Use of the Theoretical Domains Framework to explore factors influencing paediatric fever management practices and antipyretic use in New Zealand emergency departments.

AIM: To explore factors influencing fever management practices and antipyretic use among New Zealand Emergency Department (ED) doctors and nurses using the Theoretical Domains Framework (TDF). METHODS: Cross-sectional survey of doctors and nurses across 11 New Zealand EDs. The questionnaire examined eight of 12 TDF domains, based on a generic questionnaire validated to assess TDF-based determinants of health-care professional behaviour. Relevant domains were identified by the frequency of beliefs; the presence of conflicting beliefs within a domain; and the likely strength of impact of a belief on paediatric fever management in the ED. RESULTS: About 602 participants (243 doctors, 353 nurses and 6 unknown) completed the survey (response rate 47.5%). Over half (351/591, 59.6%, 95% confidence interval (CI) 55.5-63.5%) knew the content of clinical practice guidelines regarding antipyretic use in febrile children (TDF Domain Knowledge), or had been trained to ensure antipyretics are given to febrile children only if they appear distressed (347/592, 58.6%, 95% CI 54.5-62.6%) (Skills). Over 40% (246/590, 95% CI 37.7-45.8%) aim to reduce the fever before discharge (Goals). Most (444/591, 75.1%, 95% CI 71.4-78.6%) participants felt capable of explaining appropriate antipyretic use to parents/care givers (Beliefs about Capabilities). Only a minority (155/584, 26.5%, 95% CI 23.0-30.3%) thought that they can ensure antipyretics are given to febrile children only if they appear distressed when the ED is busy (Environmental Context and Resources). CONCLUSIONS: Using the TDF, we identified factors influencing fever management practices and antipyretic use in the ED. These factors can guide the design of targeted, theory-informed knowledge translation strategies.

Optimising POCUS programs: A summary of EMUG's recommendations for the development and maintenance of ED POCUS programs.

OBJECTIVES: Point-of-care ultrasound (POCUS) use is widespread in EDs and throughout those practising medicine. Between institutions and specialities, there is widespread variety and training. With this comes risk of patient harm and backlash to a clinically useful modality. Our objective is to form a statement that encompasses current published and unpublished guidance for creating and maintaining robust POCUS programs in EDs. METHODS: Emergency Medicine Ultrasound Group (EMUG) identified this gap and volunteers from the group undertook a literature search of current best practice and institution guidelines relating to POCUS programs. They contacted colleagues from other specialities to find and get access to other countries and colleges' POCUS guidelines. EMUGs regularly run discussion forums (Collab-labs) and points from these were considered. Recommendations were then formed from these and recurrent unpublished obstacles the group had encountered. The result was reviewed by Clinical Leads in Ultrasound and POCUS users in Australasia. RESULTS: The recommendations were organised under five pillars: Infrastructure, Governance, Administration, Education and Quality. CONCLUSION: These recommendations complement existing guidelines and are not intended to replace them; however, we hope to promote discussion and provide reference support for those developing POCUS programs. Implementing a comprehensive and robust ED POCUS program will ensure safe, effective, and standardised high-quality POCUS use, with the aim of improving patient care across Australia and New Zealand. Patient safety will be enhanced through effective risk management and quality assurance and there will be consistency in POCUS education, training and credentialing across institutions.

Recommendations for developing a comprehensive point-of-care ultrasound (POCUS) program in the emergency department: an Emergency Medicine Ultrasound Group advocacy statement.

OBJECTIVES: Point-of-care ultrasound (POCUS) use is widespread in EDs and throughout those practising medicine. Between institutions and specialities, there is widespread variety and training. With this comes the risk of patient harm and backlash to a clinically useful modality. Our objective is to form a statement that encompasses current published and unpublished guidance for creating and maintaining robust POCUS programs in EDs. METHODS: Emergency Medicine Ultrasound Group (EMUG) identified this gap and volunteers from the group undertook a literature search of current best practice and institution guidelines relating to POCUS programs. They contacted colleagues from other specialities to find and get access to other countries and colleges' POCUS guidelines. EMUGs regularly run discussion forums (Collab-labs) and points from these were considered. Recommendations were then formed from these and recurrent unpublished obstacles the group had encountered. The result was reviewed by clinical leaders in ultrasound and POCUS users in Australasia. RESULTS: The recommendations were organised under five pillars: Infrastructure, Governance, Administration, Education and Quality. CONCLUSION: These recommendations complement existing guidelines and are not intended to replace them; however, we hope to promote discussion and provide reference support for those developing POCUS programs. Implementing a comprehensive and robust ED POCUS program will ensure safe, effective and standardised high-quality POCUS use, with the aim of improving patient care across Australia and New Zealand. Patient safety will be enhanced through effective risk management and quality assurance and there will be consistency in POCUS education, training and credentialing across institutions.

Paediatric fever management practices and antipyretic use among doctors and nurses in New Zealand emergency departments.

OBJECTIVES: To assess (i) paediatric fever management practices among New Zealand ED doctors and nurses, including adherence to best practice guidelines; and (ii) the acceptability of a randomised controlled trial (RCT) of antipyretics for relief of discomfort in young children. METHODS: A cross-sectional survey of doctors and nurses across 11 New Zealand EDs. The primary outcome of adherence to paediatric fever management best practice guidelines was assessed with clinical vignettes and defined as single antipyretic use for the relief of fever-related discomfort. RESULTS: Out of 602 participants (243 doctors, 353 nurses and six unknown; response rate 47.5%), only 64 (10.6%, 95% confidence interval [CI] 8.3-13.4%) demonstrated adherence to best practice guidelines. In a febrile settled child with normal fluid intake, the percentage of participants that would use antipyretics doubled with abnormal vital signs (33.7% vs 72.9%, difference -39.2%, 95% CI -44.4% to -34.0%). Most participants would use antipyretics for reduced fluid intake (n = 494, 82.1%, 95% CI 78.8-85.0%) in a febrile settled child. Over half (n = 339, 57.1%, 95% CI 53.0-61.1%) would advise giving antipyretics to prevent febrile convulsions. Most (n = 467, 80.0%, 95% CI 76.5-83.1%) participants agreed that a RCT of antipyretics in febrile children <2 years of age with relief of discomfort as a primary outcome is needed. CONCLUSIONS: Just over 10% of New Zealand ED doctors and nurses demonstrated adherence to paediatric fever management best practice guidelines. A RCT of antipyretics in febrile children <2 years of age specifically addressing relief of discomfort as a primary outcome is strongly supported.

Workplace wellbeing in emergency departments in Aotearoa New Zealand 2020.

AIM: To quantify staff burnout and wellbeing in emergency departments (EDs) throughout New Zealand (NZ). METHODS: A national cross sectional electronic survey of New Zealand clinical and non-clinical ED staff was conducted between 9 March and 3 April 2020. Burnout and wellbeing were assessed using the Copenhagen Burnout Inventory (CBI) and a variety of quantitative measures. Differences between measures were assessed by demography and work role using univariate analyses. Multivariate analyses assessed associations between burnout and wellbeing. RESULTS: 1,372 staff responded from 22 EDs around New Zealand (response rate 43%). Most were female (n=678, 63%), NZ European (n=799, 59%), aged 20-39 years (n=743, 54%) and nurses (n=711, 52%). The overall prevalence of personal burnout was 60%, work-related burnout 55% and patient-related burnout 19%. There was a wide variation of burnout across all EDs. Females and nurses showed the highest degree of burnout by gender and role, respectively. Measures of wellbeing with significant negative correlations with burnout were work-related happiness, work-life balance, job satisfaction and perceived workplace excellence. Work stress had significant positive correlation with burnout. CONCLUSION: New Zealand ED staff have a high degree of burnout. Safety, financial sustainability and quality of care are likely being adversely affected. Stakeholders can be informed by findings from this study to inspire meaningful interventions in EDs and throughout the New Zealand healthcare system.

Cardiac tamponade--still a difficult clinical diagnosis.

A 51-year-old man with multiple risk factors for ischaemic heart disease attended the emergency department (ED) with sudden-onset chest pain, dizziness and breathlessness. He was tachycardic but had normal heart sounds and normal QRS complexes on ECG. Bedside ultrasound was performed, revealing a pericardial effusion. Emergent pericardiocentesis was performed with excellent outcome. This case highlights the importance of early detection of cardiac tamponade as well as the role of bedside ultrasound in diagnosis and management of the condition.