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PubMed2002

The effects of the absence of emergency medicine residents in an academic emergency department.

OBJECTIVE: What are the quality effects of an emergency medicine (EM) residency, and the associated 24/7 supervision of residents by faculty, in an academic emergency department (ED)? The authors evaluated activity and quality indicators when there were no EM residents present. The hypothesis of the study was that there was no difference between the patient care provided by faculty supervising EM residents and that with an alternative model without EM residents (AbsenceEMResident). METHODS: To support the weekly residency educational program (Thursday), EM residents are not scheduled clinically for a 24-hour period (ConfDay). Emergency medicine resident coverage (mean 62.7 hours) was replaced with incremental faculty and mid-level providers (mean 41.0 hours). This study was limited to adult patients (22,527 visits of 39,190 ED total) for six months (January-June 2001) and compared indicators for ConfDay (n = 23) with all other days (NotConfDay, n = 158). RESULTS: Comparing ConfDay (2,842 visits) with NotConfDay (19,685 visits), there was no difference in mean daily visits, inpatient admissions, intensive care unit admissions, or emergency medical services arrivals. ConfDay decision-to-admit time (333 vs. 313 min, p = 0.03) and length of stay for admissions (490 vs. 445 min, p = 0.000) were longer, with no difference for treat/release patients. There was no difference in the numbers of laboratory or radiology tests, consultations, unscheduled return visits, or patient satisfaction. CONCLUSION: During the study period, there was no measurable difference for most of the quality indicators studied. The AbsenceEMResident model is less efficient in admitting patients. Faculty supervision results in the same number of laboratory and radiology tests and consultations. Other specialties may consider this model if off-hours care becomes a concern.

Adult↗
PubMed2003

The effect of a new emergency medicine residency program on patient length of stay in a community hospital emergency department.

OBJECTIVES: It is not clear how emergency medicine residents affect emergency department (ED) efficiency. The objective of this study was to determine whether a new emergency medicine residency program affected the length of stay (LOS) of patients in a community hospital ED. METHODS: A before-and-after observational study was conducted during a one-year period prior to, and for three years after, the start of a new residency. An additional year's worth of data were collected during the fifth year after the residency started. Patients were excluded if their LOS was less than 30 minutes and they were admitted directly to the hospital. Explanatory variables included scheduled resident and student hours/day; scheduled faculty hours/day; nursing plus clerk hours/day; patients/day; ambulances/day; and admissions/day. The data were analyzed using descriptive and correlation statistics and regression analysis. RESULTS: Average patient LOS prior to the residency was 122.9 minutes. During the first year of residency, it was 126.6 minutes; second year, 129.9 minutes; third year, 158.9 minutes; and fifth year, 162.4 minutes. There was a positive correlation between LOS and third-postgraduate-year resident (PGY-3) hours (rho = 0.43), and between LOS and PGY-3 hours/patients/day (rho = 0.42). All other correlations were poor (rho < 0.4). CONCLUSIONS: In this ED, there was a weak, positive correlation between ED patient length of stay and the presence of PGY-3 emergency medicine residents.

Analysis of Variance↗
PubMed2003

Emergency medicine crisis resource management (EMCRM): pilot study of a simulation-based crisis management course for emergency medicine.

OBJECTIVES: To determine participant perceptions of Emergency Medicine Crisis Resource Management (EMCRM), a simulation-based crisis management course for emergency medicine. METHODS: EMCRM was created using Anesthesia Crisis Resource Management (ACRM) as a template. Thirteen residents participated in one of three pilot courses of EMCRM; following a didactic session on principles of human error and crisis management, the residents participated in simulated emergency department crisis scenarios and instructor-facilitated debriefing. The crisis simulations involved a computer-enhanced mannequin simulator and standardized patients. After finishing the course, study subjects completed a horizontal numerical scale survey (1 = worst rating to 5 = best rating) of their perceptions of EMCRM. Descriptive statistics were calculated to evaluate the data. RESULTS: The study subjects found EMCRM to be enjoyable (4.9 +/- 0.3) (mean +/- SD) and reported that the knowledge gained from the course would be helpful in their practices (4.5 +/- 0.6). The subjects believed that the simulation environment prompted realistic responses (4.6 +/- 0.8) and that the scenarios were highly believable (4.8 +/- 0.4). The participants reported that EMCRM was best suited for residents (4.9 +/- 0.3) but could also benefit students and attending physicians. The subjects believed that the course should be repeated every 8.2 +/- 3.3 months. CONCLUSIONS: The EMCRM participants rated the course very favorably and believed that the knowledge gained would be beneficial in their practices. The extremely positive response to EMCRM found in this pilot study suggests that this training modality may be valuable in training emergency medicine residents.

Adult↗
PubMed2003

Who can drive home from the emergency department? A questionnaire based study of emergency physicians' knowledge of DVLA guidelines.

OBJECTIVE: To determine whether doctors working in emergency departments are aware which of the common conditions seen have driving restrictions associated with them and whether they routinely advise patients of these restrictions. METHODS: 200 questionnaires were distributed to all grades of doctor currently working in 15 emergency departments in Wessex and the south west. The survey was anonymous so follow up of non-responders was not possible. Doctors were asked to indicate which of the 20 commonly seen conditions listed had DVLA guidelines restricting driving activity at least temporarily, and in which of these conditions they actually advised patients appropriately about their driving. In addition the MDU, GMC, and the Department of Transport web site were contacted to establish what they considered to be good medical practice regarding issuing advice about driving. RESULTS: 102 doctors (51%) responded to the survey. Knowledge regarding restrictions for various conditions varied, with 87.5% responding correctly about a first fit to only 7.8% regarding a collapse query cause. With regard to advising patients, 79.4% of doctors responding said that they routinely advised patients about stopping driving after a first fit, 32% advised patients after a single transient ischaemic attack, and only 7% after a collapse query cause. CONCLUSIONS: Doctors working in emergency departments are aware of conditions that lead to an inpatient admission that have driving restrictions. However, knowledge of conditions where patients are likely to be discharged was not as complete and advice was less likely to be given to patients. Emergency department doctors need to be more aware of restrictions that apply to conditions where patients are to be discharged.

Automobile Driving↗
PubMed2004

On-scene alternatives for emergency ambulance crews attending patients who do not need to travel to the accident and emergency department: a review of the literature.

With rising demand and recognition of the variety of cases attended by emergency ambulance crews, services have been considering alternative ways of providing non-urgent care. This paper describes and appraises the research literature concerning on-scene alternatives to conveyance to an emergency department, focusing on the: (1) profile and outcomes of patients attended but not conveyed by emergency crews; (2) triage ability of crews; (3) effectiveness and safety of protocols that allow crews to convey patients to alternative receiving units or to self care. The literature search was conducted through standard medical databases, supplemented with manual searches. Very few "live" studies were identified, and fewer still that included a control group. Findings indicated a complex area, with the introduction of protocols allowing crews to leave patients at scene carrying clinical risk. Robust research evidence concerning alternatives to current emergency care models is needed urgently to inform service and practice development.

Ambulances↗
PubMed2006

Does telephone triage of emergency (999) calls using Advanced Medical Priority Dispatch (AMPDS) with Department of Health (DH) call prioritisation effectively identify patients with an acute coronary syndrome? An audit of 42,657 emergency calls to Hampshire Ambulance Service NHS Trust.

INTRODUCTION: The National Service Framework for Coronary Heart Disease requires identification of patients with an acute coronary syndrome (ACS) to enable prompt identification of those who may subsequently require pre-hospital thrombolysis. The Advanced Medical Priority Dispatch System (AMPDS) with Department of Health (DH) call prioritisation is now the common triage tool for emergency ('999') calls in the UK. We retrospectively examined patients with ACS to identify whether this triage tool had been able to allocate an appropriate emergency response. METHODS: All emergency calls to Hampshire Ambulance Service NHS Trust (HAST) from the Southampton area over an 8 month period (January to August 2004) were analysed. The classification allocated to the patient by AMPDS (version 10.4) was specifically identified. Data from the Myocardial Infarct National Audit Project) were obtained from the receiving hospital in Southampton to identify the actual number of patients with a true ACS. RESULTS: In total, 42 657 emergency calls were made to HAST from the Southampton area. Of these, 263 patients were subsequently diagnosed in hospital as having an ACS. Of these 263 patients, 76 presented without chest pain. Sensitivity of AMPDS for detecting ACS in this sample was 71.1% and specificity 92.5%. Positive predictive value was 5.6% (95% confidence interval 4.8 to 6.4%), and 12.5% (33/263) of patients with confirmed ACS were classified as non-life threatening (category B) incidents. CONCLUSION: Only one of approximately every 18 patients with chest pain has an ACS. AMPDS with DH call prioritisation is not a tool designed for clinical diagnosis, and its extension into this field does not enable accurate identification of patients with ACS.

Chest Pain↗
PubMed2006

Announcing the emergent patient in the emergency department: a randomised trial.

OBJECTIVE: To determine which of three commonly used methods for notifying medical staff of the arrival of an emergent case to the triage area of an emergency department (ED) is optimal. METHODS: Prospective, randomised trial. Patients arriving with conditions rated as emergencies (triage category 2) were randomised to one of three notification arms: by microphone, by telephone, or by computer. The proportion of patients seen by a doctor within 10 minutes of arrival to the ED in each arm was compared. RESULTS: A total of 1000 patients were enrolled. The proportion seen within 10 minutes for patients announced by microphone was significantly greater than those announced by telephone or computer (67.0% v 63.2% v 57.3%, respectively; chi2 6.30, p = 0.04). No method achieved the benchmark proportion of 80% of patients seen within 10 minutes of arrival. CONCLUSIONS: A microphone announcement heard by overhead speakers should be incorporated with other strategies to improve the timeliness of medical assessment of emergent cases.

Adolescent↗
PubMed1995

Interpretation of emergency department radiographs by radiologists and emergency medicine physicians: teleradiology workstation versus radiograph readings.

PURPOSE: To compare accuracy of interpretation by radiologists and emergency medicine physicians of conventional radiographs and digitized images on a workstation. MATERIALS AND METHODS: One author selected 120 radiographs from the radiology department library, including 62 musculoskeletal, 20 abdominal, and 38 chest examinations. Analog radiographs were digitized. There were 60 positive and 60 control cases. Positive cases demonstrated clinically important disease and had a high degree of diagnostic difficulty. Thirty-one cases were judged to be critical to the patient's immediate care, requiring prompt accurate interpretation. Four groups of readers were used: staff radiologists and emergency medicine physicians and second-year radiology and emergency medicine residents. RESULTS: All reader groups performed better when interpreting conventional radiographs than digitized images. Differences in favor of radiograph reading were statistically significant for overall accuracy related to all cases and to critical cases (P < .05, one-tailed test). CONCLUSION: Results with the teleradiology system were found unacceptable for primary interpretation of the spectrum of radiographs seen in an emergency department.

Baltimore↗
PubMed1999

Emergency departments and the inappropriate attender--is it time for a reconceptualisation of the role of primary care in emergency facilities?

The appropriateness of Emergency Department (ED) usage is often questioned, with recognition at an international level of the growing prevalence of 'inappropriate attenders'. This term is used to describe individuals who present for treatment that could more appropriately be provided in the primary health care setting. This is an issue of concern for staff working in New Zealand Emergency Departments. The present article offers a review of currently identified issues concerning ED attendance, and examines the core question of the role of primary care in the Emergency Department. It asks whether this is an appropriate use of ED resources, and if so, what are the implications for the role of the emergency nurse?

Emergency Nursing↗
PubMedDate not supplied

[Outcome of 89 psychiatric emergencies managed by 3 mental health centers in an emergency service].

This paper deals with the assessment after 2 years of the outcome of 89 psychiatric emergencies taking in charge in Saint-Luc hospital's (Brussels) emergency room, by 3 community mental health services. After the triangulation of the demand, in the emergency room, 91% of the patients go to the community mental health service. In 92.5% of cases, the crisis intervention is carried out by the same therapists they met in the emergency room with the collaboration of other members of the outpatient team. Crisis interventions are brief (less than 3 months) in 50% of cases, less than 1 years in 11.5% of cases and lead in 35% of cases to long-term in charge (more than 2 years: psychiatric and social follow-up).

Adult↗
PubMed1991

Surgical emergencies in Ireland. An audit of the emergency surgical caseload of an Irish district general hospital.

Emergency cases are an increasing part of the workload of a general surgical unit. Little accurate quantitative data is presently available on the nature and impact of this workload on a typical district general surgical service. This study reports the results of a prospective one year audit of the emergency cases dealt with by a typical Irish district general surgical service. The general surgical service admitted 2,278 patients acutely, which represented 58% of the total number of admissions to the service. Eighteen patients required immediate transfer for specialist neurosurgical (11), vascular (6) or plastics (1) treatment. Of those cases admitted 1,396 (61.3%) were males and 882 (38.7%) were females. There were 1,786 (78%) adults and 492 (21.6%) paediatric cases. Abdominal pain (48.0%), head injury (23.8%) and urological problems (11.0%) accounted for the majority of the caseload. Within the abdominal pain group, the pre-dominant diagnoses were non-specific abdominal pain (36.0%), appendicitis (19.5%), cholecystitis/obstructive jaundice (10.8%) and peptic ulcer disease (10.0%). There were 456 emergency operations performed, representing 19.5% of all the inpatient general surgical procedures. 328 (72%) of these were performed out of normal working hours. Only 12% of the procedures were major. The commonest operations were appendicectomy (51%), abscess drainage (13%), wound toilet (13%) and laparotomy (11%). The emergency peri-operative mortality was 1.1%. The positive appendicectomy rate was 92%.

Emergencies↗
PubMed1984

Accuracy of emergency radiograph interpretation by emergency physicians.

The incidence of abnormalities in 1,869 sets of radiographs was recorded, and the accuracy of the interpretation of these films by emergency physicians was assessed. Abnormalities were most frequent in hip/femur (52.5%), thoracic spine (46.7%), and shoulder (44.8%) films and least frequent in skull (5.7%), cervical spine (14.9%), and foot (15.7%) films. The accuracy of interpretation by emergency physicians for all categories of films was 93.6%, with 1.8% false positives and 4.6% false negatives. Overreading of abnormalities occurred most often in thoracic spine (12.5%) and hip/femur radiographs (9.1%). The incidence of missing existing pathology was highest for abdomen (40.0%) and knee (31.6%) films. The overall accuracy of the emergency physicians in interpretation of emergency films was excellent. Increased didactics in particular areas of interpretive inaccuracies should be considered.

Clinical Competence↗
PubMed2005

Emergency department overcrowding: the Emergency Department Cardiac Analogy Model (EDCAM).

Increasing patient numbers, changing demographics and altered patient expectations have all contributed to the current problem with 'overcrowding' in emergency departments (EDs). The problem has reached crisis level in a number of countries, with significant implications for patient safety, quality of care, staff 'burnout' and patient and staff satisfaction. There is no single, clear definition of the cause of overcrowding, nor a simple means of addressing the problem. For some hospitals, the option of ambulance diversion has become a necessity, as overcrowded waiting rooms and 'bed-block' force emergency staff to turn patients away. But what are the options when ambulance diversion is not possible? Christchurch Hospital, New Zealand is a tertiary level facility with an emergency department that sees on average 65,000 patients per year. There are no other EDs to whom patients can be diverted, and so despite admission rates from the ED of up to 48%, other options need to be examined. In order to develop a series of unified responses, which acknowledge the multifactorial nature of the problem, the Emergency Department Cardiac Analogy model of ED flow, was developed. This model highlights the need to intervene at each of three key points, in order to address the issue of overcrowding and its associated problems.

Crowding↗
PubMed2006

Emergency Department overcrowding and ambulance diversion: the impact and potential solutions of extended boarding of admitted patients in the Emergency Department.

Emergency Department (ED) crowding and ambulance diversion have been increasingly significant national problems for more than a decade. Surveys of hospital directors have reported overcrowding in almost every state and 91% of hospital ED directors report overcrowding as a problem. The problem has developed because of multiple factors in the past 20 years, including a steady downsizing in hospital capacity, closures of a significant number of EDs, increased ED volume, growing numbers of uninsured, and deceased reimbursement for uncompensated care. Initial position statements from major organizations, including JCAHO and the General Accounting Office, suggested the problem of overcrowding was due to inappropriate use of emergency services by those with no urgent conditions, probably cyclical, and needed no specific policy response. More recently, the same and other organizations have more forcefully highlighted the problem of overcrowding and focused on the inability to transfer emergency patients to inpatient beds as the single most important factor contributing to ED overcrowding. This point has been further solidified by initial overcrowding research. This article will review how overcrowding occurred with a focus on the significance and potential remedies of extended boarding of admitted patients in the Emergency Department.

Ambulances↗
PubMed1999

Emerging technology for vehicular safety and emergency response to roadway crashes.

Emerging technology for vehicular safety and emergency response to roadway crashes is the topic of this article. Reduction in emergency medical services system notification time, improvements in vehicular safety, crash avoidance and protection, post-crash injury control, triage, national automatic crash notification systems, and technologic improvements in emergency diagnostics and treatment during the past year are discussed.

Accidents, Traffic↗
PubMed1994

Hantavirus: emergency department response to a disaster from an emerging pathogen.

In May 1993, the appearance of critically ill patients with unexplained respiratory distress was noted in the Four Corners area formed by New Mexico, Arizona, and Colorado. This epidemic was ultimately linked to a hantavirus, an emerging pathogen. The impact on the emergency department of a new infectious disease with respiratory distress is described. A model is proposed to manage infectious disease disasters. Emerging infections that are important to emergency physicians are discussed. Recommendations that focus on disaster management and prevention of the spread of an unknown pathogen are developed.

Bunyaviridae Infections↗
PubMed1999

A comparison of emergency medicine ultrasound training with guidelines of the Society for Academic Emergency Medicine.

STUDY OBJECTIVES: To compare the current state of emergency medicine residency ultrasound training with guidelines for that training from the Society for Academic Emergency Medicine (SAEM). METHODS: A brief questionnaire was sent to program directors from 119 emergency medicine residency programs in the United States. Responses were compared with the SAEM guidelines for clinical experience (150 total ultrasounds) and didactic experience (40 hours of didactic instruction). RESULTS: The overall response rate was 92%. Seventy-six (69%) of the programs own an ultrasound machine (ownership defined as 24-hour availability and complete discretion over use). Of these, 12 (16%) indicated that their average 1998 graduate had done at least 150 total ultrasound scans during residency, although none of the programs had average numbers that exceeded the minimum guidelines for all 4 procedure categories. Information on didactic curriculum was available from 74 ultrasound-owning programs: the duration was 0 to 20 hours in 49 (66%), 20 to 40 hours in 19 (26%), and 40 to 100 hours in 6 (8%). Only 1 program's average graduate met or exceeded the SAEM guidelines for both didactic and clinical training. CONCLUSION: Most emergency medicine residency programs own at least 1 ultrasound machine, with more than half of these obtaining their first machine within the past 3 years. Only 1 program currently meets SAEM training guidelines.

Clinical Competence↗
PubMed1999

Increasing compliance with the Residency Review Committee requirements for follow-up in academic emergency departments. Emergency Medicine Follow-up Study Group.

STUDY OBJECTIVES: The purpose of this study was to assess patient follow-up activities and changes in compliance with the Residency Review Committee follow-up requirements among emergency medicine residency training programs over a 12-year period. METHODS: A cross-sectional survey of residency directors of all accredited programs in emergency medicine listed in the Graduate Medical Education Directory was performed in 1996. Program director responses were matched with the results of our study group's previous surveys performed in 1984, 1988, and 1992. The survey requested information regarding the mechanism for follow-up on patients admitted to the hospital, as well as those treated and released from the emergency department. RESULTS: All residency programs responded to the survey. Seventy-four percent of the residency programs surveyed reported a formal system of follow-up for admitted patients, and 51% had a formal system in place for discharged patients. Inpatient follow-up mechanisms included follow-up case conferences (56%), discharge summaries (55%), follow-up book/cards (47%), or follow-up rounds (11%). Outpatient follow-up mechanisms included routine telephone follow-up (86%), follow-up document (37%), ED follow-up clinic (24%), or home visits (<1%). During the past 12 years, compliance with the Residency Review Committee requirements for follow-up activity has improved from 38% to 78% for inpatients and from 33% to 52% for outpatients. CONCLUSION: Emergency medicine residency training programs report an increasing compliance with residency requirements for ED patient follow-up. However, a significant number of programs still lack a formal mechanism. Compliance continues to be much better for patients admitted to the hospital than those treated and released. Specific suggestions and model follow-up mechanisms are described.

Continuity of Patient Care↗