The challenge of interprofessional collaboration in emergency department team triage - An interpretive description.

AIMS: To explore emergency nurses' and physicians' experience of collaboration and collective decision-making when triaging older Emergency Department patients within the interprofessional team triage system. DESIGN: Qualitative. METHODS: Semi-structured interviews were conducted with seven nurses and five physicians. Transcripts were analysed via Interpretive Description between September 2016-May 2017. RESULTS: 'Negotiating collaboration' was developed as the main theme. Three subthemes influenced the negotiation process: Participants described divergent opinions on how an optimal triage system should work ('preferences for triage systems'); they had conflicting perceptions of each profession's role ('role perceptions'); and they expressed different coping strategies regarding 'perceived time pressure'. The compatibility of participants' views on these sub-themes determined whether the nurse and physician were able to successfully negotiate their collaboration. These themes became more evident when the team triaged older ED patients. CONCLUSION: Improving interprofessional team triage requires working with the involved nurses' and physicians' values and beliefs. The strengths of both professions need to be considered and a flexible approach to collaboration established according to the patients' situations. IMPACT: Emergency Department leaders need to consider nurses' and physicians' values and beliefs to promote interprofessional collaboration in team triage.

Validation of the Clinical Frailty Scale for Prediction of Thirty-Day Mortality in the Emergency Department.

STUDY OBJECTIVE: We validate the Clinical Frailty Scale by examining its independent predictive validity for 30-day mortality, ICU admission, and hospitalization and by determining its reliability. We also determine frailty prevalence in our emergency department (ED) as measured with the Clinical Frailty Scale. METHODS: This was a prospective observational study including consecutive ED patients aged 65 years or older, from a single tertiary care center during a 9-week period. To examine predictive validity, association with mortality was investigated through a Cox proportional hazards regression; hospitalization and ICU transfer were investigated through multivariable logistic regression. We assessed reliability by calculating Cohen's weighted κ for agreement of experts who independently assigned Clinical Frailty Scale levels, compared with trained study assistants. Frailty was defined as a Clinical Frailty Scale score of 5 and higher. RESULTS: A total of 2,393 patients were analyzed in this study, of whom 128 died. Higher frailty levels were associated with higher hazards for death independent of age, sex, and condition (medical versus surgical). The area under the curve for 30-day mortality prediction was 0.81 (95% confidence interval [CI] 0.77 to 0.85), for hospitalization 0.72 (95% CI 0.70 to 0.74), and for ICU admission 0.69 (95% CI 0.66 to 0.73). Interrater reliability between the reference standard and the study team was good (weighted Cohen's κ was 0.74; 95% CI 0.64 to 0.85). Frailty prevalence was 36.8% (n=880). CONCLUSION: The Clinical Frailty Scale appears to be a valid and reliable instrument to identify frailty in the ED. It might provide ED clinicians with useful information for decisionmaking in regard to triage, disposition, and treatment.

Patient complaints as a means to improve quality of hospital care. Results of a qualitative content analysis / Patientenrückmeldung als Möglichkeit die Versorgungsqualität von Spitalpatienten zu verbessern. Ergebnisse einer qualitativen Inhaltsanalyse

Background: Many hospitals have defined procedures for a complaint management. A systematic analysis of patient complaints helps to identify similar complaints and patterns so that targeted improvement measures can be derived (Gallagher & Mazor, 2015). Aim: Our three-month, nurse-led practice development project aimed 1) to identify complaints regarding communication issues, 2) to systemise and prioritise complaints regarding communication issues, and 3) to derive clinic-specific recommendations for improvement. Method: We analysed 273 complaints of patients documented by the quality management (secondary data analysis). Using content analysis and applying the coding taxonomy for inpatient complaints by Reader, Gillespie and Roberts (2014), we distinguished communication-related complaints. By further inductive differentiation of these complaints, we identified patterns and prioritised fields of action. Results: We identified 186 communication-related complaints divided into 16 subcategories. For each subcategory, improvement interventions were derived, discussed and prioritised. Conclusions: Thus, patient complaints provided an excellent opportunity for reflection and workplace learning for nurses. The analysis gave impulse to exemplify the subject "person-centered care" for nurses.

Screening for elder mistreatment in a Swiss emergency department: a prospective cohort study.

AIM OF THE STUDY: The mistreatment of older adults is a global and complex problem with varying prevalence. As there are no data on the prevalence of elder mistreatment in European emergency department populations, we aimed to translate and culturally adapt the Emergency Department Senior Abuse Identification (ED Senior AID) tool for German use, assess the positive screen rate for elder mistreatment with the German version, and compare characteristics of patients who screened positive and negative. METHODS: To assess the prevalence of elder mistreatment, we created a German version of the ED Senior AID tool. This tool identifies intentional or negligent actions by a caregiver or trusted person that cause harm or risk to an older adult. Then, the German ED Senior AID tool was applied to all consecutively presenting patients aged ≥65 years at our academic emergency department in the Northwest of Switzerland from 25 April to 30 May 2022. Usability was defined as the percentage of patients with completed assessments using the German ED Senior AID tool. RESULTS: We included 1010 patients aged ≥65 years, of whom 29 (2.9%) screened positive with the ED Senior AID tool. The patients who screened positive were older, more severely cognitively impaired, hospitalised more frequently, and presented with higher frailty scores than those who screened negative. Mortality up to 100 days after presentation was comparable in all patients (p = 0.861), regardless of their screening result. The tool showed good usability, with 73% of assessments completed. CONCLUSION: This is the first prospective investigation on the prevalence of elder mistreatment in a European emergency department setting. Overall, 2.9% of patients screened positive using a validated screening tool translated into German. TRIAL REGISTRATION: This study was registered with the National Institute of Health on ClinicalTrials.gov with the registration number NCT05400707.

Clinical Frailty Scale at presentation to the emergency department: interrater reliability and use of algorithm-assisted assessment.

PURPOSE: The Clinical Frailty Scale (CFS) allows health care providers to quickly stratify older patients, to support clinical decision-making. However, few studies have evaluated the CFS interrater reliability (IRR) in Emergency Departments (EDs), and the freely available smartphone application for CFS assessment was never tested for reliability. This study aimed to evaluate the interrater reliability of the Clinical Frailty Scale (CFS) ratings between experienced and unexperienced staff (ED clinicians and a study team (ST) of medical students supported by a smartphone application to assess the CFS), and to determine the feasibility of CFS assignment in patients aged 65 or older at triage. METHODS: Cross-sectional study using consecutive sampling of ED patients aged 65 or older. We compared assessments by ED clinicians (Triage Clinicians (TC) and geriatric ED trained nurses (geriED-TN)) and a study team (ST) of medical students using a smartphone application for CFS scoring. The study is registered on Clinicaltrials.gov (NCT05400707). RESULTS: We included 1349 patients aged 65 and older. Quadratic-weighted kappa values for ordinal CFS levels showed a good IRR between TC and ST (Ï° = 0.73, 95% CI 0.69-0.76), similarly to that between TC and geriED-TN (Ï° = 0.75, 95% CI 0.66-0.82) and between the ST and geriED-TN (Ï° = 0.74, 95% CI 0.63-0.81). A CFS rating was assigned to 972 (70.2%) patients at triage. CONCLUSION: We found good IRR in the assessment of frailty with the CFS in different ED providers and a team using a smartphone application to support rating. A CFS assessment occurred in more than two-thirds (70.2%) of patients at triage.

Prognosis for older people at presentation to emergency department based on frailty and aggregated vital signs.

BACKGROUND: Risk stratification for older people based on aggregated vital signs lack the accuracy to predict mortality at presentation to the Emergency Department (ED). We aimed to develop and internally validate the Frailty adjusted Prognosis in ED tool (FaP-ED) for 30-day mortality combining frailty and aggregated vital signs. METHODS: Single-center prospective cohort of undifferentiated ED patients aged 65 or older, consecutively sampled upon ED presentation from a tertiary Emergency Center. Vital signs were aggregated using the National Early Warning Score (NEWS) as a measure of illness or injury severity and frailty was assessed with the Clinical Frailty Scale (CFS). The FaP-ED was constructed by combining NEWS and CFS in multivariable logistic regression. The primary outcome was 30-day mortality. Measures of discrimination and calibration were assessed to evaluate predictive performance and internally validated using bootstrapping. RESULTS: 2250 patients were included, 67 (1.8%) were omitted from analyses due to missing CFS, loss to follow-up, or terminal illness. Thirty-day mortality rate was 5.4% (N = 122, 95% CI = 4.5%-6.4%). Median NEWS was 1 (Inter-Quartile Range (IQR): 0-3) and median CFS was 4 (IQR: 3-5). The Area Under Receiver Operating Characteristic (AUROC) for FaP-ED was 0.86 (95% CI = 0.83-0.90). This was significantly higher than NEWS (0.81, 95% CI = 0.77-0.85, DeLong: Z = 3.5, p < 0.001) or CFS alone (0.82, 95% CI = 0.78-0.86, DeLong: Z = 4.4, p < 0.001). Bootstrapped estimates of FaP-ED AUROC, calibration slope, and intercept were 0.86, 0.95, and -0.09, respectively, suggesting internal validity. A decision-threshold of CFS 5 and NEWS 3 was proposed based on qualitative comparison of positive Likelihood Ratio at all relevant FaP-ED cutoffs. CONCLUSION: Combining aggregated vital signs and frailty accurately predicted 30-day mortality at ED presentation and illustrated an important clinical interaction between frailty and illness severity. Pending external validation, the Fap-ED operationalizes the concept of such "geriatric urgency" for the ED setting.

Camera-based measurement of respiratory rates is reliable.

OBJECTIVES: Respiratory rate (RR) is one of the most important vital signs used to detect whether a patient is in critical condition. It is part of many risk scores and its measurement is essential for triage of patients in emergency departments. It is often not recorded as measurement is cumbersome and time-consuming. We intended to evaluate the accuracy of camera-based measurements as an alternative measurement to the current practice of manual counting. MATERIALS AND METHODS: We monitored the RR of healthy male volunteers with a camera-based prototype application and simultaneously by manual counting and by capnography, which was considered the gold standard. The four assessors were mutually blinded. We simulated normoventilation, hypoventilation and hyperventilation as well as deep, normal and superficial breathing depths to assess potential clinical settings. The volunteers were assessed while being undressed, wearing a T-shirt or a winter coat. RESULTS: In total, 20 volunteers were included. The results of camera-based measurements of RRs and capnography were in close agreement throughout all clothing styles and respiratory patterns (Pearson's correlation coefficient, r=0.90-1.00, except for one scenario, in which the volunteer breathed slowly dressed in a winter coat r=0.84). In the winter-coat scenarios, the camera-based prototype application was superior to human counters. CONCLUSION: In our pilot study, we found that camera-based measurements delivered accurate and reliable results. Future studies need to show that camera-based measurements are a secure alternative for measuring RRs in clinical settings as well.