Real time shift reporting by emergency physicians predicts overall ED performance.

OBJECTIVE: To investigate factors associated with emergency physician perception of the shift and to determine whether these perceptions were predictors of overall daily emergency department (ED) performance indicators. METHODS: This was an observational study conducted at an inner city ED in New South Wales. Shift reports completed by the emergency physician in charge at clinical handover times between February and July 2012 were included. Variables collected by the shift report included (1) total number of patients in ED, (2) number of patients in the ED with length of stay (LOS) greater than 4 h, (3) number of admitted patients, (4) number of patients waiting to be seen by a doctor and (5) medical staffing levels. Outcomes of interest for this study were shift perception scores (1=very poor to 5=very good) and daily ED performance measures. Performance measures were the proportion of patients admitted or discharged from ED within 4 h (National Emergency Access Target, NEAT) and the percentage of inpatient admissions leaving ED within 8 h of ED arrival time. RESULTS: The number of patients in ED with LOS >4 h (OR 0.83, 95% CI 0.79 to 0.87, p value <0.001) and number of patients waiting to be seen (OR 0.92, 95% CI 0.88 to 0.95, p value <0.001) were the factors most strongly associated with shift perception score. After adjustment, the mean NEAT performance improved 6% for each incremental increase in average shift perception score (ß=0.06 95% CI 0.04 to 0.07, p<0.001). CONCLUSIONS: Shift reports and shift perceptions by emergency physicians may be used to predict overall ED performance.

Use of a syndromic surveillance system to describe the trend in cycling-related presentations to emergency departments in Sydney.

OBJECTIVES: To describe population-based trends in cycling-related presentations to EDs over the past decade. METHODS: A retrospective cohort of road trauma patients (motor vehicle, motor cyclist, cyclist and pedestrian) presenting to EDs in the Sydney Greater Metropolitan Area between 2004 and 2013 was obtained using the Public Health Real-time Emergency Department Surveillance System. The outcomes of interest were the cycling-related ED presentation rate per 1000 population, as well as the proportion of cycling-related presentations that died in ED or were admitted to a critical care ward. Trends in ED presentation rates based on presentation counts and Sydney population data were plotted and described. RESULTS: There were 68,438 cycling-related presentations identified, representing 30% of all road trauma patients presenting to EDs in Sydney. There was a 91% increase in cycling-related presentations for the 35 to 64-year-old age group and a 123% increase in cycling-related presentations in the 65-year-old and over age group. All other age groups were associated with a stable or decrease in cycling-related ED presentation rates. The proportion of presentations requiring critical care ward admission or death in ED has decreased by 20%. CONCLUSION: Using an ED syndromic surveillance system, cycling-related ED presentation rates in Sydney Australia have increased in those aged 35 years and over the past 10 years, with a relative decrease in the proportion of deaths in ED or those requiring critical care admission.

Emergency department clinical redesign, team-based care and improvements in hospital performance: A time series analysis.

OBJECTIVE: The objective was to evaluate the impact of an ED clinical redesign project that involved team-based care and early senior assessment on hospital performance. METHODS: This was an interrupted time series analysis performed using daily hospital performance data 6 months before and 8 months after the implementation of the clinical redesign intervention that involved Emergency Consultant-led team-based care, redistribution of ED beds and implementation of a senior nursing coordination roles in the ED. The primary outcome was the daily National Emergency Access Target (NEAT) performance (proportion of total daily ED presentations that were admitted to an inpatient ward or discharged from ED within 4 h of arrival). Secondary outcomes were daily ALOS in ED, inpatient Clinical Emergency Response System (CERS) calls and hospital mortality. Autoregressive Integrated Moving Average analysis was used to model NEAT performance. Hospital mortality was modelled using negative binomial regression. RESULTS: After adjusting for patient volume, inpatient admissions, ambulance, hospital occupancy, weekends ED Consultant numbers, weekends and underlying trends, there was a 17% improvement in NEAT associated with the post-intervention period (95% CI 12, 19% P < 0.001). There was no change in the number of CERS calls and the median daily hospital mortality rate reduced from 1.04% to 0.96% (P = 0.025). CONCLUSION: An ED-focused clinical redesign project was associated with a 17% improvement in NEAT performance with no evidence of an increase in clinical deterioration on inpatient wards and evidence for an improvement in hospital mortality.

Randomised control trial of humidified high flow nasal cannulae versus standard oxygen in the emergency department.

OBJECTIVES: The aim of the study was to determine if oxygen delivered through humidified high flow nasal cannulae (HHFNC) reduced the need for escalation in ventilation management and work of breathing in the ED patients presenting with acute undifferentiated shortness of breath compared with standard oxygen therapy. METHODS: This was an unblinded randomised control trial conducted at two hospital EDs in Sydney, Australia. Eligible patients presenting with shortness of breath were randomised to HHFNC or standard oxygen therapy. Primary outcomes were the need to escalate ventilation therapy or a reduction in respiratory rate of 20% or more within 2 h of commencement. RESULTS: One hundred patients were enrolled in the trial. The intervention group receiving HHFNC was associated with a higher proportion of patients with a reduced respiratory rate at 2 h (66.7% vs 38.5%, P = 0.005) and a lower proportion of patients requiring escalation in ventilation therapy (4.2% vs 19%, P = 0.02) compared with standard oxygen therapy. CONCLUSIONS: The use of high flow nasal cannula oxygenation was associated with improved respiratory state in selected patients presenting to the ED with acute undifferentiated shortness of breath.

Senior work-up assessment and treatment team in an emergency department: a randomised control trial.

OBJECTIVE: To evaluate the impact of a senior early assessment model of care on performance measures in a single ED. METHODS: A pragmatic single-blinded randomised control trial with day of ED presentation randomised to one of three study arms: senior work-up assessment and treatment (SWAT) model of care intervention, non-SWAT control or control. PRIMARY OUTCOME: The primary outcomes were the proportion of patients meeting National Emergency Access Target (NEAT) criteria (ED length of stay less than 4 h) and ED length of stay. Secondary outcome measured was time to decision to admit in the subgroup of admitted patients. RESULTS: A total of 1737 patients were analysed. There was no overall difference in NEAT performance (48% [95% CI 44, 51] vs 41% ([95% CI 37, 45] vs 46% [95% CI 41, 50], P = 0.09) or ED length of stay (P = 0.65) between SWAT, non-SWAT and standard of care control groups, respectively. In the subgroup of patients discharged from ED (non-admitted), the SWAT intervention group was associated with higher NEAT performance (P = 0.004) compared with non-SWAT and control. CONCLUSION: A senior early assessment model of care was not associated with improved overall NEAT performance and ED length of stay. However, there is evidence that improvements were made in the subgroup of discharged patients. There was no difference in overall NEAT performance among the three study groups.

Impact of technical assistants for venepuncture and intravenous cannulation on overall emergency department performance.

OBJECTIVE: The objective of the article was to determine the effect of a technical assistant for venepuncture and i.v. cannulation on triage performance and patient length of stay in an ED. METHODS: An observational study of daily ED performance was conducted at an inner city tertiary referral ED. Over a period of 158 consecutive days, data on triage performance and average length of stay were collected. A technical assistant was employed for 8-10 h per day to perform venepuncture, i.v. cannulation and electronic order entry. Study groups compared were days staffed by a technical assistant and days that were not staffed. RESULTS: Days staffed by a technical assistant were associated with significantly higher triage performance for triage category three (mean 0.66, 95% CI 0.63-0.69 vs 0.58, 95% CI 0.54-0.62; P=0.003) and lower average length of stay per patient for triage category two patients (mean length of stay 390 min, 95% CI 369-411 vs 425 min, 95% CI 399-451; P=0.04). Triage performance thresholds for triage category three (75% of patients seen within 30 min) were met over twice as often on staffed days compared with control (39/96 [38%]vs 10/62 [16%], P=0.004). CONCLUSION: Staffing the ED with a technical assistant was associated with improved ED performance for triage category three and average length of stay for triage category two patients.

Community acquired needlestick injuries in non-health care workers presenting to an urban emergency department.

OBJECTIVES: To review the epidemiology and demographics of community acquired needlestick injuries in non-health care workers attending an urban ED. METHODS: A retrospective analysis of patients with needlestick injuries attending the Royal Prince Alfred Hospital from 1996 to 2001. RESULTS: One hundred and twenty cases were reviewed. The most common mechanism of injury was exposure to discarded syringes (68%). Forty three (36%) injuries were work related. Twenty four (20%) were non-accidental. Ten (8%) patients received human immunodeficiency virus post exposure prophylaxis. There were no viral seroconversions in the patients with data available. CONCLUSIONS: We have identified three groups, males, cleaners and police officers, who are at particular risk of injury. Community education is required so that medical assessment is sought early and to increase awareness of these injuries. The provision of post exposure prophylaxis requires individualized risk assessment, as only in a minority of cases is the source available for testing.