The Association between Emergency Department Overcrowding and Delay in Treatment: A Systematic Review

A novel approach to expedite emergency investigation for suspected cauda equina syndrome referrals from community and primary care services: A service evaluation

INTRODUCTION

Although a rare spinal emergency, cauda equina syndrome (CES) can result in significant physical, emotional, and psychological sequalae. Introducing a CES pathway enhances diagnosis but may increase Radiology and Orthopaedic workload. To address this, one NHS hospital in England introduced a novel CES pathway. Utilising a criteria-led pathway, patients were referred directly from community/primary care, via the Emergency Department, for an emergency MRI scan.

OBJECTIVE

To compare the outcomes of patients referred via an original and redesigned Community and Primary Care CES pathway.

DESIGN

A retrospective service evaluation was undertaken of all emergency MRI scans investigating suspected CES via either pathway.

METHODS

Two 3-month time periods were analysed; pre-(original) and post-implementation of the redesigned pathway; time to surgery was reviewed over two 12-month periods.

RESULTS

Increased MRI scan utilisation was seen following the implementation of the redesigned pathway: original n = 50, redesigned n = 128, increasing Radiology workload. However, the redesigned pathway resulted in a reduction in time to MRI from 3h:01m to 1h:02m; reduction in time spent in ED 4h:55m to 3h:24m; reduction in time to surgery 18h:05m to 13h:38m; reduction in out-of-hour scanning from 10 to 2 patients during the evaluation period; and a reduction in on-call Orthopaedic involvement by 38%.

CONCLUSION

All timed outcomes were improved with the implementation of this novel pathway. This suggests expediting MRI scans can result in substantial downstream benefits; albeit while increasing MRI scan utilisation. This pathway aligns with the emergency management of suspected CES under the new national CES pathway in England.

The syncope core management process in the emergency department: a consensus statement of the EUSEM syncope group

The European Society of Cardiology issued updated syncope guidelines in 2018 which included recommendations for managing syncope in the emergency department (ED) setting. However, these guidelines lack detailed process-oriented instructions regarding the fact that ED syncope patients initially present with a transient loss of consciousness (TLOC), which can have a broad spectrum of causes. This study aims to establish a European consensus on the general process of the workup and care for patients with suspected syncope and provides rules for sufficient and systematic management of the broad group of syncope (initially presenting as TLOC) patients in the ED. A variety of European diagnostic and therapeutic standards for syncope patients were reviewed and summarized in three rounds of a modified Delphi process by the European Society for Emergency Medicine syncope group. Based on a consensus statement, a detailed process pathway is created. The primary outcome of this work is the presentation of a universal process pathway for the structured management of syncope patients in European EDs. The here presented extended event process chain (eEPC) summarizes and homogenizes the process management of European ED syncope patients. Additionally, an exemplary translation of the eEPC into a practice-based flowchart algorithm, which can be used as an example for practical use in the ED, is provided in this work. Syncope patients, initially presenting with TLOC, are common and pose challenges in the ED. Despite variations in process management across Europe, the development of a universally applicable syncope eEPC in the ED was successfully achieved. Key features of the consensus and eEPC include ruling out life-threatening causes, distinguishing syncope from nonsyncopal TLOCs, employing syncope risk stratification categories and based on this, making informed decisions regarding admission or discharge.

Linking patient safety, caring behaviours and professional self-efficacy with missed nursing care among Filipino emergency room nurses: A structural equation model study

AIMS

To investigate the interrelationships of patient safety, caring behaviours, professional self-efficacy and missed nursing care among emergency room nurses.

DESIGN

Cross-sectional, correlational study.

METHODS

Filipino emergency room nurses (n = 345) participated via convenience sampling from September 2023 to January 2024. Four validated self-report scales were used to collect data and were analysed using Spearman rho, covariance-based structural equation modelling, mediation and path analyses.

RESULTS

The emerging model of study variables displayed satisfactory fit indices. Patient safety directly influenced caring behaviours and professional self-efficacy, while negatively influencing missed nursing care. Caring behaviours directly and indirectly affected professional self-efficacy and missed nursing care, respectively. Professional self-efficacy negatively influences missed nursing care. Finally, caring behaviours and professional self-efficacy were significant mediators between the association of patient safety and missed nursing care.

CONCLUSION

Caring behaviours and professional self-efficacy of emergency room nurses demonstrated mediating effects that can potentially improve patient safety practices thereby minimizing unfinished or missed nursing care.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nurses and healthcare organizations should commit to consistently maintain a workplace culture that fosters patient safety, caring behaviours and professional self-efficacy to minimize avoidable injuries and omitting nursing care tasks.

REPORTING METHOD

STrengthening the Reporting of OBservational studies in Epidemiology (STROBE).

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Unveiling the Heartbeat of Healing: Exploring Organizational Culture in a Tertiary Hospital's Emergency Medicine Department and Its Influence on Employee Behavior and Well-Being

This study examined the organizational culture of an emergency medicine department (EMD) in a tertiary hospital in Karnataka, India, using a prospective cross-sectional design from January to February 2024. It aimed to identify the predominant and supporting organizational cultures within the EMD and their influence on employee behavior and well-being, including job satisfaction, burnout, stress levels, and coping strategies. A total of 82 participants, including physicians, emergency medical technicians, and nurses, completed the Organizational Culture Assessment Instrument (OCAI) and a self-designed questionnaire. Ethical clearance was obtained (IEC2-656). Clan culture emerged as the dominant culture (73.17%), emphasizing collaboration and adaptability, correlated with lower stress levels and high job satisfaction (90.78%). Emotional exhaustion was the most common burnout symptom (53.66%). The coping strategies varied, with employees in Clan cultures seeking social support, while those in Hierarchy cultures sought guidance from superiors. This study highlighted the significant role of organization culture in employee well-being and EMD effectiveness, influenced by social values like respect for authority. The limitations included single-setting analysis, an uneven subgroup representation, and a lack of qualitative insights. Future research should involve multiple hospitals and qualitative methods for a comprehensive understanding.

How Do Pharmacists Distribute Their Work Time during a Clinical Intervention Trial?-A Time and Motion Study

Emergency departments (EDs) handle urgent medical needs for a diverse population. Medication errors and adverse drug events pose safety risks in the ED. Clinical pharmacists, experts in medication use, play a crucial role in identifying and optimizing medication therapy. The aim of this study was to investigate how clinical pharmacists introduced into the ED interdisciplinary teams distribute their work time. In a time and motion study, we used the Work Observation Method By Activity Timing (WOMBAT) to observe pharmacists in two Norwegian EDs. The pragmatic approach allowed pharmacists to adapt to ED personnel and patient needs. The pharmacists spent 41.8% of their work time on medication-related tasks, especially those linked to medication reconciliation, including documenting medication-related issues (16.2%), reading and retrieving written information (9.6%), and obtaining oral information about medication use from patients (9.5%). The remaining time was spent on non-medication-related tasks (41.8%), and on standby and movement (17.4%). In conclusion, ED pharmacists spent 42% of their work time on medication-related tasks, predominantly medication reconciliation. Their relatively new role in the interdisciplinary team may have limited their broader clinical impact. Relative to other ED healthcare professionals, ED pharmacists' goal remains to ensure accurate patient medication lists and appropriate medication use.

Cardiology department versus intensive care unit admission after successful uncomplicated transcatheter aortic valve replacement (TAVR)

BACKGROUND

Most patients after transcatheter aortic valve replacement (TAVR) are admitted directly to the cardiac intensive care unit (CICU) despite low complication rates. Reducing unnecessary CICU hospitalization reduces healthcare costs. This study aimed to compare the outcomes between patients admitted directly to the cardiology department (CD) and those admitted to CICU based on prespecified protocols.

METHODS

Historical cohort study of all patients who underwent TAVR and were admitted directly to the CD according to a prespecified protocol (uncomplicated procedure, hemodynamically stable, without new conduction abnormalities) in 2017-2018, and the same number of patients meeting the same criteria who were admitted to the CICU in 2015-2016 before direct CD admission was initiated. Pacemaker implantation during the procedure was not considered a new conduction abnormality. In-hospital outcomes and 30-day post-discharge outcomes were compared.

RESULTS

Overall, 260 patients (130 CICU + 130 CD) were included in the study. There was no in-hospital mortality in either group, and the post-procedure length of stay was shorter for patients admitted to CD (median and IQR: 2, 2-4 vs. 4, 3-5 days, p <0.001). There was no significant difference in 30-day emergency department visits between groups (CICU:13.9% vs. CD:16.2%, p = 0.602), rehospitalization rate (9.3%) was the same in both groups, and one patient from the CICU group died. Similar results were observed in multivariable analysis and after matching.

CONCLUSION

Direct admission to the CD after TAVR, according to the proposed criteria, may be considered as a safe and less expensive alternative for stable patients after an uncomplicated TAVR procedure.

Perceived Causes and Effects of Overcrowding Among Nurses in the Emergency Departments of Tertiary Hospitals: A Multicenter Study

Purpose

Emergency department (ED) overcrowding is a significant concern in many hospitals in Saudi Arabia, resulting in long waiting times, delays in treating patients who need urgent care, and, consequently, decreased patient satisfaction. Additionally, ED overcrowding has been linked to increased nurse turnover rates. Therefore, this study aimed to assess nurses' perceived causes and effects of overcrowding in the EDs of five tertiary hospitals in Saudi Arabia.

Methods

This study used a descriptive cross-sectional design. We surveyed 311 nurses working in the EDs of five tertiary hospitals in Saudi Arabia using the convenience sampling technique. The self-administered questionnaires used in the study were developed by the researchers. The study was conducted from October 16 to November 10, 2022. Consensus-Based Checklist for Reporting of Survey Studies was followed.

Results

The results revealed that the primary perceived causes of ED overcrowding in five tertiary hospitals were unnecessary visits due to a lack of standard procedures (mean = 2.70; SD = 0.58) and lack of inpatients beds (mean = 2.69; SD = 0.65). The perceived effect of overcrowding was stress and burnout among nurses (mean = 2.85; SD = 0.47). The perceived causes and effects of overcrowding in the ED were found to be highly significant (p <0.001) based on Pearson correlation and Spearman's rank correlation.

Conclusion

Unnecessary visits due to a lack of standard procedures lead to overcrowding. In addition, a lack of inpatient beds in the ED affects the care provided to patients seeking immediate medical attention. This may prolong patient waiting time, causing their conditions to deteriorate and prolonging hospital stay. Overcrowding leads to increased stress and burnout among nurses. The results of this study can be used to develop a comprehensive action plan to address ED overcrowding and its effects on patients, staff, and ED flow.

The chain of survival and rehabilitation for sepsis: concepts and proposals for healthcare trajectory optimization

This article describes the structures and processes involved in healthcare delivery for sepsis, from the prehospital setting until rehabilitation. Quality improvement initiatives in sepsis may reduce both morbidity and mortality. Positive outcomes are more likely when the following steps are optimized: early recognition, severity assessment, prehospital emergency medical system activation when available, early therapy (antimicrobials and hemodynamic optimization), early orientation to an adequate facility (emergency room, operating theater or intensive care unit), in-hospital organ failure resuscitation associated with source control, and finally a comprehensive rehabilitation program. Such a trajectory of care dedicated to sepsis amounts to a chain of survival and rehabilitation for sepsis. Implementation of this chain of survival and rehabilitation for sepsis requires full interconnection between each link. To date, despite regular international recommendations updates, the adherence to sepsis guidelines remains low leading to a considerable burden of the disease. Developing and optimizing such an integrated network could significantly reduce sepsis related mortality and morbidity.

Hypothermia: Beyond the Narrative Review-The Point of View of Emergency Physicians and Medico-Legal Considerations

Hypothermia is a widespread condition all over the world, with a high risk of mortality in pre-hospital and in-hospital settings when it is not promptly and adequately treated. In this review, we aim to describe the main specificities of the diagnosis and treatment of hypothermia through consideration of the physiological changes that occur in hypothermic patients. Hypothermia can occur due to unfavorable environmental conditions as well as internal causes, such as pathological states that result in reduced heat production, increased heat loss or ineffectiveness of the thermal regulation system. The consequences of hypothermia affect several systems in the body-the cardiovascular system, the central and peripheral nervous systems, the respiratory system, the endocrine system and the gastrointestinal system-but also kidney function, electrolyte balance and coagulation. Once hypothermia is recognized, prompt treatment, focused on restoring body temperature and supporting vital functions, is fundamental in order to avert preventable death. It is important to also denote the fact that CPR has specificities related to the unique profile of hypothermic patients.

Facilitators and barriers of appropriate and timely initiation of intravenous fluids in patients with sepsis in emergency departments: a consensus development Delphi study

BACKGROUND

Sepsis is a life-threatening medical emergency in which appropriate and timely administration of intravenous fluids to patients with features of hypotension is critical to prevent multi-organ failure and subsequent death. However, compliance with recommended fluid administration is reported to be poor. There is a lack of consensus among emergency clinicians on some of the determinant factors influencing fluid administration in sepsis. Thus, the aim of this study was to identify the level of consensus among key stakeholders in emergency departments regarding the facilitators, barriers, and strategies to improve fluid administration.

METHODS

The modified Delphi questionnaire with 23 statements exploring barriers, facilitators, and strategies to improve fluid administration was developed from the integration of findings from previous phases of the study involving emergency department clinicians. A two-round modified Delphi survey was conducted among key stakeholders with managerial, educational, supervision and leadership responsibilities using a "Reactive Delphi technique" from March 2023 to June 2023. The statements were rated for importance on a 9-point Likert scale. The RAND/UCLA Appropriateness Method (RAM) was used to identify the level of consensus (agreement/disagreement).

RESULTS

Of the 21 panellists who completed Round 1 survey, 18 (86%) also completed Round 2. The panellists rated 9 out of 10 (90%) barriers, 3 out of 4 (75%) facilitators and all 9 (100%) improvement strategies as important. Out of the total 23 statements, 18 (78%) had agreement among the panellists. Incomplete vital signs at triage (Median = 9, IQR 7.25 to 9.00) as a barrier, awareness of importance of fluid administration in sepsis (Median = 9, IQR 8.00 to 9.00) as facilitator and provision of nurse-initiated intravenous fluids (Median = 9, IQR 8.00 to 9.00) as an improvement strategy were the highest rated statements.

CONCLUSION

This is the first Delphi study identifying consensus on facilitators, barriers, and strategies to specifically improve intravenous fluid administration in sepsis in Australia. We identified 18 consensus-based factors associated with appropriate and timely administration of intravenous fluids in sepsis. This study offers empirical evidence to support the implementation of the identified strategies to improve patient outcomes.

Factors Relating to Decision Delay in the Emergency Department: Effects of Diagnostic Tests and Consultations

Purpose

The purpose of this study is to investigate the factors increasing waiting time (WT) and length of stay (LOS) in patients, which may cause delays in decision-making in the emergency departments (ED).

Patients and Methods

Patients who arrived at a training hospital in the central region of Izmir City, Turkey, during the first quarter of 2020 were retrospectively analyzed. WT and LOS were the outcome variables of the study, and gender, age, arrival type, triage level determined based on the clinical acuity, diagnosis encoded based on International Classification of Diseases-10 (ICD-10), the existence of diagnostic tests or consultation status were the identified factors. The significance of the differences in WT and LOS values based on each level of these factors was analyzed using independent sample t-tests and ANOVA.

Results

While patients for which no diagnostic testing or consultation was requested had a significantly higher WT in EDs, their LOS values were substantially lower than those for which at least one diagnostic test or consultation was ordered (p≤0.001). Besides, elderly and red zone patients and those who arrived by ambulance had significantly lower WT and higher LOS values than other levels for all groups of patients for which laboratory-type or imaging-type diagnostic test or consultation was requested (p≤0.001 for each comparison).

Conclusion

Besides ordering diagnostic tests or consultation in EDs, different factors may extend patients' WT and LOS values and cause significant decision-making delays. Understanding the patient characteristics associated with longer waiting times and LOS values and, thus, delayed decisions will enable practitioners to improve operations management in EDs.