Medical perspectives regarding goals-of-care consultations in Emergency Departments.

Goals-of-care discussions aim to establish patient values for shared medical decision-making. These discussions are relevant towards end-of-life as patients may receive non-beneficial treatments if they have never discussed preferences for care. End-of-life care is provided in Emergency Departments (EDs) but little is known regarding ED-led goals-of-care discussions. We aimed to explore practitioner perspectives on goals-of-care discussions for adult ED patients nearing end-of-life. We report the qualitative component of a mixed methods study regarding a 'Goals-of-Care' form in an Australian ED. Eighteen out of 34 doctors who completed the form were interviewed. We characterised ED-led goals-of-care consultations for the first time. Emergency doctors perceive goals-of-care discussions to be relevant to their practice and occurring frequently. They aim to ensure appropriate care is provided prior to review by the admitting team, focusing on limitations of treatment and clarity in the care process. ED doctors felt they could recognise end-of-life and that ED visits often prompt consideration of end-of-life care planning. They wanted long-term practitioners to initiate discussions prior to patient deterioration. There were numerous interpretations of palliative care concepts. Standardisation of language, education, collaboration and further research is required to ensure Emergency practitioners are equipped to facilitate these challenging conversations.

An economic evaluation of the costs of training a medical scribe to work in Emergency Medicine.

OBJECTIVE: To undertake a cost analysis of training medical scribes in an ED. METHODS: This was a pilot, observational, single-centre study at Cabrini ED, Melbourne, Australia, studying the costs of initiating a scribe programme from the perspective of the hospital and Australian Health sector. Recruitment and training occurred between August 2015 and February 2016 and comprised of a prework course (1 month), prework training sessions and clinical training shifts for scribe trainees (2-4 months, one shift per week) who were trained by emergency physicians. Costs of start-up, recruitment, administration, preclinical training, clinical training shifts and productivity changes for trainers were calculated. RESULTS: 10 trainees were recruited to the prework course, 9 finished, 6 were offered clinical training after simulation assessment, 5 achieved competency. Scribes required clinical training ranging from 68 to 118 hours to become competent after initial classroom training. Medical students (2) required 7 shifts to become competent, premedical students (3) 8-16 shifts, while a trainee from an alternative background did not achieve competency. Based on a scribe salary of US$15.91/hour (including 25% on-costs) plus shift loadings, costs were: recruitment and start-up US$3111, education US$1257, administration US$866 and clinical shift costs US$1137 (overall cost US$6317 per competent scribe). Physicians who trained the clinical trainee scribes during shifts did not lose productivity. CONCLUSIONS: Training scribes outside the USA is feasible using an on-line training course and local physicians. It makes economic sense to hire individuals who can work over a long period of time to recoup training costs. TRIAL REGISTRATION NUMBER: ACTRN12615000607572.

Review article: Goals-of-care discussions for adult patients nearing end of life in emergency departments: A systematic review.

Goals-of-care discussions at end-of-life are associated with increased patient satisfaction and reduced treatment burdens, reduced family and healthcare worker distress and healthcare costs, while achieving equal life-expectancy. It is unclear how goals-of-care discussions should occur. The objective of the study was to determine which patients could benefit, requirements, content, documentation, and harms and benefits of emergency medicine goals-of-care discussions. We sought primary evidence on goals-of-care discussions in EDs with adult patients nearing end-of-life, published in English after 1989. Data sources included Medline, Embase, PsycINFO, CINAHL, Web of Science and reference lists of included articles. One thousand nine hundred and twenty abstracts were screened, five articles selected. There was no consensus on the meaning of goals-of-care, which is often confused with advanced care planning and treatment limitation. Emergency clinicians can identify most patients needing discussions following training. There was no evidence for how to involve stakeholders, nor how to adapt conversations to meet cultural and linguistically diverse needs. Expert panels have suggested requirements and content for conversations with little supporting evidence. There was no evidence for how emergency conversations differ to those in other settings, nor for harms or benefits for holding goals-of-care conversations in EDs. Increased ED goals-of-care conversations increased hospice referral and reduced in-patient admissions. Most studies were of moderate quality only, outcomes were not standardised and sample sizes were small. 'Goals-of-care' is used inconsistently across the literature. This is the first systematic review regarding goals-of-care discussions in EDs. Further research is needed on all aspects of these conversations.

Testing a new form to document 'Goals-of-Care' discussions regarding plans for end-of-life care for patients in an Australian emergency department.

OBJECTIVE: There is limited literature to inform the content and format of Goals-of-Care forms, for use by doctors when they are undertaking these important conversations. METHODS: This was a prospective, qualitative and quantitative study evaluating the utility of a new 'Goals-of-Care' form to doctors in a private, tertiary ED, used from December 2016 to February 2017 at Cabrini, Melbourne. A Goals-of-Care form was designed, incorporating medical aims of therapy and patient values and preferences. Doctors wishing to complete a Not-for-CPR form were also supplied with the trial Goals-of-Care form. Form use, content and patient progress were followed. Doctors completing a form were invited to interview. RESULTS: Forms were used in 3% of attendances, 120 forms were taken for use and 108 were analysed. The median patient age was 91, 81% were Supportive and Palliative Care Indicators Tool (SPICT) positive and patients had a 48% 6-month mortality. A total of 34 doctors completed the forms, 16 were interviewed (two ED trainees, 11 senior ED doctors and three others). Theme saturation was only achieved for the senior doctors interviewed. Having a Goals-of-Care form was valued by 88% of doctors. The frequency of section use was: Aims-of-Care 91%; Quality-of-Life 75% (the term was polarising); Functional Impairments 35%; and Outcomes of Value 29%. Opinions regarding the ideal content and format varied. Some doctors liked free-text space and others tick-boxes. The median duration of the conversation and documentation was 10 min (interquartile range 6-20 min). CONCLUSIONS: Having a Goals-of-Care form in emergency medicine is supported; the ideal contents of the form was not determined.

Accuracy of electrocardiogram interpretation improves with emergency medicine training.

OBJECTIVE: To assess whether electrocardiogram (ECG) interpretation accuracy improves with advancing years of emergency medicine training. METHODS: A prospective cross-sectional double-blinded study of emergency medicine trainees attending teaching sessions in ACEM accredited Victorian hospitals. Subjects completed a survey about level of training, rotations completed and ECG training. They were then asked for the 'main diagnosis' on 10 clinically significant ECG. Those in their fourth year of advanced training onwards, or in active preparation for fellowship examination (senior trainees) were compared with trainees in earlier years (other trainees). RESULTS: There were 122 trainees surveyed in total. In the present study, 48/122 were senior trainees and 74/122 were other trainees. The overall accuracy of ECG interpretation was 67.5% (95% confidence interval [CI] 63.2-71.8%) for the senior trainees and 49.6% (95% CI 45.2-53.9%) for the others. Results for some of the individual ECG were: left bundle branch block: 81.3% (95% CI 69.9-92.6%) seniors and 58.1% (95% CI 46.6-69.7%) others; ventricular tachycardia: 43.8% (95% CI 29.3-58.2%) seniors and 37.8% (95% CI 26.5-49.2%) others; and ventricular fibrillation: 70.8% (95% CI 57.6-84.1%) seniors and 63.5% (95% CI 52.2-74.9%) others. CONCLUSION: There is an improvement in ECG interpretation accuracy with advancing years of emergency medicine training in Victoria. There exists, however, a low level of accuracy for some critical ECG diagnoses. There is a call by trainees for more formalized and regular ECG education to begin earlier in their training.

The 9-Item Physician Documentation Quality Instrument (PDQI-9) score is not useful in evaluating EMR (scribe) note quality in Emergency Medicine.

BACKGROUND: Scribes are assisting Emergency Physicians by writing their electronic clinical notes at the bedside during consultations. They increase physician productivity and improve their working conditions. The quality of Emergency scribe notes is unevaluated and important to determine. OBJECTIVE: The primary objective of the study was to determine if the quality of Emergency Department scribe notes was equivalent to physician only notes, using the Physician Documentation Quality Instrument, Nine-item tool (PDQI-9). METHODS: This was a retrospective, observational study comparing 110 scribed to 110 non-scribed Emergency Physician notes written at Cabrini Emergency Department, Australia. Consultations during a randomised controlled trial of scribe/doctor productivity in 2016 were used. Emergency physicians and nurses rated randomly selected, blinded and de-identified notes, 2 raters per note. Comparisons were made between paired scribed and unscribed notes and between raters of each note. Characteristics of individual raters were examined. The ability of the tool to discriminate between good and poor notes was tested. RESULTS: The PDQI-9 tool has significant issues. Individual items had good internal consistency (Cronbach's alpha=0.93), but there was very poor agreement between raters (Pearson's r=0.07, p=0.270). There were substantial differences in PDQI-9 scores allocated by each rater, with some giving typically lower scores than others, F(25,206)=1.93, p=0.007. The tool was unable to distinguish good from poor notes, F(3,34)=1.15, p=0.342. There was no difference in PDQI-9 score between scribed and non-scribed notes. CONCLUSIONS: The PDQI-9 documentation quality tool did not demonstrate reliability or validity in evaluating Emergency Medicine consultation notes. We found no evidence that scribed notes were of poorer quality than non-scribed notes, however Emergency scribe note quality has not yet been determined.

Timed Up and Go test is not useful as a discharge risk screening tool.

OBJECTIVE: To determine whether the 'Timed Up and Go' (TUG) test is a useful test for predicting re-attendance at an ED, emergency hospital admission or death within 90 days in elderly patients discharged from the ED. METHODS: This was a prospective blinded cohort study at a tertiary referral ED. Patients completed a TUG test during their Allied Health assessment prior to discharge from the department. After 90 days, patient ED attendances, emergency admissions to hospital or deaths were recorded and confirmed by phone. Data were analysed using logistic regression and reported as odds ratios (OR) or log-transformation and Pearson analysis. RESULTS: One hundred patients were enrolled: 78 (78%, 95% confidence interval [CI] 70-86%) patients remained event free, 22 (22%, 95% CI 14-30%) patients re-attended an ED and 15 (15%, 95% CI 8-22%) were admitted to hospital as an emergency admission. There was no significant difference between TUG test times and whether patients re-attended an ED (OR 1.0 [0.93-1.06] P = 0.9) or were admitted to hospital (OR 0.99 [0.91-1.07] P = 0.74). There was no significant correlation between a patient's TUG test time and the number of days to ED re-attendance (Pearson correlation coefficient 0.38 [-0.04 to 0.69] P = 0.08) or admission (Pearson correlation coefficient 0.32 [-0.23 to 0.71] P = 0.25). CONCLUSION: This study did not detect any predictive value of the TUG test for ED re-attendance or hospital admission within 90 days of discharge among aged ED patients.

Medical scribes in emergency medicine produce financially significant productivity gains for some, but not all emergency physicians.

OBJECTIVE: The present study aims to determine if a scribe in an Australian ED can assist emergency physicians to work with increased productivity and to investigate when and where to allocate a scribe and to whom. METHODS: This was a prospective observational single-centre study conducted at a private ED in Melbourne. It evaluated one American scribe and five doctors over 6 months. A scribe is a trained assistant who performs non-clinical tasks usually performed by the doctor. The primary outcomes were patients/hour/doctor and billings/patient. Additional analyses included individual doctor productivity, productivity by ED region, shift time, day of the week and physician learning curves. Door-to-doctor time, time spent on ambulance bypass and door-to-discharge time were examined, also complaints or issues with the scribe. RESULTS: There was an overall increase in doctor consultations of 0.11 (95%CI 0.07-0.15) primary consultations per hour (13%). There was variation seen between individual doctors (lowest increase 0.06 [6%] to highest increase 0.12 [15%]). Billings per patients, door-to-doctor, door-to-discharge and ambulance bypass times remained the same. There was no advantage to allocating a scribe to a specific time of day, day of week or region of the ED. There was no learning period found. CONCLUSIONS: In the present study, scribe usage was associated with overall improvements in primary consultations per hour of 13% per scribed hour, and this varied depending on the physician. There is an economic argument for allocating scribes to some emergency physicians on days, evenings and weekends, not to trainees.

The ancient drug salicylate directly activates AMP-activated protein kinase.

Salicylate, a plant product, has been in medicinal use since ancient times. More recently, it has been replaced by synthetic derivatives such as aspirin and salsalate, both of which are rapidly broken down to salicylate in vivo. At concentrations reached in plasma after administration of salsalate or of aspirin at high doses, salicylate activates adenosine monophosphate-activated protein kinase (AMPK), a central regulator of cell growth and metabolism. Salicylate binds at the same site as the synthetic activator A-769662 to cause allosteric activation and inhibition of dephosphorylation of the activating phosphorylation site, threonine-172. In AMPK knockout mice, effects of salicylate to increase fat utilization and to lower plasma fatty acids in vivo were lost. Our results suggest that AMPK activation could explain some beneficial effects of salsalate and aspirin in humans.

Arsenic-induced SUMO-dependent recruitment of RNF4 into PML nuclear bodies.

In acute promyelocytic leukemia (APL), the promyelocytic leukemia (PML) protein is fused to the retinoic acid receptor alpha (RAR). Arsenic is an effective treatment for this disease as it induces SUMO-dependent ubiquitin-mediated proteasomal degradation of the PML-RAR fusion protein. Here we analyze the nuclear trafficking dynamics of PML and its SUMO-dependent ubiquitin E3 ligase, RNF4 in response to arsenic. After administration of arsenic, PML immediately transits into nuclear bodies where it undergoes SUMO modification. This initial recruitment of PML into nuclear bodies is not dependent on RNF4, but RNF4 quickly follows PML into the nuclear bodies where it is responsible for ubiquitylation of SUMO-modified PML and its degradation by the proteasome. While arsenic restricts the mobility of PML, FRAP analysis indicates that RNF4 continues to rapidly shuttle into PML nuclear bodies in a SUMO-dependent manner. Under these conditions FRET studies indicate that RNF4 interacts with SUMO in PML bodies but not directly with PML. These studies indicate that arsenic induces the rapid reorganization of the cell nucleus by SUMO modification of nuclear body-associated PML and uptake of the ubiquitin E3 ligase RNF4 leading to the ubiquitin-mediated degradation of PML.