The CLOQS trial protocol: a cluster-randomized trial evaluating a simple, low-cost intervention to reduce treatment times in acute stroke.

RATIONALE: In acute stroke, time is brain: faster tissue plasminogen activator treatment improves patient outcomes. Published guidelines for door-to-scanner time are <25 minutes, and for door-to-needle time <60 minutes. These benchmarks are rarely met. Paradoxically, the earlier a stroke patient arrives to hospital, the longer treatment takes. There is an urgent need to shift focus away from the 4.5 hour time window, towards treatment times <60 minutes. AIMS: The objective of the Countdown Lights to Optimize Quality in acute Stroke (CLOQS) trial is to determine whether a simple, low-cost organizational behavior intervention, a large, red stopwatch timer attached to the stretcher upon arrival, will decrease door-to-scanner and door-to-needle treatment times for tissue plasminogen activator-treated patients. DESIGN: A multicenter, time-clustered randomized control trial. The stopwatch timers will be used in Emergency Departments for all acute stroke patients across the University of Toronto Stroke Program. The order of intervention (ON) and control (OFF) blocks will be randomly assigned in a 1:1 ratio over an 18 month period. Blocks will be weighted in a 2:1 ratio of ON/OFF using a permuted block design (ON blocks last two weeks; OFF blocks last one week). STUDY OUTCOMES: The primary end-point is percentage of patients achieving best-practice guidelines (door-to-needle treatment time <60 minutes). Secondary end-points are median time intervals for 1) door-to-scanner and 2) door-to-needle times during ON versus OFF blocks. Tertiary end-points are in-hospital mortality and time series analysis to determine change in treatment times from prior to study onset through study completion.

Implementing wait-time reductions under Ontario government benchmarks (Pay-for-Results): a Cluster Randomized Trial of the Effect of a Physician-Nurse Supplementary Triage Assistance team (MDRNSTAT) on emergency department patient wait times.

BACKGROUND: Internationally, emergency departments are struggling with crowding and its associated morbidity, mortality, and decreased patient and health-care worker satisfaction. The objective was to evaluate the addition of a MDRNSTAT (Physician (MD)-Nurse (RN) Supplementary Team At Triage) on emergency department patient flow and quality of care. METHODS: Pragmatic cluster randomized trial. From 131 weekday shifts (8:00-14:30) during a 26-week period, we randomized 65 days (3173 visits) to the intervention cluster with a MDRNSTAT presence, and 66 days (3163 visits) to the nurse-only triage control cluster. The primary outcome was emergency department length-of-stay (EDLOS) for patients managed and discharged only by the emergency department. Secondary outcomes included EDLOS for patients initially seen by the emergency department, and subsequently consulted and admitted, patients reaching government-mandated thresholds, time to initial physician assessment, left-without being seen rate, time to investigation, and measurement of harm. RESULTS: The intervention's median EDLOS for discharged, non-consulted, high acuity patients was 4:05 [95th% CI: 3:58 to 4:15] versus 4:29 [95th% CI: 4:19-4:38] during comparator shifts. The intervention's median EDLOS for discharged, non-consulted, low acuity patients was 1:55 [95th% CI: 1:48 to 2:05] versus 2:08 [95th% CI: 2:02-2:14]. The intervention's median physician initial assessment time was 0:55 [95th% CI: 0:53 to 0:58] versus 1:21 [95th% CI: 1:18 to 1:25]. The intervention's left-without-being-seen rate was 1.5% versus 2.2% for the control (p = 0.06). The MDRNSTAT subgroup analysis resulted in significant decreases in median EDLOS for discharged, non-consulted high (4:01 [95th% CI: 3:43-4:16]) and low acuity patients (1:10 95th% CI: 0:58-1:19]), as well as physician initial assessment time (0:25 [95th% CI: 0:23-0:26]). No patients returned to the emergency department after being discharged by the MDRNSTAT at triage. CONCLUSIONS: The intervention reduced delays and left-without-being-seen rate without increased return visits or jeopardizing urgent care of severely ill patients. TRIAL REGISTRATION NUMBER: NCT00991471 ClinicalTrials.gov.

Emergency nurse responsibilities for mechanical ventilation: a national survey.

INTRODUCTION: Few data describe the role of registered nurses working in emergency departments in caring for ventilated patients, yet these patients may remain in the emergency department for prolonged durations because of the unavailability of intensive care unit beds. Our objective was to examine the exposure of emergency nurses to patients requiring mechanical ventilation, as well as their responsibilities and education on ventilation received. METHODS: A cross-sectional mailed survey was sent to members of the National Emergency Nursing Association in Canada. Domains and items were refined from a survey of ventilation roles and responsibilities in intensive care. RESULTS: The response rate was 247 of 526 (47%); 39% of respondents provided care to 10 ventilated patients or fewer over a period of 2 weeks, 32% up to 5 patients or fewer monthly, and 27% to 5 patients or fewer over a period of 6 months. A 1:1 nurse-patient ratio for ventilated patients was reported by 38% of respondents, whereas 45% managed 1 or 2 additional patients and 15% managed 3 or more additional patients. Most respondents (54%) reported that respiratory therapists (RTs) remained in the emergency department until patients' condition stabilized, 28% reported that an RT was on call, 11% reported that an RT remained until patient transfer, and 7% reported that no RT was available. Few nurses reported primary responsibility for initial ventilator setting selection (7%) or titration of ventilation (6%); nurse responsibility was influenced by RT availability (P < .001). Primary responsibility for monitoring patient response to ventilation, alarm troubleshooting, and oxygenation management was reported by 44%, 36%, and 30% of respondents, respectively. Education was received by 51% of respondents before exposure to ventilated patients; most (57%) indicated that competency was never assessed. DISCUSSION: Emergency nurses had variable exposure to ventilated patients. Responsibility for ventilator management was influenced by RT availability. Low nurse-patient ratios; inconsistent availability of education; lack of competency assessment; and infrequent use of guidelines, protocols, or pre-printed order sets pose potential concerns for patient safety while ventilated in the emergency department.