Factors associated with the experience of patients presenting in pain to the emergency department.

AIMS AND OBJECTIVES: This study aims to examine the association between person, environment, health and illness factors, pain care and the patient experience in the emergency department, guided by symptom management theory. BACKGROUND: Current outcome measures of pain care in the emergency department focus on process measures such as the time taken to deliver analgesic medication. Patient-reported outcomes of pain care are rare in emergency department literature and predominantly focus on patient satisfaction. Measuring overall patient experience is common, with extensive surveys undertaken in the United Kingdom, United States of America and Australia; however, these are not used as an outcome of pain care. DESIGN: Prospective cohort study. METHODS: One hundred and ninety patients arriving at a large, inner-city adults-only emergency department in moderate to severe pain were recruited to answer a modified version of the emergency department patient experience of care survey. RESULTS: Fifteen factors were identified as influencing the patient experience of care when presenting in pain. These influences of patient experience included the emergency department environment, time to first analgesic medication and the provision of analgesic medication. CONCLUSIONS: In addition to pain care factors, there is a significant association between the emergency department environment-especially workload, throughput and patient placement-and the experience of patients who present in pain to the emergency department. RELEVANCE TO CLINICAL PRACTICE: This study demonstrated an association between time to first analgesic medication and the patient experience of care. Providing timely care, including pain care, in emergency departments is difficult, but necessary to improve the patient experience of care.

Factors associated with time to first analgesic medication in the emergency department.

AIM AND OBJECTIVE: To examine the factors associated with time to first analgesic medication in the emergency department. BACKGROUND: Pain is the most common symptom presenting to the emergency department, and the time taken to deliver analgesic medication is a common outcome measure. Factors associated with time to first analgesic medication are likely to be multifaceted, but currently poorly described. DESIGN: Retrospective cohort study. METHODS: Cox proportional hazards regression modelling was undertaken to evaluate the associations between person, environment, health and illness variables within Symptom Management Theory and time to first analgesic medication in a sample of adult patients presenting with moderate-to-severe pain to an emergency department over twelve months. This study was completed in line with the STROBE statement. RESULTS: 383 patients were included in the study, 290 (75.92%) of these patients received an analgesic medication in a median time of 45 minutes (interquartile range, 70 minutes). A model containing nine explanatory variables associated with time to first analgesic medication was identified. These nine variables (employment status, discharge location, triage score, Charlson score, arrival pain score, socio-economic status, first location, daily total treatment time and patient time to be seen) represent all of the domains of the Symptom Management Theory. CONCLUSIONS: Person, environment, health and illness factors are associated with the time taken to deliver analgesic medication to those in pain in the emergency department. This study demonstrates the complexity of factors associated with pain care and the applicability of Symptom Management Theory to pain care in the emergency department. RELEVANCE TO CLINICAL PRACTICE: Identifying a model of factors that are associated with the time in which the most common symptom presenting to the emergency department is treated allows for targeted interventions to groups likely to receive poor care and a framework for its evaluation.

A randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners.

INTRODUCTION: Stress and burnout are highly prevalent among medical doctors, and are associated with negative consequences for doctors, patients, and organizations. The purpose of the current study was to examine the effectiveness of a mindfulness training intervention in reducing stress and burnout among medical practitioners, by means of a Randomised Controlled Trial design. METHODS: Participants were 44 intern doctors completing an emergency department rotation in a major Australian hospital. Participants were randomly assigned to either an active control (one hour extra break per week) or the 10-week mindfulness training intervention. Measures of stress and burnout were taken pre-, mid- and post intervention. RESULTS: Participants undergoing the 10-week mindfulness training program reported greater improvements in stress and burnout relative to participants in the control condition. Significant reduction in stress and burnout was observed for participants in the mindfulness condition. No such reductions were observed for participants in the control condition. CONCLUSIONS: Mindfulness interventions may provide medical practitioners with skills to effectively manage stress and burnout, thereby reducing their experience of these symptoms. It is likely that doctors would benefit from the inclusion of such a training program as a part of their general medical education.

Tracking the patient journey by combining multiple hospital database systems.

With new national targets for patient flow in public hospitals designed to increase efficiencies in patient care and resource use, better knowledge of events affecting length of stay will support improved bed management and scheduling of procedures. This paper presents a case study involving the integration of material from each of three databases in operation at one tertiary hospital and demonstrates it is possible to follow patient journeys from admission to discharge.

Admission of medical patients from the emergency department: An assessment of the attitudes, perspectives and practices of internal medicine and emergency medicine trainees.

OBJECTIVE: We sought to obtain a deeper understanding of the differing needs and expectations of inpatient and ED medical staff regarding the admission process for medical patients. DESIGN: Online questionnaire regarding their attitudes to and perceptions of various aspects of the admission process was used. SETTING: The setting is a tertiary 640-bed adult hospital with over 60 000 ED presentations per year and an inpatient admission rate of 30%. RESULTS: A total of 42 out of 56 (75%) internal medical trainees (IMT) felt that the ED admission workup standard was lower or much lower than the inpatient standard; however, 10 of 16 (62.5%) ED trainees (EDT) thought it was similar (P = 0.009). Regarding why IMT order additional tests in the ED, the major reason supported by IMT was to 'identify or exclude urgent pathology' (53/56, 96.4%); however, this reason ranked only fifth for EDT (2/16, 12.5%) who ranked 'to ensure nothing was missed' (12/15, 80%) first. A total of 24 out of 56 (42.8%) IMT felt that if ED admissions were enacted without IMT review, inappropriate admissions to hospital would occur regularly although only one of 16 EDT (6.3%) agreed (P = 0.025). A total of 14 out of 16 (87.5%) EDT but only 16 of 56 (23.2%) IMT were comfortable with admissions occurring without inpatient review in the ED (P < 0.001). The top two perceived barriers to a smooth and timely admission process for IMT were patient instability (34/43, 79.1%) and inadequate ED workup (37/49, 75.5%); for EDT, they were excessive IMT workload (11/14, 78.6%) and referral close to the end of an IMT shift (7/11, 63.6%). CONCLUSION: Substantial barriers to more harmonious admission processes exist. A 'paradigm shift' where roles and responsibilities are clear might be required. Defusing tension across the ED-inpatient interface should improve efficiency and ensure that patient outcomes remain the focus.

Impact of formal teaching on medical documentation by interns in an emergency department in a Queensland teaching hospital.

OBJECTIVES: This study's objective was to determine whether tuition in medical documentation enhanced the ability of emergency medicine interns to produce effective medical records. METHODS: The study adopted a case control design, using a retrospective document audit methodology, following an education intervention during the 'More Learning for Interns in Emergency' (MoLIE) programme. It was conducted in a tertiary hospital that supports five 10 week rotations of 12 interns each year (n = 60). Controls were drawn from records written in March 2012 and cases from March 2013. A total of 250 medical records written by interns were audited, 125 from each year. RESULTS: Three categories of documentation were investigated: patient characteristics, clinical impressions and management plan using a purpose-designed score sheet. Three individual items (differential diagnosis [DDX], Support and Impressions [Impress]) showed significant improvement. The proportion of excellent scores for DDX increased by 50% from 40.8% to 61.6%. A χ(2) test for independence (with Yates continuity correction) indicated a significant association between the intervention and subsequent score (X(2) [1, n = 250] = 10.006, P < 0.001, phi -0.208). For Impress, a 48% increase in excellent scores was seen (39.2% to 58.4%). A χ(2) test for independence indicated a significant association between the intervention and subsequent score (X(2) [2, n = 250] = 11.249, P = 0.004, Cramer's V 0.212). The variable Support also improved (X(2) [2, n = 250] = 8.297, P = 0.012, Cramer's V 0.189) with the number of excellent scores increasing from 37.6% to 48.0%. CONCLUSION: The study demonstrated that documentation of clinical notes by interns can be enhanced by formal tuition.

Nurses' perceived benefits of trauma nursing rounds (TNR) on clinical practice in an Australian emergency department: a mixed methods study.

BACKGROUND: Trauma nursing rounds (TNR) are a unique type of bedside teaching round that facilitate discussion of individual trauma patient's condition and care, and provide a novel and innovative approach to nursing education in an informal setting. This study introduced TNR to the emergency department in an Australian metropolitan hospital. METHODS: Registered nurses, assistants-in-nursing, and nursing students participated in seven TNR over a 12-week period. The primary care nurse presented the trauma case utilising a modified handover tool. This was followed by discussion of the patient's condition and management among all those present including the patient. A participant questionnaire provided feedback from the nurses about TNR perceived benefits. A representative sample of participants was subsequently interviewed. RESULTS: Fifty-three participants attended the rounds, 47 responded to the questionnaire, and nine were interviewed. Participants were universally positive about the TNR structure and its potential impact on clinical practice. Interviewees indicated that TNR have the potential to enhance collegiality, and allow the patients and their families to be involved and informed in their care. CONCLUSIONS: The introduction of TNR was successful. TNR provide the potential to improve assessment and care of trauma patients, promote collaborative learning, and promote patients' understanding and involvement in their care.

It Takes Two to Tango: Improving Patient Referrals from the Emergency Department to Inpatient Clinicians.

BACKGROUND: The transfer of responsibility for patient care across clinical specialties is a complex process. Published and anecdotal data suggest that referrals often fail to meet the needs of one or both parties and that patient focus can be lost during the process. Little is known about the Australian situation. METHODS: To obtain a more complete understanding of the referral process, including the nature of communication in an Australian context, we conducted semistructured interviews in a convenience sample of 25 volunteers. Two established strategies for analyzing qualitative data were used. RESULTS: All respondents considered the following information essential components of a referral: an account of the patient's current condition, a working diagnosis or problem statement and history of the presenting concern, key test results or tests awaiting results, a potential management plan, and any special characteristics of the patient. Respondents acknowledged implied, if not literal, power to accept or reject an emergency department (ED) referral and said the imbalance of power was reinforced when the ED physician was junior to the inpatient clinician. Respondents also noted that in addition to the predominant organizational culture, an independent culture is associated with specific shifts. Foremost among the nonclinical aspects of a referral considered to be important was the timeliness of the contact made to achieve the transition. Respondents also said the success of a referral depended on the speaking and listening abilities of all parties. The individual's motivation to accept or reject a referral can also have an impact on communication. CONCLUSION: Respondents attributed the difficulty of negotiating the transfer of a patient's care across the ED and inpatient interface to three distinct factors: variations in the clinical information required, the culture of the organization and of the clinical team in which the transaction takes place, and the characteristics of the individuals involved in the process. Improving communication skills has the potential to improve patient outcomes.

Development and evaluation of a consumer's guide to residential aged care.

This three-phase study aimed to develop and evaluate an information guide for potential consumers of residential aged care. Phase 1 consisted of a series of six focus groups with 41 seniors to determine the information needs of potential consumers. Phase 2 comprised a 2 round Delphi survey in which a panel of 10 industry stakeholders prioritised the themes identified by the focus groups. Phase 3 consisted of a pilot test and evaluation of the prototype information booklet by 19 seniors and their families. A feature of the guide is that its contents were identified by seniors themselves as information they wanted to know about residential care.

Exploration of the perceptions of emergency physicians and interns regarding the medical documentation practices of interns.

OBJECTIVES: The primary objective of the present study was to learn the factors that influence the documentation practices of ED interns. A second objective was to identify the expectations of emergency physicians (EPs) towards the medical record documentation of ED interns. METHODS: A qualitative design was adopted using semi-structured interviews in convenience samples drawn from both groups. RESULTS: Eighteen interviews were conducted with intern volunteers and 10 with EP volunteers. One (5%) intern and two (20%) EPs had received medical documentation training. Factors that encouraged interns' documentation included: patient acuity (the more critical the condition, the more comprehensive the documentation) and the support of senior colleagues. Inhibiting factors included uncertainty about how much to write, and the shift being worked (interns indicated they wrote less at night). Factors of consequence to senior personnel included the apparent reluctance of interns to document management plans. They noted that interns frequently confine their notes to assessment, investigations and treatments, whereas EPs preferred records that demonstrated intern thought processes and included such matters as future actions to follow immediate treatment. A positive theme that emerged included the high level of support interns received from their senior colleagues. Another theme, the influence of patient acuity, held both positive and negative implications for intern writing practices. CONCLUSION: The lack of formal training is an impediment to the production of useful medical records by ED interns. One solution proposed by both interns and senior personnel was the introduction of the subject into intern education programmes.

Consumer expectations of residential aged care: reflections on the literature.

The decision-making process that accompanies aged-care home placement is complex and there is a paucity of literature documenting the experiences of those who undertake the activity. The deficiency extends to an understanding of consumer expectations about the quality of the services they encounter once admission has been obtained. Although fewer than 7% of Australian women and 3% of Australian men aged 65 years occupied residential aged care places in 1999-2000, the probability that they will do so at some point in their lives is 0.42 and 0.24, respectively. This study examined 20 papers on this subject found through an extensive search of the literature. Themes identified include the search and selection process of residential aged-care facilities, consumer expectations and satisfaction of placement outcomes, and global and community expectations of quality of care.