Use of the Delphi method to generate guidance in emergency nursing practice: A systematic review

AIM

To examine the application and methodological quality of the Delphi method used in developing guidance for emergency nursing practice.

BACKGROUND

Emergency nursing scope of practice has rapidly expanded in response to increasing patient acuity, complexity and technological innovation. Determining best practice is crucial for delivering high quality, safe and effective emergency nursing care. The Delphi method has been used to identify, prioritise complex issues and develop evidence-driven guidance in emergency nursing practice. The use and quality of the Delphi method in emergency nursing practice has not been examined.

DESIGN

Systematic literature review.

DATABASES AND DATA TREATMENT

A systematic literature search was conducted using the following databases: SCOPUS, EMBASE, Medline and ProQuest from date of inception to August 2019. The database search was limited to scholarly articles or peer-reviewed journals. No language restrictions were applied. The Cochrane Collaboration method and PRISMA checks were utilized to conduct the review.

RESULTS

Of 246 records identified 22 (8.9%) studies met the inclusion criteria. A modified Delphi method was commonly used (n = 15; 68.2%) and often conducted online (n = 11; 50.0%). Eight practice guidance themes were identified. Overall study quality was high (score 12/14; range 4-13), transparency of reporting varied.

CONCLUSION

Based on this review, the Delphi method is an appropriate method for exploring emergency nursing practice. The studies reviewed demonstrated that knowledge, skills and clinical expertise has progressively expanded in the specialty of emergency nursing. Variation in the application, conduct and transparency of reporting in Delphi studies developing guidance for emergency nursing practice is discussed.

How do we capture the emergency nurse practitioners’ contribution to value in health service delivery?

The emergency nurse practitioner is now a well established and respected member of the healthcare team. Evaluation of the role has focused on patient safety, effectiveness and quality of care outcomes. Comparisons of the role continue to focus on cost, with findings based on incomplete and almost impossible to define, recognition of contribution to service delivery by paralleled practitioners. Currently there is no clear definition as to how nurse practitioners contribute to value in health service delivery. Robust and rigorous research needs to be commissioned taking into consideration the unique hybrid nature of the emergency nurse practitioner role and focusing on the value they contribute to health care delivery.

Minor injuries in older adults have different characteristics, injury patterns, and outcomes when compared with younger adults: an emergency department correlation study

AIM

To examine the injury patterns, characteristics, and outcomes of older adults presenting with minor injuries compared with younger adults.

BACKGROUND

Sustaining a minor injury is one of the most common reasons people present to an Emergency Department. Many presentations involve older Australians and greater than 50% of older adults are discharged from the Emergency Department. However, little is known about the characteristics, injury patterns, and outcomes of minor injuries in older adults compared to younger adults.

METHODS

A 12-month exploratory correlational study was conducted using Emergency Department electronic medical record data from a single metropolitan hospital located in Sydney, Australia. Older adults were defined as ≥65 years with younger adults defined as 18-64 years. Minor injuries were classified by diagnoses as fractures/dislocations, sprains/strains, wounds/burns/infections, minor head injuries, eye/ear/nose/oral injuries. Exclusion criteria included: triage category 1 or 2, major trauma, critical care admission, or injuries and fractures to the hip or neck of femur.

RESULTS

There were 36,671 Emergency Department presentations of which 7582 (21%) were for older adults and 19,234 (52%) were younger adults (aged 18-64). Injuries represented 21% (n = 7754) of all Emergency Department presentations with 1294 (17%) occurring in those aged 65 years and older and 3937 (20%) in younger adults. Of the minor injuries (n = 3594; 10%), the most common presentation in younger adults was sprains/strains (n = 1045; 36%) but in older adults it was fractures (n = 229; 32%). There was a statistical (Pearson's χ(2) test 63.4, df = 4, P < 0.001) difference with injury pattern when comparing age groups. Older adults were allocated proportionately higher triage categories when compared with younger adults (Pearson's χ(2) test 26.3, df = 2, P < 0.001). Older adults with minor injuries had a longer mean stay (315 min; SD 238.9 min; younger adults 198 min, SD 132.3 min) and this difference was statistically (P ≤ 0.001) and clinically significant. Fewer older adults were discharged home (n = 531, 73%; n = 2648, 92%; P < 0.001) and more were admitted for minor injuries (n = 179, 25%; n = 156, 5%; P < 0.001) when compared with younger adults.

CONCLUSION

Older adults with minor injuries have different injury patterns, higher acuity, longer length of stay, and lower discharge rates compared with younger adults. Clinicians may need to modify their approach and differential diagnoses when treating older adults with minor injuries. Further research is needed to explore the reasons for these differences and whether older adults have different service needs compared with younger adults with minor injuries.

Patient perceptions of emergency department fast track: a prospective pilot study comparing two models of care

BACKGROUND

Emergency department (ED) fast track has been shown to improve patient flow for low complexity presentations.(1) The optimal model of care and service delivery for fast track patients has not been established.

AIMS

The objective of this pilot study was to compare patient satisfaction using two models of ED fast track - one in a tertiary hospital emergency department staffed by doctors and the other in a nearby urban district hospital staffed by nurse practitioners. We also wanted to determine the proportion of fast track patients who would prefer to see a General Practitioner (GP) instead of presenting to the ED. This pilot study was the foundation for subsequent studies later conducted by Dinh et al.(2,3) METHODS: This was an observational study using a convenience sample of patients. Eligible fast track patients were asked to complete a standardised satisfaction survey. Presenting problems and waiting times of patients were collected using patient information systems. Primary outcome measure was satisfaction rating using a 5-point Likert scale. Secondary outcomes were surrogate satisfaction measures encompassing questions on likelihood of returning to ED. A multivariate analysis was performed to obtain odds ratio for higher satisfaction scores.

RESULTS

In total, 353 patients were recruited: 212 patients in the doctor treated group (DR) and 141 were in the nurse practitioner treated group (NP). The two groups had similar baseline characteristics in terms of age, gender, referral source and waiting times. Overall, 320/353(86%) patients rated their care as either very good or excellent, with only 0.6% rating their care as poor. Satisfaction scores in the NP group were higher than those in the DR group (median score 4 vs. 3, p<0.01). A greater proportion of patients in the NP group reported that they would return to the ED for a similar problem (99% vs. 91% p<0.01). Overall, 175/353 (50%) of patients indicated that they would prefer to see a general practitioner for a similar problem if available nearby. These numbers were slightly lower in the NP group (43% vs. 53%, p=0.05).

CONCLUSIONS

Most patients were satisfied with ED fast track, irrespective of model of care. Patient satisfaction was greater in the group of patients using the nurse practitioner model of care. Around half of the fast track patients would prefer to see a general practitioner for a similar problem if available nearby.

Periradicular therapy in lumbar radicular syndromes: methodology and results

Periradicular therapy (PRT) has become popular in the treatment of lumbar radicular complaints, both primary, due to disc herniations (Group 1), and postoperative, following disc surgery (Group 2). However, hitherto reported data on 'periradicular injections' are more of a technical nature. The present study was designed to evaluate the therapeutic success of CT- versus fluoroscope-guided periradicular injections of local anaesthetics and corticoids, and to investigate the impact of imaging procedures on the results. We report on 80 patients who underwent CT-guided (n = 40) or fluoroscope-guided (n = 40) PRT for lumbar radicular irritation since April 1993. Forty patients had primary nerve root irritation due to disc protrusion, and 40 suffered from postoperative epidural fibrosis. Follow-up consisted in a clinical examination and an interview one day after each injection as well as 1 and 6 months later. Assessment was based on a score taking into account the clinical findings, the patient's complaints, and the patient's evaluation. Six months following treatment there was a significant reduction of ischialgia in both Groups 1 and 2 (p < 0.001). However, the results were significantly poorer in Group 2 (postoperative). Among the patients not operated on, those who underwent CT-guided injections had a significantly better outcome (p < 0.001). PRT had no significant influence on low back pain or pseudoradicular syndromes. The improvement of sensory disturbances achieved by both CT- and fluoroscope-guided injections in patients not previously submitted to surgery is statistically significant (p < 0.05). As compared to Group 1 (no surgery), the positive effects in patients of Group 2 were of significantly shorter duration (p < 0.05). Motor deficits were not influenced by the treatment. Long-term follow-up shows that there is no positive effect in those patients in whom the first two PRT attempts had failed. Thus, PRT represents a useful long-term therapeutic alternative for lumbar radicular syndromes, particularly when due to primary discogenic compression. CT-guided injection is superior to fluoroscope-assisted treatment for both its visualization and its longer-lasting effect.

Lens-corrected visual field sensitivity and diabetes

PURPOSE

To examine whether peripheral S-cone system and achromatic sensitivity was reduced in patients with diabetes compared to normal controls.

METHODS

Perimetric measurements were obtained to study peripheral S-cone system and achromatic sensitivity in patients with diabetes and normal controls. Measures of individual lens absorption of short-wavelength light were used to correct visual field sensitivity values for attenuation of test light due to lens absorption.

RESULTS

Both before and after correction for lens absorption of test spot light, peripheral field-averaged S-cone system and achromatic sensitivities were not significantly reduced among patients with diabetes compared to normals of the same age. However, localized sensitivity losses in the visual field were found in most patients with diabetes both before and after lens absorption correction, compared to age norms. The amount of localized loss (number of field locations with reduced sensitivity) was significantly correlated with the level of retinopathy. Statistical analysis showed that after the effects of age and duration were removed, field-averaged S-cone system sensitivity in patients with diabetes was also significantly reduced as a function of increasing severity of retinopathy.

CONCLUSIONS

Patients with diabetes may have areas of reduced S-cone system sensitivity with development of diabetic retinopathy.

Genetic studies of variation in Rayleigh and photometric matches in normal trichromats

The inheritance of Rayleigh match midpoints and photometric matches (551-667 nm) was studied in observers with normal color vision. An analysis was performed to evaluate whether the measured interobserver variations in these two traits were consistent with single gene allelic variation, polygenic variation, or environmental factors. A bipartite 2 deg field and a computerized tracking method were used to obtain Rayleigh matches; a new photometric technique, termed heterochromatic modulation photometry (HMP), was used to obtain photometric matches. Data were collected from 72 nonrelated males to determine distribution characteristics for the normal population. The distributions were analyzed for evidence of multimodality and the results indicated that the distributions for Rayleigh match midpoints and HMP matches obtained in this study were unimodal and symmetrical. Data from 52 observers from 5 families were used to study the transmission of the two traits in pedigrees. Statistical analysis of the pedigree data suggested that the major source of variations for Rayleigh match midpoints and for HMP matches were each due to allelic variation at single gene loci; that is, each may be determined by a single gene. Results were inconclusive as to whether variation in the two traits could be determined by the same gene.

Lumbar disk compliance and degeneration

Comparison between 242 intradiscal pressure/volume recordings and corresponding diskograms (performed at the same occasion) has shown a significant (p less than 0.01) correlation between disk compliance and the degree of diskographic degeneration. Intradiscal pressure/volume testing is a simple, reliable, and risk-free procedure that should precede every diskogram and be incorporated into the preoperative diagnostic routine of patients undergoing chemonucleolysis or percutaneous diskectomy.

[Initial experiences with implanted drug pumps for continuous intrathecal calcitonin therapy in therapy-resistant pain]

The hormone calcitonin has proved itself for some years in the treatment of chronic pain syndromes. In addition to its known influence on calcium exchange it gives vise to an analgesic effect within the central nervous system and this follows systemic administration or after bolus intrathecal injection. Two patients with chronic non malignant pain are presented in whom continuous delivery pumps have been used for intrathecal Lachs-Calcitonin (Karil, Fa. Sandoz).

Aging of the human lens

The optical density of the human lens changes during life. Literature concerning both the spectral density function and the rate of such changes is reviewed. Analysis indicates that two components govern the spectral lens density function, with one increasing gradually during life. The average lens density increases linearly at 400 nm by 0.12 density unit per decade between the ages of 20 and 60 and by 0.40 density unit per decade above age 60. A tabulation of the two components of the average 32-yr old lens is given, as are equations to derive the average spectral lens density functions for observers aged 20-80.