A cross-sectional study of Victorian mobile intensive care ambulance paramedics knowledge of the Valsalva manoeuvre

Background

The Valsalva Manoeuvre (VM) is a primary measure for terminating haemodynamically stable supraventricular tachycardia (SVT) in the emergency care setting. The clinical use and termination success of the VM in the prehospital setting has not been investigated to date. The objective of this study was to determine Melbourne Mobile Intensive Care Ambulance (MICA) Paramedic knowledge of the VM, and to compare this understanding with an evidence-based model of VM performance.

Methods

A cross-sectional study in the form of a face-to-face interview was used to determine Melbourne MICA Paramedic understanding of VM instruction between January and February, 2008. The results were then compared with an evidence-based model of VM performance to ascertain compliance with the three criteria of position, pressure and duration. Ethics approval was granted.

Results

There were 28 participants (60.9%) who elected a form of supine posturing, some 23 participants (50%) selected the syringe method of pressure generation, with 16 participants (34.8%) selecting the "as long as you can" option for duration. On comparison, one out of 46 MICA Paramedics correctly identified the three evidence-based criteria.

Conclusions

The formal education of Melbourne's MICA Paramedics would benefit from the introduction of an evidence based model of VM performance, which would impact positively on patient care and may improve reversion success in the prehospital setting. The results of this study also demonstrate that an opportunity exists to promote the evidence-based VM criteria across the primary emergency care field.     

Treatment of Out-of-hospital Supraventricular Tachycardia: Adenosine vs Verapamil

Objective: To compare the use of adenosine and the use of verapamil as out-of-hospital therapy for supraventricular tachycardia (SVT). Methods: A period of prospective adenosine use (March 1993 to February 1994) was compared with a historical control period of verapamil use (March 1990 to February 1991) for SVT. Data were obtained for SVT patients treated in a metropolitan, fire-department-based paramedic system serving a population of approximately 1 million persons. Standard drug protocols were used and patient outcomes (i.e., conversion rates, complications, and recurrences) were monitored. Results: During the adenosine treatment period, 105 patients had SVT; 87 (83%) received adenosine, of whom 60(69%) converted to a sinus rhythm (SR). Vagal maneuvers (VM) resulted in restoration of SR in 8 patients (7.6%). Some patients received adenosine for non-SVT rhythms: 7 sinus tachycardia, 18 atrial fibrillation, 7 wide-complex tachycardia (WCT), and 2 ventricular tachycardia; no non-SVT rhythm converted to SR and none of these patients experienced an adverse effect. Twenty-five patients were hemodynamically unstable (systolic blood pressure < 90 mm Hg), with 20 receiving drug and 13 converting to SR; 8 patients required electrical cardioversion. Four patients experienced adverse effects related to adenosine (chest pain, dyspnea, prolonged bradycardia, and ventricular tachycardia). In the verapamil period, 106 patients had SVT; 52 (49%) received verapamil (p < 0.001, compared with the adenosine period), of whom 43 (88%) converted to SR (p = 0.11). Two patients received verapamil for WCT; neither converted to SR and both experienced cardiovascular collapse. VM resulted in restoration of SR in 12 patients (11.0%) (p = 0.52). Sixteen patients were hemodynamically unstable, with 5 receiving drug (p = 0.005) and 5 converting to SR; 9 patients required electrical cardioversion (p = 0.48). Four patients experienced adverse effects related to verapamil (hypotension, ventricular tachycardia, ventricular fibrillation). Recurrence of SVT was noted in 2 adenosine patients and 2 verapamil patients in the out-of-hospital setting and in 23 adenosine patients and 15 verapamil patients after ED arrival, necessitating additional therapy (p = 0.48 and 0.88, for recurrence rates and types of additional merapies, respectively). Hospital diagnoses, outcomes, and ED dispositions were similar for the 2 groups. Conclusion: Adenosine and verapamil were equally successful in converting out-of-hospital SVT in patients with similar etiologies responsible for the SVT. Recurrence of SVT occurred at similar rates for the 2 medications. Rhythm misidentification remains a common issue in out-of-hospital cardiac care in this emergency medical services system.     

U.S. Emergency Department Visits for Supraventricular Tachycardia, 1993–2003

Background: Supraventricular tachycardia (SVT) is often described as a recurrent condition that leads to emergency department (ED) visits. However, the epidemiology of ED visits for SVT is unknown.
Objectives: To define the frequency of SVT in U.S. EDs and to analyze patient characteristics, ED management, and disposition for such visits.
Methods: The authors analyzed data from the National Hospital Ambulatory Medical Care Survey, 1993–2003. SVT cases were identified by using the International Classification of Diseases, Ninth Revision, Clinical Modification codes 426.7 or 427.0 in any of the three diagnostic fields.
Results: Of the 1.1 billion ED visits over the 11-year study period, an estimated 555,000 (0.05%; 95% confidence interval [CI] = 0.04% to 0.06%) were related to SVT. The annual frequency and population rate appear stable between 1993 and 2003 (p for trend = 0.35). Compared with non-SVT visits, those with SVT were more likely to be older than 65 years of age (26% vs. 15%, p < 0.01) and female (70% vs. 53%, p < 0.01). Electrocardiograms were documented for most visits (91%; 95% CI = 85% to 96%). Approximately half of the patients (51%; 95% CI = 40% to 61%) received an atrioventricular nodal blocking medication, most frequently adenosine (26%; 95% CI = 17% to 36%). SVT visits ended in hospital admission for 24% (95% CI = 15% to 34%). At the other extreme, 44% (95% CI = 32% to 56%) were discharged without planned follow-up.
Conclusions: Supraventricular tachycardia accounts for approximately 50,000 ED visits each year. Higher visit rates in older adults and female patients are consistent with prior studies of SVT in the general population. This study provides an epidemiologic foundation that will enable future research to assess and improve clinical management strategies of SVT in the ED.     

Methamphetamine-related Emergency Department Utilization and Cost

Objective:  To quantify the frequency, cost, and characteristics associated with emergency department (ED) visits that are related to methamphetamine use.
Methods:  This was a prospective observational study. The authors performed a training program for ED clinicians on the acute and chronic effects of methamphetamine and the signs of methamphetamine abuse. A standardized two question survey was administered to clinicians concerning the relationship between the ED visit and the patient's methamphetamine use. The survey was embedded in the patient tracking system and was required for all ED patients before disposition. Survey results were merged with administrative data on demographics, diagnosis, disposition, and charges. Univariate analyses were used to determine patient characteristics associated with methamphetamine-related ED visits.
Results:  The authors examined 15,038 ED visits over a 20-week period from February 2006 to June 2006. There were a total of 353 methamphetamine-related visits, for an average of 17.65 visits per week (2.4% of all visits). Hospital charges for methamphetamine-related ED visits averaged $133,181 per week, for an estimated total of $6.9 M in annual charges. Methamphetamine-related ED patients were more likely to be male (odds ratio [OR] 1.6, 95% confidence interval [CI] = 1.30 to 2.01), white (OR 1.8, 95% CI = 1.38 to 2.29), and uninsured (OR 3.2, 95% CI = 2.21 to 4.69). The top four medical conditions associated with methamphetamine-related visits were mental health (18.7%), trauma (18.4%), skin infections (11.1%), and dental diagnoses (9.6%).
Conclusions:  Methamphetamine abuse accounts for a modest but substantial proportion of ED utilization and hospital cost. Methamphetamine-related ED visits are most commonly related to mental illness, trauma, skin, and dental-related problems.     

Development of an observational instrument to determine variations in the patient care process and patient flow among emergency physicians and internists at the emergency department

Background

The increasing demand for acute care and restructuring of hospitals resulting in emergency department (ED) closures and fewer inpatient beds are reasons to improve ED efficiency. The approach towards the patient care process varies among doctors. The objective of this study was to determine variations in the patient care process and patient flow among emergency physicians (EP’s) and internists at the ED of Leiden University Medical Centre (LUMC), the Netherlands.

Methods

An observational instrument was developed during a pilot study at the LUMC ED, following observations of activities performed by EP’s and internists. The instrument divides all different types of activities a clinician can perform on the ED into eight categories. Using the observational instrument, their activities were observed and registered for 10 separate days. Primary outcomes were defined as the time spend on the eight separate activity categories, the total length of stay (LOS) and the number of patients seen during an interval. Secondary outcomes were general observations of working routine features that determine patient flow at the ED. The obtained data were analyzed into SPSS.

Results

Ten doctors were observed during a total of ± 36 hours in which 42 patients were seen. Although EP’s were observed for a shorter period of time than internists (13:48 vs. 22:10 hrs, -38%), they saw more patients (26 vs. 16, +62%). EP’s tended to spend a higher proportion of their time on patient contact than internists (27.2% vs. 17.3%, p = 0.06). Both groups dedicated the highest proportion of their time to documentation (31.5% and 33.4%, p = 0.75) and had little communication with ED nurses (3.7% and 2.4% p = 0.57). The average LOS of internal patients was higher than that of EP’s patients (5.25 ± sd 1:33 and 2.26 ± sd 1:32 hours). Internists occupied more treatment rooms at the same time (2.41 vs. 2.08, p < 0.00) and followed a more sequential working routine.

Conclusions

This paper describes the determination of variations in the ED care process and patient flow among EP’s and internists by an observational instrument. A pilot study with the instrument showed variations in the patient care process and patient flow among the two groups at the LUMC ED.     

A new algorithm for the initial evaluation and management of supraventricular tachycardia

Interpretations by physicians and those generated by electrocardiograph computer softwares have poor ability to recognize different types of supraventricular tachycardia (SVT). Therefore, we developed and tested a new SVT algorithm based on easily identifiable morphological characteristics and a simple dichotomous yes/no format regarding initial electrocardiographic manifestation and response pattern. The algorithm was then tested by medical house staff during the initial evaluation of 50 adult ED and cardiac intensive care unit patients suspected of having SVT. For a wide representation of SVTs, the new algorithm gave an overall diagnostic accuracy rate of 90%. Adenosine use was limited to 54% of the cases. No patient developed hemodynamic instability after algorithm-dictated interventions were carried out. Electrocardiograph computer-generated diagnoses correctly identified the specific type of SVT in 38% of the cases. This study shows the effectiveness of the proposed new algorithm in the rapid bedside evaluation and management of SVTs and confirms that computer-generated diagnoses are unreliable.     

Untreated Hypertension and the Emergency Department: A Chance to Intervene?

Objectives:  Untreated hypertension (HTN) is a major public health problem. Screening for untreated HTN in the emergency department (ED) may lead to appropriate treatment of more patients. The authors investigated the accuracy of identifying HTN in the ED, the proportion of ED patients with untreated HTN, patient characteristics predicting untreated HTN, and provider documentation of untreated HTN.
Methods:  The authors performed a retrospective cross-sectional study on a random sample of 2,061 adults treated at an urban academic ED. The validity of six candidate definitions of HTN in the ED was assessed in a subsample using outpatient clinic records as the reference standard. "Untreated HTN" was HTN without a HTN medication listed in the ED history. "Documentation of untreated HTN was documentation of HTN as a visit problem, specific referral for HTN, or ED discharge with a HTN" information sheet or a HTN medication. Multivariable logistic regression was used to determine associations.
Results:  The preferred definition of HTN in the ED had sensitivity of 86% (95% confidence interval [CI] = 80% to 90%), specificity of 78% (95% CI = 69% to 85%), and accuracy of 83% (95% CI = 78% to 87%). Of the 42% (95% CI = 40% to 44%) of ED patients with HTN, 43% (95% CI = 39% to 46%) had untreated HTN. Patients who were younger and male, without primary care physicians, with fewer prior ED visits, and without cardiovascular comorbidities, had higher odds of untreated HTN. Of those with untreated HTN, 8% (95% CI = 5% to 11%) had their untreated HTN documented.
Conclusions:  Untreated HTN was common in the ED but rarely documented. Providers can use ED blood pressures along with patient characteristics to identify those with untreated HTN for referral to primary care.     

Patient Opinions and Attitudes toward Medical Student Procedures in the Emergency Department

OBJECTIVES: To determine emergency department (ED) patients' preferences about having medical students perform procedures as part of medical student clinical training. METHODS: A questionnaire was administered to a sequential sample of 150 patients of 196 approached (76.5% participation rate) in a teaching hospital ED. Patients were asked how many procedures a medical student should have performed on other patients before the participant would allow the student to perform the procedure on them. The procedures included venipuncture, starting an IV, suturing the face, suturing the arm, performing a lumbar puncture, starting a central line, inserting a nasogastric tube, intubation, and cardioversion. RESULTS: If they had their preference, only a minority of patients would allow medical students to perform their first procedure on them for any of the procedures (a high of 42% for venipuncture, with a low of 7% for a lumbar puncture). Many patients prefer that medical students never perform a procedure on them (a high of 56% for a central line and a low of 21% for venipuncture). Patient beliefs were independent of age, gender, or insurance status. CONCLUSIONS: Patients are reluctant to be a medical student's first patient when it comes to procedures in the ED. This has implications for medical training and informed consent.     

Testing emergency medical personnel response to patients with suspected infectious disease

OBJECTIVES: In the United States (US), hospitals are required to have disaster plans and stage drills to test these plans in order to satisfy the Joint Accreditation Commission of Healthcare Organizations. The focus of this drill was to test if emergency response personnel, both prehospital and hospital, would identify a patient with a potentially communicable infectious disease, and activate their respective disaster plan. METHODS: Twelve urban/suburban emergency departments (ED) received patients via car and ambulance. Patients were moulaged to imitate a smallpox infection. Observers with checklists recorded what happened. The drill's endpoints were: (1) predetermined end time; (2) identification of the patient and hospital "lock-down"; and (3) breach of drill protocol. RESULTS: None of the ambulance personnel correctly identified their patients. Of the total 13 mock patients assessed in the ED, seven (54%) were identified by the ED staff as possibly being infected with a highly contagious agent and, in turn, the hospital's biological agent protocol was initiated. Of the correctly identified patients, five (71%) were placed in isolation, and the remaining two (29%), although not isolated, were identified prior to their ED discharge and the appropriate protocol was activated. The six remaining mock patients (46%) were incorrectly diagnosed and discharged. Of the hospitals that had correctly identified their "infected" patients, only two (29%) followed their notification protocol and contacted the local health department. CONCLUSION: This drill was successful in identifying this area's shortcomings, highlighted positive reactions, and raised some interesting questions about the ability to detect a patient with a possibly highly contagious disease.     

Introduction of a Stat Laboratory Reduces Emergency Department Length of Stay

Objectives:  Emergency department (ED) length of stay (LOS) impacts patient satisfaction and overcrowding. Laboratory turnaround time (TAT) is a major determinant of ED LOS. The authors determined the impact of a Stat laboratory (Stat lab) on ED LOS. The authors hypothesized that a Stat lab would reduce ED LOS for admitted patients by 1 hour.
Methods:  This was a before-and-after study conducted at an academic suburban ED with 75,000 annual patient visits. All patients presenting to the ED during the months of August and October 2006 were considered. A Stat lab located within the central laboratory was introduced in September 2006 to reduce laboratory TAT. The test TATs and ED LOS before (August 2006) and after (October 2006) implementing the Stat lab for all ED patients were the data of interest. ED LOS before and after the Stat lab was introduced was compared with the Mann-Whitney U-test. A sample size of 5,000 patients in each group had 99% power to detect a 1-hour difference in ED LOS.
Results:  There were 5,631 ED visits before and 5,635 visits after implementing the Stat lab. Groups were similar in age (34 years vs. 36 years) and gender (51% males in both). The percentages of patients with laboratory tests before and after Stat lab implementation were 68.7 and 71.3%, respectively. Test TATs for admitted patients were significantly improved after the Stat lab introduction. Implementation of the Stat lab was associated with a significant reduction in the median ED LOS from 466 (interquartile range [IQR] = minutes before to 402 (IQR = 296–553) minutes after implementing the Stat lab. The effects of the Stat lab on ED LOS were less marked for discharged patients.
Conclusions:  Introduction of a Stat lab dedicated to the ED within the central laboratory was associated with shorter laboratory TATs and shorter ED LOS for admitted patients, by approximately 1 hour.     

The first ambulatory screening on thromboembolism: a multicentre, cross-sectional, observational study on risk factors for venous thromboembolism

Summary.  Objectives:  To assess the prevalence of risk factors for venous thromboembolism (VTE) and the prevalence of recent (<1 year) VTE [including superficial vein thrombosis (SVT), deep vein thrombosis (DVT) and pulmonary embolism (PE)] amongst patients attending general practitioner (GP) surgeries. Design:  Multicentre, cross-sectional, observational study. Setting:  A total of 1536 GP surgeries. Participants:  A total of 15 180 adult, co-operative subjects, who had consulted their GP for a health disorder and signed the informed consent form. Interventions:  None. Main outcome measures:  Prevalence of known VTE risk factors graded according to importance and prevalence of recent (<1 year) VTE events (including SVT), based on interviews. Results:  About 1:5 patients had at least one strong risk factor and about 1:20 had at least two risk factors, with no difference between sexes. The prevalence of strong risk factors increased with age. Most were related to medical conditions: history of SVT and/or DVT/PE, heart failure and malignancy. About 3:4 women and 2:3 men had at least one moderate to weak risk factor; nearly 1:2 women and 1:3 men had at least two moderate to weak risk factors. The most common were: history of VTE, smoking, history of miscarriage, estrogen therapy, obesity, and varicose veins. Overall, 80% women and 67% men had at least one risk factor, and 50% women and 35% men had at least two risk factors. The prevalence of recent (<1 year) VTE was 3.4% in women and 2.4% in men, and increased with age. The majority of cases were SVT in both sexes (2.5% in women and 1.5% in men). Conclusions:  The prevalence of risk factors for VTE amongst patients attending GP surgeries is high. GPs should bear this in mind during their daily practice.     

Management of supraventricular tachycardia using the Valsalva manoeuvre: a historical review and summary of published evidence

Use of the Valsalva manoeuvre (VM) as a first-line management tool for the reversion of supraventricular tachycardia (SVT) in both emergency medicine and prehospital emergency-care settings has presented challenges, requiring continuous examination and refinement to define both its appropriateness and effectiveness. This report details the evolution of knowledge related to SVT and the historical evolution and controversies associated with VM; it also highlights the ongoing development of an evidence-based model of practice for the management of SVT in the emergency medicine and prehospital emergency-care settings. A two-part review of the literature using electronic medical databases was conducted. Other relevant texts or articles unavailable within the electronic search were also identified. Part 1 of the search criteria identified the historical evolution of the pathophysiology of SVT, whereas part 2 identified the use of VM for the clinical management of SVT. Part 1 of the review identified a total of 38 articles with eight meeting the inclusion criteria, and part 2 of the review identified a total of 44 articles with 17 meeting the inclusion criteria. An evidence-based model of practice requires clarification. The differentiation of nodal re-entrant tachycardias may, with further research, lead to identification of the specificity of VM in reversion of SVT during the early stages of arrhythmia. There is a need for further prehospital and emergency department research to quantify an evidence-based approach to VM.     

Handover in the emergency department: deficiencies and adverse effects

Objective: To determine problems resulting from ED handover, deficiencies in current procedures and whether patient care or ED processes are adversely affected. Methods: A prospective observational study at three large metropolitan ED comprising three components: observation of handover sessions, 2 h post‐handover surveys of the receiving doctors and a general survey of ED doctors. Results: The handovers of 914 patients were observed during 60 handover sessions in a 3‐month period. Medical information, including presenting complaints, was handed over better than communication and disposition information. Seven hundred and seven (77.4%) of 914 potential post‐handover interviews were undertaken. Most (88.3%) doctors thought the handover was ‘adequate/good’. However, information was perceived as lacking in 109 (15.4%) handovers, especially details of management (35, 5.0%), investigations (33, 4.7%) and disposition (33, 4.7%). There was a significant difference in the perceived quality of handovers (1–5 scale where 5 = excellent) when all required information was handed over and when it was not (median scores 4.0 vs 3.0, respectively, P < 0.001). As a result of perceived inadequate handovers, the doctor/ED and patient were affected adversely in 62 (8.8%) and 33 (4.7%) cases, respectively, for example, repetition of assessment, delays in disposition and care. Fifty doctors completed the general survey. Most believed communications made to inpatient units, inaccurate/incomplete information and disorganization were problematic. Conclusion: Deficiencies in handover processes exist, especially in communication and disposition information. These affect doctors, the ED and patients adversely. Recommendations for improvement include guideline development to standardize handover processes, the greater use of information technology facilities, ongoing feedback to staff, and quality assurance and education activities.     

Patient perceptions of caring and association with emergency department activity and access block

Objective: To develop and validate a questionnaire isolating patients' perceptions of caring as individuals provided by ED doctors. This tool was then applied to explore the relationship between ED activity and patient perceptions of caring. Methods: Following questionnaire development and reliability analysis, a prospective, cross‐sectional study was performed of ED patients who completed the written questionnaire regarding perceptions of caring. The ED tracking database obtained demographic data, patient visit characteristics and markers of departmental activity. Spearman's rho evaluated associations between perceptions of caring and activity. Free text responses were analysed thematically. Results: In reliability testing the questionnaire demonstrated Kappa 0.679, Cronbach's alpha 0.891. The survey was completed by 467 patients. Over 95% of patients agreed that ED doctors: identified themselves; took the problem seriously; treated patients with respect; were courteous and considerate; and demonstrated an overall caring attitude towards patients. Lower agreement occurred with doctors: not distracted by other issues; patient involvement in decisions about care; respect for cultural or religious needs; and doctors going out of their way to help. There were no significant differences in the proportion of patients recruited from different days of the week, shifts or sex. No clinically important associations were demonstrated between perceptions of caring and departmental activity. Least liked aspects of ED care related to system issues rather than the interpersonal relationship with the ED doctors. Conclusions: This study has validated a questionnaire isolating caring attributes. ED activity was not associated with patients' perceptions of being cared for by ED doctors.     

Distances to Emergency Department and to Primary Care Provider's Office Affect Emergency Department Use in Children

Objectives:  Patients of all ages use emergency departments (EDs) for primary care. Several studies have evaluated patient and system characteristics that influence pediatric ED use. However, the issue of proximity as a predictor of ED use has not been well studied. The authors sought to determine whether ED use by pediatric Medicaid enrollees was associated with the distance to their primary care providers (PCPs), distance to the nearest ED, and distance to the nearest children's hospital.
Methods:  This historical cohort study included 26,038 children age 18 and under, assigned to 332 primary care practices affiliated with a Medicaid health maintenance organization (HMO). Predictor variables were distance from the child's home to his or her PCP site, distance from home to the nearest ED, and distance from home to the nearest children's hospital. The outcome variable was each child's ED use. A negative binomial model was used to determine the association between distance variables and ED use, adjusted for age, sex, and race, plus medical and primary care site characteristics previously found to influence ED use. Distance variables were divided into quartiles to test for nonlinear associations.
Results:  On average, children made 0.31 ED visits/person/year. In the multivariable model, children living greater than 1.19 miles from the nearest ED had 11% lower ED use than those living within 0.5 miles of the nearest ED (risk ratio [RR] = 0.89, 95% CI = 0.81 to 0.99). Children living between 1.54 and 3.13 miles from their PCPs had 13% greater ED use (RR = 1.13, 95% CI = 1.03 to 1.24) than those who lived within 0.7 miles of their PCP.
Conclusions:  Geographical variables play a significant role in ED utilization in children, confirming the importance of system-level determinants of ED use and creating the opportunity for interventions to reduce geographical barriers to primary care.     

Medical Clearance of the Psychiatric Patient in the Emergency Department

Background: As part of the emergency department (ED) evaluation of patients with psychiatric complaints, emergency physicians are often asked to perform screening laboratory tests prior to admitting psychiatric patients, the value of which is questionable. Study Objective: To determine if routine screening laboratory studies performed in the ED on patients with a psychiatric chief complaint would alter ED medical clearance (evaluation, management or disposition) of such patients. Methods: In this retrospective chart review, the patient charts were reviewed for triage notes, history and physical examination, laboratory study results, and patient disposition. The study investigators subjectively determined if any of the laboratory abnormalities identified after admission would have changed ED management or disposition of the patient had they been identified in the ED. Results: Subjects were 519 consecutive adult patients (18 years of age and older) admitted to the Medical College of Georgia's inpatient psychiatric ward through the ED. There were 502 patients who met inclusion criteria, and 50 of them had completely normal laboratory studies. Laboratory studies were performed in the ED for 148 patients. The most common abnormalities identified were positive urine drug screen (n = 221), anemia (n = 136), and hyperglycemia (n = 139). There was one case (0.19%) identified in which an abnormal laboratory value would have changed ED management or disposition of the patient had it been found during the patient's ED visit. Conclusions: Patients presenting to the ED with a psychiatric chief complaint can be medically cleared for admission to a psychiatric facility by qualified emergency physicians using an appropriate history and physical examination. There is no need for routine medical screening laboratory tests.     

The influence of key clinical practices on the knowledge of first year doctors about the patients under their care

Aims: In 2009 in the United Kingdom the 48‐h working week was introduced for junior doctors. To comply with this traditional working practices have changed. This study aims to assess how much first year (FY1) doctors know about the acute surgical patients they manage and how this is influenced by changes in key working practices. Methods: Surgical FY1s working in NHS hospitals answered 16 clinical questions about a standard acute surgical patient under their care 48 h after admission. Scores were analysed according to how long the FY1 had been looking after the patient, whether they had clerked the patient in, attended the post take ward round (PTWR), used a handover sheet to answer the questions and had sole or shared responsibility for the patient. Results: Two hundred and seventy‐four FY1s (92% response rate) from 36 hospitals were surveyed. The overall median score was 11/16 (inter‐quartile range 8–13). Only 8.4% (23/274) FY1s had clerked in the patient and 58.4% (160/274) had attended the PTWR. Clerking patients and attending the PTWR resulted in significantly higher test scores compared to FY1s who did not perform these activities (p = < 0.001 and 0.001 respectively). The scores of the 67.2% who used a handover sheet were significantly lower than those who did not (p = 0.001). Having sole or shared responsibility and duration of care made no significant difference (p = 0.143 and p = 0.458 respectively) Conclusions: The results demonstrate that junior doctors’ knowledge of their patients is significantly enhanced when they have the opportunity to perform the admission clerking and attend the PTWR. Because of working hours’ restrictions this is now rare. Although use of handover sheets appears to ensure that certain key facts immediately related to the current admission are passed on, it is associated with significantly poorer wider knowledge of the patient.     

Use, Understanding, and Beliefs about Complementary and Alternative Medicines among Emergency Department Patients

OBJECTIVES: To describe the extent of complementary and alternative medicine (CAM) use among emergency department (ED) patients, to evaluate patients' understanding of CAMs, and to determine gender differences in beliefs about CAMs. METHODS: This study was a convenience sampling of patients seen in an urban ED. Patient demographics were recorded. A questionnaire was administered that assessed patients' knowledge and use of CAMs. Patients were also asked about their beliefs on safety, medication interactions, and conveying information about these substances to their physicians. RESULTS: A total of 350 ED patients were included in the study; 87% had heard of at least one of the CAMs. There was no difference between genders or races concerning knowledge about CAMs. The most commonly known CAMs were ginseng (75%), ginkgo biloba (55%), eucalyptus (58%), and St. John's wort (57%). Forty-three percent of the responders had used CAMs at some time and 24% were presently using CAMs. The most commonly used CAMs were ginseng (13%), St. John's wort (6%), and ginkgo biloba (9%). All CAMs were considered to be safe by 16% of the patients. Only 67% would tell their doctors they were using CAMs. Females were more likely than males to believe that CAMs do not interact with other medications (15% vs 7%, difference 8%, 95% CI = 2% to 15%). CONCLUSIONS: Complementary and alternative medicines are familiar to most patients and used by many of them. Despite this, a large percentage of patients would not tell their physicians about their use of alternative medications. Emergency medicine providers should be aware of the commonly used CAMs, and questions about their use should be routinely included in ED exams.     

Reliability of the Color Analog Scale: Repeatability of Scores in Traumatic and Nontraumatic Injuries

Objectives:  The objective was to assess in a pediatric emergency department (ED) the reliability of the color analog scale (CAS) for acute pain assessment, overall and between traumatic and nontraumatic pain etiology.
Methods:  This was a prospective study of children aged 5 to 16 years in the ED of a children's hospital who had a complaint of pain. The CAS was administered to the patient at admission and at 30 minutes. To evaluate repeatability, a second measurement was obtained 1 minute following each assessment. This assumed there would be no substantial change in pain intensity within 1 minute. The authors used the intraclass correlation coefficient (ICC) to evaluate the repeatability of 1-minute interval measurements.
Results:  A total of 170 patients were enrolled. The origin of pain was traumatic in 81 cases (48%). Regardless of pain etiology, the CAS scores were highly repeatable ( r  = 0.97, 95% confidence interval [CI] = 0.95 to 0.98).
Conclusions:  The color analog scale is both a valid and a reliable self-reporting tool in the assessment of acute pain in children.