Using transprofessional care in the emergency department to reduce patient admissions: A retrospective audit of medical histories

The demand for emergency department (ED) services has increased significantly, due to our increasingly ageing population and limited access to primary care. This article reports outcomes from a transprofessional model of care in an ED in Victoria, Australia. Nurses, physiotherapists, social workers, and occupational therapists undertook additional education to increase the range of services they could provide and thereby expedite patient flow through the ED. One hundred patients who received this service were matched against 50 patients who did not. The most common reasons for patient admission were limb injury/limb pain (n = 47, 23.5%) and falls (n = 46, 23.0%). Transprofessional interventions included applying supportive bandages, slings, zimmer splints and controlled ankle motion (CAM) boots, and referral to new services such as case management and mental health teams. The rate of hospital admissions was significantly lower in the transprofessional group (n = 27, 18.0%) than in the reference group (n = 19, 38%, p = 0.005). This group also had a slightly lower re-presentation rate (n = 4, 2.7%) than patients in the reference group (n = 2, 4.0%). There are many benefits that support this model of care that in turn reduces ED overcrowding and work stress. A transprofessional model may offer a creative solution to meeting the varied needs of patients presenting for emergency care.     

Sedation practice in a Scottish teaching hospital emergency department

Objectives

To conduct a prospective survey in a teaching hospital emergency department to evaluate performance according to safe sedation principles, to establish the demographics of those sedated, and to review the drugs used and doses given to patients in the department. Any adverse events were reviewed for identification of preventable causes.

Methods

Pre‐sedation checklists, peri‐procedural observations, and patient notes were reviewed for 101 cases from 4 December 2004 to 3 September 2005. There are departmental guidelines outlining the principles of safe sedation.

Results

Emergency department procedural sedation was performed for a variety of acute conditions in patients aged from 7 to 91 years old. A variety of sedation agents were administered, morphine and midazolam being used most frequently. Drug administration, maximum sedation level, and time to recovery and discharge were recorded. Four adverse events were reported, none of which were clinically significant. Departmental guidelines were followed.

Conclusion

Emergency department sedation is a safe and effective procedure if appropriately trained practitioners follow the principles of safe sedation.     

Patient satisfaction with psychiatric services provided by a Melbourne tertiary hospital emergency department

The mainstreaming of psychiatric services within the general healthcare system has created fundamental changes to the manner in which patients access acute psychiatric services. This change was intended to reduce the stigma associated with psychiatric diagnosis and therefore contribute to improved treatment outcomes for patients. The aim of this paper is to discuss the results of a study designed to ascertain the level of psychiatric patient satisfaction with the services received in the emergency department of a Melbourne metropolitan hospital. The results indicate a high level of satisfaction, particularly with the availability of staff with psychiatric qualifications and experience to provident treatment, support and care. The major areas of dissatisfaction identified by patients included: lengthy waiting times, lack of privacy in the triage area and negative attitudes of general staff. These findings support the argument from the literature for psychiatric consultancy services to be available in the emergency department, and further identifies the need for triage guidelines to be tailored to the needs of mental health patients and for emergency department triage staff to be appropriately educated to adequately triage these patients.     

Multifaceted education initiative minimizes pethidine prescribing in the emergency department

Background: Pain management experts have recommended a diminished role for pethidine because of lack of superiority for any indication and greater potential for adverse effects compared with morphine. Objectives: To evaluate the impact of a multifaceted education initiative on prescribing patterns and to minimize pethidine use in the ED. Methods: This was a pre‐ and post‐intervention study. The intervention was an education initiative, introduced between December 2003 and January 2004. It comprised ED pharmacist in‐services for medical and nursing staff, championing by senior medical staff (ED consultants, surgical units, Drug and Therapeutics Committee) and concurrent prescriber feedback by ED pharmacists. The pre‐intervention prescribing practices guided the development of in‐services and the educational programme. The intervention was evaluated by a medical record review of analgesic prescribing in March–April of both 2003 (pre‐intervention period) and 2004 (post‐intervention period). Outcome measures were the proportions of patients who were prescribed pethidine and the proportions of pethidine ampoules supplied to the ED. Results were analysed as differences in proportions. Results: In the pre‐intervention period, 60 ampoules of pethidine (7.2% of opiate doses) and 777 ampoules of morphine (92.8% of opiate doses) were administered compared with 15 ampoules of pethidine (1.7%) and 869 ampoules of morphine (98.3%) in the post‐intervention period (P < 0.001). Of patients who received an opiate dose, 50 of 798 (6.3%) and 11 of 747 (1.5%) received pethidine in the pre‐ and post‐intervention periods, respectively (P < 0.001). Conclusion: Our education initiative resulted in a sustained and significant reduction in pethidine prescribing in the ED. Sustainability requires ongoing in‐services for ED staff, usually as part of the orientation programme.     

Headache patients in the emergency department of a Greek tertiary care hospital

The aim of this study was to record the demographic and epidemiological data on adult patients with headache who attend the emergency department (ED) and the diagnoses that made by the neurologists in the ED of a tertiary care hospital in metropolitan Thessaloniki (Greece). In an open prospective study, demographic and epidemiological data were collected on all patients who reported headache (as chief complaint or not) and presented to the ED of Papageorgiou Hospital between August 2007 and July 2008. Headache patients accounted for 1.3% of all ED patients and for 15.5% of patients primarily referred to the ED neurologist. Tension type headache was the most frequent diagnosis, followed by secondary headaches and migraine. The large number of patients without final ED diagnosis and ward admission for further evaluation sheds a light on the immense workload of Greek ED physicians. Furthermore, we found evidence for the misuse of Emergency Medical Services by chronic headache patients. These findings indicate shortcomings in the pre-hospital (primary care) management of headache patients in the Greek National Health System to an extent unreported so far.     

The district hospital emergency department: Why do parents present?

Objective: To identify parental reasons for presenting their child to the emergency department and their expectations of the consultation. Method: Cross‐sectional survey of parents of children and adolescents aged 14 years and under who presented to the Fairfield Emergency Department over a 2‐month period. Results: A questionnaire was returned from 694 of 839 eligible presentations (83%), with 51% having an urgent triage and 26% being admitted. Proximity was nominated as the reason for choosing the Fairfield Emergency Department by 48%, 62% of presentations were self‐referred and 44% had already seen another doctor. An urgent triage was associated with parental expectation of admission or observation in the emergency department (OR 2.79 [95% CI: 1.98–3.94]). Conclusions: The majority of presentations to the district emergency department are self‐referred and it is chosen because of proximity. The majority of children do not require admission; however, parents often have expectations that observation and further investigation will occur prior to discharge from the emergency department.     

Ultrasonography in patients without trauma in the emergency department: impact on discharge diagnosis.

OBJECTIVE: The aim of this study was to examine to what extent findings on ultrasonography performed in the emergency department (ED) after hours confirm or alter the referral diagnosis in patients without trauma as reflected in the discharge diagnosis. METHODS: In this prospective study, data from 136 ultrasonographic examinations performed in patients without trauma after hours in the ED during January and February 2002 were evaluated against the suspected preimaging diagnosis of the referring ED physician and the actual discharge diagnosis from the ED or after hospitalization. The rate of preimaging and postimaging concordance was statistically analyzed and compared by calculation of confidence intervals and by the McNemar test. RESULTS: Normal ultrasonographic findings were documented in 54 patients (40%), and pathologic findings were documented in 82 (60%). Thirty-four (25%) of the 136 examinations were concordant with the initial referring physician's diagnosis. Of the 102 studies that were not concordant with the initial referral suspected diagnoses, that is, being either a study with normal findings or offering an alternative diagnosis, 81 (79.4%) were concordant with the discharge diagnosis. CONCLUSIONS: After-hours ultrasonographic findings in patients without trauma seen in the ED seem to have a high impact on the discharge diagnosis and are concordant with it in more than 80% of cases.     

Variation in hospital admission rates between a tertiary care and two freestanding emergency departments

Background

Recently, freestanding emergency departments (FSEDs) have grown significantly in number. Critics have expressed concern that FSEDs may increase healthcare costs.