Reverse triage in COVID surge planning: a case study of an allied health supported clinical care pathway in an acute hospital setting.

Objective This case study describes the development and outcomes of a new integrated and multidisciplinary care pathway. Spearheaded by allied health, the 'COVID community navigator team', applied established principles of reverse triage to create additional surge capacity. Methods A retrospective cohort study examined workflow patterns using electronic medical records of patients who received navigator input at the Royal Melbourne Hospital between 20 September 2021 and 20 December 2021. Results There were 437 eligible patient encounters identified. On average patients stayed 4.15 h in the emergency departments (ED) (s.d. = 4.31) and 9.5 h (s.d. = 10.9) in the short stay unit. Most patients were discharged into a 'low risk pathway' with community general practitioner follow up. Of discharged patients, only 38 re-presented to the ED with symptoms related to their initial COVID-19 diagnosis (34.9% of total re-admissions). Of these re-admissions, more than half did not require admission to a ward. Conclusion The findings presented here provide support for the clinical utility of a multidisciplinary reverse triage approach in surge planning for anticipated presentation peaks.

Utility of SARS-CoV-2 rapid antigen testing for patient triage in the emergency department: A clinical implementation study in Melbourne, Australia.

Background: Early, rapid detection of SARS-CoV-2 is essential in healthcare settings in order to implement appropriate infection control precautions and rapidly assign patients to care pathways. Rapid testing methods, such as SARS-CoV-2 rapid antigen testing (RAT) may improve patient care, despite a lower sensitivity than real-time PCR (RT-PCR) testing. Methods: Patients presenting to an Emergency Department (ED) in Melbourne, Australia, were risk-stratified for their likelihood of active COVID-19 infection, and a non-randomised cohort of patients were tested by both Abbott Panbio™ COVID-19 Ag test (RAT) and SARS-CoV-2 RT-PCR. Patients with a positive RAT in the 'At or High Risk' COVID-19 group were moved immediately to a COVID-19 ward rather than waiting for a RT-PCR result. Clinical and laboratory data were assessed to determine test performance characteristics; and length of stay in the ED was compared for the different patient cohorts. Findings: Analysis of 1762 paired RAT/RT-PCR samples demonstrated an overall sensitivity of 75.5% (206/273; 95% CI: 69·9-80·4) for the Abbott Panbio™ COVID-12 Ag test, with specificity of 100% (1489/1489; 95% CI: 99·8-100). Sensitivity improved with increasing risk for COVID-19 infection, from 72·4% (95% CI: 52·8-87·3) in the 'No Risk' cohort to 100% (95% CI: 29·2-100) in the 'High Risk' group. Time in the ED for the 'At/High Risk' group decreased from 421 minutes (IQR: 281, 525) for those with a positive RAT result to 274 minutes (IQR:140, 425) for those with a negative RAT result, p = 0.02. Interpretation: The positive predictive value of a positive RAT in this setting was high, allowing more rapid instigation of COVID-19 care pathways and an improvement in patient flow within the ED. Funding: Royal Melbourne Hospital, Melbourne, Australia.

Emergency physicians' experience of stress during resuscitation and strategies for mitigating the effects of stress on performance.

OBJECTIVE: This study explored the perspectives and behaviours of emergency physicians (EPs), regularly involved in resuscitation, to identify the sources and effects of any stress experienced during a resuscitation as well as the strategies employed to deal with these stressors. METHODS: This was a two-centre sequential exploratory mixed-methods study of EPs consisting of a focus group, exploring the human factors related to resuscitation, and an anonymous survey. Between April and June 2020, the online survey was distributed to all EPs working at Australia's largest two major trauma centres, both in Melbourne, and investigated sources of stress during resuscitation, impact of stress on performance, mitigation strategies used, impact of the COVID-19 pandemic on stress and stress management training received. Associations with gender and years of clinical practice were also examined. RESULTS: 7 EPs took part in the focus group and 82 responses to the online survey were received (81% response rate). The most common sources of stress reported were resuscitation of an 'unwell young paediatric patient' (81%, 95% CI 70.6 to 87.6) or 'unwell pregnant patient' (71%, 95% CI 60.1 to 79.5) and 'conflict with a team member' (71%, 95% CI 60.1 to 79.5). The most frequently reported strategies to mitigate stress were 'verbalising a plan to the team' (84%, 95% CI 74.7 to 90.5), 'implementing a standardised/structured approach' (73%, 95% CI 62.7 to 81.6) and 'asking for help' (57%, 95% CI 46.5 to 67.5). 79% (95% CI 69.3 to 86.6) of EPs reported that they would like additional training on stress management. Junior EPs more frequently reported the use of 'mental rehearsal' to mitigate stress during a resuscitation (62% vs 22%; p<0.01) while female EPs reported 'asking for help' as a mitigator of stress more frequently than male EPs (79% vs 47%; p=0.01). CONCLUSIONS: Stress is commonly experienced by EPs during resuscitation and can impact decision-making and procedural performance. This study identifies the most common sources of stress during a resuscitation as well as the strategies that EPs use to mitigate the effects of stress on their performance. These findings may contribute to the development of tailored stress management training for critical care clinicians.

Knowledge, attitudes and practices of healthcare workers within an Australian tertiary hospital to managing high-consequence infectious diseases.

BACKGROUND: Adequate preparation and support for healthcare workers (HCWs) managing high-consequence infectious diseases (HCIDs) is critical to the overall clinical management of HCIDs. Qualitative studies examining how well prepared and supported HCWs feel are lacking despite their key role. This study investigated how prepared and supported front-line HCWs at an Australian tertiary hospital felt about managing HCIDs such as viral haemorrhagic fever (VHF). METHODS: A qualitative research approach was used to undertake interviews with 45 Royal Melbourne Hospital medical and nursing staff from emergency, intensive care and infectious diseases. Interview questions captured data on HCWs' role, familiarity with using protocols, psychological attributes and training for scenarios related to VHF patient management. Interviews were recorded and transcribed. Categorical responses were analysed quantitatively and open-ended responses were analysed thematically. RESULTS: Ninety-eight percent of participants indicated feeling capable of undertaking their role in managing VHF patients; 77% felt supported through personnel/resources. However, 69% indicated barriers to managing these patients effectively; and 68% felt anxious at the prospect of managing VHF patients. Themes emerging from participants' observations included concerns about training frequency, miscommunication, difficulty with uncertainty, feeling underprepared, and fear of transmitting infection to others. CONCLUSION: Although the majority of HCWs feel confident about their ability to care for VHF patients, they also have a moderately-high degree of anxiety. Perceptions of interviewed staff have fed into recommendations to increase HCW preparedness and reduce anxiety, which include investigating support services, and exploring training options that create multi-departmental groups of highly specialised medical officers and nurses.

Managing healthcare worker well-being in an Australian emergency department during the COVID-19 pandemic.

Emergency Medicine staff in Australia and New Zealand are at the forefront of the healthcare response to COVID-19. This article describes a well-being plan for ED staff that has been devised to mitigate against the negative psychological impact of the COVID-19 pandemic.

Potential interactions between prescription drugs and complementary and alternative medicines among patients in the emergency department.

STUDY OBJECTIVE: To determine the nature and prevalence of potential interactions between prescription drugs and complementary and alternative medicines (CAMs) and the reasons some patients do not advise their physicians of CAM use. DESIGN: Cross-sectional survey. SETTING: The emergency department of the Royal Melbourne Hospital, a tertiary referral center. PATIENTS: Four hundred four adult patients (>or= 18 yrs) who visited the emergency department between February 1, 2002, and March 31, 2003. Intervention. A specifically designed, self-administered questionnaire, available in seven languages. MEASUREMENTS AND MAIN RESULTS: Main outcome measures were the prevalence of potential prescription drug-CAM interactions and the reasons some patients do not advise their physicians of CAM use. Mean +/- SD patient age was 50.6 +/- 20.0 years; 220 patients were men (54.5%, 95% confidence interval [CI] 49.5-59.4%). When asked about use during the previous year, 275 patients (68.1%, 95% CI 63.2-72.5%) reported having taken a CAM; of these, 138 were also taking a prescription drug. We identified 15 documented potential drug-CAM interactions in nine patients (3.3% of CAM users, 95% CI 1.6-6.3%) and 97 theoretical potential drug-CAM interactions in 51 patients (18.6% of CAM users, 95% CI 14.2-23.8%). Aspirin and warfarin were the most commonly involved drugs. Of CAM users, 197 (71.6%, 95% CI 65.9-76.8%) never informed their physician about CAM use, most frequently because they were not asked. CONCLUSION: The prevalence of potential drug-CAM interactions among patients in the emergency department is considerable, and some of these interactions could be clinically significant. Practitioners should increase their awareness of potential drug-CAM interactions, and education initiatives aimed at encouraging patient-physician discussion of CAM use are recommended, such as a CAM history in their patient evaluation. Further research is required to better determine the clinical significance of drug-CAM interactions.

Use and toxicity of complementary and alternative medicines among emergency department patients.

OBJECTIVE: To determine the prevalence and type of complementary and alternative medicines (CAM) used by ED patients, to identify patient subgroups more likely to use CAM, the conditions for which they were taken, and the prevalence of side-effects and toxicity associated with CAM use. METHODS: This was an analytical cross-sectional survey of patients at a large tertiary referral ED. Consenting patients completed a specifically designed study questionnaire, in their preferred language if required. Information was collected on CAM use on the day of presentation and within the previous week and previous year. RESULTS: Four hundred and four patients were enrolled (participation rate 97.1%). Fifty (12.4%, 95% CI 9.4, 16.1) patients had taken a CAM on the day of presentation, 203 (50.2%, 95% CI 45.3, 55.2) within the previous week and 275 (68.1%, 95% CI 63.2, 72.5) within the previous year. CAM users were significantly younger, better educated and more likely to be female than non-CAM users (P < 0.01). 103 different CAM had been taken for a wide variety of reasons. Side-effects were experienced in 53 of the 1182 CAM courses taken (side-effect rate of 4.5%). One patient presented suffering specifically from CAM toxicity. CONCLUSION: Complementary and alternative medicines are used by a considerable proportion of ED patients. The potential for side-effects, toxicity and interaction with traditional medication indicates the need for consideration of CAM use in patient assessment.