Improving Emergency Department Patient Experience Through Implementation of an Informational Pamphlet.

OBJECTIVE: Patient satisfaction is emerging as a new health-care metric. We hypothesized that an emergency department (ED) informational pamphlet would significantly improve patient understanding of ED operations and ultimately improve patient satisfaction. METHODS: We performed a prospective study of patients presenting to a single tertiary care center ED from April to July 2017. All patients were given a pamphlet on alternating weeks with regular care on opposite weeks and were surveyed upon ED discharge. The primary outcome was patient satisfaction with ED care. Secondary outcomes included patient understanding of various wait times (test results, consultants), discharge process, who was on the care team and what to expect during the ED visit. RESULTS: Four hundred ninety-four patients were included in this study and 266 (54%) were in the control group. Of 228 (46%) patients who were given the pamphlet, 116 (51%) were unaware they received it. Of the remaining 112 (49%) patients who remembered receiving the pamphlet, 43 (38%) stated they read it. Among those reading the pamphlet, only two statements were significant: knowing what to expect during the ED visit (88% vs 71%; P = 0.012) and waiting time for test results (95% vs 75%; P = 0.003) when compared to those who did not receive or read the pamphlet. CONCLUSION: An ED informational pamphlet, when utilized by patients, does improve patient understanding of some aspects of the ED visit but does not appear to be the best tool to convey all information. Ultimately, sustained improvement in patient satisfaction is a complex and dynamic issue necessitating a multifactorial approach and other methods should be explored.

Grab a Seat! Nudging Providers to Sit Improves the Patient Experience in the Emergency Department.

OBJECTIVE: We assessed whether provider sitting influenced patient satisfaction in an academic emergency department (ED) and if education and/or environmental manipulation could nudge providers to sit. METHODS: This was a prospective, controlled pre-post trial of provider sitting and its influence on patient satisfaction within 2 urban, academic EDs. A 12-item survey was administered to a convenience sample of patients to assess for care satisfaction before, during, and after study interventions. Study interventions included (a) placement of branded folding seats and (b) an educational campaign. Only the intervention ED received folding seats. The primary outcome examined the influence of provider sitting on patient satisfaction. A secondary outcome examined the frequency of provider sitting. RESULTS: During the entire study period, 2827 patients were surveyed; 63% were female and 65% were between the ages of 26 and 65. Sitting at any point during an ED encounter improved responses to satisfaction questions (polite [67% vs 59%], cared [64% vs 54%], listened [60% vs 52%], informed [57% vs 47%], time [56% vs 45%], P < .0001 for all measures). The odds of provider sitting increased 30% when a seat was placed in the room (odds ratio [OR] = 1.3, 95% confidence interval [CI]: 1.1-1.5). No change in provider sitting was observed in the control ED (OR = 1.0, 95% CI: 0.8-1.2). CONCLUSIONS: Placing a seat in a patient's room nudges providers to sit during an ED encounter. Education alone did not influence provider behavior. Sitting down resulted in significantly higher patient satisfaction scores during an ED visit.

Alterations in Mitochondrial Function in Blood Cells Obtained From Patients With Sepsis Presenting to an Emergency Department.

OBJECTIVE: Mitochondrial dysfunction has been implicated as a key cellular event leading to organ dysfunction in sepsis. Our objective is to measure changes in mitochondrial bioenergetics in subjects with early presentation of sepsis to provide insight into the incompletely understood pathophysiology of the dysregulated host response in sepsis. DESIGN: Prospective observational study. SETTING: Single site tertiary academic emergency department. SUBJECTS: We enrolled a total of 48 subjects in the study, 10 with sepsis or septic shock, 10 with infection without sepsis, 14 older and 14 younger healthy controls. INTERVENTIONS: Peripheral blood mononuclear cells were measured with high-resolution respirometry (OROBOROS O2K). MEASUREMENTS AND MAIN RESULTS: The median age in patients with sepsis, infection only, older control and younger controls were 63, 34, 61, and 29 years old, respectively. In the Sepsis group, the median 1st 24-h SOFA score was 8, and the initial median lactate was 4.2 mmol/dL, compared with 1.1 in the Infection Group. The 30-day mortality of the sepsis/septic shock group was 50%, with a median length of stay of 7-days. The Sepsis Group had significantly lower routine and Max respiration when compared with the other groups as well as uncoupled Complex I respiration. There was also a significant decrease in ATP-linked respiration along with the Spare Reserve Capacity in the Sepsis Group when compared with the other group. There were no age-related differences in respiration between the Older and Younger control group. CONCLUSIONS: Bedside measurement of mitochondrial respiration can be minimally invasive and performed in a timely manner. Mitochondrial dysfunction, detected by decreased oxygen consumption utilized for energy production and depleted cellular bioenergetics reserve.

Exploring opportunities to prevent cirrhosis admissions in the emergency department: A multicenter multidisciplinary survey.

Patients with cirrhosis have high admission and readmission rates, and it is estimated that a quarter are potentially preventable. Little data are available regarding nonmedical factors impacting triage decisions in this patient population. This study sought to explore such factors as well as to determine provider perspectives on low-acuity clinical presentations to the emergency department, including ascites and hepatic encephalopathy. A survey was distributed in four liver transplant centers to both emergency medicine and hepatology providers, who included attending physicians, house staff, and advanced practitioners; 196 surveys were returned (estimated response rate 50.6%). Emergency medicine providers identified several influential nonmedical factors impacting inpatient triage decisions, including input from a hepatologist (77.7%), inadequate patient access to outpatient specialty care (68.6%), and patient need for diagnostic testing for a procedure (65.6%). When given patient-based scenarios of low-acuity cases, such as ascites requiring paracentesis, only 7.0% believed patients should be hospitalized while 48.9% said these patients would be hospitalized at their institution (P < 0.0001). For mild hepatic encephalopathy, the comparable numbers were 19.5% and 55.2%, respectively (P < 0.001). Several perceived barriers were cited for this discrepancy, including limited resources both in the outpatient setting and emergency department. Most providers believed that an emergency department observation unit protocol would influence triage toward an emergency department observation unit visit instead of inpatient admission for both ascites requiring large volume paracentesis (83.2%) and mild hepatic encephalopathy (79.4%). Conclusion: Many nonmedical factors that influence inpatient triage for patients with cirrhosis could be targeted for quality improvement initiatives. In some scenarios, providers are limited by resource availability, which results in triage to an inpatient admission even when they believe this is not the most appropriate disposition. (Hepatology Communications 2018;2:237-244).

End Points of Sepsis Resuscitation.

Resuscitation goals for the patient with sepsis and septic shock are to return the patient to a physiologic state that promotes adequate end-organ perfusion along with matching metabolic supply and demand. Ideal resuscitation end points should assess the adequacy of tissue oxygen delivery and oxygen consumption, and be quantifiable and reproducible. Despite years of research, a single resuscitation end point to assess adequacy of resuscitation has yet to be found. Thus, the clinician must rely on multiple end points to assess the patient's overall response to therapy. This review will discuss the role and limitations of central venous pressure (CVP), mean arterial pressure (MAP), and cardiac output/index as macrocirculatory resuscitation targets along with lactate, central venous oxygen saturation (ScvO2), central venous-arterial CO2 gradient, urine output, and capillary refill time as microcirculatory resuscitation endpoints in patients with sepsis.