Coping and Caregiving: Leveraging Environmental Design to Moderate Stress Among Healthcare Workers in the Emergency Department Setting.

BACKGROUND: Due to exposure to overwhelming work stressors, approximately half of emergency department (ED) physicians and nurses experience burnout, leading to lower productivity, lower quality of care, higher risk of medical errors, higher rates of absenteeism, and eventually turnover. Growing evidence suggests that the physical environment can be leveraged to support healthcare workers' well-being. OBJECTIVES: This study aimed to identify (1) self-care behaviors that healthcare workers engage in to help them cope with job-related stress, (2) where they engage in those behaviors, (3) attributes of the built environment that may support coping behaviors. METHODS: A mixed-methods study was conducted in three EDs, using online questionnaires (n = 85) and interviews (n = 20). RESULTS: Job-related stress was derived from interruptions, workload and inability to take breaks, insufficient workspace, lack of privacy, unpredictability of EDs, and security concerns. Talking with a colleague, getting something to eat or drink, listening to music, and taking a walk were considered destressing activities. The bathroom was considered a place for destressing by the majority of participants, followed by outside areas, physician-only areas, and care team stations. Supportive environmental features included sufficient workspace, maximized privacy, reduced noise and clutter, controlled temperature and lighting, spaces for decompressing, spaces for documentation, close-by breakrooms with enough eating space and massage chairs, chairs with back support, standing desks, food options, and convenient bathrooms. CONCLUSIONS: Design decisions play an important role in supporting stress reduction among healthcare workers. This study provides several strategies to achieve this aim.

Investigating the Impact of Healthcare Environmental Design on Staff Security: A Systematic Review.

OBJECTIVE: To systematically review the literature regarding the role of the physical environment in preventing or mitigating aggressive behavior toward healthcare professionals in acute care, outpatient, and psychiatric/behavioral health facilities. BACKGROUND: Globally, the incidence of violence against healthcare professionals is alarming. Poor environmental design has been identified as a risk factor of violence toward employees. The design of the physical setting in which healthcare is provided may moderate the incidence and severity of violence against healthcare workers. METHODS: We conducted electronic database searches of PubMed and CINAHL through November 2018. RESULT: Findings were organized according to four categories identified in the literature regarding crime prevention through environmental design (CPTED) including natural surveillance, access control, territoriality, and other CPTED elements. Fifteen studies (published between 1991 and 2017) met the inclusion criteria. Of the 15 studies, 4 incorporated environmental interventions. In the 11 remaining studies, physical environment attributes (i.e., layout, location, ambient conditions, equipment) were among the factors affecting violent incidents and staff security. Most study settings were hospital-based (11, with 10 of those specifically focused on emergency departments), followed by behavioral health facilities (4 studies). Design-focused recommendations, such as providing a second door in a triage room and a sub-waiting area inside the treatment zone, were summarized according to CPTED categories. CONCLUSION: This review suggests that the physical environment in healthcare facilities may affect the incidence of violence by patients or visitors against staff. Further research is needed to identify environmental design strategies that may protect the safety of healthcare professionals.

Data-Driven Design Strategies to Address Crowding and Boarding in an Emergency Department: A Discrete-Event Simulation Study.

OBJECTIVE: To address prolonged lengths of stay (LOS) in a Level 1 trauma center, we examined the impact of implementing two data-driven strategies with a focus on the physical environment. BACKGROUND: Crowding in emergency departments (EDs) is a widely reported problem leading to increased service times and patients leaving without being seen. METHODS: Using ED historical data and expert estimates, we created a discrete-event simulation model. We analyzed the likely impact of initiating care and boarding patients in the hallway (hallway care) instead of the exam rooms and adding a dedicated triage space for patients who arrive by emergency medical services (EMS triage) to decrease hallway congestion. The scenarios were compared in terms of LOS, time spent in exam rooms and hallway spaces, service time, blocked time, and utilization rate. RESULTS: The hallway care scenario resulted in significantly lower LOS and exam room time only for EMS patients but when implemented along with the EMS triage scenario, a significantly lower LOS and exam room time was observed for all patients (EMS and walk-in). The combination of two simulated scenarios resulted in significant improvements in other flow metrics as well. CONCLUSIONS: Our findings discourage boarding of admitted patients in ED exam rooms. If space limitations require that admitted patients be placed in ED hallways, designers and planners should consider enabling hallway spaces with features recommended in this article. Alternative locations for boarding should be prioritized in or out of the ED. Our findings also encourage establishing a triage area dedicated to EMS patients in the ED.

Design Strategies to Improve Emergency Departments' Performance During Mass Casualty Incidents: A Survey of Caregivers.

OBJECTIVES: To identify effective facility design strategies to improve the performance of healthcare providers and patient flow during mass casualty incidents (MCIs) in emergency departments. BACKGROUND: Emergency departments (EDs) are the first line of medical care in MCIs. While operational surge management plans are well described in literature, physical design strategies to improve performance and patient flow during disasters are discussed scarcely. METHOD: An online questionnaire was sent to EDs' caregivers nationwide asking them to rate the effectiveness of nine physical design strategies, discussed in the literature, to improve caregivers' performance and patient flow during MCIs. Assessed strategies were about providing expandable departments and care areas, alternate care facilities for the least sick to maximize care areas for critical patients, care areas from nonemergency units, increased number of decontamination units, dedicated isolation units, within-hospital and close emergency operation centers, and within-hospital media areas. RESULTS: All suggested strategies were rated as effective. The most effective and agreed-upon solution was identified as maximizing the care area for critical patients by establishing an alternate care facility with separate entrance and exit doors from the emergency department for the least critical patients. The least effective and agreed-upon strategy was identified as locating a media unit within the hospital outside of the ED. CONCLUSIONS: Caregivers who work in EDs consider design strategies to be effective in surge management during disasters. Designers can consider implementing identified strategies in designing new emergency departments or expansion and renovation projects.

An outbreak of acute delirium from exposure to the synthetic cannabinoid AB-CHMINACA.

BACKGROUND: Synthetic cannabinoid containing products are a public health threat as reflected by a number of outbreaks of serious adverse health effects over the past 4 years. The designer drug epidemic is characterized by the rapid turnover of synthetic cannabinoid compounds on the market which creates a challenge in identifying the particular etiology of an outbreak, confirming exposure in cases, and providing current information to law enforcement. RESULTS: Between 28 May 2014 and 8 June 2014, 35 patients were evaluated and treated at the University of Florida Health Medical Center in Gainesville following reported exposure to a synthetic cannabinoid containing product obtained from a common source. Patients demonstrated acute delirium (24) and seizures (14), and five required ventilator support and ICU-level care; none died. The presence of N-[(1S)-1-(aminocarbonyl)-2-methylpropyl]-1-(cyclohexylmethyl)-1H-indazole-3-carboxamide (AB-CHMINACA), or one of its predicted metabolites was confirmed in 15 of 21 cases. A rapid public health response and aggressive public messaging prevented further morbidity, identified the source, and led to law enforcement seizure of the implicated product. DISCUSSION: The significance of this outbreak lies as much in the rapid occurrence of unpredictable, life-threatening adverse health effects from a newly identified synthetic cannabinoid compound as it does in the multidisciplinary investigation and novel partnership between local public health, the laboratory, and the chemical industry, resulting in termination of the outbreak. CONCLUSION: A coordinated response and collaboration between law enforcement, the local public health, emergency medical services and Health Center staff, were all key interventions in preventing a more substantial public health outbreak resulting from use of a novel synthetic cannabinoid compound. Real time collaborations between toxicology laboratories, suppliers of analytical standards and the public health system may be useful in the face of future novel chemical exposures.

The use of bedside ultrasound in the evaluation of patients presenting with signs and symptoms of pulmonary embolism.

Evaluation of patients that present to the emergency department with concerns for the diagnosis of pulmonary embolism can be difficult. Modalities including computerized tomography (CT) of the chest, pulmonary angiography, and ventilation perfusion scans can expose patients to large quantities of radiation especially if the study has to be repeated due to poor quality. This is particularly a concern in the pregnant population that has an increased incidence of pulmonary embolism and may not be able to undergo multiple radiographic studies due to fetal radiation exposure. This paper presents a case of a pregnant patient with signs and symptoms concerning pulmonary embolism. The paper discusses the use of bedside ultrasound in the evaluation of patients with pulmonary embolism.

Aortic dissection and thrombosis diagnosed by emergency ultrasound in a patient with leg pain and paralysis.

The authors present a case of aortic dissection and abdominal aortic aneurysm thrombosis in a 78-year-old male who presented to the emergency department (ED) complaining of lower extremity and paralysis for the past 1.5 hours. The initial vital signs in the ED were as follows: blood pressure (BP) 132/88 mmHg, heart rate (HR) 96, respiratory rate (RR) 14, and an oxygen saturation of 94% at room air. Physical exam was notable for pale and cold left leg. The ED physician was unable to palpate or detect a Doppler signal in the left femoral artery. Bedside ultrasound was performed which showed non-pulsatile left femoral artery and limited flow on color Doppler. Abdominal aortic aneurysm screening ultrasound was performed showing a 4.99 cm infrarenal abdominal aortic aneurysm and an intra-aortic thrombus with an intimal flap. Vascular surgery was promptly contacted and the patient underwent emergent aorto-bi-femoral bypass, bilateral four compartment fasciotomy, right common femoral artery endarterectomy with profundoplasty, and subsequent left leg amputation. Emergency physicians should utilize bedside ultrasound in patients who present with risk factors or threatening signs and symptoms that may suggest aortic dissection or aneurysm. Bedside ultrasound decreases time to definitive treatment and the mortality of the patients.

Fibroelastoma as a culprit of syncope.

We present a case of a valvular mass diagnosed by emergency department bedside ultrasonography in a young patient with syncope. Bedside ultrasound has become a valuable tool in the evaluation of patients with syncope in the emergency department. This patient was believed to have a fibroelastoma on ultrasound that was confirmed by magnetic resonance and ultimately by postsurgical pathological evaluation. The indications and findings of using ultrasonography as part of the workup of syncope in the emergency department are discussed.

Role of bedside ultrasound in CMV retinitis: a case report.

We present a case of retinal detachment diagnosed by emergency department bedside ultrasonography in a patient with CMV retinitis. The indications and findings of ocular ultrasonography are discussed.

An unusual case of abdominal pain.

Renal calyceal rupture is a usual etiology of abdominal pain in the emergency department. We present a case of unexpected renal calyx rupture in a patient with symptomatology of renal colic. A discussion and review are provided.