‘They shouldn’t be coming to the ED, should they?’ A qualitative study of why patients with palliative care needs present to the emergency department

Green, E. et al. BMJ Supportive &  Palliative Care. Published online: 12 May 2016

Introduction: Across the developed world, there are concerns about ‘inappropriate’ use of the emergency department (ED). Patients with palliative care needs frequently attend the ED. Previous studies define the ‘reason’ for presentation as the ‘presenting symptom’, which ignores the perspectives of service users. This paper addresses an acknowledged gap in the literature, which fails to examine the decision-making process that brings patients to the ED.

Methods: In-depth narrative interviews were conducted with 7 patients (known to a specialist palliative care service and presenting to the ED during a 10-week period) and 2 informal caregivers. Analysis drew on ‘Burden of Treatment Theory’ to examine the meaning attributed by participants to their experience of serious acute illness, their capacity for action and the work required to access emergency care.

Results: 5 themes were identified about how and why emergency services were accessed: capacity for action, making sense of local services, making decisions to access emergency services, experience of emergency care and coping with change. All narratives captured concerns surrounding the complexity of services. Participants struggled to piece together the jigsaw of services, and were subsequently more likely to attend the ED. Differences between the ways that patients with chronic obstructive pulmonary disease and cancer accessed the ED were prominent.

Conclusions: Further work is needed to understand and respond to decisions leading patients with palliative care needs to the ED, particularly in the context of locally fragmented services, poor signposting and confusion about available healthcare. The perspectives of service users are essential in shaping emergency care.

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Effectiveness of a multimodal hand hygiene improvement strategy in the emergency department

 

Arntz, P.R.H. et al. American Journal of Infection Control. Published online: 6 May 2016

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Highlights:

  • A total of 1,007 opportunities for handrubs were recorded in the emergency department. Hand hygiene (HH) compliance increased significantly (P < .001) after the first intervention week to 40.5% (95% confidence interval [CI], 33%-48%) and stabilized (P = .075) after the second intervention week to 49.5% (95% CI, 43%-56%).
  • The total number of alcohol dispensers was increased from 25 to 55. Within every 5-m radius in the emergency department an alcohol dispenser was placed. Existing alcohol-based handrub was switched for a different brand for its proven skin friendliness.
  • Profession-specific analysis revealed a significant increase over the phases of the study in both subgroups, the physicians and nurses.
  • Regarding the frequency of hand hygiene indications, indication 4 (hand hygiene after touching a patient) composed most indications (31.6%). The increase of compliance applied for all indications; the highest and lowest relative improvements appeared to be indication 3, after contact with body fluids (700% of baseline), and indication 4, after patient contact (136% of baseline), respectively.
  • During the baseline observations, the effect of the time of day (day vs evening and week vs weekend) and the type of patient (surgical patients vs patients with infection vs others without infection) showed no significant effect on hand hygiene compliance.

 

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EMERGENCY DEPARTMENT SURVEY OF ALCOHOL IDENTIFICATION AND INTERVENTION ACTIVITY

Alcohol Research UK. Published online: 4 May 2016.

New research published today (4 May) by Alcohol Research UK shows that while more adults are being routinely screened for alcohol-related problems in Emergency Departments in England more specialist support is needed to help young people and the vulnerable.

alcoholae

Image source: Alcohol Research UK

A new study by researchers based at the University of Surrey, funded by Alcohol Research UK, shows that Emergency Departments in England have increased the level of alcohol screening for adults – with the offer of specialist support for those attending with alcohol-related health problems and for those who frequently attend.

However, while most Emergency Departments attending to under-18s ask them about their drinking few do so routinely. This needs to improve to ensure young people considered to be at risk of developing drink-related ill health receive the specialist support they need.

Key findings from the study show that:

  • Almost two-thirds (63.6%) of adults are routinely questioned about alcohol use (compared to 47.7% in 2011).
  • Routine questioning about alcohol use among under-18s remains limited, with 11.6% being routinely asked about their drinking (up from 8.9% in 2011).
  • Access to Alcohol Health Workers or Clinical Nurse Specialists has increased by 13.4% since 2011 to 85.2% for adults displaying alcohol-related problems.
  • Forty per cent of emergency departments have ‘assertive outreach’ strategies in place to tackle frequent attendance by adult patients affected by alcohol-related problems.
  • Improved communication between Emergency Departments and GPs about alcohol-related attendance highlights a move towards multidisciplinary care, with 85% (compared to 74.8% in 2011) of GPs now routinely informed.

Read the full commentary here

Read the original research report here 

Influence of CT utilisation on patient flow in the emergency department: a retrospective 1-year cohort study

Li, C-J. et al. BMJ Open. 2016. 6:e010815. Published online: 4 May 2016

11531-2Objective: CT, an important diagnostic tool in the emergency department (ED), might increase the ED length of stay (LOS). Considering the issue of ED overcrowding, it is important to evaluate whether CT use delays or facilitates patient disposition in the ED.

Design: A retrospective 1-year cohort study.

Setting: 5 EDs within the same healthcare system dispersed nationwide in Taiwan.

Participants: All adult non-trauma patients who visited the 5 EDs from 1 July 2011 to 30 June 2012.

Interventions: Patients were grouped by whether or not they underwent a CT scan (CT and non-CT groups, respectively).

Primary and secondary outcome measures: The ED LOS and hospital LOS between patients who had and had not undergone CT scans were compared by stratifying different dispositions and diagnoses.

Results: CT use prolonged patient ED LOS among those who were directly discharged from the ED. Among patients admitted to the observation unit and then discharged, patients diagnosed with nervous system disease had shorter ED LOS if they underwent a CT scan. CT use facilitated patient admission to the general ward. CT use also accelerated patients’ admission to the intensive care unit (ICU) for patients with nervous system disease, neoplasm and digestive disease. Finally, patients admitted to the general wards had shorter hospital LOS if they underwent CT scans in the ED.

Conclusions: CT use did not seem to have delayed patient disposition in ED. While CT use facilitated patient disposition if they were finally hospitalised, it mildly prolonged ED LOS in cases of patients discharged from the ED.

Read the abstract here

Are Split Flow and Provider in Triage Models in the Emergency Department Effective in Reducing Discharge Length of Stay?

Pierce, B. A. & Gormley, D. Journal of Emergency Nursing. Published online: 26 April 2016

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A quality improvement (QI) project was completed early in 2015 to evaluate the split flow model of care delivery and a provider in triage model within a newly constructed emergency department. The QI project compared 2 emergency departments of similar volumes, one that splits the patient flow and employs a provider in triage model and the other that blends the patient flow and employs a traditional nurse triage model. A total of 68,603 patients were included in this project.

The purpose of the split flow model is to create a second flow stream of patients through the emergency department, parallel to the regular acute/critical care flow stream, for patients with problems that are not complex. Specific patient outcomes that were evaluated for the purpose of this QI project were door to discharge or discharge length of stay (DLOS) for all ED patients. The provider in triage model enhances patient triage assessment, as well as patient flow within the emergency department, by allowing patients to be evaluated by an ED provider immediately at the point of triage when the patient first presents to the emergency department.

The QI project demonstrated that the split flow model alone reduced DLOS for all ED patients, and when coupled with the provider in triage model, a greater reduction in DLOS, as well as an improvement in front-end throughput metrics, was realized.

Read the abstract here