Optimal management of mental health patients in Australian emergency departments: Barriers and solutions

Objectives: The study aimed to describe: (i) the perceived barriers faced by emergency clinicians in the assessment and management of patients presenting with a mental health complaint to Australian hospital EDs; and (ii) perceived strategies to optimize care of the mentally unwell in the ED. Methods: Semistructured interviews with open and closed question formats were used to explore the barriers perceived by ED doctors and nurses in assessing and managing patients with mental health presentations. Interviews were transcribed verbatim and thematically coded by two researchers using the Framework Approach. Results: Thirty‐six interviews were conducted with 20 members of the Australasian College for Emergency Medicine and 16 members of the College of Emergency Nursing Australasia representing the various Australian jurisdictions. Thematic analyses revealed that a range of resource, environmental, staff and patient factors contribute to difficulties in managing mental health patients. Solutions suggested by interviewees included improved resources, ED redesign and improved links to resources outside the ED. An overwhelming majority of participants perceived the need for more educational opportunities in mental health. Conclusion: Although the provision of timely and quality care is expected for all patients attending EDs, there exist multiple barriers to provision of adequate care for ED patients presenting with mental illness. Many of these are systems‐based and thus require systems‐based solutions. ED clinician's perceive that improved educational opportunities in mental health, however, might alleviate some barriers they face. Consideration should be given to a comprehensive, quantitative mental health‐related learning needs analysis of ED clinicians.     

Effect of a review course on emergency medicine residents' self‐confidence

Objectives: Several organizations offer review courses designed to guide final‐year (postgraduate year five) residents' study for their certification examination. The effect of these courses on residents' confidence is unknown. Self‐confidence has been positively linked with examination performance. The present study measures the impact of a review course on fifth‐year emergency medicine residents' overall confidence and confidence in their: (i) knowledge and its application; (ii) planned study strategies to master the knowledge/application; and (iii) recognition that mastery of knowledge/application had been achieved. Methods: Before/after study. Over the initial 2 years, 46 postgraduate year five residents from all 12 Canadian emergency medicine programmes attended the course. They prospectively completed a pre‐/post‐course questionnaire on the above‐listed aspects of self‐confidence, for each of 22 clinical domains. A 5‐point Likert‐type scale was used for each question. Pre‐/post‐course means were compared using t‐tests for matched pairs. Results: Data were complete for 36 participants (78%). The course significantly increased residents' overall self‐confidence (mean difference 0.38, standard error of the mean [SEM] 0.06, P < 0.001), confidence in knowledge/application (mean difference 0.28, SEM 0.06, P < 0.001), in their study strategies to master knowledge/application (mean difference 0.48, SEM 0.08, P < 0.001) and in their recognition of knowledge/application mastery (mean difference 0.45, SEM 0.11, P < 0.001). Domains showing increased self‐confidence did not match domains specifically addressed in the course, suggesting that the course effects extend beyond the selected topics. Conclusions: A review course increased emergency medicine residents' self‐assessed confidence in their knowledge/application, in their study strategies and in their recognition of mastery, beyond the course specifics.     

Optimizing triage consistency in Australian emergency departments: The Emergency Triage Education Kit

Objective: The Emergency Triage Education Kit was designed to optimize consistency of triage using the Australasian Triage Scale. The present study was conducted to determine the interrater reliability of a set of scenarios for inclusion in the programme. Methods: A postal survey of 237 paper‐based triage scenarios was utilized. A quota sample of triage nurses (n = 42) rated each scenario using the Australasian Triage Scale. The scenarios were analysed for concordance and agreement. The criterion for inclusion of the scenarios in the programme was κ ≥ 0.6. Results: Data were collected during 2 April to 14 May 2007. Agreement for the set was κ = 0.412 (95% CI 0.410–0.415). Of the initial set: 92/237 (38.8%, 95% CI 32.6–45.3) showed concordance ≥70% to the modal triage category (κ = 0.632, 95% CI 0.629–0.636) and 155/237 (65.4%, 95% CI 59.3–71.5) showed concordance ≥60% to the modal triage category (κ = 0.507, 95% CI 0.504–0.510). Scenarios involving mental health and pregnancy presentations showed lower levels of agreement (κ = 0.243, 95% CI 0.237–0.249; κ = 0.319, 95% CI 0.310–0.328). Conclusion: All scenarios that showed good levels of agreement have been included in the Emergency Triage Education Kit and are recommended for testing purposes; those that showed moderate agreement have been incorporated for teaching purposes. Both scenario sets are accompanied by explanatory notes that link the decision outcome to the Australasian College for Emergency Medicine Guidelines on the Implementation of the Australasian Triage Scale. Future analysis of the scenarios is required to identify how task‐related factors influence consistency of triage.     

Sex differences in self‐reported anxiety in rural adolescents

An anxiety disorder affects 13 out of every 100 children. The purpose of this paper is to determine if there are differences in self‐reported anxiety between male and female rural adolescents. In total, 193 students aged 14–17 years in three western Pennsylvania rural high schools, USA, were surveyed. The majority of participants were Caucasian (86.5%, n = 167), female (53.4%, n = 103), and aged 15.57 years (SD = 0.93). The females' mean self‐reported anxiety score was higher than the males' score (P < 0.0001). The females' mean score was 25.09 (SD = 13.83; a score ≥25 may indicate the need for further evaluation for the presence of a potential anxiety disorder), while the males' mean score was 16.88 (SD = 10.81). Of interest, all the five factor (specific types of anxiety) scores were significantly different between males and females at P < 0.05. Evidence‐based implications for the mental health nurse's practice will be discussed. Anxiety screening is promoted to identify adolescents who may need mental health treatment and referrals, especially rural female adolescents.     

Involuntary psychiatric attendances at an Australasian emergency department: A comparison of police and health‐care worker initiated presentations

Objective: To identify any significant differences in the population of patients brought in to a hospital ED under involuntary mental health orders, based on whether the orders are initiated by police or health professionals. Methods: A retrospective analysis of consecutive presentations to a tertiary hospital ED with a co‐located psychiatric emergency care centre over a 12 month period, with univariate and multivariate statistical comparisons. Results: Two hundred and eighty‐two patients (making 378 ED presentations) met the case definition and were analysed. Compared with patients on medical orders, patients on police orders had significantly more presentations related to violence, longer stays in ED and lower rates of admission to an inpatient bed, but were no more likely to require restraint or security intervention within the ED. Conclusions: Patients on police and medical orders differ considerably, but the impact of these differences on ED workload is small.     

Australasian emergency physicians: A learning and educational needs analysis. Part Two: Confidence of FACEM for tasks and skills

Objective: To determine the degree of confidence perceived by Fellows of the Australasian College for Emergency Medicine for a variety of procedural, patient management, educational and research skills, and tasks that may be required of them. Method: Mailed survey with Likert scales and grouped qualitative responses. Results: More than 90% of emergency physicians (EP) feel usually or always confident of their skills for peripheral vascular access, procedural sedation, fluid resuscitation, tube thoracostomy, managing patients with altered conscious state, cardiac emergencies, behavioural disturbance, and interpreting acid base and other blood tests. Less than 50% felt confident performing surgical airways, ED ultrasound, managing neonatal emergencies or interpreting MRI. Of non‐clinical skills, while most EP were confident of their ability to write references, debrief staff, lead group tutorials and prepare slides, a minority felt usually or always confident about budgeting and finance, preparing submissions, dealing with the media, appearing in court or marking examination papers. Whilst nearly 75% were confident about the information technology skills required of them for clinical practice, less than 25% of EP felt confident about conducting research and less than 15% were confident applying or interpreting statistics. Conclusion: This information may assist in the planning of future educational interventions for EP.     

乡村医务人员对护理知识需求的调查分析

目的:了解乡村医务人员对护理知识的需求情况。方法:采用自制问卷对116名乡村医务人员进行调查。结果:58.62％的乡村医务人员身兼诊疗及护理工作;91.38％的乡村医务人员认为护理知识对自己的工作很重要;目前需要学习的护理知识首位是社区慢性病病人的护理知识(65.52％),其次是各种注射技术(34.48％);学习途径以各种学习班的讲课、讲座为主(79.31％)。结论:护理知识与技能对乡村医务人员的工作非常重要,乡村医务人员对护理知识需求迫切;应加强乡村医务人员护理知识与技能的系统培训和指导。     

Quantifying off-hour emergency physician coverage of in-hospital codes: a survey of community emergency departments

Background

Community emergency physicians (EPs) are often required to respond to unstable patients outside of their department during off-hours.

Objective

The primary objective of this study was to describe the critical care responsibility of community EPs outside of their departments.

Methods

A one-page survey was mailed to emergency department (ED) directors of 10 states and Washington, DC.

Results

Three hundred forty of 1169 surveys were returned. The median (interquartile range [IQR]) number of hospital and intensive care unit (ICU) beds was 145 (IQR 60–242) and 11 (IQR 6–20), respectively. Median ED annual volume and ICU admission percentage was reported to be 25 K (IQR 14–40) and 5% (IQR 2–10), respectively. Seventy-six percent of reporting institutions require EPs to leave their department and respond to medical codes on the floors after hours. In 57% of institutions, the EP was the only physician required to respond. In addition, 48% of EPs must respond to unstable patients in the ICUs after hours. Hospitals in which EPs were required to respond to medical codes and unstable ICU patients were more likely to have fewer hospital beds (137 vs. 275; p < 0.001), fewer ICU beds (12 vs. 27; p < 0.001), and have a smaller ED annual volume (24 K vs. 39 K; p < 0.001).

Conclusions

Many community EPs are responsible for covering critically ill patients outside of their ED. Further investigation is required to determine the impact on patient care.     

Australasian emergency physicians: A learning and educational needs analysis. Part Four: CPD topics desired by emergency physicians

Objective: To report the preferences of Fellows of the Australasian College for Emergency Medicine for topics they would desire for their continuing professional development (CPD). Method: A mailed survey of Fellows of the Australasian College for Emergency Medicine asked for Likert type responses on the desirability of CPD on 15 procedural skills, 13 management skills, 11 clinical emergency topics, 9 topics related to teaching, 7 related to diagnostics and 5 evidence based practice topics. Results: CPD in procedural skills of advanced and surgical airways, ED ultrasound, ventilation, skills, plastic procedures and regional anaesthesia were nominated as desirable by 85% of emergency physicians (EP). More than 90% desired CPD in ophthalmological, otorhinolaryngeal, neonatal and paediatric emergencies. Of diagnostic skills, more than 80% considered CPD on computerized tomography, electrocardiography and plain X‐ray interpretation as desirable, well as CPD about teaching in general, simulation and preparing candidates for fellowship exams. Of the 12 management skills, 11 were seen as desirable topics by more than 70%, with counter disaster planning, giving feedback and dealing with complaints the most popular. All evidence based practice related skills, including interpreting statistics and undertaking literature searches were seen as desirable topics by more than 80% of EP. Conclusion: This information may assist in the planning of future educational interventions for emergency physicians. EP seek CPD on management, educational and other non clinical skills, as well as topics relating directly to patient care.