Interdisciplinary collaboration and the electronic medical record

PURPOSE: To examine interdisciplinary collaboration via electronic medical records (EMRs) with a focus on physicians' perception of nursing documentation. DESIGN: Quality improvement project using a survey instrument. LOCATION: Tertiary care pediatric hospital. PARTICIPANTS: Thirty-seven physicians. OUTCOME MEASURE: Physicians perceptions of nursing documentation after EMR implementation KEY FINDINGS: Physicians desire nursing documentation with greater clarity and additional information. Physicians indicate checklists alone for patient assessment and intervention data are insufficient for effective nurse/physician collaboration. Narrative nursing summaries are invaluable references that guide medical treatment decisions. Physicians see detailed assessments and well-described interventions of nurses' as critical to their ability to effectively practice medicine. KEY CONCLUSIONS: Health care technology is called to develop EMRs that enable nurses to document detailed patient data in a swift and straightforward manner. Joint collaboration between nurses, physicians, and technology specialists is recommended to develop effective EMR systems.     

Doing unto Others? Emergency Medicine Residents' Willingness to Be Treated by Moonlighting Residents and Nonphysician Clinicians in the Emergency Department

OBJECTIVE: Contentious moonlighting policies and the proliferation of nonphysician clinicians (NPCs) in academic emergency departments (EDs) send conflicting messages to emergency medicine (EM) residents regarding appropriate ED staffing patterns. The objective was to assess EM resident (EMR) views on the ED utilization of unsupervised residents and NPCs from their perspectives as both physicians and prospective patients. METHODS: A survey was mailed to a random sample of senior EMRs (sampling fraction, 68%) from the Emergency Medicine Residents Association membership list. Respondents were instructed to assume the role of patient when presented with hypothetical clinical scenarios of increasing severity; outcomes included provider preferences and the impacts of medical urgency, time delays, costs, and supervision on those preferences. Survey items asked about willingness to see residents, nurse practitioners (CRNPs), and physician assistants (PAs), and perceived impact of NPCs on professional identity. RESULTS: A total of 251 EMRs responded. Senior EMRs are more willing to have their care handled by residents as opposed to mid-level providers. For a moderate illness or injury scenario, 54% agreed to be seen by a resident alone compared with only 17% and 24% willing to be seen by a CRNP and PA, respectively. Only a small fraction of the residents (22.7%) would allow another resident to treat them for a major injury or illness. Residents are more willing to be seen by mid-level providers if a savings in time can be realized but showed little interest in using NPCs to save money. Approximately one-third (34%) of the residents view mid-level providers as a professional threat, but logistic regression reveals this perception to be 2.25 (1.3, 4.0) times higher in male EMRs and 1.94 (1.1, 3.4) times higher in those with higher household incomes (> or =$75,000). CONCLUSIONS: When assuming the patient role, senior EMRs have preferences for ED care that are consistent with restrictive EMR moonlighting and NPC staffing policies.     

Physician and nurse satisfaction with an Electronic Medical Record system

Electronic Medical Records (EMRs) are intended to support clinical activity, improve efficiency, and reduce error. Reluctance to use EMRs may exist among clinicians. The purpose of this study was to assess physician and nurse satisfaction with an Emergency Department (ED) EMR. We surveyed Emergency Medicine (EM) physicians and nurses at a large urban teaching hospital after implementation of an Emergency Department EMR. The questionnaire assessed: 1) computer background and experience; 2) perceptions regarding EMR use; and 3) concerns about impact upon quality of patient care. The clinicians find the EMR easy to use and are generally satisfied with the impact on their work. However, they report that the EMR has no positive impact on patient care. They report confusion in following the sequence of screens, and are concerned with the amount of time it takes to use the EMR and the confidentiality of patient information. Similar results were found between physicians and nurses. Nurses, but not physicians, report that they are able to finish work much faster than before implementation (p < 0.05). We were unable to correlate computer background and experience with satisfaction with an EMR. This survey suggests that EM physicians and nurses favor the use of an EMR and suggests opportunities for EMR enhancement.     

Establishing a high level of knowledge regarding bioterrorist threats in emergency department physicians: methodology and the results of a national bio-preparedness project

INTRODUCTION: Medical systems worldwide are facing the new threat of morbidity associated with the deliberate dispersal of microbiological agents by terrorists. Rapid diagnosis and containment of this type of unannounced attack is based on the knowledge and capabilities of medical staff. In 2004, the knowledge of emergency department physicians of anthrax was tested. The average test score was 58%. Consequently, a national project on bioterrorism preparedness was developed. The aim of this article is to present the project in which medical knowledge was enhanced regarding a variety of bioterrorist threats, including cutaneous and pulmonary anthrax, botulinum, and smallpox. METHODS: In 2005, military physicians and experts on bioterrorism conducted special seminars and lectures for the staff of the hospital emergency department and internal medicine wards. Later, emergency department senior physicians were drilled using one of the scenarios. RESULTS: Twenty-nine lectures and 29 drills were performed in 2005. The average drill score was 81.7%.The average score of physicians who attended the lecture was 86%, while those who did not attend the lectures averaged 78.3% (NS). CONCLUSIONS: Emergency department physicians were found to be highly knowledgeable in nearly all medical and logistical aspects of the response to different bioterrorist threats. Intensive and versatile preparedness modalities, such as lectures, drills, and posters, given to a carefully selected group of clinicians, can increase their knowledge, and hopefully improve their response to a bioterrorist attack.     

Emergency Department Sexually Transmitted Disease and Human Immunodeficiency Virus Screening: Findings from a National Survey

Objectives: To use a previously conducted national physician survey to determine the extent of human immunodeficiency virus (HIV) and sexually transmitted disease (STD) screening by emergency physicians compared with physicians practicing in other settings (primary care offices, hospital ambulatory care clinics, or other).
Methods: From the survey responses, the authors determined the percentage of emergency physicians and physicians not practicing in EDs screening various patient groups for syphilis, gonorrhea, chlamydia, and HIV. Additional data from the survey (for practice location, physician gender, and patient demographics of race and gender) were used in multivariate logistic regressions to determine adjusted odds ratios (ORs).
Results: Of 3,838 survey respondents providing answers to all questions analyzed for this study, 401 (10.5%) practiced in an emergency department. Of the remaining 3,437 physicians, 89% practiced in primary care offices or hospital ambulatory care clinics. Based on unadjusted ORs, emergency physicians were less likely than physicians not practicing in EDs to screen for all STDs and HIV in all patient groups (men, nonpregnant women, and pregnant women), although the differences in screening rates in male patients for chlamydia or gonorrhea were not significant. The adjusted ORs varied from 0.136 (for HIV screening of pregnant women) to 1.177 (for gonorrhea screening of pregnant women). All adjusted ORs that were significant at p < 0.05 were < 1.0.
Conclusions: Although prior research has shown that STD and HIV rates are relatively high in emergency department patients compared with the population as a whole, screening rates are lower than in other settings. Addressing barriers may increase screening rates.     

Management of emergencies in the medical office

As a result of requests by members of the medical staff, a course entitled "Management of Emergencies in the Medical Office" was developed by an emergency physician and was taught at the 1984 Annual Scientific Meeting of the Michigan State Medical Society. Forty-two of the 100 physician participants responded to a questionnaire given during the course. More than 50% stated that each of the above-listed emergencies had occurred in their offices more than once. Eleven percent had adequate equipment to manage common office emergencies. Seventy-nine percent were BCLS-certified, 35% were ACLS-certified, 19% had defibrillators, 35% had intravenous (IV) catheters, and 40% had laryngoscopes. The questionnaire shows that a large percentage of office physicians are poorly prepared to deal with common office emergencies. This educational deficiency presents a good opportunity for emergency physicians to interact with their colleagues. This type of positive educational experience may lead to better rapport between the staff and emergency physicians.     

Personal digital assistants change management more often than paper texts and foster patient confidence.

INTRODUCTION: Rapid retrieval of information, including drug treatment options, is critical to emergency department practice. OBJECTIVES: To assess feasibility and patient acceptance of personal digital assistants and to determine the scope of management changes. METHODS: Emergency medicine residents (EMRs, n = 18) and emergency medicine attending (EMAs, n = 12) used personal digital assistants with drug database and clinical references. Text versions were also available in the emergency department. We did a prospective, random, cross-over time-motion study, recording retrieval time, source, and changes to patient care for 16 and 8 h for EMRs and EMAs, respectively. We surveyed patients for confidence in EMRs and EMAs with personal digital assistants, and perceived efficiency. RESULTS: EMRs accessed paper (n = 131) or personal digital assistant (n = 181) information on 92.3% of patients (n = 17, both). They accessed personal digital assistant on 61.4% of patients vs. 44.5% with texts (odds ratio 1.99, 95% confidence interval 1.4-2.80). Mean access times were 9.3 and 9.4 s, respectively, +1.4 for both. Personal digital assistant access was 75%/25% between pharmacopeia and clinical resource. Personal digital assistants changed drug choice in 39/181 patients (21.5%), and other management (diagnosis, treatment or disposition) in 15/181 patients (8.3%). Odds ratio for change in management for personal digital assistant vs. paper was 2.00 (95% confidence interval 1.11-3.60). We surveyed patient perception for 198 of 295 patients (67.1%). Fifty percent reported more confidence in their EMRs and EMAs with a personal digital assistant, while 5% reported less confidence. Sixty percent agreed strongly that there is too much medical information to remember. CONCLUSIONS: Personal digital assistants are feasible in an academic emergency department and change management more often than texts. EMRs accessed personal digital assistants more often than paper texts. Patient perceptions of physicians who use personal digital assistants are neutral or favorable.     

Medication errors in the emergency department: a systems approach to minimizing risk

Adverse drug events caused by medication errors represent a common cause of patient injury in the practice of medicine. Many medication errors are preventable and hence particularly tragic when they occur, often with serious consequences. The enormous increase in the number of available drugs on the market makes it all but impossible for physicians, nurses, and pharmacists to possess the knowledge base necessary for fail-safe medication practice. Indeed, the greatest single systemic factor associated with medication errors is a deficiency in the knowledge requisite to the safe use of drugs. It is vital that physicians, nurses, and pharmacists have at their immediate disposal up-to-date drug references. Patients presenting for care in EDs are usually unfamiliar to their EPs and nurses, and the unique patient factors affecting medication response and toxicity are obscured. An appropriate history, physical examination, and diagnostic workup will assist EPs, nurses, and pharmacists in selecting the safest and most optimum therapeutic regimen for each patient. EDs deliver care "24/7" and are open when valuable information resources, such as hospital pharmacists and previously treating physicians, may not be available for consultation. A systems approach to the complex problem of medication errors will help emergency clinicians eliminate preventable adverse drug events and achieve a goal of a zero-defects system, in which medication errors are a thing of the past. New developments in information technology and the advent of electronic medical records with computerized physician order entry, ward-based clinical pharmacists, and standardized bar codes promise substantial reductions in the incidence of medication errors and adverse drug events. ED patients expect and deserve nothing less than the safest possible emergency medicine service.     

Coping Responses of Emergency Physicians and Nurses to the 2003 Severe Acute Respiratory Syndrome Outbreak

Objectives: During the 2003 severe acute respiratory syndrome (SARS) outbreak, health care workers (HCWs) experienced unusual stressors. The study hospital introduced psychosocial interventions to help HCWs. This study aimed to examine the coping strategies adopted by the emergency department (ED) HCWs who cared for the SARS patients. Methods: In November 2003, a self-administered questionnaire of physicians and nurses was conducted in the hospital ED that is the national SARS screening center in Singapore. Data collected included demographics and responses to these instruments: 1) the Coping Orientation to Problems Experienced (COPE) to assess coping strategies, 2) the Impact of Event Scale (IES) to measure psychological reactions, and 3) the General Health Questionnaire 28 (GHQ 28) to measure psychiatric morbidity. Results: Thirty-eight of 41 (92.7%) physicians and 58 of 83 (69.9%) nurses responded. The respondents reported a preference for problem-focused and emotion-focused coping measures. The physicians chose humor as a coping response significantly more frequently (p < 0.001) than nurses, scoring 9.61/16 (95% CI = 8.52 to 10.69), compared with the nurses' score of 7.05/16 (95% CI = 6.28 to 7.83). The Filipino HCWs turned to religion as a coping response significantly more frequently (p < 0.001) than the non-Filipino HCWs, scoring 14.38/16 (95% CI = 13.33 to 15.42), compared with 9.93/16 (95% CI = 9.00 to 10.87) for the non-Filipinos. Psychiatric morbidity was 17.7% on the IES and 18.8% on the GHQ 28, with the trend for physicians to report lower psychiatric morbidity. Conclusions: With a supportive hospital environment, ED HCWs chose adaptive coping in response to the outbreak and reported low psychiatric morbidity. Physicians chose humor and Filipinos chose turning to religion as their preferred responses. Psychosocial interventions to help HCWs need to take these preferences into account.     

Learning how we learn: an ethnographic study in a neonatal intensive care unit

Title.  Learning how we learn: an ethnographic study in a neonatal intensive care unit.
Aim.  This paper is a report of a study to identify how nurse clinicians learn with and from each other in the workplace.
Background.  Clinicians' everyday practices and interactions with each other have recently been targeted as areas of research, because it is there that quality of care and patient safety are achieved. Orientation of new nurses and doctors into a specialty unit often results in stress.
Method.  An ethnographic approach was used, including a 12-month period of fieldwork observations involving participation and in-depth interviews with nurse, doctor and allied health clinicians in their workplace. The data were collected in 2005–2006 in a paediatric teaching hospital in Australia.
Findings.  The findings were grouped into four dimensions: orientation of nurses, orientation of medical registrars, preceptoring and decision-making. The orientation of new staff (nursing and medical) is a complex and multi-layered process which accommodates multiple kinds of learning, in addition to formal learning. Workplace learning also can be informal, incidental, interpersonal and interactive. Interactive and interpersonal learning and the transfer of knowledge include codified and tacit knowledge as well as intuitive understandings of 'how we do things here'.
Conclusion.  Research into how nurses learn is crucial for illuminating learning that is non-formal and less recognized than more formal kinds. To provide a safe practice environment built on a foundation of knowledge and best practice, there needs to be an allocation of time in the busy workday for learning and reflection.     

工作场所暴力对急诊护士影响及医院应对现状的调查

目的 了解工作场所暴力对急诊护士的影响及医院应对现状.方法 采用工作场所暴力调查表对164名急诊护士进行调查.结果 124名(75.6%)护士遭受过暴力,对护士的生理、心理和职业态度产生较大影响,医院缺乏规范、有效的应对暴力措施.结论 急诊护士是遭受工作场所暴力的高危人群.医院应建立预防和应对暴力的系统模式,创造和谐的医疗环境.     

Assessment of knowledge,attitude and practice regarding oxygen therapy at emergency departments in Riyadh in 2017: A cross-sectional study

BACKGROUND: Administering oxygen therapy (OT) has an essential role in preventing/managing hypoxemia in both acute and chronic conditions. It should be adjusted to achieve the normal oxygen saturation of 94%-98% in most cases. This study aims to evaluate knowledge, attitude and practice (KAP) of nurses, paramedics, emergency medical technicians (EMTs) and Emergency Medical Services (EMS) physicians working at emergency departments (ED) in Riyadh, Saudi Arabia. METHODS: In this cross-sectional study, a structured questionnaire was used to assess KAP related to OT of nurses, paramedics, EMTs and EMS physicians currently working at an ED of a tertiary care hospital. Knowledge and attitude were assessed using a Likert scale from 1-5, whereas practice was assessed as a yes/no categorical variable. RESULTS: A total of 444 emergency health-care workers (EHCWs) participated, of which 225 (50.7%) were male, with the majority (77%) in the age group of 20-35 years. Over half of the sample were nurses (266; 59.9%). The mean score for knowledge about OT was 5.51±1.45, attitude was 26.31±3.17 and for practices 4.55±1.76. The main factors which were associated with poor KAP were workload and lack of local guidelines. The distribution of overall practice score was significantly better among paramedics - nurses group and EMT - nurses group. CONCLUSION: This study demonstrates that there is a gap in EHCWs’ KAP, particularly regarding when to provide OT to a patient. This gap can affect patients’ safety. Extensive educational and training programs about OT are needed to raise awareness among health-care providers.     

Medical Error Identification,Disclosure, and Reporting: Do Emergency Medicine Provider Groups Differ?

Objectives: To determine if the three types of emergency medicine providers—physicians, nurses, and out‐of‐hospital providers (emergency medical technicians [EMTs])—differ in their identification, disclosure, and reporting of medical error. Methods: A convenience sample of providers in an academic emergency department evaluated ten case vignettes that represented two error types (medication and cognitive) and three severity levels. For each vignette, providers were asked the following: 1) Is this an error? 2) Would you tell the patient? 3) Would you report this to a hospital committee? To assess differences in identification, disclosure, and reporting by provider type, error type, and error severity, the authors constructed three‐way tables with the nonparametric Somers' D clustered on participant. To assess the contribution of disclosure instruction and environmental variables, fixed‐effects regression stratified by provider type was used. Results: Of the 116 providers who were eligible, 103 (40 physicians, 26 nurses, and 35 EMTs) had complete data. Physicians were more likely to classify an event as an error (78%) than nurses (71%; p = 0.04) or EMTs (68%; p < 0.01). Nurses were less likely to disclose an error to the patient (59%) than physicians (71%; p = 0.04). Physicians were the least likely to report the error (54%) compared with nurses (68%; p = 0.02) or EMTs (78%; p < 0.01). For all provider and error types, identification, disclosure, and reporting increased with increasing severity. Conclusions: Improving patient safety hinges on the ability of health care providers to accurately identify, disclose, and report medical errors. Interventions must account for differences in error identification, disclosure, and reporting by provider type.     

Post‐SARS knowledge sharing and professional commitment in the nursing profession

Aim. The aim of the present study was to examine the 2003 severe acute respiratory syndrome (SARS) crisis in relation to the degree of knowledge sharing and professional commitment, as perceived by the current nursing staff in Taiwan. Background. The mortality rate for medical personnel during the SARS outbreak in Taiwan, which began in April 2003, was the highest among Asian countries. The SARS crisis severely challenged not only the medical skills of nurses, but also their professional commitment. Design. Survey. Methods. This study was conducted between August–December 2005, in Taiwan. Data were collected by structured questionnaire. The questionnaire was distributed by post to 8056 nurses nationwide; 2833 nurses completed and returned the questionnaire for a valid response rate of 39%. Results. The results showed that knowledge sharing correlated positively with professional commitment but negatively with the impact of SARS. Professional commitment negatively correlated with SARS impact (r = ?0·074, p < 0·001); however, as knowledge sharing was a controlled variable, the partial correlation between SARS impact and professional commitment was ?0·039 with a p‐value of 0·045, indicating virtual insignificance. That is, knowledge sharing was an antecedent variable for both SARS impact and professional commitment. Conclusion. This cross‐sectional study provides preliminary evidence that knowledge sharing is significantly correlated with impact of SARS and professional commitment of nursing personnel. Relevance to clinical practice. Hospitals and healthcare services can enhance retention of medical personnel by encouraging knowledge sharing, which enhances professional commitment and alleviates the impact of newly introduced contagious diseases.     

The Internet and access to evidence: how are nurses positioned?

BACKGROUND: Published literature that describes the use of the Internet by nurses is scant, but it does reveal that there has been a delay in the acceptance of the Internet as a workplace tool by the medical community and, in particular by nurses. AIMS: The purpose of this article is to report on a study of how often and from what location nurses accessed the Internet, as well as the types of information they were seeking. In addition, our goal was to compare nurses' Internet use with that of physicians and the public at large, and to highlight structural and institutional challenges to nurses' use. METHODS: Surveys (1996 and 1998) of Alberta Registered Nurses were used to examine their use of technology at work and at home. Additional data sources were used to compare nurses to physicians and to the general public. RESULTS: While nurses' Internet and e-mail use at home increased over the 2-year period and was comparable with other groups, Internet use at work was low compared with other groups despite adequate workplace access. CONCLUSIONS: Nurses are more likely to value interpersonal contact, and prefer to use personal experience and communication with colleagues and patients rather than on-line and traditional sources of practice knowledge. In order for an information source to be seen as valuable in the clinical setting, contextually relevant information needs to be accessed quickly and efficiently. Energies should be focused on constructing information systems that address the particular needs of nurses.     

Effects of postgraduate emergency training among general practitioners working in emergency units in Denizli,Turkey

INTRODUCTION: Emergency medicine is characterised by rapid decisionmaking to help patients in life-threatening situations. For this purpose, special qualifications are necessary. The aim of our study was to evaluate the emergency medicine knowledge obtained during an obligatory postgraduate emergency medicine training programme that has been recently applied among Turkish physicians. METHODS: The training targeted all general practitioners (GPs) working in emergency units in the city hospitals, city-wide primary healthcare centres, public health offices, emergency services and private hospitals. Over an 8-month period between September 2004 and April 2005, seven individual groups of approximately 45 physicians were formed. Each group undertook an identical 5-day training programme and every participant completed identical pre-and post-training tests. RESULTS: Two-hundred and ninety-eight physicians participated in the training programme. The majority of participants were male (n=224, 75.2%), aged between 35 and 39 years (n=127, 42.6%), had been in the medical professional for 11 to 15 years (n=121, 40.7%), and were employed in city hospitals (n=102, 34.2%). Surprisingly, the majority of GPs had never participated in a postgraduate training programme before (n=166, 55.7%). Mean post-test scores of the participants were significantly higher than the pre-test scores (89.70%+/-12.41% vs 43.15%+/-10.47%, respectively; P<0.001). Mean pretest scores were significantly higher in the emergency services subgroup (51%, P=0.001) and in the subgroup of participants that had previously undertaken two or more postgraduate training courses (47.9%, P=0.004) compared with the mean pre-test scores of the other subgroups. However post-test scores were not statistically different between the groups. CONCLUSIONS: This postgraduate emergency medicine training programme appears to be effective in improving physicians' knowledge regarding emergencies. Any developing emergency medicine system in Turkey should include continuous, up-to-date, standardised educational programmes for emergency professionals. These may include postgraduate workshops to improve the knowledge and skill levels of emergency professionals.