The experience of gatekeeping: a psychiatric nurse in an emergency department

Emergency departments are increasingly identified as the entry point to mental health services. In the hope of facilitating the flow of psychiatric patients through a general hospital's emergency department, experienced psychiatric nurses were asked to participate in a pilot project in a general hospital in Canada. This paper is a reflection of one emergency psychiatric nurse's (EPN) experience of her role being transformed into that of a gatekeeper. The notion of "gatekeeper" as a metaphor highlights "keeping psychiatric patients out" of an already strained emergency system. As a means to balance fiscal demands with patient care, the EPN inadvertently served to obscure entry for patients with mental illness who were seeking emergency services.     

Planning emergency patients: An attempt to change the nature of the emergency department.

Throughout the day, arrivals of patients at the emergency department (ED) are unannounced, unpredictable and fully determined by chance. Healthcare professionals in the ED naturally react as quickly as possible when patients arrive. We wondered whether they could somehow act in advance. We introduced a planning system that enabled the ED to regulate arrival times of emergency patients referred by the general practitioner. The system established direct contact between the general practitioner and the ED at the press of a button. As a result, the ED was able to schedule a fraction of its unpredictable patient demand. Implementation of the system at large was unsuccessful however. Changing the nature of the ED turned out to be far more difficult than expected. In our opinion, successfully planning emergency patients requires that the ED has full control over the referral process, and that scheduled patients are treated in a separate, undisturbed care process.     

Using online learning in a traditional face-to-face environment

A model for designing online learning was developed and implemented in a Registered Nurse-to-Bachelor of Science in Nursing course using online and face-to-face methodologies. The combination of online and face-to-face learning modalities may help the student who is a novice Internet explorer or seasoned Web navigator by offering technological support as well as providing constant in-person feedback regarding course requirements. The face-to-face component facilitates a sense of community and peer support that sometimes is lacking in an entirely online course. During the 2 semesters this model was used, students expressed satisfaction with having the course facilitator/professor physically available for consultation and advisement. Evaluation of this online/on-site course is ongoing and uses computer-administered qualitative questionnaires, a facilitator-moderated focus group, and Likert-type course evaluations.     

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.     

Readiness to change problematic drinking assessed in the emergency department as a predictor of change

OBJECTIVES: The goal of this study was to determine if baseline readiness to change the drinking behavior (pre-contemplation, contemplation, preparation, and action stages) was predictive of change in drinking after unrelated emergency department (ED) visit and screening and interviewing for alcohol problems. METHODS: From August 1998 through December 2000, the Alcohol Use Disorders Identification Test (AUDIT) was administered to all consented ED patients aged 18 to 29 years. A brief motivational interviewing was provided to screen-positive patients (AUDIT score >5 of 40). Outcome at 3-month follow-up was measured as a decrease in the scores within the AUDIT domains of alcohol intake, harm, and dependency. RESULTS: Sixty percent of the screen-positive patients continued to drink at 3 months. Patients became more open to change their drinking behavior. Compared with patients in the pre-contemplation stage, those in the action stage were twice as likely to reduce their alcohol intake (OR, 2.24; 95% CI, 1.06-4.72), nearly 3 times as likely to reduce their alcohol-related harm behavior (OR, 2.80; 95% CI, 1.59-4.91), and almost 4 times more likely to decrease their dependency symptoms (OR, 3.59; 95% CI, 1.97-6.57). Compared with pre-contemplation patients, those in the contemplation stage were nearly twice as likely to reduce their alcohol-related harm (OR, 1.85; 95% CI, 1.02-3.33) and those in the preparation stage were more than twice as likely to reduce their dependency symptoms (OR, 2.20, 95% CI, 1.13-4.27). CONCLUSIONS: Stages of change at baseline appeared to be significant predictors of change in alcohol intake, harm, and dependency symptoms among young adult ED patients.     

急诊有创呼吸支持方法的临床研究

目的 观察在急诊抢救危重患者的呼吸阶梯化管理中应用有创呼吸支持方法的效果.方法 总结1994年至2004年中对实施有创呼吸通路方法的292例急诊抢救患者相关临床资料并进行统计分析,比较环甲膜穿刺术、气管切开术、气管穿刺导入气管套管术、气管穿刺旋切术四种有创呼吸支持方法.结果 采用气管切开术203例（69.5%）、气管穿刺导入气管套管术58例（19.8%）、环甲膜穿刺术25例（8.6%）、气管穿刺旋切术6例（2.1%）;使用呼吸机占95例（32.5%）.常规气管切开术常需两个人以上操作,15～30 min完成;气管穿刺导入气管套管术只需单人操作,最快可在90 s以内完成,一般在3～5 min内完成,出血少,损伤小,对生命体征影响小,术中术后并发症少,伤口愈合快.结论 急诊快速建立有创呼吸通路应该视病情紧急程度按时间标准决定选择不同的方法.从速度由快到慢顺序是：环甲膜穿刺术、气管穿刺导入气管套管术、气管穿刺旋切术、气管切开术;从安全可靠性推荐：气管穿刺导入气管套管术、气管穿刺旋切术、气管切开术、环甲膜穿刺术.     

Quantifying emergency department admission rates for people with a learning disability

No data is routinely collected by emergency departments (ED) in the UK to identify people who attend and who have a learning disability. This group have numerous additional needs in their healthcare management and a lack of support could be detrimental to their care. F800 codes from the International Classification of Diseases (ICD-10) that identify disorders of psychological development are often used to categorise specific disorders once admitted to hospital. Consequently, the F800 codes of patients who were admitted to hospital from Birmingham Heartlands Hospital ED for 1 year have been analysed to obtain some of this data. This study argues that, although only a small proportion of the admissions from this ED were by people with an F800 code, the exact numbers of attendances in many EDs remain unknown and the impact of their disabilities on their immediate care and the workload of the ED medical staff may be significant.     

Teaching and learning in the emergency department

Emergency physicians are increasingly being called upon to take on roles as teachers. For many, this is a new role and one for which they feel ill-prepared. This paper aims to provide an overview of some of the key issues and challenges that accompany the acceptance of this new role.     

Managing change in the emergency department: a personal view

This is a contribution to the occasional series on simulated interactive management     

Use of computers in emergency department practice

This article discusses current applications of computers in the Emergency Department. Different approaches for computerization are compared, and difficulties and problems of computerization are discussed.     

Meeting the needs of people with a learning disability in the emergency department

Nurses in the emergency department will regularly encounter individuals with a learning disability in their day to day work. Admission to hospital and especially the emergency department can be very problematic for people with a learning disability. For a number of reasons the health, safety and welfare of this group of patients may be seriously compromised. An awareness of the risks associated with hospital care for these patients, along with an understanding of their specific needs, will help to minimise the potential for problems to occur.     

Using a simulated environment to support students learning clinical skills

Within intellectual disability nursing students are prepared within a biopsychosocialeducational model and curriculum address these challenges. Using a simulated learning environment has great potential for promoting competence and in-depth knowledge of substantive topics relevant to practice. This article presents an assignment designed to more closely resemble real–world activities to allow students develop and exercise skills that translate to practice activities and incorporates a student's reflective comments on the process. The assignment was designed to foster intellectual disability student nurses ability to facilitate family/client education. The aim of the assignment was fulfilled through the students designing a clinical skill teaching session that could be used with families/clients. The sessions were recorded and the student reviewed their recording to reflect on their performance and to self assess. To facilitate student learning the modules academic lecturer also reviewed the recording and both lecturer and student meet to discuss the reflection and self assessment.     

浅谈急诊科应对突发性灾害事件的管理实践体会

目的 总结本院急诊科在应对突发性灾害事件中的具体做法及效果。方法 2008年以小组为单位。对全科室医护人员进行应对突发性灾害事件的培训,包括健全应急体系、理论知识和操作技能的训练、防止交叉感染等。结果 2008年完善突发性灾害事件管理措施后,与2007年相比,2008年本院出车次数、1min内出车率、危重病人抢救成功率有所上升;而医疗纠纷、医疗差错的发生率则较2007年有所下降。结论 建立和完善突发性灾害事件急救措施是成功应对突发性灾害事件的关键。     

Accident and emergency as a clinical learning environment

This paper suggests that Accident & Emergency (A&E) can be a suitable learning environment with benefits for students, trained staff and the speciality of A&E nursing. Features of a suitable clinical learning environment are identified and a process which can be followed for educational audit set out.The unique opportunities for learning, suitable for both pre- and post-registration students, that are available in A&E are identified, and suggestions made as to how these might fit into the curriculum.     

Computerising emergency department guidelines with an Intranet

An emergency department's guidelines/protocols can be transferred simply and cheaply to a secure ‘intranet’ using readily available software and hardware. This format facilitates revision and distribution of the protocols and provides access at the clinical workstation. The use of hypertext links facilitates access and allows incorporation of video, graphic and audio files to the protocols.     

Fast Track in the emergency department: a one-year experience with nurse practitioners.

The use of a Fast Track system in the emergency department is becoming increasingly popular in order to provide fast and efficient service to patients with minor emergencies. In this paper we describe the one-year results of our system staffed by nurse practitioners. During the first year of operation, a total of 4468 patients were seen in Fast Track. Approximately 28% of patients are triaged to Fast Track during its hours of operation. The average patient seen in Fast Track was ready for discharge 94.4 minutes after presentation. Fewer than 1% of patients required admission to the hospital. Overall, patients and medical staff were highly satisfied with the Fast Track system. Our experience demonstrates that nurse practitioners can effectively and efficiently staff a Fast Track in an academic emergency department.