Barriers to CPR initiation and continuation during the emergency call relating to out-of-hospital cardiac arrest: A descriptive cohort study.

AIM: To describe the barriers to cardiopulmonary resuscitation (CPR) initiation and continuation in emergency calls for out-of-hospital cardiac arrest (OHCA). METHODS: We analysed 295 consecutive emergency calls relating to OHCA over a four-month period (1 January - 30 April 2021). Calls included were paramedic-confirmed, non-traumatic, non-EMS-witnessed OHCA, where the caller was with the patient. Calls were listened to in full and coded in terms of barriers to CPR initiation and continuation, and patient and caller characteristics. RESULTS: Overall, CPR was performed in 69% of calls and, in 85% of these, callers continued performing CPR until EMS arrival. Nearly all callers (99%) experienced barriers to CPR initiation and/or continuation during the call. The barriers identified were classified into eight categories: reluctance, appropriateness, emotion, bystander physical ability, patient access, leaving the scene, communication failure, caller actions and call-taker instructions. Of these, bystander physical ability was the most prevalent barrier to both CPR initiation and continuation, occurring in 191 (65%) calls, followed by communication failure which occurred in 160 (54%) calls. Callers stopping or interrupting CPR performance due to being fatigued was lower than expected (n = 54, 26% of callers who performed CPR). Barriers to CPR initiation that related to bystander physical ability, caller actions, communication failure, emotion, leaving the scene, patient access, procedural barriers, and reluctance were mostly overcome by the caller (i.e., CPR was performed). CONCLUSION: Barriers to CPR initiation and continuation were commonly experienced by callers, however they were frequently overcome. Future research should investigate the strategies that were successful.

A scoping review to determine the barriers and facilitators to initiation and performance of bystander cardiopulmonary resuscitation during emergency calls.

Background: To maximise out-of-hospital cardiac arrest (OHCA) patients' survival, bystanders should perform continuous, good quality cardiopulmonary resuscitation (CPR) until ambulance arrival. Objectives: To identify published literature describing barriers and facilitators between callers and call-takers, which affect initiation and performance (continuation and quality) of bystander CPR (B-CPR) throughout the OHCA emergency call. Eligibility criteria: Studies were included if they reported on the population (emergency callers and call-takers), concept (psychological, physical and communication barriers and facilitators impacting the initiation and performance of B-CPR) and context (studies that analysed OHCA emergency calls). Sources of evidence: Medline, CINAHL, Cochrane CENTRAL, Embase, Scopus and ProQuest were searched from inception to 9 March 2022. Charting methods: Study characteristics were extracted and presented in a narrative format accompanied by summary tables. Results: Thirty studies identified factors that impacted B-CPR initiation or performance during the emergency call. Twenty-eight studies described barriers to the provision of CPR instructions and CPR initiation, with prominent themes being caller reluctance (psychological), physical ability (physical), and callers hanging up the phone prior to CPR instructions (communication). There was little evidence examining barriers and facilitators to ongoing CPR performance (2 studies) or CPR quality (2 studies). Conclusions: This scoping review using emergency calls as the source, described barriers to the provision of B-CPR instructions and B-CPR initiation. Further research is needed to explore facilitators and barriers to B-CPR continuation and quality throughout the emergency call, and to examine the effectiveness of call-taker strategies to motivate callers to perform B-CPR.

Behavioural drivers influencing emergency department attendance in Victoria during the 2020 COVID-19 pandemic: A mixed methods investigation.

OBJECTIVE: To identify behavioural drivers and barriers that may have contributed to changes in ED attendance during the first 10 months of the coronavirus disease 2019 (COVID-19) pandemic in Victoria. METHODS: We conducted a mixed methods analysis of patients who attended one of eight participating EDs between 1 November 2019 and 31 December 2020. A random sample of patients were chosen after their visit and invited to participate in an online survey assessing behavioural drivers and barriers to attendance. The study timespan was divided into four periods based on local and world events to assess changes in attitudes and behaviours over this period. RESULTS: A total of 5600 patients were invited to complete the survey and 606 (11%) submitted sufficient information for analysis. There were significant differences in participants' attitudes towards healthcare and EDs, levels of concern about contracting and spreading COVID-19 and the influence of mask wearing. Patients expressed more concern about the safety of an ED during the largest outbreak of COVID-19 infections than they did pre-COVID, but this difference was not sustained once community infection numbers dropped. General concerns about hospital attendance were higher after COVID than they were pre-COVID. A total of 27% of patients specifically stated that they had delayed their ED attendance. CONCLUSION: Patients expressed increased concerns around attending ED during the first 10 months of the 2020 COVID-19 pandemic and frequently cited COVID-19 as a reason for delaying their presentation. These factors would be amenable to mitigation via focussed public health messaging.

Length of stay outcomes in patients receiving ketamine sedation versus Bier's block anaesthesia for procedural closed fracture reduction: A retrospective audit of paediatric emergency department patients.

OBJECTIVE: To compare length of stay (LOS) for paediatric patients receiving ketamine sedation or Bier's block anaesthesia for procedural closed fracture reduction. METHODS: We conducted a retrospective audit of paediatric ED patients aged 3-18 years presenting at one of three metropolitan hospitals in Victoria, Australia (2012-2017). Outcomes were post-procedural LOS (PPLOS), total LOS, incidence of ketamine and Bier's block procedures, and recorded adverse effects. Groups were compared using t-tests. Association between treatment group and admission to a short stay unit (SSU) was assessed using univariate logistic regression. RESULTS: Across all three sites, 449 patients were included, 379 of whom received ketamine sedation and 73 of whom underwent Bier's block anaesthesia. Mean age was 9.1 years (ketamine group: 8.3 years; Bier's block group: 13.1 years). Median PPLOS was 75 min shorter for patients who received a Bier's block than for those sedated with ketamine (P < 0.001). Patients sedated with ketamine were also 9.01 times more likely to be admitted to an SSU than those who received Bier's block anaesthesia (95% confidence interval 3.82-21.31, P < 0.001). Ketamine sedation was more common than Bier's block across the three sites. No major adverse events occurred in either group. CONCLUSION: Bier's block anaesthesia is a safe alternative to ketamine sedation for paediatric patients presenting to the ED with closed fractures. It is associated with reduced LOS and need for post-procedural observation. However, ketamine may remain preferable for younger paediatric patients, on whom it places fewer demands for cooperation.

Battlefield acupuncture added no benefit as an adjunct analgesic in emergency department for abdominal, low back or limb trauma pain.

OBJECTIVES: To ascertain whether ear acupuncture (modified Battlefield technique) as an adjunct (Adj-BFA) to standard analgesia care (SAC) significantly reduces pain scores compared with sham acupuncture (Adj-Sham) or SAC alone, when delivered by medical and nursing practitioners in an ED. METHODS: A randomised controlled trial using a convenience sample of 90 patients attending an ED with acute abdominal, limb trauma or low back pain were allocated to three treatment arms: Adj-BFA, Adj-Sham and SAC. The primary outcome of change in pain scores out-of-10 (NPRS-10) from triage were assessed immediately after intervention and at 1 and 2 h post-intervention. Secondary outcomes were the percentage of patients reporting 'adequate analgesia' or ≥30% reduction in pain score, analgesic medication use (in morphine equivalent dose [milligrammes]), analgesics and needle costs (Australian dollars), adverse effects and patient satisfaction (Likert scale). RESULTS: There was no significant difference in pain scores (P = 0.582) or secondary outcomes measures between Adj-BFA, Adj-Sham and SAC. CONCLUSION: The present study on 90 patients did not show a significant difference in analgesia outcomes in the first 2 h using Adj-BFA for acute pain in the ED, and there were no significant differences for secondary outcomes between treatment arms. Given the mixed results of recent BFA trials, further research using the original BFA technique on different painful conditions, as either stand-alone or as-adjunct to non-opioid analgesia are needed before BFA can be recommended as a technique for acute pain management in the ED.

High-sensitivity troponin T use in non-chest pain presentations in the emergency department.

OBJECTIVE: To explore troponin testing yield in patients who present to the ED without chest pain. METHODS: A retrospective medical record audit of all patients who presented to ED in November 2018 and had troponin measured. RESULTS: A total of 1124 troponin assays were performed in 763 patients, 48.7% had no documented chest pain; 8.8% of these met high-risk criteria and 1.1% were diagnosed with acute coronary syndrome. CONCLUSIONS: Despite ED troponin testing in the absence of chest pain being common practice, it rarely assisted in a meaningful diagnosis. Consequences of testing may include delays to patient discharge and additional downstream testing.

Improving the patient experience in the Emergency Department Short Stay Unit.

BACKGROUND: To explore whether giving patients admitted to the Short Stay Unit (SSU) in the Emergency Department (ED) their medical notes improved patient understanding of key information. METHODS: A two armed non-blinded randomised controlled trial was performed, with patients enrolled on admission to the SSU from the ED. The intervention was provision of a copy of the patient's medical notes both on admission to SSU and on discharge, together with a plain English statement about their medical condition and a detailed care plan. Control patients were provided with standard care (verbal information). Patients were surveyed in SSU and followed up two weeks post discharge via telephone interview. Treating clinicians, in both the ED and SSU, were surveyed to establish acceptability of the intervention. RESULTS: Two hundred patients were enrolled, with 176 completing the study. The intervention group found the information provided more helpful (p=0.048) and understood their condition and treatment plan better than the control group (p=0.034). All other data points, despite a positive trend towards the intervention, were statistically insignificant. CONCLUSIONS: This study suggests that this simple intervention may positively contribute to the patient experience, with no discernible negative effect on the overall delivery of safe and efficient healthcare.

Predictive values of haematuria and hydronephrosis in suspected renal colic: An emergency department retrospective audit.

OBJECTIVE: To determine the predictive values of haematuria and hydronephrosis in suspected renal colic. METHODS: We undertook a retrospective audit of adult patients who received a computed tomography (CT) of the kidneys, ureter and bladder (CTKUB) for suspected renal colic, presenting to Eastern Health Emergency Departments in Melbourne, Australia, between 1 January 2016 and 30 June 2016. CT hydronephrosis was used as a substitute for ultrasound hydronephrosis. We looked at the association of haematuria and CT proven hydronephrosis with CT proven ureteric and obstructing pelvic calculi. RESULTS: Of 769 adult cases who received a CTKUB for suspected renal colic, 384 were positive (49.9%) and 385 were negative (50.1%). For haematuria and renal colic, sensitivity was 87.3% (83.3-90.7), specificity 33.8% (28.9-39.0), positive predictive value (PPV) 55.7% (53.7-57.8), negative predictive value (NPV) 73.6% (67.1-79.3). For CT hydronephrosis and renal colic, sensitivity was 88.0% (84.2-91.1), specificity 85.0% (80.9-88.5), PPV 85.7% (82.4-88.5), NPV 87.4% (84.0-90.2). Of 110 cases with both negative CT hydronephrosis and negative haematuria, four had ureteric calculi, NPV 96.4% (90.8-98.6). CONCLUSION: This audit suggests that a diagnostic strategy relying on the absence of haematuria or hydronephrosis, or both, to rule out ureteric calculi may result in a small number of stones being missed.

Why do paramedics choose to bring patients to a private emergency department?

OBJECTIVE: While prior experience, favourable location and anticipation of high quality care are known to influence patient choice to attend a private ED, it is likely that decision-making is also influenced by other persons. In particular, patients arriving by ambulance are under the care of paramedics, whose values towards healthcare and rationale for choosing one ED over another have not been studied. This study aimed to describe reasons why paramedics choose to bring patients to a private ED. METHODS: Exploratory, qualitative study using semi-structured, face-to-face interviews with paramedics bringing patients to a private ED from the community. Two primary questions reinforced by structured prompts were asked: 'Why did you choose to come to this emergency department?' and 'What are your general expectations of this emergency department visit?' Interviews were audio recorded, transcribed verbatim and analysed thematically. RESULTS: Fifty paramedics were interviewed with 48 interviews able to be transcribed and used in analysis. Four factors were identified to increase the likelihood of a private ED destination: specific direction, institutional allegiance, hospital logistics and systems and receiving hospital service ethos. CONCLUSIONS: Paramedics take into consideration when possible patient's wishes and are more likely to bring a patient to a private ED if they have specific direction from the patient or the patient's family or GP. The likelihood of presenting to a private ED is increased if the patient has an allegiance with the facility and the paramedics perceive favourably the hospital logistics and systems as well as service ethos.

Patient attitudes towards analgesia and their openness to non-pharmacological methods such as acupuncture in the emergency department.

OBJECTIVE: To investigate patient attitudes to analgesia, opioids and non-pharmacological analgesia, including acupuncture, in the ED. METHODS: ED patients with pain were surveyed regarding: pain scores, satisfaction, addiction concern, non-pharmacological methods of pain relief and acupuncture. Data were analysed using logistic regression. RESULTS: Of 196 adult patients, 52.8% were 'very satisfied' with analgesia. Most patients (84.7%) would accept non-pharmacological methods including acupuncture (68.9%) and 78.6% were not concerned about addiction. Satisfaction was associated with male gender, and 'adequate analgesia' but not with opioids. CONCLUSION: Most patients were generally satisfied with ED analgesia and were open to non-pharmacologic analgesia including acupuncture.

Does Ear Acupuncture Have a Role for Pain Relief in the Emergency Setting? A Systematic Review and Meta-Analysis.

Objective: Ear acupuncture might be the form of acupuncture best suited to improving acute pain management in the emergency department (ED). The primary aim of this review was to assess the analgesic efficacy of ear acupuncture in the ED. Secondary outcomes included measures of patient satisfaction, adverse effects, cost, administration techniques, and reduction of medication usage. Methods: Seven databases and Google Scholar were searched up to April 27, 2017, using MeSH descriptors for three overarching themes (ear acupuncture, pain management, and emergency medicine). Meta-analyses were performed in 3 comparator groups: (1) ear acupuncture versus sham; (2) ear acupuncture-as-adjunct to standard care; and (3) ear acupuncture (both as sole therapy and adjuvant) versus control to calculate the standardized mean difference (SMD) and weighted mean difference (WMD) for pain scores out of 10. Results: Six randomized controlled trials and 2 observational studies, totaling 458 patients, were retrieved after exclusions. The meta-analysis used data from 4 randomized studies representing 286 patients. The above 3 comparator groups resulted in SMDs of 1.69, 1.68, and 1.66, and WMDs of 2.47, 2.84, and 2.61 respectively, all favoring acupuncture. Battlefield (ear) acupuncture was the most commonly used technique. There were no significant adverse effects and patient satisfaction improved. Results regarding if acupuncture reduced medication use were equivocal. Significant study bias and heterogeneity were found. Conclusions: While study numbers are limited, ear acupuncture, either as stand-alone or as-an-adjunct technique, significantly reduced pain scores and has potential benefits for use in the ED. Further studies will define acupuncture's role and if it reduces use of analgesic medications.

Review article: Does acupuncture have a role in providing analgesia in the emergency setting? A systematic review and meta-analysis.

Acupuncture might offer a novel approach to improve ED pain management. Our primary aim was to assess the efficacy of acupuncture in the emergency setting while secondary objectives were to explore its suitability through its side-effect profile, patient satisfaction, cost, administration time and points used. Seven databases and Google Scholar were searched up to 31 July 2016 using MeSH descriptors for three overarching themes concerning acupuncture, pain management and emergency medicine. Meta-analysis was performed on randomised trials for three comparator groups: acupuncture versus sham, acupuncture versus standard analgesia care and acupuncture-as-an-adjunct to standard care, to calculate the standardised mean difference and weighted mean difference for pain scores out of 10. Data for secondary outcomes was extracted from both randomised and observational studies. Nineteen randomised controlled trials and 11 uncontrolled observational studies totaling 3169 patients were retrieved after exclusions. Meta-analyses were performed on data from 14 randomised controlled trials representing 1210 patients. The three resulting comparator groups (as above) resulted in standardised mean differences of 1.08, 0.02 and 1.68, and weighted mean differences of 1.60, -0.04 and 2.84, respectively (all positive figures favour acupuncture). Where measured, acupuncture appears to be associated with improved patient satisfaction, lower cost and a low adverse effects profile. The data available were inadequate to ascertain the effect of acupuncture on analgesia use. Significant study bias was found, especially with respect to practitioner and patient blinding. We conclude that for some acute pain conditions in the ED, acupuncture was clinically effective compared to sham and non-inferior to conventional therapy. As an adjunct, limited data was found indicating superiority to standard analgesia care. Further studies will elucidate the most appropriate acupuncture training and techniques, use as an adjunct and the clinical situations in which they can be best applied.

Emergency department 'undercrowding' is associated with decreased waiting times.

OBJECTIVE: To evaluate the effect of a sudden and sustained decrease in patient presentations on waiting times and other measures of workload and flow following the opening of a large, greenfields ED adjacent to our own. METHOD: A descriptive study involving all patients presenting to a private urban district hospital ED for two 60 day periods, immediately before and after the opening of the tertiary hospital ED. Changes in median waiting time, case-mix distribution, method of arrival, total admissions and total waiting time were compared pre-opening and post-opening. Non-normally distributed variables were analysed using Mann-Whitney U-tests. Categorical variables were compared using χ(2) analyses. RESULTS: Patient presentations decreased by 28% with a parallel decline in median waiting time of 15 min (from 26 to 11 min) (P < 0.001). Total waiting time was approximately 29 h less per day in the post-opening period. Patient urgency by triage category did not change significantly (P = 0.316), whereas the proportion of presentations by ambulance decreased 15.9% (P = 0.048) and admission rate increased from 29.1% to 32.6% (P = 0.002). CONCLUSIONS: Patient presentation numbers are strongly associated with and likely impact on median waiting time. Understanding that controlling demand can lead to significant benefits in patient processing, flow and overall patient perceived level of care and satisfaction is relevant to any discussion on ED overcrowding and the deleterious effects of access block.