Implementation and evaluation of an integrated computerized asthma management system in a pediatric emergency department: A randomized clinical trial

ObjectiveThe use of evidence-based guidelines can improve the care for asthma patients. We implemented a computerized asthma management system in a pediatric emergency department (ED) to integrate national guidelines. Our objective was to determine whether patient eligibility identification by a probabilistic disease detection system (Bayesian network) combined with an asthma management system embedded in the workflow decreases time to disposition decision.MethodsWe performed a prospective, randomized controlled trial in an urban, tertiary care pediatric ED. All patients 2–18 years of age presenting to the ED between October 2010 and February 2011 were screened for inclusion by the disease detection system. Patients identified to have an asthma exacerbation were randomized to intervention or control. For intervention patients, asthma management was computer-driven and workflow-integrated including computer-based asthma scoring in triage, and time-driven display of asthma-related reminders for re-scoring on the electronic patient status board combined with guideline-compliant order sets. Control patients received standard asthma management. The primary outcome measure was the time from triage to disposition decision.ResultsThe Bayesian network identified 1339 patients with asthma exacerbations, of which 788 had an asthma diagnosis determined by an ED physician-established reference standard (positive predictive value 69.9%). The median time to disposition decision did not differ among the intervention (228 min; IQR = (141, 326)) and control group (223 min; IQR = (129, 316)); (p = 0.362). The hospital admission rate was unchanged between intervention (25%) and control groups (26%); (p = 0.867). ED length of stay did not differ among intervention (262 min; IQR = (165, 410)) and control group (247 min; IQR = (163, 379)); (p = 0.818).ConclusionsThe control and intervention groups were similar in regards to time to disposition; the computerized management system did not add additional wait time. The time to disposition decision did not change; however the management system integrated several different information systems to support clinicians’ communication.     

The knowledge desired by emergency medical service managers of their ambulance clinicians – A modified Delphi study

AimThe aim of the study was to identify the types of knowledge that Swedish Emergency Medical Service (EMS) managers considered desirable in their Ambulance Clinicians.BackgroundEmergency medical service managers are responsible for organisational tasking and in this are dependent on the knowledge possessed by their ambulance clinicians. It would therefore be of value to explore EMS managers’ approach to this knowledge.DesignA modified Delphi method in three rounds.MethodsIn total thirty-six EMS managers participated, and twenty-four finished all three rounds. They were encouraged to rate each sub-category, and the ten with the highest mean were interdependently ranked in the final round.ResultsFive categories and twenty-six sub-categories emerged in the first round, covering knowledge related to; contextual aspects, medical and holistic assessments, formal education and organisational issues. Eventually, the sub-category ‘Knowledge to assess the patient’s situation from a holistic perspective’ was the highest ranked, followed by ‘Medical knowledge to assess and care for different diseases’ and ‘Knowledge to be able to care for critically ill patients’.ConclusionsTaken together the knowledge areas address essentially medical care, contextual aspects and nursing. The boundaries between these can sometimes be seen as elusive, calling for ambulance clinicians to balance these areas of knowledge.     

A survey of patients with bed bugs in the emergency department

Bed bugs are one of the most important human ectoparasites in the United States, and a growing problem in the emergency department. We evaluated 40 emergency department (ED) patients found with a bed bug. The data show that ED patients with bed bugs are statistically more likely to be male, older, more likely to be admitted to the hospital, have higher triage emergency severity index (ESI) scores, and arrive by ambulance than the general ED patient population (p < 0.05). On average bed bugs were found 108 min after a patient arrived to the ED, after 35% of subjects had already received a blood draw, and after 23% had already received a radiology study; putting other ED patients and staff at risk for acquiring the infestation. We found that 13% and 18% of subjects had wheezing and a papular rash, respectively on physical exam. Of those patients found with a bed bug in the ED, 42% reported having bed bugs at home and 21% reporting having a possible home infestation.