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Mughal A, Evans C. Views and experiences of nurses in providing end-of-life care to patients in an ED context: a qualitative systematic review. Emerg Med J 2020; 37:265-272. [PMID: 32152005 DOI: 10.1136/emermed-2018-208278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/13/2020] [Accepted: 01/15/2020] [Indexed: 11/04/2022]
Abstract
INTRODUCTION With an increase in the population living with terminal illness, many patients are accessing EDs during the last days of their life. Yet EDs are often not well prepared to provide end-of-life (EOL) care. The aim of this review was to identify and synthesise studies that describe the views and experiences of emergency nurses in providing EOL care so as to understand the barriers and challenges that they face while caring for these patients and to identify factors that can support appropriate care delivery. METHOD A qualitative meta-synthesis was undertaken using a thematic approach. Study quality was assessed using the Joanna Briggs Institute Qualitative Assessment and Review Instrument tool. Five databases were searched in June 2016. RESULTS Eleven qualitative studies met the inclusion criteria and were assessed as having high quality. Sixty-nine findings were identified, combined into 11 descriptive themes and then synthesised into 3 analytical themes: (1) Incongruent ED environment and EOL care. (2) Lack of resources, systems and capacity. (3) EOL care as a rewarding act or an emotional burden. CONCLUSION The review identified a need for: (1) Additional training for nurses. (2) The development of clear guidelines in the form of pathways and protocols. (3) Having a separate space for the dying. (4) Providing a supportive environment for staff dealing with high emotional burden and challenging workloads. In order to improve EOL care, organisations must work on the barriers that hinder care provision.
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Affiliation(s)
- Amber Mughal
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Catrin Evans
- School of Health Sciences, University of Nottingham, Nottingham, UK
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Niven WGP, Wilson D, Goodacre S, Robertson A, Green SJ, Harris T. Do all HEART Scores beat the same: evaluating the interoperator reliability of the HEART Score. Emerg Med J 2018; 35:732-738. [PMID: 30217951 PMCID: PMC6287564 DOI: 10.1136/emermed-2018-207540] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 08/16/2018] [Accepted: 08/23/2018] [Indexed: 12/17/2022]
Abstract
Background Patients presenting with chest pain represent a significant proportion of attendances to the ED. The History, ECG, Age, Risk Factors and Troponin (HEART) Score is validated for the risk stratification of suspected ischaemic chest pain within the ED. The goal of this research was to establish the interoperator reliability of the HEART Score as performed in the ED by different grades of doctor and nurse. Methodology Patients with suspected ischaemic chest pain presenting to the ED of an inner city, London Hospital, were recruited prospectively between January and May 2016. Patients that had been enrolled in the study were interviewed by clinicians from four different categories: senior doctor, junior doctor, senior nurse and junior nurse. Clinicians, blinded to other raters’ results, calculated the HEART Scores for each patient with the assistance of a pocket-sized HEART Score card. The intraclass correlation coefficient (ICC) was calculated as the primary measure of reliability. 120 patients were required to achieve a desired power of 80%. Results 88 complete comparisons were obtained. There were no significant differences between the distributions of HEART Scores for each clinician group (p=0.95). The ICC for the overall HEART Score was 0.91 (95% CI 0.87 to 0.93). The ICC for troponin and age were ‘1’, for ‘history’ 0.41 (95% CI 0.30 to 0.52), ‘ECG’ 0.64 (95% CI 0.54 to0.73) and ‘risk factors’ 0.84 (95% CI 0.79 to 0.89). Conclusion This study demonstrates very strong overall interoperator reliability between the four groups of clinicians studied. This suggests that the HEART Score is reproducible when used by different professional groups and grade of clinician.
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Affiliation(s)
- William G P Niven
- Accident and Emergency Department, Homerton University Hospital, London, UK
| | - David Wilson
- Accident and Emergency Department, Homerton University Hospital, London, UK
| | - Steve Goodacre
- Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Samira Jane Green
- Accident and Emergency Department, Homerton University Hospital, London, UK
| | - Tim Harris
- Department of Emergency Medicine, Royal London Hospital, Barts Health, London, UK
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Takahashi T, Inoue N, Shimizu N, Terakawa T, Goldman RD. 'Down-triage' for children with abnormal vital signs: evaluation of a new triage practice at a paediatric emergency department in Japan. Emerg Med J 2016; 33:533-7. [PMID: 27044947 DOI: 10.1136/emermed-2015-204968] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 03/13/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Assessment of abnormal vital signs in triage is a challenge in the paediatric emergency department (PED), since vital signs may reflect anxiety, fever or pain rather than the clinical deterioration of the child. We aimed to evaluate the efficacy of subjective 'down-triage' (change of the initially determined acuity levels) of Japanese Triage and Acuity Scale (JTAS). METHODS This is a retrospective cohort study of patients in PED up to 15 years of age at a tertiary paediatric medical centre in Japan during a 1-year period. At the end of every JTAS triage process, PED nurses were allowed to 'down-triage' acuity levels of well-appearing patients with abnormal HR or RR, which were presumably attributable to fever, crying or being upset. We compared predictive performance of the triage system before and after 'down-triage' using admission rate as the primary outcome. RESULTS Among 37 961 PED visits during the study period, we analysed 37 219 records. A total of 17 089 patients (45.9%) were 'down-triaged' after their initial triage allocation upon arrival. Admission rates after 'down-triage' (83%, 33%, 7%, 1% and 3% for levels 1-5, respectively), compared with those of unmodified initial level (16%, 11%, 6%, 2% and 6% for levels 1-5, respectively), had a better apparent relevance with the anticipated admission rates of Canadian Triage and Acuity Scale. CONCLUSIONS Modification of JTAS through 'down-triage' by experienced staff improves prediction of disposition in a PED. Further research is needed to determine an objective protocol for 'down-triage' to ensure safe practice in a PED.
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Affiliation(s)
- Takuto Takahashi
- Division of General Pediatrics, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Nobuaki Inoue
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Fuchu, Tokyo, Japan
| | - Naoki Shimizu
- Division of Pediatric Critical Care Medicine, Department of Pediatric Emergency and Critical Care Medicine, Fuchu, Tokyo, Japan
| | - Toshiro Terakawa
- Division of General Pediatrics, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Ran D Goldman
- Pediatric Research in Emergency Therapeutics Program (PRETx.org), Division of Emergency Medicine, Department of Pediatrics, University of British Columbia, Child and Family Research Institute, Vancouver, British Columbia, Canada
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Cameron A, Ireland AJ, McKay GA, Stark A, Lowe DJ. Predicting admission at triage: are nurses better than a simple objective score? Emerg Med J 2016; 34:2-7. [PMID: 26864326 DOI: 10.1136/emermed-2014-204455] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 01/13/2016] [Accepted: 01/19/2016] [Indexed: 01/10/2023]
Abstract
AIM We compared two methods of predicting hospital admission from ED triage: probabilities estimated by triage nurses and probabilities calculated by the Glasgow Admission Prediction Score (GAPS). METHODS In this single-centre prospective study, triage nurses estimated the probability of admission using a 100 mm visual analogue scale (VAS), and GAPS was generated automatically from triage data. We compared calibration using rank sum tests, discrimination using area under receiver operating characteristic curves (AUC) and accuracy with McNemar's test. RESULTS Of 1829 attendances, 745 (40.7%) were admitted, not significantly different from GAPS' prediction of 750 (41.0%, p=0.678). In contrast, the nurses' mean VAS predicted 865 admissions (47.3%), overestimating by 6.6% (p<0.0001). GAPS discriminated between admission and discharge as well as nurses, its AUC 0.876 compared with 0.875 for VAS (p=0.93). As a binary predictor, its accuracy was 80.6%, again comparable with VAS (79.0%), p=0.18. In the minority of attendances, when nurses felt at least 95% certain of the outcome, VAS' accuracy was excellent, at 92.4%. However, in the remaining majority, GAPS significantly outperformed VAS on calibration (+1.2% vs +9.2%, p<0.0001), discrimination (AUC 0.810 vs 0.759, p=0.001) and accuracy (75.1% vs 68.9%, p=0.0009). When we used GAPS, but 'over-ruled' it when clinical certainty was ≥95%, this significantly outperformed either method, with AUC 0.891 (0.877-0.907) and accuracy 82.5% (80.7%-84.2%). CONCLUSIONS GAPS, a simple clinical score, is a better predictor of admission than triage nurses, unless the nurse is sure about the outcome, in which case their clinical judgement should be respected.
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Affiliation(s)
- Allan Cameron
- Acute Medicine Unit, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Gerard A McKay
- Acute Medicine Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Adam Stark
- Medical School, University of Glasgow, Glasgow, UK
| | - David J Lowe
- Emergency Department, Glasgow Royal Infirmary, Glasgow, UK.,Academic Unit of Anaesthesia, Pain and Critical Care Medicine, School of Medicine, University of Glasgow, Glasgow, UK
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Douma MJ, O'Dochartaigh D, Corry A, Brindley PG. How intravenous nitroglycerine transit time from bag-to-bloodstream can be affected by infusion technique: a simulation study. Emerg Med J 2015; 32:498-500. [PMID: 25921240 DOI: 10.1136/emermed-2014-204523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 04/07/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To measure the possible delays in intravenous nitroglycerine administration. METHODS This was a simulation study of sham intravenous nitroglycerine using a standard nitroglycerine titration protocol. Variables studied were (i) common cannulae/needles, (ii) infusion accessories and (iii) presence of a parallel intravenous saline carrier line (or drive line) infusing at 30 mL/h. Outcomes were (i) delay from bag-to-bloodstream arrival and (ii) the dosage showing on the infusion pump when the sham drug first exits the cannula (aka the 'presumed initial dosage'). RESULTS There was a statistically significant difference in both (i) time-to-bloodstream arrival and (ii) the dosage showing on the infusion pump as the sham first exits the cannula with (i) different cannulae, (ii) different accessories and (iii) presence of a carrier line. The bag-to-bloodstream time varied 10-fold: 197-2062 s. The 'presumed initial dosage' varied sixfold: 5-30 µg/min. Adding the medication to an already flowing carrier line reduced the time for the sham to exit the cannula fourfold: from 2062 to 469 s. CONCLUSIONS Despite limitations, this study outlines the importance of cannula type, infusion accessories and carrier lines. Larger cannulae and greater priming volumes substantially delay drug delivery, whereas carrier lines/drive lines substantially accelerate drug delivery. Our study also shows how patients could be exposed to clinical delays, as well as incorrect presumptions about drug dosage. Guidelines, and education efforts, should highlight the clinical importance of factors that affect bag-to-bloodstream time.
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Affiliation(s)
- Matthew J Douma
- Royal Alexandra Hospital, Edmonton, Alberta, Canada Emergency Services, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | | | - Angela Corry
- Emergency Services, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Peter G Brindley
- Division of Critical Care Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada
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Affiliation(s)
- Avinoam Nevler
- Department of General Surgery and Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel (Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel) The Dr. Pinchas Borenstein Talpiot Medical Leadership Program 2012, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Moshe Zilberman
- Department of General Surgery, The Baruch Padeh Medical Center, Poria, Lower Galilee, Israel
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Abstract
BACKGROUND The NHS has seen a great expansion in the number of emergency care practitioners (ECPs) working in prehospital, primary and acute care settings since the role was introduced in 2003. This paper updates and expands on two previous reviews of ECP roles by identifying and discussing all empirical studies to date that examined the impact of ECP services in the NHS. OBJECTIVES To summarise the national evidence-based literature on the impact of ECPs on healthcare delivery, effectiveness of practice and related health service resource use. METHODS Searches in MEDLINE, EMBASE and CINAHL databases, and two internet search engines (Google and Google Scholar). Identified publications were screened for relevance and quality before a description and synthesis of their findings. No statistical comparison was undertaken. RESULTS Studies from the peer-reviewed literature (n=15) and project reports (n=6) were included. Overall, there was evidence that investment in ECP roles is beneficial for the quality of care reported by patients and cost efficiency savings. There was clear support from staff and patients for ECP services, and a number of studies of high methodological quality described care processes (diagnosis, investigations instigated and treatment initiated) provided by ECPs to be equivalent to or better to that provided by practitioners with traditional roles. Prehospital ECPs provided 'added value' by treating more patients at the scene thereby reducing unnecessary referral to emergency departments. It was often unclear whether the ECP intervention was part of a larger service change and/or new investment. CONCLUSIONS Successful implementation of the ECP role has been described. Further evaluations should consider whether the beneficial impact of the role transfers equally across all operational settings and patient groups, and is not just a reflection of new investment in clinical services.
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Affiliation(s)
- Harry Hill
- Institute of Health and Society, University of Newcastle, Newcastle, UK
| | - Peter McMeekin
- Institute of Health and Society, University of Newcastle, Newcastle, UK
| | - Christopher Price
- Institute for Ageing and Health, Institute of Health and Society, University of Newcastle, Newcastle, UK
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