Retrospective analysis of Methicillin-Resistant Staphylococcus Aureus (MRSA) skin and Soft-Tissue Infections (SSTI) in a university hospital emergency department (ED)

Study Objective: Identify the most frequent risk factors of Community Acquired-MRSA (CA-MRSA) Skin and Soft-tissue Infections (SSTIs) using a case series of patients and characterize them by age, race/ethnicity, gender, abscess location, druguse and intravenous drug-user (IVDU), underlying medical conditions, homelessness, treatment resistance, sepsis, those whose last healthcare visit was within the last 12 months, and describe the susceptibility pattern from this central Texas population that have come into the University Medical Center Brackenridge (UMCB) Emergency Department (ED). ^ Methods: This study was a retrospective case-series medical record review involving a convenience sample of patients in 2007 from an urban public hospital's ED in Texas that had a SSTI that tested positive for MRSA. All positive MRSA cultures underwent susceptibility testing to determine antibiotic resistance. The demographic and clinical variables that were independently associated with MRSA were determined by univariate and multivariate analysis using logistic regression to calculate odds ratios (OR), 95% confidence intervals, and significance (p≤ 0.05). ^ Results: In 2007, there were 857 positive MRSA cultures. The demographics were: males 60% and females 40%, with the average age of 36.2 (std. dev. =13) the study population consisted of non-Hispanic white (42%), Hispanics (38%), and non-Hispanic black (18.8%). Possible risk factors addressed included using recreational drugs (not including IVDU) (27%) homelessness (13%), diabetes status (12.6%) or having an infectious disease, and IVDU (10%). The most frequent abscess location was the leg (26.6%), followed by the arm and torso (both 13.7%). Eighty-three percent of patients had one prominent susceptibility pattern that had a susceptibility rate for the following antibiotics: trimethoprim/sulfamethoxazole (TMP-SMX) and vancomycin had 100%, gentamicin 99%, clindamycin 96%, tetracycline 96%, and erythromycin 56%. ^ Conclusion: The ED is becoming an important area for disease transmission between the sterile hospital environment and the outside environment. As always, it is important to further research in the ED in an effort to better understand MRSA transmission and antibiotic resistance, as well as to keep surveillance for the introduction of new opportunistic pathogens into the population. ^

ED-HOME: improving educator confidence and patient education in the emergency department

BACKGROUND: Barriers to effective patient communication in the emergency department (ED) are well recognised; time, resources and staff and consumer expectations. This project aimed to improve the quality of health education provided in the ED by increasing nurses' confidence as educators.

METHOD: By providing a staff information package including the introduction of a new structured education tool; ED-HOME, and by assessing the confidence and self-efficacy of the nurses in the process, we hoped to determine if an improvement in practice and confidence was achieved. A quantitative, pre and post-test questionnaire comparison study was undertaken before and after a four week implementation period. The project examined the attitudes and practices of registered emergency nurses and was conducted in one metropolitan emergency department.

RESULTS: Results indicated that nurse confidence and self-efficacy improved by using the new structured ED-HOME format and both staff satisfaction and education competence increased. Participants positively responded to the new tool and recommended future use in the ED.

CONCLUSION: This project demonstrates that if emergency nurses feel more confident with their educating practices and by using a structured format, patients will benefit from better quality patient education provided in the ED.

Evaluating the effect of a patient education brochure on patients’ expectations and satisfaction with emergency department service

Introduction: The purpose of this study was to assess the capacity of a written intervention, in this case a patient information brochure, to improve patient satisfaction during an Emergency Department (ED) visit. For the purpose of measuring the effect of the intervention the ED journey was conceptualised as a series of distinct areas of service comprising waiting time, service by the triage nurse, care from doctors and nurses and information giving Background of study: Research into patient satisfaction has become a widespread activity endorsed by both governments and hospital administrations. The literature on ED patient satisfaction has consistently indicated three primary areas of patient dissatisfaction: waiting time, nursing care and communication. Recent developments in the literature on patient satisfaction studies however have highlighted the relationship between patients. expectations of a service encounter and their consequent assessment of the experience as dissatisfying or satisfying. Disconfirmation theory posits that the degree to which expectations are confirmed will affect subsequent levels of satisfaction. The conceptual framework utilised in this study is Coye.s (2004) model of disconfirmation. Coye while reiterating satisfaction is a consequence of the degree expectations are either confirmed or disconfirmed also posits that expectations can be modified by interventions. Coye.s work conceptualises these interventions as intra encounter experiences (cues) which function to adjust expectations. Coye suggests some cues are unintended and may have a negative impact which also reinforces the value of planned cues intended to meet or exceed consumer expectations. Consequently the brochure can be characterized as a potentially positive cue, encouraging the patient to understand processes and to orient them in what can be a confronting environment. Only a limited number of studies have examined the effect of written interventions within an ED. No studies could be located which have tested the effect of ED interventions using a conceptual framework which relates the effect of the degree to which expectations are confirmed or disconfirmed in terms of satisfaction with services. Method: Two studies were conducted. Study One used qualitative methods to explore patients. expectations of the ED from the perspective of both patients and health care professionals. Study One was used in part to direct the development of the intervention (brochure) in Study Two. The brochure was an intervention designed to modify patients. expectations thus increasing their satisfaction with the provision of ED service. As there was no existing tools to measure ED patients. expectations and satisfaction a new tool was also developed based on the findings and the literature of Study One. Study Two used a non-randomised, quasi-experimental approach using a non-equivalent post-test only comparison group design used to investigate the effect of the patient education brochure (Stommel and Wills, 2004). The brochure was disseminated to one of two study groups (the intervention group). The effect of the brochure was assessed by comparing the data obtained from both the intervention and control group. These two groups consisted of 150 participants each. It was expected that any differences in the relevant domains selected for examination would indicate the effect of the brochure both on expectation and potentially satisfaction. Results: Study One revealed several areas of common ground between patients and nurses in terms of relevant content for the written intervention, including the need for information on the triage system and waiting times. Areas of difference were also found with patients emphasizing communication issues, whereas focus group members expressed concern that patients were often unable to assimilate verbal information. The findings suggested the potential utility of written material to reinforce verbal communication particularly in terms of the triage process and other ED protocols. This material was synthesized within the final version of the written intervention. Overall the results of Study Two indicated no significant differences between the two groups. The intervention group did indicate a significant number of participants who viewed the brochure of having changed their expectations. The effect of the brochure may have been obscured by a lack of parity between the two groups as the control group presented with statistically significantly higher levels of acuity and experienced significantly shorter waiting times. In terms of disconfirmation theory this would suggest expectations that had been met or exceeded. The results confirmed the correlation of expectations with satisfaction. Several domains also indicated age as a significant predictor with older patients tending to score higher satisfaction results. Other significant predictors of satisfaction established were waiting time and care from nurses, reinforcing the combination of efficient service and positive interpersonal experiences as being valued by patients. Conclusions: Information presented in written form appears to benefit a significant number of ED users in terms of orientation and explaining systems and procedures. The degree to which these effects may interact with other dimensions of satisfaction however is likely to be limited. Waiting time and interpersonal behaviours from staff also provide influential cues in determining satisfaction. Written material is likely to be one element in a series of coordinated strategies to improve patient satisfaction during periods of peak demand.

The effects of ambulance ramping on Emergency Department length of stay and mortality

Background: Ambulance ramping within the Emergency Department (ED) is a common problem both internationally and in Australia. Previous research has focused on various issues associated with ambulance ramping such as access block, ED overcrowding and ambulance bypass. However, limited research has been conducted on ambulance ramping and its effects on patient outcomes. ----- ----- Methods: A case-control design was used to describe, compare and predict patient outcomes of 619 ramped (cases) vs. 1238 non-ramped (control) patients arriving to one ED via ambulance from 1 June 2007 to 31 August 2007. Cases and controls were matched (on a 1:2 basis) on age, gender and presenting problem. Outcome measures included ED length of stay and in-hospital mortality. ----- ----- Results: The median ramp time for all 1857 patients was 11 (IQR 6—21) min. Compared to nonramped patients, ramped patients had significantly longer wait time to be triaged (10 min vs. 4 min). Ramped patients also comprised significantly higher proportions of those access blocked (43% vs. 34%). No significant difference in the proportion of in-hospital deaths was identified (2%vs. 3%). Multivariate analysis revealed that the likelihood of having an ED length of stay greater than eight hours was 34% higher among patients who were ramped (OR 1.34, 95% CI 1.06—1.70, p = 0.014). In relation to in-hospital mortality age was the only significant independent predictor of mortality (p < 0.0001). ----- ----- Conclusion: Ambulance ramping is one factor that contributes to prolonged ED length of stay and adds additional strain on ED service provision. The potential for adverse patient outcomes that may occur as a result of ramping warrants close attention by health care service providers.

Improving patient privacy and confidentiality in one regional Emergency Department – a quality project

Background: Patient privacy and confidentiality (PPaC) is an important consideration for nurses and other members of the health care team. Can a patient expect to have confidentiality and in particular privacy in the current climate of emergency health care? Do staff who work in the Emergency Department (ED) see confidentiality as an important factor when providing emergency care? These questions are important to consider. Methods: This is a two phased quality improvement project, developed and implemented over a six month period in a busy regional, tertiary referral ED. Results: Issues identified for this department included department design and layout, overcrowding due to patient flow and access block, staff practices and department policies which were also impacted upon by culture of the team, and use of space. Conclusions: Changes successful in improving this issue include increased staff awareness about PPaC, intercom paging prior to nursing handover to remove visitors during handover, one visitor per patient policy, designated places for handover, allocated bed space for patient reviews/assessment and a strategy to temporarily move the patient if procedures would have been undertaken in shared bed space. These are important issues when considering policy, practice and department design in the ED.

Barriers to information transfer for multi-trauma patients upon discharge from the Emergency Department in a tertiary level hospital

Purpose: Communication is integral to effective trauma care provision. This presentation will report on barriers to meaningful information transfer for multi-trauma patients upon discharge from the Emergency Department (ED) to the care areas of Intensive Care Unit, High Dependency Unit, and Perioperative Services. This is an ongoing study at one tertiary level hospital in Queensland. Method: This is a multi-phase, mixed method study. In Phase 1 data were collected about information transfer. This Phase was initially informed by a comprehensive literature review, then via focus groups, chart audit, staff survey and review of national and international trauma forms. Results: The barriers identified related to nursing handover, documented information, time inefficiency, patient complexity and stability and time of transfer. Specifically this included differences in staff expectations and variation in the nursing handover processes, no agreed minimum dataset of information handed over, missing, illegible or difficult to find information in documentation (both medical and nursing), low compliance with some forms used for documentation. Handover of these patients is complex with information coming from many sources, dealing with issues is more difficult for these patients when transferred out of hours. Conclusions and further directions: This study investigated the current communication processes and standards of information transfer to identify barriers and issues. The barriers identified were the structure used for documentation, processes used (e.g. handover), patient acuity and time. This information is informing the development, implementation and evaluation of strategies to ameliorate the issues identified.

Application of operations research techniques to improve efficiency in the emergency department

The main aim of this thesis is to analyse and optimise a public hospital Emergency Department. The Emergency Department (ED) is a complex system with limited resources and a high demand for these resources. Adding to the complexity is the stochastic nature of almost every element and characteristic in the ED. The interaction with other functional areas also complicates the system as these areas have a huge impact on the ED and the ED is powerless to change them. Therefore it is imperative that OR be applied to the ED to improve the performance within the constraints of the system. The main characteristics of the system to optimise included tardiness, adherence to waiting time targets, access block and length of stay. A validated and verified simulation model was built to model the real life system. This enabled detailed analysis of resources and flow without disruption to the actual ED. A wide range of different policies for the ED and a variety of resources were able to be investigated. Of particular interest was the number and type of beds in the ED and also the shift times of physicians. One point worth noting was that neither of these resources work in isolation and for optimisation of the system both resources need to be investigated in tandem. The ED was likened to a flow shop scheduling problem with the patients and beds being synonymous with the jobs and machines typically found in manufacturing problems. This enabled an analytic scheduling approach. Constructive heuristics were developed to reactively schedule the system in real time and these were able to improve the performance of the system. Metaheuristics that optimised the system were also developed and analysed. An innovative hybrid Simulated Annealing and Tabu Search algorithm was developed that out-performed both simulated annealing and tabu search algorithms by combining some of their features. The new algorithm achieves a more optimal solution and does so in a shorter time.

Is language a barrier for quality care in hospitals? A case series from an Emergency Department of a teaching hospital in Brisbane

Aim: The aim of this pilot study is to describe the use of an Emergency Department (ED) at a large metropolitan teaching hospital by patients who speak English or other languages at home. Methods: All data were retrieved from the Emergency Department Information System (EDIS) of this tertiary teaching hospital in Brisbane. Patients were divided into two groups based on the language spoken at home: patients who speak English only at home (SEO) and patients who do not speak English only or speak other language at home (NSEO). Modes of arrival, length of ED stay and the proportion of hospital admission were compared among the two groups of patients by using SPSS V18 software. Results: A total of 69,494 patients visited this hospital ED in 2009 with 67,727 (97.5%) being in the SEO group and 1,281 (1.80%) in the NSEO group. The proportion of ambulance utilisation in arrival mode was significantly higher among SEO 23,172 (34.2%) than NSEO 397 (31.0%), p <0.05. The NSEO patients had longer length of stay in the ED (M = 337.21, SD = 285.9) compared to SEO patients (M= 290.9, SD = 266.8), with 46.3 minutes (95%CI 62.1, 30.5, p <0.001) difference. The admission to the hospital among NSEO was 402 (31.9%) higher than SEO 17,652 (26.6%), p <0.001. Conclusion: The lower utilisation rates of ambulance services, longer length of ED stay and higher hospital admission rates in NSEO patients compared to SEO patients are consistent with other international studies and may be due to the language barriers.

Impact of opening a new emergency department on healthcare service and patient outcomes : analyses based on linking ambulance, emergency and hospital databases

Background Emergency department (ED) crowding caused by access block is an increasing public health issue and has been associated with impaired healthcare delivery, negative patient outcomes and increased staff workload. Aim To investigate the impact of opening a new ED on patient and healthcare service outcomes. Methods A 24-month time series analysis was employed using deterministically linked data from the ambulance service and three ED and hospital admission databases in Queensland, Australia. Results Total volume of ED presentations increased 18%, while local population growth increased by 3%. Healthcare service and patient outcomes at the two pre-existing hospitals did not improve. These outcomes included ambulance offload time: (Hospital A PRE: 10 min, POST: 10 min, P < 0.001; Hospital B PRE: 10 min, POST: 15 min, P < 0.001); ED length of stay: (Hospital A PRE: 242 min, POST: 246 min, P < 0.001; Hospital B PRE: 182 min, POST: 210 min, P < 0.001); and access block: (Hospital A PRE: 41%, POST: 46%, P < 0.001; Hospital B PRE: 23%, POST: 40%, P < 0.001). Time series modelling indicated that the effect was worst at the hospital furthest away from the new ED. Conclusions An additional ED within the region saw an increase in the total volume of presentations at a rate far greater than local population growth, suggesting it either provided an unmet need or a shifting of activity from one sector to another. Future studies should examine patient decision making regarding reasons for presenting to a new or pre-existing ED. There is an inherent need to take a ‘whole of health service area’ approach to solve crowding issues.

Emergency department in hospitals, a window of the world : a preliminary comparison between Australia and China

BACKGROUND: This study aimed to make a preliminary comparison of emergency department (ED) presentations between Australia and China. The comparison could provide insights into the health systems and burden of diseases and potentially stimulate discussion about the development of acute health system in China. METHODS: An observational study was performed to compare Australian ED presentations using data obtained from a single adult tertiary-referral teaching hospital in metropolitan Brisbane against Chinese ED presentations using public domain information published in existing Chinese and international medical journals. RESULTS: There are major differences in ED presentations between Australia and China. In 2008, 1) 35.4% of patients arrived at a tertiary teaching hospital ED in Brisbane, Australia by ambulance; 2) 1.7% were treated for poisoning; 3) 1.4% for cerebral vascular disease; 4) 1.7% for cardiac disease; and 5) 42.6% for trauma. The top events diagnosed were mental health problems including general psychiatric examination, psychiatric review, alcohol abuse, and counselling for alcohol abuse, which accounted for 5.5% of all ED presentations. Among ED patients in China, 6.7% arrived at a tertiary teaching hospital by ambulance in Shenyang in 1997; 3.7% were treated for poisoning in Shanxi Zhouzhi County People's Hospital ED in 2006; 14.9% for cerebral vascular diseases at Qinghai People's Hospital ED in 1993-1995; 1.7% for cardiac diseases at the Second People's Hospital ED, Shenzhen Longgang in 1993; and 44.3% for trauma at Shanxi Zhouzhi County People's Hospital ED in 2006. The top events were trauma and poisoning among the young and cerebral infarction in the older population. CONCLUSIONS: Compared with Australian, Chinese ED patients had 1) lower ambulance usage; 2) higher proportion of poisoning; 3) higher proportion of cerebral vascular diseases; 4) similar proportion of cardiac disease; 5) similar proportion of trauma; and 6) little reported mental health problems. Possible explanations for these differences in China include a pay for service pre-hospital care system, lack of public awareness about poisons, inadequate hypertension management, and lack of recognition of mental health problems.

Patients perceptions of emergency department services : better specialised staff, convenient and available services

Many factors are identified as contributing to the high demand for emergency department (ED) care. Similarly, there have been many initiatives taken to minimise the impact that is placed on EDs. Many of these, however, do not consider the patient's opinions and motivations. The aim of this cross-sectional study was to understand patients’ perspectives and reasons behind their decision to present to EDs. 911 surveys were collected from patients presenting to eight QLD EDs in 2011. Based on the Principal Component Analysis technique, a six-item scale entitled "Best services at emergency departments" was extracted (α = 0.729) measuring patients' opinions and perspectives. Further, the independent t-tests were conducted between various groups of ED users. The results suggest that multiple users more likely viewed EDs as the best place for their conditions than the first-time users (Median 10.73 v 11.56, p<0.001). Moreover, patients who made the decision to present by themselves had a more favourable perception of the ED services than those for whom the decision was made or others were involved (Median 11.38 v 10.80, p=0.003). Method of arrival did not affect the respondents’ perception of ED (11.13 v 11.00, p=0.65). The results of this research indicate that patients’ perception of ED as the best and most appropriate place for attention to their medical conditions plays an important role in their decision to present and keep returning to ED. Understanding patients’ reasons and decisions enhances the success of planning and implementing alternative services to manage the demand for ED services.

A needle in a haystack : the use of routinely collected emergency department injury surveillance data to help identify physical child abuse

A retrospective, descriptive analysis of a sample of children under 18 years presenting to a hospital emergency department (ED) for treatment of an injury was conducted. The aim was to explore characteristics and identify differences between children assigned abuse codes and children assigned unintentional injury codes using an injury surveillance database. Only 0.1% of children had been assigned the abuse code and 3.9% a code indicating possible abuse. Children between 2-5 years formed the largest proportion of those coded to abuse. Superficial injury and bruising were the most common types of injury seen in children in the abuse group and the possible abuse group (26.9% and 18.8% respectively), whereas those with unintentional injury were most likely to present with open wounds (18.4%). This study demonstrates that routinely collected injury surveillance data can be a useful source of information for describing injury characteristics in children assigned abuse codes compared to those assigned no abuse codes.

A comparative analysis of risk stratification tools for emergency department patients with chest pain

Background: Appropriate disposition of emergency department (ED) patients with chest pain is dependent on clinical evaluation of risk. A number of chest pain risk stratification tools have been proposed. The aim of this study was to compare the predictive performance for major adverse cardiac events (MACE) using risk assessment tools from the National Heart Foundation of Australia (HFA), the Goldman risk score and the Thrombolysis in Myocardial Infarction risk score (TIMI RS). Methods: This prospective observational study evaluated ED patients aged ≥30 years with non-traumatic chest pain for which no definitive non-ischemic cause was found. Data collected included demographic and clinical information, investigation findings and occurrence of MACE by 30 days. The outcome of interest was the comparative predictive performance of the risk tools for MACE at 30 days, as analyzed by receiver operator curves (ROC). Results: Two hundred eighty-one patients were studied; the rate of MACE was 14.1%. Area under the curve (AUC) of the HFA, TIMI RS and Goldman tools for the endpoint of MACE was 0.54, 0.71 and 0.67, respectively, with the difference between the tools in predictive ability for MACE being highly significant [chi2 (3) = 67.21, N = 276, p < 0.0001]. Conclusion: The TIMI RS and Goldman tools performed better than the HFA in this undifferentiated ED chest pain population, but selection of cutoffs balancing sensitivity and specificity was problematic. There is an urgent need for validated risk stratification tools specific for the ED chest pain population.

Pulmonary embolism in the emergency department : a Singaporean nursing case review

Introduction The presentation of pulmonary embolism to the emergency department (ED) can prove challenging because of the myriad of potential disease processes that mimic its signs and symptoms. The incidence of pulmonary embolism and indeed the mortality associated with it is relatively high. Early diagnosis and treatment is crucial in off-setting the potential deleterious effects associated with this condition. The aim of this article is to present a nursing case review of a patient presenting to the ED with a diagnosis of pulmonary embolism. Method We chose to use a case review to highlight the nursing and medical care that was provided for a patient who presented to the emergency department acutely with dyspnoea, chest pain and pyrexia. The use of case reviews are useful in reporting unusual or rare cases and this format is typically seen more in medicine than in nursing. They can naturally take one of two formats—a single case report or a series of case reports; in this case we opted to report on a single case. Discussion The gentleman in question was an ambulance admissionto the ED with a three day history of chest pain, shortness of breath and one episode of syncope which brought him to the ED. Over the course of his admission a variety of treatment modalities were used successfully to alleviate the problem. More notable from a nursing perspective was the use of diagnostic tools as an interpretation to guide his care and provide a platform from which a deeper understanding and appreciation of the intricacies the critically ill patient often presents. Conclusion We found the use of case review very enlightening in understanding the disease process and the decision-making that accompanies this. Whilst our patient was successfully rehabilitated home, we learnt a lot from the experience which has been most beneficial in supporting our understanding of pulmonary embolism.

Time to analgesia for care delivered by nurse practitioners in the emergency department: A retrospective chart audit

Objectives To evaluate quality of care delivered to patients presenting to the emergency department (ED) with pain and managed by emergency nurse practitioners by measuring: 1) Evaluate time to analgesia from initial presentation 2) Evaluate time from being seen to next analgesia 3) Pain score documentation Background The delivery of quality care in the emergency department (ED) is emerging as one of the most important service indicators being measured by health services. Emergency nurse practitioner services are designed to improve timely, quality care for patients. One of the goals of quality emergency care is the timely and effective delivery of analgesia for patients. Timely analgesia is an important indicator of ED service performance. Methods A retrospective explicit chart review of 128 consecutive patients with pain and managed by emergency nurse practitioners was conducted. Data collected included demographics, presenting complaint, pain scores, and time to first dose of analgesia. Patients were identified from the ED Patient Information System (Cerner log) and data were extracted from electronic medical records Results Pain scores were documented in 67 (52.3%; 95% CI: 43.3-61.2) patients. The median time to analgesia from presentation was 60.5 (IQR 30-87) minutes, with 34 (26.6%; 95% CI: 19.1-35.1) patients receiving analgesia within 30 minutes of presentation to hospital. There were 22 (17.2%; 95% CI: 11.1-24.9) patients who received analgesia prior to assessment by a nurse practitioner. Among patients that received analgesia after assessment by a nurse practitioner, the median time to analgesia after assessment was 25 (IQR 12-50) minutes, with 65 (61.3%; 95% CI: 51.4-70.6) patients receiving analgesia within 30 minutes of assessment. Conclusions The majority of patients assessed by nurse practitioners received analgesia within 30 minutes after assessment. However, opportunities for substantial improvement in such times along with documentation of pain scores were identified and will be targeted in future research.