The prognostic and risk-stratified value of heart-type fatty acid–binding protein in septic patients in the emergency department

Purpose

To evaluate the prognostic and risk-stratified ability of heart-type fatty acid–binding protein (H-FABP) in septic patients in the emergency department (ED).

Materials and Methods

From August to November 2012, 295 consecutive septic patients were enrolled. Circulating H-FABP was measured. The predictive value of H-FABP for 28-day mortality, organ dysfunction on ED arrival, and requirement for mechanical ventilation or a vasopressor within 6 hours after ED arrival was assessed by the receiver operating characteristic curve and logistic regression and was compared with Acute Physiology and Chronic Health Evaluation (APACHE) II score, Mortality in Emergency Department Sepsis (MEDS) score, and Sequential Organ Failure Assessment score.

Results

The 28-day mortality, APACHE II, MEDS, and Sequential Organ Failure Assessment scores were much higher in H-FABP–positive patients. The incidence of organ dysfunction at ED arrival and requirement for mechanical ventilation or a vasopressor within 6 hours after ED arrival was higher in H-FABP–positive patients. Heart-type fatty acid–binding protein was an independent predictor of 28-day mortality and organ dysfunction. The area under the receiver operating characteristic curve for H-FABP predicting 28-day mortality and organ dysfunction was 0.784 and 0.755, respectively. Combination of H-FABP and MEDS improved the performance of MEDS in predicting organ dysfunction, and the difference of AUC was statistically significant (P < .05). The combinations of H-FABP and MEDS or H-FABP and APACHE II also improved the prognostic value of MEDS and APACHE II, but the areas under the curve were not statistically different.

Conclusions

Heart-type fatty acid–binding protein was helpful for prognosis and risk stratification of septic patients in the ED.     

Can mortality rates for patients who die within the emergency department,within 30 days of discharge from the emergency department,or within 30 days of admission from the emergency department be easily measured?

Objectives

Death rates are an outcome that can be used to describe a service. We measured three death rates that can be used to describe an emergency department (ED): death rates for those seen in the ED and discharged, those that die within the ED, and those that die after admission. We also wanted to establish how easy it was to obtain these rates and how frequently autopsy was performed.

Setting

ED within a large teaching hospital.

Results

Between 1 December 2003 and 1 December 2004, 76 060 patients attended the ED of which 205 died within the department. A total of 16 489 were admitted of which 876 died within 30 days. A total of 59 366 were discharged home of which 111 subsequently died over the next 30 days. The rates were 0.19% (111/59 366) for those discharged, 4.6% (766/16 489) for those admitted, and 0.27% (205/76 060) for those patients attending the ED who died within it. The autopsy rate was low (20%) and was more likely if the patient died in the department, died within the first few days of admission, or was young. The data were easy to collect.

Conclusions

These three death rates were easy to calculate and could be used to describe the outcome of an ED service. Further research to establish the range of rates for different departments is now required to determine their potential use.     

Lean techniques for the improvement of patients’ flow in emergency department

BACKGROUND:

Emergency departments (EDs) face problems with overcrowding, access block, cost containment, and increasing demand from patients. In order to resolve these problems, there is rising interest to an approach called “lean” management. This study aims to (1) evaluate the current patient flow in ED, (2) to identify and eliminate the non-valued added process, and (3) to modify the existing process.

METHODS:

It was a quantitative, pre- and post-lean design study with a series of lean management work implemented to improve the admission and blood result waiting time. These included structured re-design process, priority admission triage (PAT) program, enhanced communication with medical department, and use of new high sensitivity troponin-T (hsTnT) blood test. Triage waiting time, consultation waiting time, blood result time, admission waiting time, total processing time and ED length of stay were compared.

RESULTS:

Among all the processes carried out in ED, the most time consuming processes were to wait for an admission bed (38.24 minutes; SD 66.35) and blood testing result (mean 52.73 minutes, SD 24.03). The triage waiting time and end waiting time for consultation were significantly decreased. The admission waiting time of emergency medical ward (EMW) was significantly decreased from 54.76 minutes to 24.45 minutes after implementation of PAT program (P<0.05).

CONCLUSION:

The application of lean management can improve the patient flow in ED. Acquiescence to the principle of lean is crucial to enhance high quality emergency care and patient satisfaction.KEYWORDS: Lean, Triage, Waiting time, Patient flow, Emergency department     

Change and challenge the expected: “Nurse practitioner emergency department vulnerable patients model of care”

A new innovative approach and model to the Emergency Nurse Practitioner. By challenging and changing tradition of Emergency NP role the model closes the gap and addresses deficits that vulnerable patients are exposed to in the emergency care setting.Our Emergency Nurse Practitioner model focuses on the vulnerable populations that are cared for in the emergency department that need more than the traditional medical health care model delivers¹.It focus on the holistic approach to the patient’s     

Nurses’ experiences and expectations of family and carers of older patients in the emergency department

BackgroundOlder people are often accompanied by family/carers to the emergency department (ED). Few studies investigate nurses’ experiences of interacting with these family/carers.AimThis study was an exploration of the experiences and expectations that ED nurses have of family and carers accompanying the older adult patient.MethodFocus group interviews (four, n = 27) were conducted and interviews were audio-taped, transcribed and then thematically analysed.ResultsThree themes emerged relating to the way nurses judged family/carers of the older person, with the main theme the importance of time. Family/carers were evaluated as supportive and helpful when they saved nurses time and demanding and obstructive when they cost nurses time. A second theme was the family/carer as a knowledge resource. Nurses evaluated family/carers according to whether they could provide timely and useful information on the older patient. The third theme centred on nurses’ evaluations of family/carers getting in the way of assessing or treating the patient, by their physical presence and demands and by limiting open communication with the patient.ConclusionEmergency nurses have clear expectations of older patients’ families and/or carers. Future research must determine how nursing roles can sustain positive interactions with older patients’ families and/or carers in the ED.     

Continuity of care in the transition from emergency department to general practitioner: Is it adequate?

Objective : To assess the adequacy of continuity of care for patients who are discharged to home or admitted to hospital from the emergency department. Methods : Questionnaire survey of emergency department communication practices. Results : Seventy-five of 86 emergency departments (87.2%) participated. Emergency departments failed to communicate with general practitioners upon disposition of many patients. For patients discharged to home, significantly more private emergency departments contacted general practitioners directly by telephone (P < 0.01) or by letter (P < 0.001). Significantly more public emergency departments gave patients a letter to take to their general practitioners (P < 0.01). Overall, emergency departments gave the patient a general practitioner letter some (33.3% of emergency department) or most (40.0%) of the time. Few letters were posted or faxed and little use of Email was made. Pre-formatted letters were used less than was expected. On patient admission, the telephone was used most frequently to advise general practitioners. Conclusions : Continuity of patient care may be inadequate in many emergency departments. Emergency departments should establish a check system to ensure that a communication is made with the general practitioners of all patients. Telephone or facsimile communication is recommended on patient admission. Other modes may be more appropriate on patient discharge to home. Structured, pre-formatted letters/facsimiles are recommended. Emergency department–general practitioner communications should be used as a performance indicator of emergency department practice.     

The impact of introducing the Modified Early Warning Score ‘MEWS’ on emergency nurses’ perceived role and self-efficacy: A quasi-experimental study

BackgroundEarly warning Score is a bedside track and trigger system used to facilitate early detection and management of deteriorating patients. Although emergency department nurses are the key to implement this task, their interaction and contribution to provide an estimate of patients’ severities is still suboptimal and neglected.AimThis study aimed to introduce an educational programme using the Modified Early Warning Score (MEWS) to nurses working in the emergency departments and to assess the programme impact on nurses’ self-efficacy and perceived role.MethodsThis non-equivalent, multi-centre, quasi-experimental study, assigned two groups of emergency nurses into intervention and control. The intervention group received three interactive educational sessions totalling 12 h relevant to the application of MEWS in emergency situations using a validated programme called ‘COMPASs’. The other group received no intervention. Both groups were assessed for self-efficacy and perceived role in the pre-test, immediate post-test, and three months later follow-up phase.ResultsA total of 232 participants were divided into intervention and control groups (118 and 114, respectively), having no variations in age, gender, or experience as registered nurses. The intervention group showed a significant improvement in the self-efficacy scores for the nurses (F: 152.21, df: 2, p < 0.001). Similarly, the intervention nurses exhibited a significant improvement in the perceived role scores after the intervention (F: 121.20, df: 2, p < 0.001). The control group showed no changes in either variable across the three phases. While older nurses with longer experience showed higher self-efficacy after the programme, the perceived role explained an additional 57.0% of the variance in self-efficacy after controlling these two demographics (Beta: 0.743, p < 0.001, CI: 1.18–1.66).ConclusionThe existence of an early warning system in the emergency department is able to enhance nurses’ self-efficacy and perceived role coinciding with nursing interactions with the multidisciplinary team.     

Adding value to the patient experience in emergency medicine: What features of the emergency department visit are most important to patients?

Abstract Objectives: To identify the features of the emergency department visit most important to patients, and to compare emergency staff ranking of the same features. Setting: The Royal Hobart Hospital, Tasmania is a 520-bed public hospital with an annual department of emergency medicine census of 33 000. Methods: Five hundred and fifty-five emergency patients, and 60 emergency department medical and nursing staff were surveyed, asking each to rank 10 features of the emergency department visit in order of importance to patients. Analysis was by Chi-squared test and Mann –Whitney U-test to compare survey responses between the patient and staff populations. Results: Response rates were 36% for patients and 78% for staff. Patients ranked waiting time as most important, followed by symptom relief, a caring and concerned attitude from staff and diagnosis of the presenting complaint. Staff identified the same four factors as important but ranked waiting time fourth. Waiting times during the survey week were within Australian College for Emergency Medicine performance benchmarks of 84% of the emergency department census. Conclusions: This survey identified a mismatch between patient concerns and emergency staff perceptions, particularly with regard to waiting times. The results justify the use of waiting times as a performance indicator for emergency medicine.     

A “Top Five” list for emergency medicine: a policy and research agenda for stewardship to improve the value of emergency care

United States health care costs are growing at an unsustainable rate; one significant contributor has been the overuse of health services. Physicians have a professional ethical obligation to serve as stewards of society’s resources and take responsibility for health care costs. We propose a framework for identifying overused services and a research and implementation agenda to guide stewardship efforts to demonstrate the value of emergency care. Examples of interventions to reduce the cost of emergency care along six value streams are discussed: laboratory tests, high-cost imaging, medication administration, intravenous fluids and medications, hospital admissions and post-discharge care. Structural and political hurdles such as the Emergency Medical and Active Labor Act mandate, medico-legal concerns, lack of provider knowledge about costs and economic conflicts are identified. A research agenda focused on identifying low value clinical actions and potential interventions for overuse reduction is detailed. A policy agenda is proposed for organized emergency medicine to convene a structured, collaborative process to identify and prioritize clinical decisions that are of little value to patients, amenable to improvement through standardization, and actionable by front-line providers. Emergency medicine cannot wait longer to identify areas of low value care, or else other groups will impose external standards on our practice. Development of a Top Five list for emergency medicine will begin to demonstrate our professional ethical commitment to our patients and health system improvement.     

Errors in fracture diagnoses in the emergency department – characteristics of patients and diurnal variation

Background

Evaluation of the circumstances related to errors in diagnosis of fractures at an Emergency Department may suggest ways to reduce the incidence of such errors.

Methods

Retrospective analysis of all cases during a two year period (2002–2004) where a fracture had been overlooked or an injury had been erroneously diagnosed as a fracture (n = 61). 100 random selected patients with correctly diagnosed fractures served as control group.

Results

In the two year period 5879 patients visited the ED with injuries. 1% of all visits to the ED resulted in an error in fracture diagnosis and 3.1% of all fractures were not diagnosed at the initial visit to the ED. 86% of such errors had consequences for treatment. No patient characteristics could be identified as risk factors for a misdiagnosis of a fracture. There was a peak in errors in fracture diagnoses between 8 pm and 2 am (47% against 20% in controls, p < 0.005).

Conclusion

A considerable number of fractures were not correctly diagnosed at the initial ED visit. There was a diurnal variation in the rate of misdiagnosis of fractures with a significant peak from 8 pm to 2 am. Where there was an error in fracture diagnosis, the patients did not appear to have a characteristic profile as regarding e.g. age, sex or capability to communicate with the ED staff. Increased consultancy service in radiology may reduce the frequency of errors in diagnosis, particularly in the evenings between 8 pm and 2 am.