The International Federation for Emergency Medicine report on emergency department crowding and access block: A brief summary.

OBJECTIVE: To develop comprehensive guidance that captures international impacts, causes and solutions related to emergency department (ED) crowding and access block. METHODS: Emergency physicians representing 15 countries from all International Federation of Emergency Medicine (IFEM) regions composed the Task Force. Monthly meetings were held via video-conferencing software to achieve consensus for report content. The report was submitted and approved by the IFEM Board on June 1, 2020. RESULTS: A total of 14 topic dossiers, each relating to an aspect of ED crowding, were researched and completed collaboratively by members of the Task Force. CONCLUSIONS: The IFEM report is a comprehensive document intended to be used in whole or by section to inform and address aspects of ED crowding and access block. Overall, ED crowding is a multifactorial issue requiring systems-wide solutions applied at local, regional, and national levels. Access block is the predominant contributor of ED crowding in most parts of the world.

'Do you know where your cyanide kit is?': a study of perceived and actual antidote availability to emergency departments in the South West of England.

OBJECTIVE: The authors set out to investigate perceived and actual availability of antidotes recommended for stocking in emergency departments (EDs) by the College of Emergency Medicine in EDs in the South West of England. METHODS: Data collectors were asked to physically locate each relevant antidote in the ED, and check whether the recommended quantity was available. If the antidote was not available in the department, the data collector located where in the hospital stocks were available. Senior medical and nursing staff were asked to specify where they believed the antidotes were stored or who they would ask if they did not know. It was then ascertained whether their source of advice would have known the location. RESULTS: 5 out of 6 departments returned data with an overall response rate from senior medical and nursing staff of 80%. Knowledge of common antidote locations was variable, and stocking of antidotes did not universally meet the College of Emergency Medicine recommendations. CONCLUSION: Stocking of important antidotes should be rationalised and simplified using central locations, preferably close to the ED. Clinically important antidotes may not be available for patients when they need them. Clear guidance should be available for staff detailing the location of antidotes. There is a need for clarification around the treatment of cyanide poisoning to facilitate rational antidote stocking for this potentially lethal condition.

Emergency department crowding.

BACKGROUND: Emergency department (ED) crowding is a significant international problem. There is increasing overseas research into this field. In the UK, the focus has been on waiting times in EDs, and on the government's 4 h standard, rather than on crowding itself. AIMS: To examine the causes and effects of ED crowding, along with solutions. To consider whether the 4 h standard has had an effect on ED crowding in the UK. METHODS: A structured literature review on ED crowding. RESULTS: The evidence base largely consists of retrospective or descriptive studies (65% combined) from North America and Australasia (89% combined). Measurement of crowding is not well developed, and the lack of a gold standard additionally limits the quality of research. The main cause of crowding is access block, because of high levels of hospital occupancy. Crowding carries a number of adverse consequences for patients and staff. Many solutions are described, but with weak evidence behind them. Most of these focus on interventions in the ED, despite the fact that the main causes lie outside. Solutions aimed at achieving the 4 h standard may mitigate crowding. CONCLUSION: The extent of ED crowding in the UK is unknown. The problem is probably mitigated by process standards such as the 4 h standard. The causes and effects of crowding are likely to be the same as overseas, but there is little research to validate this. The best solutions are not known.

The International Federation for Emergency Medicine report on emergency department crowding and access block: A brief summary.

OBJECTIVE: To develop comprehensive guidance that captures international impacts, causes, and solutions related to ED crowding and access block. METHODS: Emergency physicians representing 15 countries from all the International Federation for Emergency Medicine (IFEM) regions composed the task force. Monthly meetings were held via video-conferencing software to achieve consensus for report content. The report was submitted and approved by the IFEM Board on June 1, 2020. RESULTS: A total of 14 topic dossiers, each relating to an aspect of ED crowding, were researched and completed collaboratively by members of the task force. CONCLUSIONS: The IFEM report is a comprehensive document intended to be used in whole or by section to inform and address aspects of ED crowding and access block. Overall, ED crowding is a multifactorial issue requiring systems-wide solutions applied at local, regional, and national levels. Access block is the predominant contributor of ED crowding in most parts of the world.

Prospective observational measurement of tracheal tube cuff pressures in the emergency department.

BACKGROUND: Tracheal mucosal blood flow is impaired when tracheal tube cuff pressure is above 30 cm of water, with the potential for tracheal mucosal necrosis. Previous studies have found excessive cuff pressures in simulated patients intubated by North American emergency physicians as well as patients intubated in the prehospital setting and emergency department (ED). This study assessed whether patients intubated in a UK prehospital setting or ED had excessive cuff pressures. METHOD: Prospective observational study in five ED in southwest England over a 2-month period. All patients over 18 years and intubated in the prehospital setting or in the ED were included. Clinical staff independent of the patients' care recorded the following: age, sex, presenting complaint and indication for intubation, tube size and cuff pressure. Neither the paramedics nor the participating ED staff were aware of the study purpose. Cuff pressure measurements were recorded using a standardised cuff inflator pressure gauge. RESULT: 61 patients were recruited. The median and mean cuff pressures were 58 and 62 cm of water, respectively. 75% of patients had a cuff pressure greater than 30 cm of water. The median cuff pressures in those patients intubated by senior emergency physicians, junior emergency physicians and paramedics were 70, 46 and 79 cm of water, respectively. CONCLUSION: Excessive tracheal tube cuff pressures were demonstrated in the majority of patients intubated both in the prehospital setting and ED. This is in keeping with existing evidence. Early measurement and adjustment of cuff pressures is recommended for those patients who require ongoing care.

Early lessons from COVID-19 that may reduce future emergency department crowding.

The COVID-19 pandemic has produced significant changes in emergency medicine patient volumes, clinical practice, and has accelerated a number of systems-level developments. Many of these changes produced efficiencies in emergency care systems and contributed to a reduction in crowding and access block. In this paper, we explore these changes, analyse their risks and benefits and examine their sustainability for the future to the extent that they may combat crowding. We also examine the necessity of a system-wide approach in addressing ED crowding and access block.

Validation of the short form of the International Crowding Measure in Emergency Departments: an international study.

OBJECTIVE: There is little consensus on the best way to measure emergency department (ED) crowding. We have previously developed a consensus-based measure, the International Crowding Measure in Emergency Departments. We aimed to externally validate a short form of the International Crowding Measure in Emergency Department (sICMED) against emergency physician's perceptions of crowding and danger. METHODS: We performed an observational validation study in seven EDs in five different countries. We recorded sICMED observations and the most senior available emergency physician's perceptions of crowding and danger at the same time. We performed a times series regression model. RESULTS: A total of 397 measurements were analysed. The sICMED showed moderate positive correlations with emergency physician's perceptions of crowding, r = 0.4110, P < 0.05) and safety (r = 0.4566, P < 0.05). There was considerable variation in the performance of the sICMED between different EDs. The sICMED was only slightly better than measuring occupancy or ED boarding time. CONCLUSION: The sICMED has moderate face validity at predicting clinician's concerns about crowding and safety, but the strength of this validity varies between different EDs and different countries.

What should we do about crowding in emergency departments?

Our emergency departments have never been under so much pressure. Crowding in these departments is both a cause and symptom of this pressure. Crowding kills patients and harms staff. It is the most important problem affecting emergency departments in the UK. The causes are described and include factors relating to input, throughput and output. Interventions aimed at these causes may confer benefit, but the most important problem remains unsolved. This is exit block caused by lack of beds, and flow through those beds, exacerbated by downgrading of capacity in unscheduled care in the evenings, weekends and during holiday periods.

Payment by results: a guide for emergency physicians.

Payment by results is a new funding mechanism being introduced into the National Health Service. It is a key part of current health reforms and will impact significantly on the way emergency departments are financed and run. This paper aims to describe the basics of payment by results, examines how it relates to and impacts upon emergency medicine, and considers how emergency physicians can set about integrating this new system into current practice and thinking.

The 4-hour standard is a meaningful quality indicator: correlation of performance with emergency department crowding.

BACKGROUND: The 4-h standard performance is a controversial quality indicator. Crowding in emergency departments (EDs) causes increased patient morbidity and mortality. The aim of this study was to investigate the relationship between 4-h standard performance and ED crowding as measured by occupancy. METHODS: A retrospective observational study was carried out using the computerized Emergency Department Information System. Daily occupancy was considered in three ways: as minutes per day spent at occupancy thresholds of 70, 80, 90 and 100%; as the peak occupancy of resuscitation and majors beds at any point in the day; and as a percentage of the total potential ED bed minutes used during the day. RESULTS: An inverse relationship was observed between occupancy and 4-h standard performance using each method. Performance could be sustained at 70% occupancy, but deteriorated in a linear manner at a progressively increasing rate at 80, 90 and 100% occupancy (all P<0.01). A stepwise decrease in the mean performance was observed with increasing peak occupancy (P<0.001). A similar decrease in performance was observed with increasing 24-h overall occupancy (P<0.001). CONCLUSION: This study has identified a clear and consistent correlation between ED crowding and performance against the 4-h standard. Because crowding is associated with harm, the 4-h standard is a meaningful quality metric for UK hospitals. Systematic measurement of ED crowding using occupancy may play a role in improving the quality of care delivered within the urgent care system.

Tranexamic acid in major trauma: implementation and evaluation across South West England.

OBJECTIVE: To carry out a prospective evaluation of tranexamic acid (TXA) use in trauma patients. PATIENTS AND METHODS: TXA was introduced to all emergency ambulances and emergency departments in the South West, UK, on 1 December 2011. We carried out a prospective evaluation of TXA use in trauma patients in the South West Peninsula between December 2011 and December 2012. We collected prehospital and hospital data on TXA administration using the Trauma Audit Research Network database. Data on prehospital administration of TXA were cross-checked with the South Western Ambulance Service Trust. Data were analysed using SPSS (version 20). RESULTS: Altogether, 82 patients were administered TXA during the study period. The median age of the patients was 49 years (IQR 30, 66), and 72% were men. One-third of the patients arrived at hospital by air ambulance. During the first 3 months, administration of TXA was limited to one patient each month receiving the drug. However, an upward trend was observed after June until October 2012, with the increment being more than 10 fold in July, September and October 2012. CONCLUSION: This is the first study to evaluate the use of TXA in civilian practice in the UK. Our study shows that ambulance service personnel and emergency departments can effectively administer TXA.

Why do parents use the emergency department for minor injury and illness? A cross-sectional questionnaire.

OBJECTIVE: To understand decision-making when bringing a child to an emergency department. DESIGN: A cross-sectional survey of parents attending with children allocated a minor triage category. SETTING: Emergency department in South West England, serving 450,000 people per annum. PARTICIPANTS: All English-speaking parents/caregivers whose children attended the emergency department and were triaged as minor injury/illness. MAIN OUTCOME MEASURES: Parental and child characteristics, injury/illness characteristics, advice seeking behaviour, views regarding emergency department service improvement, GP access and determinants of emergency department use. RESULTS: In sum, 373 responses were analysed. The majority of attendances were for minor injury, although illness was more common in <4 year olds. Most presentations were within 4 h of injury/illness and parents typically sought advice before attending. Younger parents reported feeling more stressed. Parents of younger children perceived the injury/illness to be more serious, reporting greater levels of worry, stress, helplessness and upset and less confidence. Parents educated to a higher level were more likely to administer first-aid/medication. Around 40% did not seek advice prior to attending and typically these were parents aged <24 and parents of <1 year olds. The main determinants of use were: advised by someone other than a GP; perceived urgency; perceived appropriateness. The need for reassurance also featured. CONCLUSIONS: The findings suggest that it is difficult for parents to determine whether their child's symptoms reflect minor conditions. Efforts should focus on building parental confidence and self-help and be directed at parents of younger children and younger parents. This is in addition to appropriate minor injury/illness assessment and treatment services.

Factors affecting blood sample haemolysis: a cross-sectional study.

OBJECTIVE: To determine the effect of blood sampling through an intravenous catheter compared with a needle in Emergency Department blood sampling. METHODS: We undertook a prospective, cross-sectional study in a UK university teaching hospital Emergency Department. A convenience sample of 985 patients who required blood sampling via venepuncture was collected. A total of 844 complete sets of data were analysed. The median age was 63 years, and 57% of patients were male. The primary outcome measure was the incidence of haemolysis in blood samples obtained via a needle compared with samples obtained via an intravenous catheter. Secondary outcome measures defined the effect on sample haemolysis of the side of the patient the sample was obtained from, the anatomical location of sampling, the perceived difficulty in obtaining the sample, the order of sample tubes collected, estimated tourniquet time and bench time. Data were analysed with logistic regression, and expressed as odds ratios (95% confidence intervals; P-values). RESULTS: Blood samples obtained through an intravenous catheter were more likely to be haemolysed than those obtained via a needle, odds ratio 5.63 (95% confidence interval 2.49-12.73; P<0.001). CONCLUSION: Blood sampling via an intravenous catheter was significantly associated with an increase in the likelihood of sample haemolysis compared with sampling with a needle. Wherever practicable, blood samples should be obtained via a needle in preference to an intravenous catheter. Future research should include both an economic evaluation, and staff and patient satisfaction of separating blood sampling and intravenous catheter placement.

Do radiographs requested from a paediatric emergency department in New Zealand need reporting?

OBJECTIVES: To ascertain whether plain radiographs interpreted by doctors working in a paediatric ED need reporting by radiologists. METHODS: Prospective observational study based in a paediatric teaching hospital. RESULTS: The overall disagreement rate was 26.1%. The clinically significant disagreement rate was 4.8%. There was no relationship between seniority or confidence of ED doctor, and likelihood of disagreement. Disagreement was more likely where radiographs were interpreted during normal working hours (P < 0.05). Chest films, then abdominal films, then skeletal films were more likely to result in disagreement (P < 0.0001). However, this relationship was reversed when considering rates of clinically significant disagreement (P < 0.05). The highest risk of disagreement was in chest films initially thought to be normal, and the lowest in skeletal films initially thought to be abnormal. CONCLUSION: All radiographs requested on patients discharged from the paediatric ED should be reported. Reporting need not be immediate.

Tariffs in emergency care.

The crisis in emergency medicine in the UK was no surprise to staff in the specialty, but was not expected by the Department of Health. This article explains how chronic, systematic under-resourcing of emergency care has caused emergency departments to decompensate, and discusses actions that are necessary to prevent recurrence.