A systematic review of triage-related interventions to improve patient flow in emergency departments

Background Overcrowding in emergency departments is a worldwide problem. A systematic literature review was undertaken to scientifically explore which interventions improve patient flow in emergency departments. Methods A systematic literature search for flow processes in emergency departments was followed by assessment of relevance and methodological quality of each individual study fulfilling the inclusion criteria. Studies were excluded if they did not present data on waiting time, length of stay, patients leaving the emergency department without being seen or other flow parameters based on a nonselected material of patients. Only studies with a control group, either in a randomized controlled trial or in an observational study with historical controls, were included. For each intervention, the level of scientific evidence was rated according to the GRADE system, launched by a WHO-supported working group. Results The interventions were grouped into streaming, fast track, team triage, point-of-care testing (performing laboratory analysis in the emergency department), and nurse-requested x-ray. Thirty-three studies, including over 800,000 patients in total, were included. Scientific evidence on the effect of fast track on waiting time, length of stay, and left without being seen was moderately strong. The effect of team triage on left without being seen was relatively strong, but the evidence for all other interventions was limited or insufficient. Conclusions Introducing fast track for patients with less severe symptoms results in shorter waiting time, shorter length of stay, and fewer patients leaving without being seen. Team triage, with a physician in the team, will probably result in shorter waiting time and shorter length of stay and most likely in fewer patients leaving without being seen. There is only limited scientific evidence that streaming of patients into different tracks, performing laboratory analysis in the emergency department or having nurses to request certain x-rays results in shorter waiting time and length of stay.

Constructive alignment in Computer Engineering and Informatics departments at Dalarna University : An empirical investigation

Background: Constructive alignment (CA) is a pedagogical approach that emphasizes the alignment between the intended learning outcomes (ILOs), teaching and learning activities (TLAs) and assessment tasks (ATs) as well as creation of a teaching/learning environment where students will be able to actively create their knowledge. Objectives: This paper aims at investigating the extent of constructively-aligned courses in Computer Engineering and Informatics department at Dalarna University, Sweden. This study is based on empirical observations of teacher’s perceptions of implementation of CA in their courses. Methods: Ten teachers (5 from each department) were asked to fill a paper-based questionnaire, which included a number of questions related to issues of implementing CA in courses. Results: Responses to the items of the questionnaire were mixed. Teachers clearly state the ILOs in their courses and try to align the TLAs and ATs to the ILOs. Computer Engineering teachers do not explicitly communicate the ILOs to the students as compared to Informatics teachers. In addition, Computer Engineering teachers stated that their students are less active in learning activities as compared to Informatics teachers. When asked about their subjective ratings of teaching methods all teachers stated that their current teaching is teacher-centered but they try to shift the focus of activity from them to the students. Conclusions: From teachers’ perspectives, the courses are partially constructively-aligned. Their courses are “aligned”, i.e. ILOs, TLAs and ATs are aligned to each other but they are not “constructive” since, according to them, there was a low student engagement in learning activities, especially in Computer Engineering department.

Accompanying critically ill relatives in emergency departments

Background. Family members are a crucial part of the holistic approach to care in emergency departments. In particular, they are a group who are vulnerable, yet have been overlooked when considering care options.

Aim. The primary aim of this systematic review was to appraise research relevant to identifying and meeting the needs of family members who accompany a critically ill person into the Emergency Department (ED). The information was intended to inform future research into the care of these people.

Method. A quality assessment strategy was specifically developed to evaluate the various research designs used. The outcomes of the highest quality studies were used to develop evidence-based clinical practice guidelines to inform clinicians caring for family members who accompany a critically ill person into the ED.

Results. Recommendations for family care drawn from this review provide the foundation for more rigorous methodologies in future research into this topic. Key findings concern family needs for communication, proximity, support, comfort, assurance and to locate meaning in the event.

Conclusion. The review has revealed current knowledge about the care of family members who accompany a critically ill person into the ED that provides guidelines for practice. Despite significant limitations, the knowledge can lead to recommendation to guide and inform future intervention research.

Families needs in emergency departments: instument development

Background. Families who accompany critically ill relatives in emergency departments (EDs) are an integral part of the care unit. However, there are few empirical data on their needs during this phase of care. In order to guide quality care, general and specific needs of families accompanying these critically ill relatives should be systematically examined.

Aim. The aim of this pilot project was to test the tool, methods and analysis plan for a study to examine the perceived needs of family members accompanying critically ill patients in EDs and their perceptions of ED staff's ability to meet these needs.

Method. Over a 6-week period in 1996, 84 relatives who met the inclusion criteria were recruited to the study. A postal questionnaire, to uncover the needs of family members, was pilot tested. The questionnaire consisted of 40 need statements reflecting five major themes: meaning, proximity, communication, comfort and support. Of the 84 relatives selected for the study, 73% returned completed questionnaires.

Results. The findings of this pilot study suggest that the questionnaire is a valid and reliable tool for researchers wishing to examine and rank the needs of family members who accompany critically ill people in EDs. In addition, the analysis plan was found to be appropriate.

Conclusions. This pilot study provides both a method and a tool for further research into family needs. Examination of the pilot data supported the reliability and validity of the tool and produced findings that challenge nurses to move beyond traditional practice that has excluded families from being an integral part of caring for critically ill patients in EDs.

Environmental reporting in annual reports: an examination of Australian state government departments

The nature and extent of environmental reporting within the annual reports of four Australian state government departments over a six year period from 2000-2006 is examined in this study. The Victorian Government Department of Sustainability and Environment (DSE), the New South Wales Department of Energy, Utilities and Sustainability (DEUS), the South Australian Department for Environment and Heritage (DEH) and the Tasmanian Department of Primary Industries, Water and Environment (DPIWE) have been selected. These departments are responsible for environmentally sensitive areas such as conservation, water management and public land management. The nature of these areas is a factor which might potentially affect disclosure practices so it might be expected that these departments disclose more environmental information than departments in less environmentally and politically sensitive areas. These departments also have a number of politically active stakeholder groups, including Aboriginal communities and organisations, environmental groups and forest and timber industries. This study found a reduction in environmental reporting after a five year period of increases.

Environmental management system adoption by government departments/agencies

Purpose: – This paper seeks to examine the adoption of an environmental management system (EMS) in government departments involved in one Australian state and identify the key factors that contribute to successful adoption.

Design/methodology/approach: – Data were collected through semi-structured interviews conducted with environmental coordinators involved in the EMS adoption. The external consultant appointed by the Environmental Protection Authority who provided the training on behalf of the government departments was also interviewed.

Findings: – The results from the analysis shows that environmental coordinators valued the training as it enhanced their knowledge and skills. They experienced a combination of both tangible and intangible benefits. The lack of contribution and support from top management; difficulty in accessing resources; and resistance from employees were the main challenges experienced during EMS implementation. Recommendations made by the interviewees included: providing training to top management to increase their understanding of the EMS process and its benefits; selection of the right champion; provision of adequate resources; and, training of employees.

Research limitations/implications: – The findings are based on interviews conducted in only one Australian state and no follow up interviews could be undertaken to track the progress made by various departments.

Originality/value: – The findings of this paper are original as no other similar study has been undertaken in this Australian state documenting the experiences of environmental coordinators when implementing an EMS. Our findings have practical implications for public sector organisations and government departments implementing EMS.

Small rural emergency departments are not simply cut-down large urban emergency departments

 It is important to understand how small rural emergency departments work. They are a significant fraction of a state’s medical system. Although they each see only a few thousand patients a year, as a group they are likely to treat more emergency patients than the largest city hospital. It is a myth that they only deal with minor ailments. 

Psychosocial care of family of critically-ill patients in emergency departments

Responding to families with a critically ill relative is difficult for emergency department clinicians. This innovative research program used best evidence, integrated with perspectives from families and clinicians, to develop context specific guidelines and sensitive tools to assist emergency department clinicians provide quality psychosocial care to meet multidimensional family needs.