Effectiveness of Emergency Medicine Wards in reducing length of stay and overcrowding in emergency departments

ObjectiveThis study aims to evaluate the effectiveness of an Emergency Medicine Ward (EMW) in reducing the length of stay (LOS) in the emergency department, length of hospitalization, emergency medical admission rate, and the hospital bed occupancy rate.MethodsThis study is a cross-sectional, observational study with a retrospective, quantitative record review conducted at the EMW of a regional acute hospital in Hong Kong from January 2009 to June 2009.ResultsDuring the study, a retrospective audit was conducted on 1834 patient records. The five main groups of patients admitted into EMW suffered from cardiac disease (26.5%), pneumonia (19.6%), dizziness (16.2%), Chronic Obstructive Pulmonary Disease (12.3%), and gastroenteritis (7.9%). The mean LOS in the EMW was 1.27 days (SD = 0.59). The average emergency medical admission rate within the six-month period was significantly reduced relative to that before the EMW became operational (January 2008 to June 2008). Clinically, the medical in-patient bed occupancy was significantly reduced by 6.2%. The average LOS during in-patient hospitalization after the EMW was established decreased to 4.13 days from the previous length of 5.16 days.ConclusionsEMWs effectively reduce both the LOS during in-patient hospitalization and the avoidable medical admission rate.     

The patient experience in emergency departments: a review of the literature

This paper analyses the literature on the patient experience within emergency departments. We identify six themes within the literature: waiting times, communication, cultural aspects of care, pain, the environment and dilemmas in accessing the patient experience. Overall, the literature has a North American bias and is largely quantitative in approach. Although levels of patient satisfaction are high, a number of issues arise within the review, which suggest areas where quality of care could improve. We also identify the problematic nature of accessing the patient experience and suggest future areas for researchers to explore.     

Use of emergency observation and assessment wards: a systematic literature review

Introduction: Observation and assessment wards allow patients to be observed on a short-term basis and permit patient monitoring and/or treatment for an initial 24–48 hour period. They should permit concentration of emergency activity and resources in one area, and so improve efficiency and minimise disruption to other hospital services. These types of ward go under a variety of names, including observation, assessment, and admission wards. This review aims to evaluate the current literature and discuss assessment/admission ward functionality in terms of organisation, admission criteria, special patient care, and cost effectiveness.

Methods: Search of the literature using the Medline and BIDS databases, combined with searches of web based resources. Critical assessment of the literature and the data therein is presented.

Results: The advantages and disadvantages of the use of assessment/admission wards were assessed from the current literature. Most articles suggest that these wards improve patient satisfaction, are safe, decrease the length of stay, provide earlier senior involvement, reduce unnecessary admissions, and may be particularly useful in certain diagnostic groups. A number of studies summarise their organisational structure and have shown that strong management, staffing, organisation, size, and location are important factors for efficient running. There is wide variation in the recommended size of these wards. Observation wards may produce cost savings largely relating to the length of stay in such a unit.

Conclusion: All types of assessment/admission wards seem to have advantages over traditional admission to a general hospital ward. A successful ward needs proactive management and organisation, senior staff involvement, and access to diagnostics and is dependent on a clear set of policies in terms of admission and care. Many diagnostic groups benefit from this type of unit, excluding those who will inevitably need longer admission. Vigorous financial studies have yet to be undertaken in the UK. Definitions of observation, assessment, and admission ward are suggested.

     

The role of teamwork and communication in the emergency department: A systematic review

The aim of this study was to develop a systematic review using international research to describe the role of teamwork and communication in the emergency department, and its relevance to physiotherapy practice in the emergency department. Searches were conducted of CINAHL, Academic Search Premier, Scopus, Cochrane, PEDro, Medline, Embase, Amed and PubMed. Selection criteria included full-text English language research papers related to teamwork and/or communication based directly in the emergency department, involvement of any profession in the emergency department, publication in peer-reviewed journals, and related to adult emergency services. Studies were appraised using a validated critical appraisal tool. Fourteen eligible studies, all of mid-range quality, were identified. They demonstrated high levels of staff satisfaction with teamwork training interventions and positive staff attitudes towards the importance of teamwork and communication. There is moderate evidence that the introduction of multidisciplinary teams to the ED may be successful in reducing access block, and physiotherapists may play a role in this. The need for teamwork and communication in the ED is paramount, and their roles are closely linked, with the common significant purposes of improving patient safety, reducing clinical errors, and reducing waiting times.     

The role of the physiotherapist practitioner in emergency departments: a critical appraisal.

The quantity of literature available on the role of physiotherapist practitioners in EDs is severely limited, a situation that probably reflects the relatively recent introduction of the role. The quality of the literature, too, is variable; much of it is generalised and intended for presentation at conferences rather than as detailed analysis for publication. Nevertheless, the literature does identify two of the major benefits of employing physiotherapist practitioners in EDs: they enhance the ability of departments to meet government targets by reducing waiting times, and they are popular with patients. The extent to which physiotherapist practitioners might serve as an educational resource for other emergency care team members is also discussed. The disadvantages of employing physiotherapist practitioners in EDs mostly relate to their caseloads being so specific that, in smaller EDs in particular, there may simply be too few patients to make the role worthwhile. This can be offset, however, by the potential benefits of employing physiotherapist practitioners in review clinics. The narrow focus of practice and clinical skills identified in this review can however fragment the care that physiotherapist practitioners provide. Physiotherapist practitioners may not be trained in applying POP, for example, so cannot care for some patients continuously from admission to discharge or referral. These disadvantages should influence and guide training programmes, and inform individual EDs, when the introduction of physiotherapist practitioners is being considered. They may also aid decision making about what combination of staff EDs should employ, and what specific roles should be undertaken by different members of staff. The role of physiotherapist practitioners is fairly new and has been evaluated using different criteria that depend on the expectations of the role, which in turn are shaped by the rationale behind the role's introduction. This variation in role according to professional and service demands was acknowledged in work by Callaghan (2004), who also notes that the scope of practice of physiotherapist practitioners depends on local need, and that the future development of the role should have a more robust and larger evidence base. Much of the published evaluative activity focuses on the effect on service provision and patient satisfaction. This may be because these are more readily measured and can reflect on the objectives of those implementing the role. While the data identified in the literature are of value, more are needed to justify the position of physiotherapist practitioners in emergency care. These data should include information concerning patient episode times, patient satisfaction and the extent to which physiotherapist practitioners enable other practitioners to manage the care of other groups of emergency care attenders more effectively and quickly. It should also attempt to quantify the benefit of the role as an educational resource. More work needs to be undertaken concerning the nature and benefit of the role in different environments such as minor injury units or walk-in centres, as well as medium sized and large emergency departments. Similarly, the amount by which the role enhances physiotherapy services by encouraging staff retention and recruitment, and the development of new career pathways, also needs to be assessed. It is still too early to accurately describe how the role has fulfilled these expectations at Solihull. However, there are many physiotherapists now interested in working within the role should it continue and expand.     

Negative health outcomes and adverse events in older people attending emergency departments: A systematic review

For the last 25 years, there have been mounting concerns that ED's fast-paced environment is not suitable to meet the care needs of the ever-increasing older population. This paper reviews the research-based literature regarding negative health outcomes and adverse events experienced by older patients in the emergency department (ED). Electronic databases were searched for relevant English references. Search terms included: ‘older person’; ‘emergency department’; ‘health outcome’; and ‘adverse event’. The literature outlines a number of negative health outcomes and adverse events in older ED patients, including outcomes related to changes in health status, administrative outcomes suggesting negative health outcomes, and adverse events potentially associated with suboptimal ED practice. Further research is needed on the extent to which these apparent outcomes and events are avoidable. There are potential gains to be made in quality of geriatric emergency care by establishing evidence-based care that attends to the identified adverse events to achieve desirable health outcomes in this vulnerable ED population.     

Feasibility of a rapid diagnosis discussion tool for reducing misdiagnosis of patients presenting to emergency departments with abdominal pain

Objectives

Providing accurate and timely diagnoses is challenging in ED settings. We evaluated the feasibility and effectiveness of a short, structured rapid diagnosis discussion (RaDD) between a patient's initial doctor and a second doctor for patients presenting to ED with abdominal pain.

Methods

Controlled pre-post, mixed-methods pilot study in a metropolitan hospital network in Melbourne, Australia. Comparisons were made between an ED using RaDD for a 1-month period (n = 155) and two control EDs within the same hospital network (n = 2227) using standard practices. A short survey of 27 clinicians was also undertaken.

Results

Provisional diagnoses changed in 24.7% (95% confidence interval 19.0, 30.4) of all cases for which a RaDD case report sheet was completed, and clinicians' confidence in their decision-making was significantly higher when using RaDD (r = 0.27). RaDD significantly increased the likelihood that patients would be sent to the short stay unit and have a blood test ordered, and significantly reduced the likelihood that patients would be discharged home from the ED or leave at their own risk. Usage of the RaDD tool was low (25.2% of eligible cases), and qualitative feedback indicated that time limitations inhibited uptake.

Conclusions

RaDD encouraged clinicians to take a more cautious, risk-averse approach to care and improved confidence in their diagnostic decisions. However, cost effectiveness of these outcomes and possible implementation barriers need to be further considered in subsequent studies.     

Exploring person-centredness in emergency departments: A literature review

Person-centred approaches to care delivery have been increasingly promoted in international policy and strategy, but despite this there is evidence of failings within healthcare systems that negatively impact on the care experience for patients and staff. This paper explores the international literature on person-centredness within emergency departments (EDs). The Person-centred Practice Framework was used as the underpinning theoretical framework. This theory contends that staff must possess certain attributes to manage the care environment appropriately to deliver effective care processes in order to achieve effective person-centred outcomes for patients and staff. An initial search of the literature identified no relevant papers that discussed person-centredness as a concept within EDs. A further search using terms drawn from a definition of person-centredness revealed literature that reflected components of person-centredness. Themes that emerged included medical-technical intervention, a culture of worthiness, managing the patient journey, nurse/doctor relationships, patients' and relatives' experience of care, and ED as a stressful environment. The themes can be mapped onto the Person-centred Practice Framework, suggesting that components of person-centred practice have emerged from studies in a fragmented fashion, without consideration of person-centredness as a whole within an ED context.     

Violence in A&E departments: a systematic review of the literature.

Violence against A&E staff is increasing, and national initiatives have been implemented to counter the threat to staff. The aim of this paper is to determine the risks to staff of working in A&E and to determine methods of risk-reduction, using searches of literature and web-based resources. There is also critical appraisal of the data therein.