; 95% CI 1.22–2.90, p = 0.004).

Conclusion

In this largest study to date examining ED vancomycin dosing, vancomycin was commonly given. Dosing outside the recommended range was frequent, and especially prevalent in patients with a higher body weight. The ED dose of vancomycin was frequently continued as an inpatient, regardless of dosing accuracy. There is significant room for improvement in dosing accuracy and indication. Vancomycin dosing in the ED may also affect clinical outcomes.     

Patient confidentiality, clinical data and NHS research--a researcher's guide

More stringent research governance in the NHS has led to an increased focus on the importance of patient confidentiality. But relatively low levels of knowledge of the Data Protection Act and common law duty of confidentiality among some researchers and research managers cause difficulties in getting research projects off the ground. The authors outline the main issues surrounding research, data protection and patient confidentiality, and provide guidance for researchers, clinicians and managers on how to conduct research appropriately.     

Drug-seeker lists are dangerous at best, require tight administrative controls

It is extremely risky to keep lists of people who show up frequently in your ED seeking drugs, and the lists may not accomplish much anyway. If you allow staff or physicians to keep such lists, you should establish tight controls. Lists can pose confidentiality concerns. Never use a list before a patient is properly screened. Take a hard-line approach with obvious drug seekers to diminish repeat visits.     

Visually impaired drivers and public protection vs confidentiality

Patients consenting to health care are usually content for information to be disclosed to other team members if it will help to provide effective health care. They rarely state at the commencement of a conversation that information is 'secret', but assume that professionals will use the information solely to assist their care. Nurses working in the field of ophthalmology regularly test patients' visual acuity. Not all patients' eyesight reaches the minimum standard required by the Driver and Vehicle Licensing Agency. What should nurses do if test results reveal a patient who they know is a driver and whose eyesight does not meet the minimum standard for driving? Should the nurse breach confidentiality? There may be a public safety issue. This article discusses the legal, ethical, professional and employment duty of the nurse, giving examples from previous case law and highlighting the standards of confidentiality required of those employed as professionals in the health service.     

Legal issues associated with genetics

With the evolution of genetic research, legal issues have emerged related to the health care delivery industry and the protection of patient information. The use of genetics or genetic enhancement expands the role of the nurse and also brings a new perspective to the nurse-patient relationship. Nurses now must discern their role in relation to patient privacy and confidentiality. In addition to reviewing the ethical and legal dilemmas of registered nurses in clinical practice, the nursing profession must review the level of responsibility appropriate when using genetic and or experimental treatments, especially when the nurse is not the primary care provider or the leader of the research team. Nurses will have to delve into privacy and confidentiality issues associated with genetic research. Although little case law exists on the relationship of nursing to genetic research and treatments, the implications of experimental research and policy associated with genetics must be analyzed to better understand their impact on the scope of nursing practice.     

Intestinal perforation after the incidental ingestion of a fishhook

The vast majority (75%) of ingested foreign bodies pass through the gastrointestinal tract spontaneously and require no surgical intervention. Indeed, the emergency department (ED) management of ingested foreign bodies is largely based on the age of the patient and the time elapsed since ingestion, as well as the physical characteristics of the foreign body. We present this case to emphasize the importance of radiologic imaging studies in the ED management of adults with an acute abdomen of unknown etiology. A 44-year-old woman presented to the ED with right upper quadrant pain of 2 days duration. There was evidence of localized peritoneal irritation on physical examination. A radio-opaque fishhook-shaped object was visualized on the plain abdominal film. Helical computed tomography demonstrated a metallic object in the small bowel with extension through the thickened and inflamed intestinal wall. The patient did not report known ingestion of a foreign body. At exploratory laparotomy, a fishhook was recovered despite the patient's unawareness of having ingested a foreign body. The ED management of an otherwise healthy adult with an acute abdomen was facilitated with plain film radiography and abdominal computed tomography.     

Decision-making processes of a nurse working in mental health,regarding disclosure of confidential personal health information of a patient assessed as posing a risk

BackgroundNurses working in mental health routinely face difficult decisions regarding confidentiality and disclosure of patient information. There is public interest in protecting patient confidentiality, and there is a competing public interest in disclosing relevant confidential information to protect the patient or others from harm. However, inappropriate disclosures may constitute a breach of confidentiality. Despite the gravity of this situation, there is a paucity of literature to guide nurses’ decision-making processes regarding confidentiality and disclosure.AimTo examine decision-making processes of a nurse working in mental health, regarding disclosure of personal health information of a patient assessed as posing a risk.MethodsQualitative interpretivist approach using thematic analysis of data derived from an instrumental case study of NK v Northern Sydney Central Coast Area Health Service 2010, a Civil and Administrative Tribunal matter in New South Wales, Australia.FindingsThree important legal concerns relevant to nurses’ decision-making processes are illuminated. Firstly, for risk assessment there was an emphasis on a static notion of dangerousness. Secondly, rules of confidentiality and disclosure were not adequately observed. Thirdly, confidential information was disclosed without valid justification.DiscussionInappropriate decision-making processes that may lead to a breach of patient confidentiality were evident in the findings. Gaps in understanding nurses’ decision-making processes pertaining to confidentiality and disclosure of patient information that may be addressed by future research were also revealed.ConclusionFuture research that addresses gaps in understanding nurses’ decision-making processes identified by this instrumental case study would provide greater guidance for nurses when making decisions regarding confidentiality and disclosure related to risk.     

Duty of care in the emergency department

This paper explores issues that relate to the management of deliberate self-harm in the emergency department (ED) from a New South Wales perspective. A scenario that is typical to the ED is presented to illustrate the dilemma that nurses face and the implications for clinical practice. Confusion and concern regarding the treatment and detention of this type of patient in the ED can often result in the inappropriate use of the Mental Health Act. It is preferable for clinicians to be aware of the treatment options they have under duty of care rather than relying on the unfounded reassurance provided by scheduling a patient under the Mental Health Act. Communication and negotiation skills are highlighted as attributes that clinicians must develop and enhance to effectively manage difficult presentations to the ED.