Missed nursing care in emergency departments: A scoping review

BackgroundPatient safety is a global health priority. Errors of omission, such as missed nursing care in hospitals, are frequent and may lead to adverse events. Emergency departments (ED) are especially vulnerable to patient safety errors, and the significance missed nursing care has in this context is not as well known as in other contexts.AimThe aim of this scoping review was to summarize and disseminate research about missed nursing care in the context of EDs.MethodA scoping review following the framework suggested by Arksey and O’Malley was used to (1) identify the research question; (2) identify relevant studies; (3) select studies; (4) chart the data; (5) collate, summarize, and report the results; and (6) consultation.ResultsIn total, 20 themes were derived from the 55 included studies. Missed or delayed assessments or other fundamental care were examples of missed nursing care characteristics. EDs not staffed or dimensioned in relation to the patient load were identified as a cause of missed nursing care in most included studies. Clinical deteriorations and medication errors were described in the included studies in relation to patient safety and quality of care deficiencies. Registered nurses also expressed that missed nursing care was undignified and unsafe.ConclusionThe findings from this scoping review indicate that patients’ fundamental needs are not met in the ED, mainly because of the patient load and how the ED is designed. According to registered nurses, missed nursing care is perceived as undignified and unsafe.     

Outcomes for Patients Who Contact the Emergency Ambulance Service and Are Not Transported to the Emergency Department: A Data Linkage Study

Objectives: Emergency ambulance services do not transport all patients to hospital. International literature reports non-transport rates ranging from 3.7–93.7%. In 2017, 38% of the 11 million calls received by ambulance services in England were attended by ambulance but not transported to an Emergency Department (ED). A further 10% received clinical advice over the telephone. Little is known about what happens to patients following a non-transport decision. We aimed to investigate what happens to patients following an emergency ambulance telephone call that resulted in a non-transport decision, using a linked routine data-set. Methods: Six-months individual patient level data from one ambulance service in England, linked with Hospital Episode Statistics and national mortality data, were used to identify subsequent health events (ambulance re-contact, ED attendance, hospital admission, death) within 3 days (primary analysis) and 7 days (secondary analysis) of an ambulance call ending in non-transport to hospital. Non-clinical staff used a priority dispatch system e.g. Medical Priority Dispatch System to prioritize calls for ambulance dispatch. Non-transport to ED was determined by ambulance crew members at scene or clinicians at the emergency operating center when an ambulance was not dispatched (telephone advice). Results: The data linkage rate was 85% for patients who were discharged at scene (43,108/50,894). After removal of deaths associated with end of life care (N?=?312), 9% (3,861/42,796) re-contacted the ambulance service, 12.6% (5,412/42,796) attended ED, 6.3% (2,694/42,796) were admitted to hospital, and 0.3% (129/42,796) died within 3 days of the call. Rates were higher for events occurring within 7 days. For example, 12% re-contacted the ambulance service, 16.1% attended ED, 9.3% were admitted to hospital, and 0.5% died. The linkage rate for telephone advice calls was low because ambulance services record less information about these patients (24% 2,514/10,634). A sensitivity analysis identified a range of subsequent event rates: 2.5–10.5% of patients were admitted to hospital and 0.06–0.24% of patient died within 3 days of the call. Conclusions: Most non-transported patients did not have subsequent health events. Deaths after non-transport are an infrequent event that could be selected for more detailed review of individual cases, to facilitate learning and improvement.     

Ambulance Diversion and Emergency Department Offload Delay: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

The emergency medical services (EMS) system is a component of a larger health care safety net and a key component of an integrated emergency health care system. EMS systems, and their patients, are significantly impacted by emergency department (ED) crowding. While protocols designed to limit ambulance diversion may be effective at limiting time on divert status, without correcting overall hospital throughput these protocols may have a negative effect on ED crowding and the EMS system. Ambulance offload delay, the time it takes to transfer a patient to an ED stretcher and for the ED staff to assume the responsibility of the care of the patient, may have more impact on ambulance turnaround time than ambulance diversion. EMS administrators and medical directors should work with hospital administrators, ED staff, and ED administrators to improve the overall efficiency of the system, focusing on the time it takes to get ambulances back into service, and therefore must monitor and address both ambulance diversions and ambulance offload delay. This paper is the resource document for the National Association of EMS Physicians position statement on ambulance diversion and ED offload time.     

Description and Evaluation of a Pilot Physician-directed Emergency Medical Services Diversion Control Program

Objectives: To describe the characteristics and feasibility of a physician‐directed ambulance destination‐control program to reduce emergency department (ED) overcrowding, as measured by hospital ambulance diversion hours. Methods: This controlled trial took place in Rochester, New York and included a university hospital and a university‐affiliated community hospital. During July 2003, emergency medical services (EMS) providers were asked to call an EMS destination‐control physician for patients requesting transport to either hospital. The destination‐control physician determined the optimal patient destination by using patient and system variables as well as EMS providers' and patients' input. Program process measures were evaluated to characterize the program. Administrative data were reviewed to compare system characteristics between the intervention program month and a control month. Results: During the intervention month, 2,708 patients were transported to the participating hospitals. EMS providers contacted the destination‐control physician for 1,866 (69%) patients. The original destination was changed for 253 (14%) patients. Reasons for redirecting patients included system needs, patient needs, physician affiliation, recent ED or hospital care, patient wishes, and primary care physician wishes. During the intervention month, EMS diversion decreased 190 (41%) hours at the university hospital and 62 (61%) hours at the community hospital, as compared with the control month. Conclusions: A voluntary, physician‐directed destination‐control program that directs EMS units to the ED most able to provide appropriate and timely care is feasible. Patients were redirected to maximize continuity of care and optimally use available emergency health care resources. This type of program may be effective in reducing overcrowding.     

Early prehospital assessment of non-urgent patients and outcomes at the appropriate level of care: A prospective exploratory study

IntroductionThe Ambulance Organization of Sweden provides qualified medical assessment and treatment by ambulance nurses based on patient needs regarding appropriate levels of care. A new model for patients with non-urgent medical conditions has been introduced. The main objective of this study was to examine early prehospital assessment of non-urgent patients, and its impact on the choice of the appropriate level of care.MethodsThe study design was a 1-year, prospective study, involving an ambulance district in southwestern Sweden with a population of 78,000. Eligible patients were from18 years of age, assessed as priority GREEN by Rapid Emergency Triage and Treatment System (RETTS). Ambulance nurses contacted primary care physicians on decisions on whether a patient should be transported to a primary healthcare unit or an A&E. Data was collected from electronic health records from April 2014 to July 2015. A comparison was made with a retrospective control group without consulting a physician concerning the appropriate level of care.Results394 patients were included, 184 in the intervention group, and 210 in the control group. There were statistically significant differences in favor of the study group (p < 0.001) regarding no transport, or transport and admission to an A&E. The groups did not differ significantly regarding transport to a primary care unit.ConclusionThis prehospital assessment model indicates a decrease in ambulance transports to an A&E and admissions to a hospital ward. Collaboration between ambulance nurses and primary physicians affects the decision for the appropriate level of care for patients with a non-urgent condition.     

Patient Navigation to Reduce Emergency Department (ED) Utilization Among Medicaid Insured,Frequent ED Users: A Randomized Controlled Trial

BackgroundSome Medicaid enrollees frequently utilize the emergency department (ED) due to barriers accessing health care services in other settings.ObjectivesTo determine whether an ED-initiated Patient Navigation program (ED-PN) designed to improve health care access for Medicaid-insured frequent ED users could decrease ED visits, hospitalizations, and costs.MethodsWe conducted a prospective, randomized controlled trial comparing ED-PN with usual care (UC) among 100 Medicaid-enrolled frequent ED users (defined as 4–18 ED visits in the prior year), assessing ED utilization during the 12 months pre- and post-enrollment. Secondary outcomes included hospitalizations, outpatient utilization, hospital costs, and Medicaid costs. We also compared characteristics between ED-PN patients with and without reduced ED utilization.ResultsOf 214 eligible patients approached, 100 (47%) consented to participate. Forty-nine were randomized to ED-PN and 51 to UC. Sociodemographic characteristics and prior utilization were similar between groups. ED-PN participants had a significant reduction in ED visits and hospitalizations during the 12-month evaluation period compared with UC, averaging 1.4 fewer ED visits per patient (p = 0.01) and 1.0 fewer hospitalizations per patient (p = 0.001). Both groups increased outpatient utilization. ED-PN patients showed a trend toward reduced per-patient hospital costs (−$10,201, p = 0.10); Medicaid costs were unchanged (−$5,765, p = 0.26). Patients who demonstrated a reduction in ED usage were older (mean age 42 vs. 33 years, p = 0.03) and had lower health literacy (78% low health literacy vs. 40%, p = 0.02).ConclusionAn ED-PN program targeting Medicaid-insured high ED utilizers demonstrated significant reductions in ED visits and hospitalizations in the 12 months after enrollment.     

End of life care pathways in the Emergency Department and their effects on patient and health service outcomes: An integrative review

IntroductionEnd of life (EOL) care in the Emergency Department (ED) requires focused, person-centred care to meet the needs of this vulnerable cohort of patients.MethodsAn integrative review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was conducted. Studies were included if they were primary research relating to patients in the ED at the EOL, and/or evaluated EOL care pathways in the ED. Databases OVID Emcare, OVID Medline, and Scopus were searched from 1966-September 2021; followed by screening and appraisal. Articles were compared and data grouped into categories.ResultsEleven research articles were included generating three categories for EOL care in ED. 1) tools/criteria to identify patients who may require EOL care in ED; 2) processes for providing EOL care, and 3) implementation methods/frameworks to support the uptake of EOL care processes.ConclusionThere were some commonalities in the criteria used to identify patients who may be at their EOL and the interventions implemented thereafter. There was no standardised process for screening for or treating EOL care needs in the ED. Further research is required to determine the impact that EOL care pathways have on patient and health service outcomes to inform strategies for future policy development.     

A N E MERGENCY M EDICAL S ERVICES P ROGRAM OF A LTERNATE D ESTINATION OF P ATIENT C ARE

Objective: The emergency department (ED) is ideally reserved for urgent health needs. The ED, however, is often the site of care for nonurgent conditions. The authors investigated whether emergency medical technicians could decrease ED use by patients with nonurgent concerns who use 911 by appropriately identifying and triaging them to alternate care destinations. Methods: From August 2000 through January 2001, two King County fire-based emergency medical services (EMS) agencies participated in an alternate care destination program for patients with specific low-acuity diagnosis codes (intervention group). Eligible patients were offered care at a clinic-based destination as an alternate to the ED (n = 1,016). The frequency of the destination of care (ED, clinic, or home) for the intervention group was compared with a matched control group that was comprised of a preintervention historical cohort of EMS encounters from the same two fire-based agencies and with the same acuity and diagnosis criteria and seasonal interval (n = 2,617). Results: Compared with the preintervention group, a smaller proportion of patients in the intervention group received care in the ED (44.6% vs. 51.8%, p = 0.001), while a greater proportion of patients in the intervention group received clinic care (8.0% vs. 4.5%, p = 0.001) or home care (no transport) (47.4 vs. 43.7%, p = 0.043). Results were comparable when adjusted for other patient characteristics. Similar relationships were not evident among nonparticipating King County EMS agencies. Based on physician review and patient interview, the alternate care intervention appeared to be safe and satisfactory. Conclusion: An EMS-based program may represent one approach to limiting nonurgent ED use.     

Demand for Emergency Services Trends in New South Wales Years 2010–2014 (DESTINY): Age and Clinical Factors Associated with Ambulance Transportation to Emergency Departments

Objectives: The study aimed to analyze ambulance transportations to Emergency Departments (EDs) in New South Wales (NSW) and to identify temporal changes in demographics, acuity, and clinical diagnoses. Methods: This was a retrospective analysis of a population based registry of ED presentations in New South Wales. The NSW Emergency Department data collection (EDCC) collects patient level data on presentations to designated EDs across NSW. Patients that presented to EDs by ambulance between January 2010 and December 2014 were included. Patients dead on arrival, transferred from another hospital, or planned ED presentations were excluded. Results: A total of 10.8 million ED attendances were identified of which 2.6 million (23%) were transported to ED by ambulance. The crude rate of ambulance transportations to EDs across all ages increased by 3.0% per annum over the five years with the highest rate observed in those 85 years and over (620.5 presentations per 1,000 population). There was an increase in the proportion of category 1 and 2 (life-threatening or potentially life-threatening) cases from 18.1% to 24.0%. Conclusion: Demand for ambulance services appears to be driven by older patients presenting with higher acuity problems. Alternative models of acute care for elderly patients need to be planned and implemented to address these changes.     

Paramedic-Initiated Home Care Referrals and Use of Home Care and Emergency Medical Services

Objective: We examined the association between paramedic-initiated home care referrals and utilization of home care, 9-1-1, and Emergency Department (ED) services. Methods: This was a retrospective cohort study of individuals who received a paramedic-initiated home care referral after a 9-1-1 call between January 1, 2011 and December 31, 2012 in Toronto, Ontario, Canada. Home care, 9-1-1, and ED utilization were compared in the 6 months before and after home care referral. Nonparametric longitudinal regression was performed to assess changes in hours of home care service use and zero-inflated Poisson regression was performed to assess changes in the number of 9-1-1 calls and ambulance transports to ED. Results: During the 24-month study period, 2,382 individuals received a paramedic-initiated home care referral. After excluding individuals who died, were hospitalized, or were admitted to a nursing home, the final study cohort was 1,851. The proportion of the study population receiving home care services increased from 18.2% to 42.5% after referral, representing 450 additional people receiving services. In longitudinal regression analysis, there was an increase of 17.4 hours in total services per person in the six months after referral (95% CI: 1.7–33.1, p = 0.03). The mean number of 9-1-1 calls per person was 1.44 (SD 9.58) before home care referral and 1.20 (SD 7.04) after home care referral in the overall study cohort. This represented a 10% reduction in 9-1-1 calls (95% CI: 7–13%, p < 0.001) in Poisson regression analysis. The mean number of ambulance transports to ED per person was 0.91 (SD 8.90) before home care referral and 0.79 (SD 6.27) after home care referral, representing a 7% reduction (95% CI: 3–11%, p < 0.001) in Poisson regression analysis. When only the participants with complete paramedic and home care records were included in the analysis, the reductions in 9-1-1 calls and ambulance transports to ED were attenuated but remained statistically significant. Conclusions: Paramedic-initiated home care referrals in Toronto were associated with improved access to and use of home care services and may have been associated with reduced 9-1-1 calls and ambulance transports to ED.     

Quality of the handover of patient care: a comparison of pre-Hospital and Emergency Department notes

AimThe aim of this audit was to evaluate the accuracy of patient information transfer from pre-hospital reports to Emergency Department (ED) documentation.MethodsThe records of 100 patients seen in the ED resuscitation room of a UK hospital were compared using a pro-forma designed by the research team. Sections of the ambulance service patient report form and the ED documentation were compared for differences. The history of the event leading to the 999 call, the patient’s previous medical history, prescribed medications, allergies and any treatment carried out by the ambulance crew were analysed.ResultsOf the 100 records, 26 had at least one instance where information recorded by the ambulance crew was either omitted or altered during transfer. These fell into various categories including the previous medical history of the patient, the timings of the event bringing them to hospital, frequency of the event occurring, allergies and medications.ConclusionThis audit quantifies the number of patient encounters where written information changes or is lost when care is passed from pre-hospital to hospital staff in the resuscitation room. We have not investigated other parts of the ED or the verbal transfer of information. Further work investigating the causes of these changes in information, any impact on patient care and whether this occurs in other parts of an ED is suggested.     

M ODIFICATION OF THE L ARYNGEAL T UBE

Background. Approximately 40% of Hennepin County Medical Center's (HCMC's) ambulance runs are for minor medical conditions as defined by billing criteria [“ALS minor,” i.e., no advanced life support (ALS) procedures done in the field]. Current metropolitan guidelines mandate that all such patients must be transported to a hospital unless they refuse this service. It has been proposed that some patients with minor medical conditions could be better served by treatment in the field by paramedics and referred to a clinic or hospital for early follow-up care. It is proposed that this approach would save costs and improve paramedic availability for patients with more serious conditions. Objective. To evaluate the feasibility and safety of implementing such a program by identifying high-volume, low-complexity groupings of cases. Such high-volume, low-complexity cases would serve as the topics for curriculum development for paramedic training in field treatment and referral. Methods. Data were obtained from ambulance run sheets and emergency department (ED) records for all patients transported by the HCMC ambulance service in 1996 who were covered by the Metropolitan Health Plan (MHP) and who were categorized for billing purposes as “ALS minor” transports. The data included demographic information, vital signs, presenting problem, diagnoses in the ED, and procedures, laboratory studies, or x-rays done in the ED. Patients were classified as “potentially treatable” in the field if they were treated and discharged from the ED without undergoing any procedures or diagnostic studies. Patients who required more extensive evaluation in the ED, or who were admitted, were classified as likely too “complex” to be treated at the scene and then referred for early follow-up. The data were analyzed to find the most common presenting problems and the numbers, characteristics, and dispositions of “potentially treatable” and “complex” patients in each group. This information was used to determine what, if any, types of patients could potentially be treated safely and effectively according to this scheme. Results. The study group comprised 1,103 patients, representing 127 different presenting medical problems. There were 523 (47%) “potentially treatable” patients and 580 (53%) “complex” patients. The 127 medical problems were grouped and the 15 most common presenting problem groups were identified. Within these groups there was no single medical problem with high volume. Each of these 15 most common problem groups contained a substantial proportion of “complex” patients, ranging from 24% to 100%. Conclusions. None of the 15 most frequently encountered problem groups consisted of a high enough proportion of “potentially treatable” cases to serve as a high-volume, low-complexity category for paramedic treatment in the field with early follow-up. Without any identified high-volume, low-complexity categories, a treatment and referral program as proposed in this article would require a substantial investment in development of appropriate criteria and in training paramedics to apply the criteria for numerous clinical entities. This would limit any cost saving, and require great care to avoid compromising patient safety accompanied by substantial professional liability exposure.     

H OSPITAL F OLLOW - UP OF P ATIENTS C ATEGORIZED AS N OT N EEDING AN A MBULANCE U SING A S ET OF E MERGENCY M EDICAL T ECHNICIAN P ROTOCOLS

Objective. Using hospital outcomes, this study evaluated emergency medical technicians' (EMTs') ability to safely apply protocols to assign transport options. Methods. Protocols were developed that categorized patients as: 1) needs ambulance; 2) may go to emergency department (ED) by alternative means; 3) contact primary care provider (PCP); or 4) treat and release. After education on application of the protocols, EMTs categorized patients at the scene prior to transport but did not change current practice. Hospital charts were reviewed to determine outcome of patients whom EMTs categorized as not needing an ambulance. Category 2 patients were assumed to need the ambulance if they were admitted to a monitored bed or intensive care unit. Category 3 and 4 patients were assumed to need the ED if they were admitted. Results. The EMTs categorized 1,300 study patients: 1,023 (79%) ambulance transport, 200 (15%) alternative means, 63 (5%) contact PCP, and 14 (1%) treat and release. Hospital data were obtained for 140 (51%) patients categorized as not needing ambulance transport. Thirteen of 140 (9%) patients who transporting EMTs determined did not need the ambulance were considered to be undertriaged: five in category 2, six in category 3, and one in category 4. Six of 13 (46%) undertriaged patients had dementia or a psychiatric disorder as one of their presenting complaints. Conclusion. These protocols led to a 9% undertriage rate. Patients with psychiatric complaints and dementia were at high risk for undertriage.     

Pre-hospital assessment by a single responder: The Swedish ambulance nurse in a new role: A pilot study

When a person with vague symptoms calls 112, the dispatchers often have difficulty prioritising the severity of the call. Their only alternative has been to send an ambulance. In Gothenburg, Sweden, a nurse-manned single responder (SR) was initiated to assess this patient group. The study aims to describe patient characteristics and assessment level made by the SR nurse among patients assessed by the dispatcher as low priority and/or vague symptoms. A consecutive journal review was conducted. During six months, 529 patients were assessed; 329 (62%) attended the emergency department (ED) or inpatient care (IC). Of these, 85 patients (26%) were assessed as high priority. Only 108 were assessed as being in need of ambulance transport. ED/IC patients were significantly older. Two hundred (38%) stayed at the scene (SS) (n = 142) or were referred to primary care (PC) (n = 58). Of the 200 SS/PC patients, 38 (19%) attended the ED within 72 hrs with residual symptoms, 20 of whom were admitted to a ward. Nine patients (4% of 200 SS/PC patients) required inpatient treatment and 11 patients stayed overnight for observation. These results suggest a relatively high level of patient safety and the usefulness of an SR among patients assessed by the dispatcher as low priority.     

RN assessments of excellent quality of care and patient safety are associated with significantly lower odds of 30-day inpatient mortality: A national cross-sectional study of acute-care hospitals

BackgroundQuality and safety in health care has been increasingly in focus during the past 10–15 years. Stakeholders actively discuss ways to measure safety and quality of care to improve the health care system as a whole. Defining and measuring quality and safety, however, is complicated. One underutilized resource worthy of further exploration is the use of registered nurses (RNs) as informants of overall quality of care and patient safety. However, research is still scarce or lacking regarding RN assessments of patient safety and quality of care and their relationship to objective patient outcomes.ObjectiveTo investigate relationships between RN assessed quality of care and patient safety and 30-day inpatient mortality post-surgery in acute-care hospitals.DesignThis is a national cross-sectional study.Data sourcesA survey (n = >10,000 RNs); hospital organizational data (n = 67); hospital discharge registry data (n > 200,000 surgical patients).Data collection and analysisRN data derives from a national sample of RNs working directly with inpatient care in surgical/medical wards in acute-care hospitals in Sweden in 2010. Patient data are from the same hospitals in 2009–2010. Adjusted multivariate logistic regression models were used to estimate relationships between RN assessments and 30-day inpatient mortality.ResultsPatients cared for in hospitals where a high proportion of RNs reported excellent quality of care (the highest third of hospitals) had 23% lower odds of 30-day inpatient mortality compared to patients cared for in hospitals in the lowest third (OR 0.77, CI 0.65–0.91). Similarly, patients in hospitals where a high proportion of RNs reported excellent patient safety (highest third) had is 26% lower odds of death (OR 0.74, CI 0.60–0.91).ConclusionsRN assessed excellent patient safety and quality of care are related to significant reductions in odds of 30-day inpatient mortality, suggesting that positive RN reports of quality and safety can be valid indicators of these key variables.