A longitudinal assessment of occupational stress in Emergency Department Nursing Staff.

AIMS: To examine perceptions of occupational stress in Emergency Department (ED) nurses and measure the impact of interventions to address them. BACKGROUND: Cross-sectional studies internationally have established that Emergency Department (ED) nursing staff experience high levels of occupational stress. Few however have examined changes in perceptions of stress over time or the impact of interventions to address them. EVALUATION: A structured questionnaire completed by volunteer nursing staff in one United Kingdom ED assessing perceptions of occupational stress and job satisfaction. Questionnaire rounds were administered in 2014 (T1), 2015 (T2) and 2017 (T3) at 18-month intervals. Statistical analyses were conducted using multivariate regression, t-tests and Mann-Whitney U tests. KEY ISSUE: Statistically significant improvements in effort-reward balance, relational justice and job satisfaction were seen between T2 and T3 for nurses completing questionnaires at all three time points, but not for other stressors. CONCLUSION: This study suggests that organisational interventions, supported by robust research data and consistent departmental leadership can positively influence perceptions of organisational stress in ED nurses. Our approach is generic, internationally applicable and can be adopted in all EDs. IMPLICATIONS OF NURSING MANAGEMENT: These occupational stressors are common to all EDs. Nurse managers should know their distribution amongst their staff. Such data can inform interventions to achieve maximal benefits for staff wellbeing and may be of value when targeting resources in times of financial pressure.

Workers' recovery from concussions presenting to the emergency department.

BACKGROUND: The emergency department (ED) is the first point of care for many patients with concussion, and post-concussion syndrome can impact vocational outcomes like successful return to work. Evaluation of concussion in general adult populations is needed. AIMS: To document the occurrence and outcomes of work-related concussion presenting to the ED for treatment. METHODS: This study enrolled adults presenting with concussion to three urban Canadian EDs. Baseline ED interviews, physician questionnaires and patient phone interviews at 30 and 90 days documented work-related events, ED management, discharge advice, patient adherence and symptom severity. Work-related injury and return to work were modelled using logistic or linear regression, as appropriate. RESULTS: Overall, 172 enrolled workers completed at least one follow-up. Work-related concussions were uncommon (n = 28). Most employees (80%) missed at least 1 day of work (median = 7; interquartile range: 3-14). Most (91%) employees returned to work within 90 days, while 41% reported persistent symptoms. Manual labour and self-reported history of attention deficit hyperactivity disorder were associated with work-related concussion, while days of missed work increased with marital status (divorced), history of sleep disorder and physician's advice to avoid work. CONCLUSION: Work-related concussions are infrequent; however, most workers who sustain a concussion will miss work, and many return while still experiencing symptoms. Work-related concussion and days of missed work are mainly affected by non-modifiable factors. Workers, employers and the workers' compensation system should take necessary precautions to ensure that workers return to work safely and successfully following a concussion.

The effect of body weight on intravenous diltiazem in patients with atrial fibrillation with rapid ventricular response.

WHAT IS KNOWN AND OBJECTIVES: To assess the effect of body weight on the total dose of intravenous (IV) diltiazem needed to reach goal heart rate (HR) for atrial fibrillation (Afib) with rapid ventricular response (RVR) in the emergency department (ED) setting. METHODS: A single-center retrospective cohort was ascertained using electronic medical record data from January 2013 to December 2016. Inclusion criteria consisted of new onset Afib with RVR, receipt of IV diltiazem in the ED, and age ≥18 years old. The primary outcome was the total dose of diltiazem needed to reach goal HR <100, stratified by patients who were <100 kg and those ≥100 kg. The secondary outcome was the total time required to reach goal HR. Demographic, clinical and medication-related data were collected, including selected safety endpoints. RESULTS AND DISCUSSION: A total of 328 patients were included. Patients required a mean of 30.1 mg (±24.6) of diltiazem and 2.3 hours (±2.9) to reach goal HR. The total dose of diltiazem was similar for patients <100 kg and ≥100 kg (28.7 vs 34.3 mg; P = .068) as was the time to reach goal HR (2.3 vs 2.3 hours; P = .949), respectively. No differences were noted in incidence of hypotension, bradycardia or need for additional rate control agents. WHAT IS NEW AND CONCLUSION: No difference in the total amount of diltiazem or time to reach goal HR was found in patients according to body weight stratification.

Pharmacist intervention to detect drug adverse events on admission to the emergency department: Two case reports of neuroleptic malignant syndrome.

WHAT IS KNOWN AND OBJECTIVE: Neuroleptic malignant syndrome (NMS) is a rare but severe adverse effect of antipsychotic drugs. CASE DESCRIPTION: We report two cases of NMS highlighted by clinical pharmacists in an emergency unit during summer. One of them was fatal. Medication reconciliation processes performed at admission identified treatment with loxapine for one of them and with loxapine and clozapine for the other. Interview of the patients highlighted clinical symptoms suggesting NMS, allowing the pharmacists to alert the medical team. WHAT IS NEW AND CONCLUSION: Adverse drug events may be severe and clinical pharmacists in emergency departments can help to detect them.

Partnered pharmacist charting on admission in the General Medical and Emergency Short-stay Unit - a cluster-randomised controlled trial in patients with complex medication regimens.

WHAT IS KNOWN AND OBJECTIVE: Patients admitted to general medical units and emergency short-stay units are often complex with multiple comorbidities, polypharmacy and at risk for drug-related problems associated with increased morbidity and mortality. The aim of this study was to evaluate the effectiveness of a partnered pharmacist charting model completed at the time of admission to prevent medication errors. METHODS: We conducted an unblinded cluster randomized controlled trial comparing partnered pharmacist charting to standard medical charting among patients admitted to general medical units and emergency short-stay units with complex medication regimens or polypharmacy. This trial was conducted at an adult major referral hospital in metropolitan Melbourne, Australia, with an annual emergency department attendance of approximately 60 000 patients. The evaluation included patients' medication charts written in the period of 16 March 2015 to 27 July 2015. Patients randomized to the intervention were managed using the partnered pharmacist charting model. The primary outcome variable was a medication error identified by an independent assessor within 24 h of admission, who was not part of the patient's admission process. RESULTS: Of the 473 patients who received standard medical staff charting during the study period, 372 (78·7%) had at least one medication error identified compared to 15 patients (3·7%) on the partnered pharmacist charting arm (P < 0·001). The relative risk of an error with standard medical charting was 21·4 (95% CI: 13·0-35·0) with a number needed to treat (NNT) to prevent one error of 1·3 (95% CI: 1·3-1·4), and the relative risk of a high or extreme risk error with standard medical charting was 150·9 (95% CI: 21·2-1072·9) with a NNT to prevent one high or extreme error of 2·7 (95% CI 2·4-3·1). WHAT IS NEW AND CONCLUSION: Partnering between medical staff and pharmacists to jointly chart initial medications on admission significantly reduced inpatient medication errors (including errors of high and extreme risk) among general medical and emergency short-stay patients with complex medication regimens or polypharmacy.