Determination of emergency nurse practitioner and plastic surgery trainee disposition decision agreement for plastic surgery emergency department presentations: A prospective study.

OBJECTIVE: To examine if there was a high degree of agreement for disposition decisions of emergency nurse practitioners (ENP) compared to plastic surgery trainees (PST) for plastic surgery presentations. METHODS: A prospective study of disposition decision agreement from February 2020 to January 2021 for patients who required plastic surgery consultation and managed exclusively by an ENP. Absolute percentages were used to determine the exact disposition decision accuracy of ENP and the PST, while Cohen's kappa compared disposition decision agreement. Sub-analyses of age, gender, ENP experience and presenting condition agreement were also completed. To mitigate confounding factors, operative management (OM) and non-OM groups were analysed. RESULTS: The study recruited 342 patients who presented mostly with finger or hand-related conditions (82%, n = 279) and managed by an ENP with less than 10 years of experience (65%, n = 224). Disposition decisions by ENP compared to PST were the same in 80% (n = 274) of cases. Disposition agreement for all patients was 0.72 (95% confidence interval 0.66-0.78). For the OM and non-OM groups, disposition decisions were the same in 94% (n = 320), with a Cohen's kappa 0.85 (95% confidence interval 0.79-0.91). Seven patients (2%) were discharged to GP care by the ENP when determined to need further plastic surgery involvement by the PST. CONCLUSIONS: Disposition decisions by ENP and PST were the same in most cases and had a high overall level of agreement. This may lead to greater autonomy of ENP care and reduced ED length of stay and occupancy.

Qualitative study using grounded theory examining collegiality among emergency physicians.

OBJECTIVES: Collegiality is considered to be any extra-role behaviour that is discretionary, not recognised by a formal reward system and that promotes the effective functioning of the organisation. Although there is much literature on the concept of collegiality, there are few studies examining collegiality in the medical profession and none looking at collegiality among emergency physicians (EPs). The aim of the present study is to explore the perceptions of different ED healthcare professionals on the meaning of collegiality among EPs, the benefits of collegiality and behaviours they identify as indicative of collegiality. METHODS: This was a qualitative study using grounded theory. Data collection was via focus group interviews of three to four participants per group. Participants included EPs, emergency medicine trainees, senior emergency nurses and nurse practitioners. Three questions were explored: 'what does collegiality mean to you?'; 'what are the benefits of collegiality?'; and 'what specific behaviours do you see as part of collegiality?' RESULTS: Ten focus group interviews involving a total of 33 participants were conducted. Several themes were identified for both the meaning of collegiality and the benefits of collegiality among EPs. Eight themes regarding collegial behaviour were identified: (i) mutual respect and trust; (ii) mutual support; (iii) attitude; (iv) work ethic; (v) staff welfare; (vi) patient management; (vii) handover; and (viii) education. CONCLUSION: The present study identified distinct themes and behaviours indicative of collegiality among EPs. Promoting these behaviours could improve staff well-being, ED efficiency, patient safety and productivity.

Effects of staff grade, overcrowding and presentations on emergency department performance: A regression model.

OBJECTIVE: To examine the effect of staffing levels by experience of medical officers and overcrowding on ED key performance indicators (KPIs). METHODS: Presentations to Nepean ED from 6 May to 3 November 2019 were examined. Staff were designated either Fellows of the Australasian College for Emergency Medicine (FACEMs), non-FACEM senior decision-makers (SDMs), non-senior decision-makers greater than 2 years postgraduate (non-SDMs) and junior medical officers up to 2 years postgraduate (JMOs). The number of admitted patients boarded in the ED waiting for a ward bed at 8 am was used as a marker for overcrowding. Multivariable regression analysis was performed using staffing levels, number of admissions at 8 am and total presentations as the independent variables and various ED KPIs as the dependent variables. RESULTS: FACEM and SDM had a significant effect on most ED KPIs, with the effect of FACEM consistently larger than the effect of SDM. There was minimal effect on performance by non-SDM and JMO staffing. There was significant effect of overcrowding as measured by the number of admitted patients in ED at 8 am on most ED KPIs. Almost no variables had an effect on Emergency Treatment Performance (4-h target) for admitted patients, suggesting poor performance was caused by factors outside of the ED. CONCLUSION: Increasing numbers of FACEM and non-FACEM SDM, but not junior staff, and a reduction in overcrowding as measured by the number of admitted patients boarded in the ED at 8 am, were associated with improvements in the ED performance.

Randomized controlled trial comparing an open surgical technique and a Seldinger technique for cricothyrotomy performed on a simulated airway.

OBJECTIVES: Emergency cricothyrotomy is a lifesaving procedure performed when intubation fails and oxygenation cannot occur. There are multiple techniques and kits to perform this procedure. However, current evidence does not provide a definitive answer as to which method is superior. Two techniques in common use are a surgical technique and a percutaneous Seldinger-based cricothyrotomy kit. The objective was to determine which of these two methods was quickest to perform and to determine which was most preferred by participants. METHODS: A prospective randomized controlled crossover trial was conducted involving emergency physicians and trainees. Each participant performed both cricothyrotomy techniques in succession on an airway model, with the technique performed first being randomized for each participant. The primary outcome was time to first insufflation of the artificial lung. A survey was completed by participants asking their comfort with each technique on a 5-point scale from 1 (not at all comfortable) to 5 (very comfortable) and which technique they preferred. RESULTS: Twenty-one emergency physicians and nine emergency medicine trainees were recruited. The surgical technique was performed the fastest, with a mean (±SD) time of 51.6 (±16.3) s versus 66.6 (±14.9) s for the Seldinger technique, with a statistically significant difference of 15.0 s (95% confidence interval = 8.5 to 21.5, p < 0.001). The surgical technique was rated the most comfortable to perform, with a median rating of 5 (interquartile range [IQR] = 4-5) versus 4 (IQR = 3-5) for the Seldinger technique. The surgical technique was most preferred by participants (80% vs 20%). CONCLUSION: The surgical technique was the fastest to perform and was rated the most comfortable to perform and the most preferred technique.

A stream for complex, ambulant patients reduces crowding in an emergency department.

OBJECTIVE: The study aims to evaluate the effect of adding a stream for complex, ambulatory patients in an ED. METHODS: The setting was an ED in a principal referral hospital in New South Wales, Australia. In 2011, a new stream was added to the pre-existing acute care (high complexity patients) and fast track (low complexity patients) streams. Space in acute care was set aside for the purpose of assessing patients who would previously have been assigned to acute care and who were capable of sitting in a chair with limited nursing care. The stream was separately resourced with staff redeployed from acute care. Early involvement of an emergency physician was a core characteristic of the process. Two 13 week periods before and after the intervention were compared. RESULTS: Presentations increased by 8.2%. Forty-three per cent of patients were triaged to the new stream. The median ED length of stay fell from 327 (interquartile range [IQR] 192-527) min to 267 (IQR 163-412) min (P < 0.001), the average daily occupancy of the department fell from 38.1 patients to 34.9 patients (95% confidence interval [CI] for difference 1.6-4.8, P < 0.001) and the proportion of patients who did not wait to be seen fell from 12% to 5.6% (95% CI for difference 5.8-7.1, P < 0.001). CONCLUSION: The use of an appropriately resourced stream directed towards seeing a complex group of patients who do not require ongoing nursing care and who are capable of sitting in a chair improved departmental flow.

The effect of a gold coin fine on C-reactive protein test ordering in a tertiary referral emergency department.

OBJECTIVE: To examine the effect of an education campaign based around a gold coin fine on ordering of C-reactive protein (CRP) tests. DESIGN AND SETTING: A retrospective analysis of CRP test ordering before and after the intervention in the emergency department (ED) of a tertiary referral hospital in metropolitan Sydney that sees about 60,000 patients per annum. The date of the intervention - 2 August 2013 - corresponded with Jeans for Genes Day. MAIN OUTCOME MEASURES: Number of CRP tests ordered in the ED. RESULTS: 1290 CRP tests were ordered before the intervention (1-31 July), and 394 were ordered after the intervention (2-31 August). This decrease in CRP test ordering was despite an increased number of ED presentations in August compared with July (5219 v 5497 presentations). This represented an absolute reduction in the rate of CRP test ordering of 17.6% (95% CI, 16.2%-18.9%; P < 0.001). CONCLUSION: The threat of a gold coin fine for ordering a CRP test, as part of a broader education campaign, significantly reduced the number of CRP tests ordered in a tertiary referral ED.

Effect of an electronic medical record information system on emergency department performance.

OBJECTIVE: To determine whether implementation of the Cerner FirstNet electronic medical record system was associated with any change in emergency department (ED) performance. DESIGN, SETTING AND PATIENTS: A retrospective observational study conducted during a 6-03 period in 2009 after the introduction of FirstNet and a corresponding 6-03 control period in 2008 when the Emergency Department Information System (EDIS) was operational. Data from all patients presenting to the ED during each period were extracted from each system and analysed for changes in key performance indicators (KPIs). Potential confounding variables, including total number of ED presentations, ED occupancy, ED staffing levels and triage category distribution, were also collected. MAIN OUTCOME MEASURES: Waiting time for all patients; waiting time, treatment time and total time for patients discharged from the ED; proportion of patients who did not wait to be seen by a doctor (DNW rate); and proportion of ambulance offload waiting times longer than 30 minutes. RESULTS: We found a reduction in performance with respect to ED KPIs after implementation of the FirstNet system. There were increases in the waiting time for all patients (median, 40 min v 78 min), and the waiting time (median, 49 min v 87 min), treatment time (median, 128 min v 147 min) and total time (median, 214 min v 280 min) for patients discharged from the ED. There were increases in the DNW rate (8.3% v 15.6%) and the proportion of ambulance offload times longer than 30 minutes (10.5% v 13.3%). All differences were statistically significant (P < 0.05). CONCLUSION: Implementation of the FirstNet electronic medical record system was associated with deterioration in ED KPIs.

Grief and the medical referral.

Helping ward registrars transition from denial to acceptance.