Towards evidence-based emergency medicine

Horner, D. (2017) Emergency Medicine Journal. 34(5) pp. 331-334.

BestBETS

Image source: BEstBETS

Best Evidence Topic reports (BETs) summarise the evidence pertaining to particular clinical questions. They are not systematic reviews, but rather contain the best (highest level) evidence that can be practically obtained by busy practicing clinicians. The search strategies used to find the best evidence are reported in detail to allow clinicians to update searches whenever necessary. Each BET is based on a clinical scenario and ends with a clinical bottom line which indicates, in the light of the evidence found, what the reporting clinician would do if faced with the same scenario again.

The BETs published below were first reported at the Critical Appraisal Journal Club at the Manchester Royal Infirmary or placed on the BestBETs website. Each BET has been constructed in the four stages that have been described elsewhere. The BETs shown here together with those published previously and those currently under construction can be seen at http://www.bestbets.org. Two BETs are included in this issue of the journal.

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Value-Based Approaches for Emergency Care in a New Era

Medford-Davis, L. et al. Annals of Emergency Medicine. Published online: January 5 2017

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Although emergency departments (EDs) play an integral role in the delivery of acute unscheduled care, they have not been fully integrated into broader health care reform efforts. Communication and coordination with the ambulatory environment remain limited, leaving ED care disconnected from patients’ longitudinal care.

In a value-based environment focused on improving quality, decreasing costs, enhancing population health, and improving the patient experience, this oversight represents a missed opportunity for emergency care. When integrated with primary and subspecialty care, emergency care might meet the needs of patients, providers, and payers more efficiently than yet realized.

This article uses the Merit-Based Incentive Payment System from the Medicare Access and CHIP Reauthorization Act as a framework to outline a strategy for improving the value of emergency care, including integrating quality and resource use measures across health care delivery settings and populations, encouraging care coordination from the ED, and implementing robust health information exchange systems.

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Urgent and emergency care pilot reports

As part of their plans to explore how they might comment on the quality of care across a local health and care system, the Care Quality Commissions has published reports of two pilots which explore what this could look like for urgent and emergency care.

The reports focus on urgent and emergency care systems in South Warwickshire and in Airedale, Wharfedale, Craven & Bradford.  In both areas the CQC looked at the contribution of the services that support people with urgent and emergency care needs, including NHS 111, A&E departments, ambulance services, GP practices, GP out of hours-services and care homes and how well they worked together for the benefit of the local population.

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Practical Guidelines for the Use of Electronic Applications by Advanced Practice Nurses in the Emergency Department

Morgan, V.A. Journal of Emergency Nursing. Published online: October 20 2016

email-1345921_960_720Although numerous electronic applications are available to health care providers on enabled devices such as smartphones and tablets, these resources remain underutilized. Available literature suggests that utilizing electronic applications provides a number of benefits, including improved ability to make quick yet accurate decisions, improved knowledge of evidence based practices, a corresponding reduction in error rates, and an increase in quality improvement measures. These benefits translated into a reduction in adverse events and hospital lengths of stay.

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Improved Administration of Antibiotics in the Emergency Department: A Practice Improvement Project

McLaughlin, J.M. et al. Journal of Emergency Nursing.July 2016. 42(4). pp. 312–316

hospital-834150_960_720Problem: Although consensus exists among experts that early intravenous antibiotic therapy has an impact on patient mortality, the medical literature includes little information about ensuring that the patient receives the complete dose. At our emergency department, it had become standard clinical practice to administer antibiotics with primary pump tubing and an infusion pump. Clinical pharmacy staff identified this practice as a cause for concern, because at least 20 mL (up to 40%) of the dose volume remains in the tubing. This practice improvement project was aimed at improving the administration of antibiotics by programming a secondary infusion to ensure the complete dose would be administered.

Methods: A multidisciplinary educational intervention was initiated consisting of one-on-one instruction with each emergency nurse (n = 103) at the department’s annual Skills Sessions, distribution of educational tip sheets, and reinforcement of the proper procedure at the patient’s bedside. Emergency nurses were educated via simulation regarding correct secondary pump programming, using smart pump technology.

Results: Surveys indicated that 8% of emergency nurses used secondary tubing along with a smart pump to administer antibiotics before the intervention, compared with 96% after the intervention (P < .0001).

Implications for Practice: This project demonstrates that our educational intervention improved awareness of the need to administer the entire antibiotic dose and adherence to the use of secondary tubing along with smart pump technology to administer antibiotics.

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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.

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