Emergency Department Escalation in Theory and Practice

Escalation policies are used by emergency departments (EDs) when responding to an increase in demand (eg, a sudden inflow of patients) or a reduction in capacity (eg, a lack of beds to admit patients) | Annals of Emergency Medicine

The policies aim to maintain the ability to deliver patient care, without compromising safety, by modifying “normal” processes. The study objective is to examine escalation policies in theory and practice.

Editor’s Capsule Summary:

  • What is already known on this topic

Care delivery organizations commonly develop “escalation policies” for managing crowding and surges in emergency department (ED) demand. The effectiveness of these policies has seldom been studied.

  • What questions this study addressed

This study used mixed methods to identify common patterns in escalation policies in UK EDs and to evaluate how well they performed in practice.

  • What this study adds to our knowledge

Formal escalation policies often presumed the availability of resources that were missing or degraded when escalation was needed. Consequently, the actual practice of managing crowding deviated from that inscribed in policy.

  • How this is relevant to clinical practice

Recognizing and monitoring the gap between formal policies and actual practice should help in the development of more realistic and useful escalation policies.

Full reference: Back, J. et al. (2017) Emergency Department Escalation in Theory and Practice: A Mixed-Methods Study Using a Model of Organizational Resilience. Annals of Emergency Medicine. Published online: 26 June 2017

Occupational stress in the ED

Occupational stress is a major modern health and safety challenges. While the ED is known to be a high-pressure environment, the specific organisational stressors which affect ED staff have not been established | Emergency Medicine Journal

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Methods: We conducted a systematic review of literature examining the sources of organisational stress in the ED, their link to adverse health outcomes and interventions designed to address them. A narrative review of contextual factors that may contribute to occupational stress was also performed. All articles written in English, French or Spanish were eligible for conclusion. Study quality was graded using a modified version of the Newcastle-Ottawa Scale.

Results: Twenty-five full-text articles were eligible for inclusion in our systematic review. Most were of moderate quality, with two low-quality and two high-quality studies, respectively. While high demand and low job control were commonly featured, other studies demonstrated the role of insufficient support at work, effort–reward imbalance and organisational injustice in the development of adverse health and occupational outcomes. We found only one intervention in a peer-reviewed journal evaluating a stress reduction programme in ED staff.

Conclusions: Our review provides a guide to developing interventions that target the origins of stress in the ED. It suggests that those which reduce demand and increase workers’ control over their job, improve managerial support, establish better working relationships and make workers’ feel more valued for their efforts could be beneficial. We have detailed examples of successful interventions from other fields which may be applicable to this setting.

Full reference: Basu, S. et al. (2017) Occupational stress in the ED: a systematic literature review. Emergency Medicine Journal. 34:441-447.

Emergency medicine: what keeps me, what might lose me?

EDs are currently under intense pressure due to increased patient demand. There are major issues with retention of senior personnel, making the specialty a less attractive choice for junior doctors | Emergency Medicine Journal

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This study aims to explore what attracted EM consultants to their career and keeps them there. It is hoped this can inform recruitment strategies to increase the popularity of EM to medical students and junior doctors, many of whom have very limited EM exposure.

Methods: Semistructured interviews were conducted with 10 consultants from Welsh EDs using a narrative approach.

Results: Three main themes emerged that influenced the career choice of the consultants interviewed: (1) early exposure to positive EM role models; (2) non-hierarchical team structure; (3) suitability of EM for flexible working. The main reason for consultants leaving was the pressure of work impacting on patient care.

Conclusion: The study findings suggest that EM consultants in post are positive about their careers despite the high volume of consultant attrition. This study reinforces the need for dedicated undergraduate EM placements to stimulate interest and encourage medical student EM aspirations. Consultants identified that improving the physical working environment, including organisation, would increase their effectiveness and the attractiveness of EM as a long-term career.

Full reference: James, F. & Gerrard, F. (2017) Emergency medicine: what keeps me, what might lose me? A narrative study of consultant views in Wales. Emergency Medicine Journal. 34:436-440

Contributing Factors of Frequent Use of the Emergency Department

Overcrowding of the emergency department is a growing problem. Frequent users contribute to the overcrowding problem in emergency departments | International Emergency Nursing

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Introduction: Overcrowding in emergency departments is an issue that has a negative impact worldwide. As attendance in emergency departments has increased, the ability to provide critical services to patients suffering from actual medical emergencies in a timely manner has decreased as these departments are many times at or over capacity. One patient population whose negative influence has been researched with regard to their impact on the overcrowding issue is that of the frequent user.

Results: A review of the literature identified two predominant factors related to frequent users in the emergency department: a lack of awareness of medical necessity and issues of access.

Discussion: To address the frequent users in emergency departments, implications for practice need to be explored and implemented. Implications for practice include education of medical necessity for the frequent users, expansion of the pre-hospital role in primary care and inappropriate use prevention, and improvement of access to alternative healthcare services.

Full reference: Burns, T.R. (2017) Contributing Factors of Frequent Use of the Emergency Department: A Synthesis. International Emergency Nursing. Published online: 5 June 2017

Only a third of MPs believe that A&E departments are adequately resourced 

Parliamentary perceptions of A&E departments |  A poll of UK MPs by Dods Research on behalf of the Royal College of Emergency Medicine

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A poll on behalf of  the Royal College of Emergency Medicine reveals just 33% of MPs believe emergency departments have the resources they need to keep patients safe.

The poll of 92 MPs of all parties and regions of the UK also found strong support for a transformation fund for emergency departments with four times as many saying they would support such an initiative as oppose it.

Over 60% of MPs said they would support Emergency Departments (EDs) receiving more money to help with the retention and recruitment of staff.

Despite government claims that the NHS was getting more than the minimum £8bn by 2020 it had asked for, the poll found that only half of Conservative MPs believe that Emergency Departments are currently being adequately resourced.

View the full report here

NHS ambulance services

The National Audit Office (NAO) has published NHS ambulance services.

This report provides an update to the NAO 2011 report and examines:

  • the challenges facing the ambulance service in England
  • the performance of the service
  • the extent to which the service is maximising its impact and supporting the challenges facing the wider health system.

It highlights that NHS ambulance services are finding it increasingly difficult to cope with rising demand for urgent and emergency services.

Full report: NHS Ambulance Services

NAO Podcast on Ambulance Service:

 

Additional links: BBC news report

ICT system to compensate for a sudden shortage of emergency department physicians

Tanaka, K. et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. Published online: 23 January 2017

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Background: A sudden shortage of physician resources due to overwhelming patient needs can affect the quality of care in the emergency department (ED). Developing effective response strategies remains a challenging research area. We created a novel system using information and communication technology (ICT) to respond to a sudden shortage, and tested the system to determine whether it would compensate for a shortage.

 

Discussion: After introducing the system, probability of multiple casualties increased. Thus the system may contribute to improvement in the ability to respond to sudden excessive patient needs in multiple causalities.

Conclusions: A novel system using ICT successfully secured immediate responses from needed physicians outside the hospital without increasing user workload, and increased the ability to respond to excessive patient needs. The system appears to be able to compensate for a shortage of physician in the ED due to excessive patient transfers, particularly during off-hours.

Read the full article here