Emergency medicine journal : EMJ
-
Handover in emergency care is an important patient safety issue and has particular problems due to different environmental, professional, organisational and cultural backgrounds. Previous work as focussed on the standardisation of handover content (including use of checklists), relatively little is known about the verbal behaviours that shape handover conversations. This study looks at both the content of the handover and the verbal behaviours during different types of handovers around the emergency department. ⋯ Handover may entail both descriptive (aimed at information transfer) and collaborative (aimed at joint decision-making) elements. Standardisation of handover needs to accommodate collaborative aspects with their greater variability according to the individual situation, and should incorporate communication of information relevant to the patient's social and psychological needs to establish appropriate care arrangements at the earliest opportunity.
-
Widespread conservative management of low-risk chest pain has motivated the development of a rapid triage strategy based on CT coronary angiography (CTCA) in the Emergency Department (ED). Recently, three prominent trials using this technology in the ED setting have presented results in support of its routine use. However, these studies fail to show the incremental prognostic value of CTCA over clinical and biomarker-based risk-stratification strategies, demonstrate additional downstream costs and interventions, and result in multiple harms associated with radio-contrast and radiation exposure. Observing the widespread overdiagnosis of pulmonary embolism following availability of CT pulmonary angiogram as a practice pattern parallel, CTCA use for low-risk chest pain in the ED should be advanced only with caution.
-
Emergency department crowding is recognised as a major public health problem. While there is agreement that emergency department crowding harms patients, there is less agreement about the best way to measure emergency department crowding. We have previously derived an eight point measure of emergency department crowding by a formal consensus process, the International Crowding Measure in Emergency Departments (ICMED). We aimed to test the feasibility of collecting this measure in real time, and to partially validate this measure. ⋯ We obtained 84 measurements, spread evenly across the four emergency departments. The measure was feasible to collect in real time, except for the 'Left Before Being Seen' variable. Increasing numbers of violations of the measure were associated with increasing clinician concerns. The Area under the Receiving Operator Curve was 0.80 (95% CI 0.72-0.90) for predicting crowding and 0.74 (95% CI 0.60-0.89) for predicting danger. The optimal number of violations for predicting crowding was three, with a sensitivity of 91.2 (95% CI 85.1-97.2) and a specificity of 100.0 (92.9-100). The measure predicted clinician concerns better than individual variables such as occupancy. Abstract 007 Table 1BeforeAfterResearch 'hotline'2 (3%)0Verbal10 (15%)3 (3%)Notes label21 (32%)14 (14%)iPad030 (30%)Not notified32 (49%)52 (52%)Total6599 CONCLUSION: The ICMED is easily to collect in multiple emergency departments with different IT systems. The ICMED seems to predict clinician's concerns about crowding and safety well, but future work is required to validate this before it can be advocated for widespread use.
-
Admissions to the Emergency Department with chest pain constitute a significant proportion of the work-load. In England it represents 6% of all Emergency Department (ED) attendances. These attendances translate to accounting for approximately 25% of acute medical admissions. One method of excluding myocardial infarction is the use of a rapid point of care Triple Cardiac Marker test. This allows testing at time point 0 and 90 minutes and negates the need for a delayed troponin. One of the markers, myoglobin, has a high sensitivity but low specificity. If there is a 25% rise in myoglobin between two tests then it is considered a positive result. The patient then requires a 12-hour troponin. Locally, there was concern over the value of including myoglobin in the triple test as it was felt that it lead to inappropriate admissions. ⋯ The use of myoglobin in the triple test does appear to be appropriate for the local population. There is a significant short-coming in the application of the triple test that is putting patients at risk of an adverse outcome. The current chest pain proforma as it stands does not appear to prevent inappropriate discharges.
-
A capacity for field-level medical assistance for people exposed to chemical, biological, radiological or nuclear (CBRN) agents or medical support for people potentially exposed to these agents is intrinsically linked to the overall risk management approach adopted by the International Committee of the Red Cross (ICRC) for an international humanitarian response to a CBRN event. This medical assistance articulates: ▸the characteristics of the agent concerned (if known) ▸the need for immediate care particularly for people exposed to agents with high toxicity and short latency ▸the imperative for those responding to be protected from exposure to the same agents. This article proposes two distinct capacities for medical assistance--CBRN field medical care and CBRN first aid--that take the above into account and the realities of a CBRN event including the likelihood that qualified medical staff may not be present with the right equipment. ⋯ Training of those who will undertake CBRN field medical care and CBRN first aid must include: ▸knowledge of CBRN agents, their impact on health and the corresponding toxidromes ▸skills to use appropriate equipment ▸use of appropriate means of self-protection ▸an understanding of the additional complexities brought by the need for and interaction of triage, transfer and decontamination. The development of CBRN field medical care and CBRN first aid continues within the ICRC while acknowledging that the opportunities for learning in real situations are extremely limited. Comments from others who work in this domain are welcome.