Clinical supervision in the emergency department: a critical incident study

Objectives

To identify the key features of effective clinical supervision in the emergency department (ED) from the perspectives of enthusiastic consultants and specialist registrars. To highlight the importance of clinical supervision within emergency medicine, and identify obstructions to its occurrence in everyday practice.

Methods

A critical incident study was undertaken consisting of structured interviews, conducted by telephone or in person, with 18 consultants and higher level trainees selected for their interest in supervision.

Results

Direct clinical supervision of key practical skills and patient management steps was considered to be of paramount importance in providing quality patient care and significantly enhancing professional confidence. The adequacy of supervision varied depending upon patient presentation. Trainees were concerned with the competence and skills of their supervisor; consultants were concerned with wider systemic constraints upon the provision of adequate supervision to juniors.

Conclusions

The value of supervision extends to all patient presentations in the ED. The study raised questions concerning the appropriate attitudes and qualifications for supervisors. Protected supervisory time for those with trainees is mandatory, and must be incorporated within ED consultant job planning.     

急诊科情景模拟带教的做法与体会

为适应护理教学改革,培养护生在急诊临床抢救工作中的配合能力,采用情景模拟带教的方式,根据情景分析病情,提出问题,总结抢救过程,提高护生的抢救配合能力,取得了良好的效果。     

A possible role of ID-Migraine™ in the emergency department: study of an emergency department out-patient population

Headache symptoms account for 1–3% of admissions to an emergency department (ED). Most patients affected by a primary headache (PH) have migraine, although they are often misdiagnosed as 'headache not otherwise specified'. We investigated the possibility of using ID-Migraine (ID-M) to improve migraine recognition in the ED setting. We planned a pilot study involving ED out-patients with a diagnosis of PH. Diagnoses of a blinded headache expert were subsequently matched with the ID-M results. We tested ID-M on 230 patients (199 PH, 31 secondary headaches). Considering only PH, ID-M exhibited a sensitivity of 0.94 and specificity of 0.83 with a positive predictive value (PPV) of 0.99. The ID-M is a simple migraine screener with high sensitivity, high specificity and high PPV, even in an ED-derived population. Methodical use of this tool in an ED setting may, once a secondary headache has been excluded, lead to rapid diagnosis of migraine.     

A simulation study to improve quality of care in the emergency department of a community hospital

In this article, a computer simulation study to improve the quality of care at the emergency department at a community hospital in Lexington, Kentucky, is presented. The simulation model is capable of evaluating the quality of care in terms of length of stay, waiting times, and patient elopement and has been validated by being compared with the data collected in the emergency department. Sensitivity analyses have been carried out to investigate the impact of workforce and diagnosis equipment on quality performance. The results suggest that, to ensure better clinical outcome, more nurses are needed; in addition, an additional computed tomography scanner is recommended. The model also shows that implementing team nursing policy (for 2 nurses) could lead to significant improvement in the emergency department's quality of care. Such a model provides a quantitative tool for continuous improvement and flow control in the emergency department and is also applicable to other departments in the hospital.     

Disposition of patients utilising the virtual emergency department service in southeast region of Melbourne (SERVED-1)

Objective

Supported by the state government, three health networks partnered to initiate a virtual ED (VED), as part of a broader roll-out of emergency telehealth services in Victoria. The aim of the present study (Southeast Region Virtual Emergency Department-1 [SERVED-1]) was to report the initial 5-month experience and included all patients assessed through the service over the first 5 months (1 February 2022 to 30 June 2022).

Methods

VED consults occurred after referral from paramedics in the pre-hospital setting. Electronic medical records were retrospectively reviewed for demographic, presenting complaint and outcome data. The primary outcome was the count of VED consultations. The secondary outcome was the proportion of patients where physical ED attendance was avoided within 72 h. The proportion of physical ED attendances avoided sub-grouped by primary presenting complaints were reported.

Results

There were 1748 patients who had a VED consultation, of which 1261 (72.1%; 95% confidence interval [CI] 70.0–74.2) patients had physical presentation to an ED avoided in the 72 h following the consult. There was a significant increase in consultations over the 5-month period (incidence rate ratio 1.27; 95% CI 1.23–1.31, P < 0.001) that was consistent in the three health services. The most common presenting complaints were COVID-19 and shortness of breath, and physical presentation was avoided most often among younger patients and those with COVID-19.

Conclusions

Initial experience demonstrated a significant increase in adoption of the service and an overall avoidance of physical ED attendance by a majority of patients. These results support ongoing VED consultations, complemented by follow up and health economic evaluations.     

Procedural sedation in children in the emergency department: A PREDICT study

Objective: To investigate current procedural sedation practice and compare clinical practice guidelines (CPG) for procedural sedation at Paediatric Research in Emergency Departments International Collaborative (PREDICT) sites. This will determine areas for improvement and provide baseline data for future multicentre studies. Methods: A questionnaire of specialist emergency physicians regarding demographics, general procedural sedation practice and specific sedation agents given to children. CPG for general sedation and sedation agents were obtained for each site. Results: Seventy‐five (71%) useable surveys returned from 105 potential respondents. Most commonly used agents were nitrous oxide (N₂O) (75, 100%), ketamine (total 72, 96%; i.v. 59, 83% and i.m. 22, 31%) and midazolam (total 68, 91%; i.v. 52, 81%, oral 47, 73%, intranasal 26, 41% and i.m. 6, 9%). Sedation was used for therapeutic and diagnostic procedures. Forty‐three (57%) used formal sedation records and sedation checklists and thirty‐one (41%) respondents reported auditing sedations. Four sites ran staff education and competency programmes. Nine sites had general sedation CPG, eight for ketamine, nine for N₂O, eight for midazolam (four parenteral, five oral and six intranasal) and three for fentanyl. No site had a guideline for propofol administration. Conclusion: Procedural sedation in this research network commonly uses N₂O, ketamine and midazolam for a wide range of procedures. Areas of improvement are the lack of guidelines for certain agents, documentation, staff competency training and auditing processes. Multicentre research could close gaps in terms of age cut‐offs, fasting times and optimal indications for various agents.     

急诊床旁超声远程临床应用现状及展望

采用文献综述的方法,对国内外公开发表的关于远程超声临床应用的文献和资料进行整理和分析,初步了解国内外远程超声临床各个方面的发展和应用。整理后发现,远程超声临床应用范围广,既可应用于院前急救,也可应用于院内远程超声会诊和远程监护等。常见应用于急诊科、产科、儿科、心血管内科等科室。远程超声有同步和异步两种实现模式。所使用的技术也开始从单一的电视监控或电话远程会诊逐渐发展为基于移动通讯设备、有线或无线网络等对数字、图像、语音等综合传输,5G技术的高速率、低延迟、大连接,以及云计算的大储存等应用于远程医疗和远程超声是近几年研究热点,将使得远程超声临床应用更加高效。     

A prospective study of pain control in the emergency department

The most common complaint in the emergency department is pain. The management of acute pain, however, has not been well studied. This prospective study was designed to assess pain intensity and relief along with satisfaction in the emergency department. Adult patients with a primary complaint of acute pain were asked to complete a two-part questionnaire administered by a research assistant. The first part was completed on arrival and the second part on discharge from the emergency department. The respondents were not permitted to see the first part of the questionnaire while completing the second. The questionnaire used an unmarked, horizontal 10-cm visual analog scale along with short answer questions to measure pain, relief, and satisfaction. Choice of drug therapy was decided by the physician according to usual treatment methods. Fifty-seven people presented with the chief complaint of pain. Of those, 30 (53%) were treated with medications. The mean level of pain on admission for treated patients was 6.64 compared with a mean level of pain on discharge of 4.02 (P =.0001). Untreated patients had a mean admission visual analog scale score of 4.19. Compared with treated patients, this difference was statistically significant (P =.001). A mean visual analog scale score of 5.43, representing the mean amount of pain relief, was reported among treated patients. Treated patients also reported a visual analog scale score of 6.46 in overall satisfaction with pain management. The results of this study indicate that there is a significant and clinical difference in levels of pain and satisfaction between admission and discharge in these patients in the emergency department.     

Barriers to medication adherence in the emergency department: A cross-sectional study

BackgroundMedication nonadherence is a common problem that leads to increased healthcare utilization. It is unclear how patient insight and attitude towards their medications affect adherence in the ED. Furthermore, it is unclear how perceived medication importance differs between patients and ED physicians.MethodsWe conducted a cross sectional study of adult patients presenting to 2 academic emergency departments from April 2015 to October 2016. Demographic data were collected and questions were asked regarding medication knowledge, perceived importance, and adherence. We also compared perceived importance of medications between patients and two physician raters. Inter-rater agreement was reported as raw percentages, and categorical data were compared using chi-squared analysis.ResultsWe identified 1268 patients, representing 4634 individual medications. We identified a significant association between knowledge of medications and perceived importance (p < .05). Secondarily, importance level was highly associated with medication adherence (p < .05). When ranking those medications that were considered “least” and “most” important among each patient's med list, our two physicians agreed with patients only 34.1% and 37% of the time respectively, as opposed to 62% and 62.8% agreement between each other.ConclusionsThese data suggest that there is a difference in perceived medication importance between ED physicians and ED patients. Knowledge of a medication's purpose is significantly associated with perceived importance, while this importance appears to be significantly associated with compliance. These results suggest that concerted efforts by ED physicians and staff to educate patients on the utility and importance of their medications may improve adherence.     

绩效考评在县级医院急诊科护理管理中的应用

目的探讨绩效考评在本院急诊科护理管理中的应用效果。方法成立科室考评小组。制订考评细则及计分标准,当月底由科室考评小组进行综合评定,下月初公布各人累积分值,无异议后将考评结果报院财务室核算发放个人绩效工资。结果实施绩效考评后患者满意度、护理部质量检查得分、科室自评得分均高于实施考评前水平（均P〈0．05）。实施绩效考评后科室年均收入及年人均绩效工资均较实施前增长了30．5％。结论将绩效考评纳入急诊科护理管理中提高了管理工作的科学性,有利于调动护理人员工作积极性,提高急诊科护理服务质量和患者满意度。     

The feasibility of bedside transvaginal ultrasonography in non-pregnant women in the emergency department

Study objectiveWe recorded data on the routine use of point-of-care transvaginal ultrasound (POC TVUS) for the evaluation of non-pregnant women with pelvic complaints in the Emergency Department (ED), and sought to determine how it altered the diagnostic impression and management.MethodsThis was a prospective observational study. Adult non-pregnant women with pelvic complaints undergoing POC TVUS were enrolled. Pre and post ultrasound, the treating physician completed a data collection form indicating the most likely cause of the patient’s pain, current treatment plan, and expected ultrasound findings. Immediately after the ultrasound, the treating physician completed another form to indicate details about the sonographic process and findings, and whether a radiologyperformed TVUS was planned.ResultsOf 113 women enrolled, 79% had both ovaries visualized and the POC TVUS led to changes in plan in 43% of patients, including 3 emergent/urgent interventions; 48% of patients had unexpected findings. Of the 25% who had an additional radiology exam, there were no instances of discordant findings when both ovaries were assessed to be normal on ED Ultrasound. The ultrasound added <10 minutes in 92% of patients. With an ED ultrasound only (n = 85), the median length of stay (LOS) was 282 (IQR 197–323) minutes, compared to 437 (IQR 367-500) minutes when a radiology ultrasound was required (n = 28) (median difference,170 minutes [95% CI 122-212 min]).ConclusionIn this study, emergency physicians were able to efficiently obtain and interpret POC TVUS images that changed assessment of non-pregnant women with pelvic pain without significantly increasing the ED length of stay.