‘Care in a chair’ – The impact of an overcrowded Emergency Department on the time to treatment and length of stay of self-presenting patients with abdominal pain

Experience of admission and readmission to the emergency department for patients with acute abdominal pain: A qualitative study

BACKGROUND

Abdominal pain is one of the most common complaints when patients are admitted to emergency departments (ED). Unfortunately, many of these patients are readmitted to the ED shortly after initial discharge. The perspectives of these patients have not yet been explored.

PURPOSE

The study aimed to explore how patients readmitted with acute abdominal pain in the ED experienced their initial admission, the time after discharge, and the cause of readmission.

METHODS

The study had a qualitative explorative design with a phenomenological-hermeneutic approach. Semi-structured individual telephone interviews were conducted with 14 patients readmitted with acute abdominal pain.

RESULTS

The analysis showed four themes: 1) being vulnerable during hospitalisation, 2) the meaning of information during hospitalisation, 3) discharged without being diagnosed, and 4) readmitted in the pursuit of relief. The patients wanted more knowledge and better communication despite their vulnerable condition. Patients were discharged whilst still in pain, and uncertainty of the situation at home contributed to mistrust of the health professionals.

CONCLUSION

Patients' experience of the first ED admission due to acute abdominal pain was loneliness, minimal contact with healthcare professionals, and lack of information and involvement in pain management. Discharge was associated with feelings of insignificance and contributed to a fear of death. Pain was the main reason for readmission. Patients described how multiple readmissions contributed to being taken seriously by healthcare professionals.

Triage-initiated intranasal fentanyl for hip fractures in an Emergency Department - Results from introduction of an analgesic guideline

BACKGROUND

Pain relief is a priority for patients with hip fractures who present to Emergency Departments (EDs). Intranasal fentanyl (INF) is an ideal option for nurse initiated analgesia as it does not require intravenous access and can expedite care prior to examination by a physician.

LOCAL PROBLEM

Pain relief in patients with hip fractures is delayed during episodes of ED crowding.

METHODS

A retrospective medical record review was conducted following introduction of an INF guideline in an adult ED in 2018. Patients were included over a 4-month period during which the guideline was introduced. Historical and concurrent control groups receiving usual care were compared to patients receiving INF.

INTERVENTIONS

This quality improvement initiative investigated whether an INF analgesia at triage guideline would decrease time to analgesic administration in adults with hip fracture in ED.

RESULTS

This study included 112 patients diagnosed with fractured hips of which 16 patients received INF. Background characteristics were similar between groups. Mean time to analgesic administration (53 v 110 minutes), time to x-ray (46 v 75 minutes), and ED length of stay (234 v 298 minutes) were significantly decreased in the intervention group. Inadequate documentation was a limiting factor in determining improved efficacy of analgesia.

CONCLUSION

Use of triage-initiated INF significantly decreased time to analgesic administration, time to imaging and overall length of stay in ED.

Factors associated with time to first analgesic medication in the emergency department

AIM AND OBJECTIVE

To examine the factors associated with time to first analgesic medication in the emergency department.

BACKGROUND

Pain is the most common symptom presenting to the emergency department, and the time taken to deliver analgesic medication is a common outcome measure. Factors associated with time to first analgesic medication are likely to be multifaceted, but currently poorly described.

DESIGN

Retrospective cohort study.

METHODS

Cox proportional hazards regression modelling was undertaken to evaluate the associations between person, environment, health and illness variables within Symptom Management Theory and time to first analgesic medication in a sample of adult patients presenting with moderate-to-severe pain to an emergency department over twelve months. This study was completed in line with the STROBE statement.

RESULTS

383 patients were included in the study, 290 (75.92%) of these patients received an analgesic medication in a median time of 45 minutes (interquartile range, 70 minutes). A model containing nine explanatory variables associated with time to first analgesic medication was identified. These nine variables (employment status, discharge location, triage score, Charlson score, arrival pain score, socio-economic status, first location, daily total treatment time and patient time to be seen) represent all of the domains of the Symptom Management Theory.

CONCLUSIONS

Person, environment, health and illness factors are associated with the time taken to deliver analgesic medication to those in pain in the emergency department. This study demonstrates the complexity of factors associated with pain care and the applicability of Symptom Management Theory to pain care in the emergency department.

RELEVANCE TO CLINICAL PRACTICE

Identifying a model of factors that are associated with the time in which the most common symptom presenting to the emergency department is treated allows for targeted interventions to groups likely to receive poor care and a framework for its evaluation.

La prise en charge de la douleur aux urgences : indicateur de qualité et de performance aux urgences

La qualité et la performance des services d'urgences sont des objectifs nationaux. La mise en place d'une stratégie d'amélioration continue de la qualité et de la performance nécessite de fédérer l'ensemble des équipes de soins autour d'un projet innovant. Les visites de certification sont un des outils que nous pouvons utiliser comme un levier pour mettre en place et améliorer la qualité. Un projet fédérateur nécessite de définir des valeurs partagées entre les équipes de soins. La lutte contre la douleur est une des valeurs fortes pour les équipes de soins, notamment aux urgences. Nous devons utiliser le projet de prise en charge de la douleur comme un moyen de revoir nos organisations, d'évaluer nos processus et de les simplifier, afin d'atteindre les objectifs définis par une cartographie des risques spécifiques. Nous présentons ici l'expérience de nos services d'urgences pour la prise en charge de la douleur d'origine traumatique, les méthodes suivies et les outils d'amélioration mis en place.

A profile of the waiting room nurse in emergency departments: An online survey of Australian nurses exploring implementation and perceptions

BACKGROUND

In response to increasing waiting times, adverse patient outcomes and patient dissatisfaction, some emergency departments introduced a Waiting Room Nurse role. Despite implementation into routine practice, there remains limited formal evaluation of the role.

AIM

To explore the implementation of a Waiting Room Nurse role in Australian emergency departments and emergency nurses' perceptions.

METHODS

Survey design. A 40-item survey was developed, piloted and then distributed to members of a professional College for online completion. Responses for closed-ended and open-ended items were reported using frequencies or proportions, and quantitative content analysis, respectively.

RESULTS

Respondents (n = 197) reported that 51 emergency departments allocated a Waiting Room Nurse, with varying hours of operation. Five key areas of responsibility were: patient care, patient safety, escalation of care, triage and communication. Role variations were identified in experience, preparation and supporting policies. Challenges, including workload and personal safety issues, were reported.

CONCLUSIONS

The role was perceived as vital, especially at times of high demand, in ensuring that patients were safe to wait, detecting deterioration and escalating care as needed. Communication and therapeutic relationships were key to effective performance. Challenges identified had clear implications for the welfare of nurses performing the role.

Emergency Department Response to Chemical, Biological, Radiological, Nuclear, and Explosive Events: A Systematic Review

Introduction

A Chemical, Biological, Radiological, Nuclear, and explosive (CBRNe) event is an emergency which can result in injury, illness, or loss of life. The emergency department (ED) as a health system is at the forefront of the CBRNe response with staff acting as first receivers. Emergency departments are under-prepared to respond to CBRNe events - recognizing key factors which underlie the ED CBRNe response is crucial to provide evidence-based knowledge to inform policies and, most importantly, clinical practice.

Problem

Challenges in detection, decontamination, and diagnosis are associated with the ED CBRNe response when faced with self-presenting patients.

Methods

A systematic review was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). An in-depth search strategy was devised to identify studies which focused on the ED and CBRNe events. The inclusion criteria were stringent in terms of the environment (ED), participants (first receivers), situation (CBRNe response), and actions (detection, decontamination, and diagnosis). Fifteen databases and topic-specific journals were searched. Studies were critically appraised using the Mixed Methods Appraisal Tool (MMAT). Papers were thematically coded and synthesized using NVivo 10 (QSR International Ltd, Melbourne, Australia).

Results

Sixty-seven full-text papers were critically appraised using the MMAT; 70% were included (n = 60) as medium- or high-quality studies. Data were grouped into four themes: preparedness, response, decontamination, and personal protective equipment (PPE) problems.

Discussion

This study has recognized the ED as a system which depends on four key factors - preparedness, response, decontamination, and PPE problems - which highlight challenges, uncertainties, inconsistencies, and obstacles associated with the ED CBRNe response. This review suggests that response planning and preparation should be considered at three levels: organizational (policies and procedures); technological (decontamination, communication, security, clinical care, and treatment); and individual (willingness to respond, PPE, knowledge, and competence). Finally, this study highlighted that there was a void specific to detection and diagnosis of CBRNe exposure on self-presenting patients in the ED.

Conclusion:

The review identified concerns for both knowledge and behaviors which suggests that a systems approach would help understand the ED response to CBRNe events more effectively. The four themes provide an evidence-based summary for the state of science in ED CBRNe response, which can be used to inform future policies and clinical procedures.

RazakS,HignettS,BarnesJ.Emergency department response to chemical, biological, radiological, nuclear, and explosive events: a systematic review.Prehosp Disaster Med.2018;33(5):543–549.

Assessing bottlenecks in Emergency Department flow of patients with abdominal pain

INTRODUCTION

Abdominal pain has a wide range of possible causes, which may lead to difficulties in diagnosing and lengthy Emergency Department (ED) stays. In this study, bottlenecks in ED processes of patients with abdominal pain were identified.

METHODS

Time-points of patients who presented to a Dutch ED with abdominal pain were observed and documented. The institutional review board approved the study.

RESULTS

In total, 3015 min of patient time were observed in 54 patients. Median length of stay (LOS) was 218 min for admitted patients, and 168 min for discharged patients. For 65 patients (27.4%), LOS exceeded 4 h. Delays were found during the diagnostic process, when multiple physicians were needed in order to make a decision, and during departure.

CONCLUSIONS

Our study concerning individual patients' time-points provides important insight into delays in the patient journey of patients with abdominal pain. Flow improvement can be achieved by focusing on these bottlenecks, for example by minimizing diagnostic delays and by simultaneous specialists' consultations for patients who need more than one physician. The optimization of ED flow for patients with abdominal pain depends on coordinated efforts between ED staff, medical specialists, radiology and laboratory staff, staff from inpatient units, and hospital supporting services.