Impact of scribes on emergency medicine doctors' productivity and patient throughput: multicentre randomised trial.

OBJECTIVES: To evaluate the changes in productivity when scribes were used by emergency physicians in emergency departments in Australia and assess the effect of scribes on throughput. DESIGN: Randomised, multicentre clinical trial. SETTING: Five emergency departments in Victoria used Australian trained scribes during their respective trial periods. Sites were broadly representative of Australian emergency departments: public (urban, tertiary, regional referral, paediatric) and private, not for profit. PARTICIPANTS: 88 physicians who were permanent, salaried employees working more than one shift a week and were either emergency consultants or senior registrars in their final year of training; 12 scribes trained at one site and rotated to each study site. INTERVENTIONS: Physicians worked their routine shifts and were randomly allocated a scribe for the duration of their shift. Each site required a minimum of 100 scribed and non-scribed shifts, from November 2015 to January 2018. MAIN OUTCOME MEASURES: Physicians' productivity (total patients, primary patients); patient throughput (door-to-doctor time, length of stay); physicians' productivity in emergency department regions. Self reported harms of scribes were analysed, and a cost-benefit analysis was done. RESULTS: Data were collected from 589 scribed shifts (5098 patients) and 3296 non-scribed shifts (23 838 patients). Scribes increased physicians' productivity from 1.13 (95% confidence interval 1.11 to 1.17) to 1.31 (1.25 to 1.38) patients per hour per doctor, representing a 15.9% gain. Primary consultations increased from 0.83 (0.81 to 0.85) to 1.04 (0.98 to 1.11) patients per hour per doctor, representing a 25.6% gain. No change was seen in door-to-doctor time. Median length of stay reduced from 192 (interquartile range 108-311) minutes to 173 (96-208) minutes, representing a 19 minute reduction (P<0.001). The greatest gains were achieved by placing scribes with senior doctors at triage, the least by using them in sub-acute/fast track regions. No significant harm involving scribes was reported. The cost-benefit analysis based on productivity and throughput gains showed a favourable financial position with use of scribes. CONCLUSIONS: Scribes improved emergency physicians' productivity, particularly during primary consultations, and decreased patients' length of stay. Further work should evaluate the role of the scribe in countries with health systems similar to Australia's. TRIAL REGISTRATION: ACTRN12615000607572 (pilot site); ACTRN12616000618459.

Conservative management of azygous vein rupture in blunt thoracic trauma.

We report a case of successful conservative management of acute traumatic rupture of the azygous vein. A 48-year-old male was involved in a motor vehicle collision. Primary survey revealed acute right intrathoracic haemorrhage. He remained haemodynamically stable with rapid infusion of warmed crystalloid solution and blood. Computed tomographic imaging showed a contained haematoma of the azygous vein. The patient was managed conservatively in the intensive care. Azygous vein laceration resulting from blunt thoracic trauma is a rare condition that carries a universally poor prognosis unless the appropriate treatment is instituted. Clinical features include acute hypovolaemic shock, widened mediastinum on chest radiograph, and a right-sided haemothorax. Haemodynamic collapse necessitates immediate resuscitative thoracotomy. Interest in this injury stems from the severity of the clinical condition, difficulty in diagnosis, the onset of a rapidly deteriorating clinical course all of which can be promptly reversed by timely and appropriate treatment. Although it is a rare cause of intramediastinal haemorrhage, it is proposed that a ruptured azygous vein should be considered in every trauma case causing a right-sided haemothorax or widened mediastinum. All cases described in the literature to date involved operative management. We present a case of successful conservative management of this condition.

Acute ankle sprain: is there a best support?

OBJECTIVE: Acute lateral ankle sprain accounts for 85% of all sprains, being generally accepted as the most common sports-related ligamentous injury. There is a lack of consensus about the optimal management of these injuries despite their frequency. The time-honoured mantra of rest, ice, elevation and compression is still commonly used, even though the current evidence for compression is conflicting. METHODS: A prospective randomized controlled clinical trial was carried out in the emergency department of a regional hospital in Ireland to compare outcomes, in terms of ankle function, pain improvement and return-to-work times, in adults presenting within 24 h of first-time acute lateral ankle sprain, among three external supports. RESULTS: We found no statistically significant differences among all three treatments in terms of ankle joint function, using the Karlsson ankle function scale, at 10 or 30-days follow-up. There was a tendency for Elastoplast bandaging to provide better average ankle function at both time points, when compared with double tubigrip and no support. Participants returned to work an average 2 days earlier, if treated with Elastoplast. CONCLUSION: This study found no statistically significant difference in ankle function between double tubigrip bandage, Elastoplast bandage and no support at 10 or 30-days follow-up.

Topical anaesthesia in children: reducing the need for specialty referral.

OBJECTIVE: The management of wounds in children is stressful, not only for the child, but also for parents and staff. In our Emergency Department (ED), we currently do not have a paediatric sedation policy, and thus children requiring suturing, not amenable to distraction and infiltrative anaesthesia, are referred to specialty teams for general anaesthesia. We proposed that the introduction of a topical anaesthetic gel (lidocaine, adrenaline, tetracaine - LAT) might help to reduce the number of referrals, by allowing the ED staff to perform the procedures, in combination with nonpharmacological approaches. METHODS: We carried out a retrospective review of ED records of all children aged 14 years or less attending with wounds, over an 8-month period, from 01 May 2007 to 31 January 2008. RESULTS: Two hundred and one (50.6%) patients presented before the introduction of LAT gel, whereas 196 (49.3%) patients presented afterwards. A total of 39 (19.4%) patients were referred for specialty review pre-LAT, whereas only 19 (9.7%) patients were referred in the LAT group. Of these, 31 (15.4%) pre-LAT and 15 (7.7%) LAT group required general anaesthesia. There is a significant difference between these two groups, using Fischer's exact test, P=0.018. CONCLUSION: We have found that the introduction of topical anaesthetic gel in ED has significantly reduced the number of children with wounds referred to specialty teams for general anaesthesia. This has important implications for patient safety and hospital resources.

Critical care in the emergency department.

BACKGROUND: The volume and duration of stay of the critically ill in the emergency department (ED) is increasing and is affected by factors including case-mix, overcrowding, lack of available and staffed intensive care beds and an ageing population. The purpose of this study was to describe the clinical activity associated with these high-acuity patients and to quantify resource utilization by this patient group. METHODS: The study was a retrospective review of ED notes from all patients referred directly to the intensive care team over a 6-month period from April to September 2004. We applied a workload measurement tool, Therapeutic Intervention Scoring System (TISS)-28, which has been validated as a surrogate marker of nursing resource input in the intensive care setting. A nurse is considered capable of delivering nursing activities equal to 46 TISS-28 points in each 8-h shift. RESULTS: The median score from our 69 patients was 19 points per patient. Applying TISS-28 methodology, we estimated that 3 h 13 min nursing time would be spent on a single critically ill ED patient, with a TISS score of 19. This is an indicator of the high levels of personnel resources required for these patients in the ED. ED-validated models to quantify nursing and medical staff resources used across the spectrum of ED care is needed, so that staffing resources can be planned and allocated to match service demands.

Complications of heroin abuse.

A 21-year-old man presented to the emergency department in St James's Hospital by ambulance. He was found collapsed at home by his uncle. He was complaining of severe pain and swelling to his left lower limb, with reduced sensation to his left foot. He was hepatitis C positive from intravenous drug use, and had most recently used both heroin and cocaine 5 days previously on his release from prison. Musculoskeletal exam showed extensive swelling of his left lower limb, with tense calf compartments. Initial laboratory results showed a raised creatine kinase of more than 155,000 IU/l. Urine toxicology was positive for methadone, heroin and benzodiazepines, whereas urinary dipstick was positive for blood, which was confirmed to be myoglobin by subsequent laboratory analysis. Atraumatic rhabdomyolysis is a syndrome characterized by injury to skeletal muscle with subsequent release of intracellular contents, that is myoglobin and creatine kinase. Drugs have direct toxic effects, but may also cause coma-induced rhabdomyolysis, owing to unrelieved pressure on gravity-dependent body parts. Diagnosis is made with history (i.e. recent heroin or cocaine use), elevated serum CK, plus the possible presence of myoglobinuria. Aggressive i.v. rehydration remains the mainstay of treatment. If there is any evidence of compartment syndrome, urgent fasciotomy is required. Electrolyte imbalances should be corrected, unless very mildly abnormal. We have learned from our experience with this case that a high index of suspicion and thereby early recognition is crucial to prevent complications in intravenous drug users presenting with unusual symptoms and signs.