Brent King

A Bayesian model for triage decision support.

OBJECTIVE To compare triage decisions of an automated emergency department triage system with decisions made by an emergency specialist. METHODS In a retrospective setting, data extracted from charts of 90 patients with chief complaint of non-traumatic abdominal pain were used as input for triage system and emergency medicine specialist. The final disposition and diagnoses of the physicians who visited the patient in Emergency Department (ED) as reflected in the medical records were considered as control. Results were compared by chi(2)-test and a binary logistic regression model. RESULTS Compared to emergency medicine specialist, triage system had higher sensitivity (90% versus 64%) and lower specificity (25% versus 48%) for patients who required hospitalization. The triage system successfully predicted the Admit decisions made in the ED whereas the emergency medicine specialist decisions could not predict the ED disposition. Both triage system and emergency medicine specialist properly disposed 56% of cases, however, the emergency medicine specialist in this study under-disposed more patients than the triage system considering Admit disposition (p=0.004) while he appropriately discharged more patients compared to the triage system (p=0.017). CONCLUSION The triage system studied here shows promise as a triage decision support tool to be used for telephone triage and triage in the emergency departments. This technology may also be useful to the patients as a self-triage tool. However, the efficiency of this particular application of this technology is unclear.

Pediatric and neonatal transport teams with and without a physician: a comparison of outcomes and interventions.

Objective: To determine whether a transport team composed of advanced practice nurses could function as effectively as a physician-nurse team, as measured by patient outcome. Design: Observational cohort study. Setting: The interfacility transport team at a tertiary care childrens hospital. Patients and other participants: Fourteen transport nurses and 539 patients. Methods: A transport team was studied during a previously planned change in composition from a physician-nurse team to a nurse-nurse team. Data were recorded by transport nurses and by subsequent review of the medical record during two 4-month periods, 1 before and 1 after the team change. Pediatric risk of mortality scores (a marker for degree of illness) were assigned for the periods before, during, and after transport. Transport time intervals, demographic data, and patient outcomes were also recorded. Data were assessed using frequency tables for discrete variables, as well as mean and standard deviation for continuous variables. For identification of group differences, χ2 test was used. Main outcome measures: Mortality, transport-related morbidity, overall transport times and interval times, and outcome of procedures performed by transport nurses. Results: Five hundred thirty-nine data sheets were received: 228 before (group 1) and 311 after (group 2) the team change. Physicians attended 128 (56.1%) group 1 transports and 15 (4.82%) group 2 transports. There were no significant differences in mean pediatric risk of mortality scores between group 1 and group 2 patients. Mortality was equivalent. Group 2 transport times were significantly shorter than group 1 times. Transport nurses performed 8 intubations; all were successful. Conclusions: Outcomes for the 2 types of teams were equivalent. Nonphysician teams responded more quickly and spent less time at the referring facility.

Opportunistic decision making and complexity in emergency care

In critical care environments such as the emergency department (ED), many activities and decisions are not planned. In this study, we developed a new methodology for systematically studying what are these unplanned activities and decisions. This methodology expands the traditional naturalistic decision making (NDM) frameworks by explicitly identifying the role of environmental factors in decision making. We focused on decisions made by ED physicians as they transitioned between tasks. Through ethnographic data collection, we developed a taxonomy of decision types. The empirical data provide important insight to the complexity of the ED environment by highlighting adaptive behavior in this intricate milieu. Our results show that half of decisions in the ED we studied are not planned, rather decisions are opportunistic decision (34%) or influenced by interruptions or distractions (21%). What impacts these unplanned decisions have on the quality, safety, and efficiency in the ED environment are important research topics for future investigation.

Procedures performed by pediatric transport nurses: how "advanced" is the practice?

Introduction Pediatric interfacility transport teams often rely on advanced practice nurses as primary care providers. These individuals may be required to transport patients without the presence of a physician. There is, however, little information in the medical literature regarding how frequently advanced practice transport nurses perform advanced procedures, how often these procedures are successfully performed, and the rate of complications associated with nurse-performed procedures. Purpose The purpose of this study was to determine how frequently advanced practice transport nurses were called on to perform advanced procedures and to determine the nurses’ procedural success and complication rates. Design Prospective convenience sample of consecutive pediatric interfacility transports. Methods Transport nurses collected data on 336 pediatric interfacility transports that were performed during a 4-month period beginning in May 1997. All patient transports occurring during the study period were included. Data regarding procedures were recorded on data collection sheets. This data included the type of procedure performed, the outcome of the procedure, and the complications associated with the procedure. The number of attempts required to successfully complete the procedure was not recorded. During or after the patient’s hospitalization, the medical record was reviewed to identify potential complications related to the transport that may not have been recorded on the data collection sheet. Results Nurses performed 95.2% of transports without the presence of a physician. Twenty-six patients (8.8%) required advanced procedures. Nurses performed eight tracheal intubations. Personnel at the referring hospital performed the remaining procedures. All tracheal intubations by transport nurses were successful. There were no complications related to these procedures. All patients were transported to the receiving hospital without incident. Conclusions Although they had considerable training for advanced procedures, the transport nurses rarely used these skills. All tracheal intubations performed by transport nurses were successful, and there were no adverse consequences related to intubation by a transport nurse.

Duty hours in emergency medicine: Balancing patient safety, resident wellness, and the resident training experience: A consensus response to the 2008 institute of medicine resident duty hours recommendations

Representatives of emergency medicine (EM) were asked to develop a consensus report that provided a review of the past and potential future effects of duty hour requirements for EM residency training. In addition to the restrictions made in 2003 by the Accreditation Council for Graduate Medical Education (ACGME), the potential effects of the 2008 Institute of Medicine (IOM) report on resident duty hours were postulated. The elements highlighted include patient safety, resident wellness, and the resident training experience. Many of the changes and recommendations did not affect EM as significantly as other specialties. Current training standards in EM have already emphasized patient safety by requiring continuous on-site supervision of residents. Resident fatigue has been addressed with restrictions of shift lengths and limitation of consecutive days worked. One recommendation from the IOM was a required 5-hour rest period for residents on call. Emergency department (ED) patient safety becomes an important concern with the decrease in the availability and in the patient load of a resident consultant that may result from this recommendation. Of greater concern is the already observed slower throughput time for admitted patients waiting for resident care, which will increase ED crowding and decrease patient safety in academic institutions. A balance between being overly prescriptive with duty hour restrictions and trying to improve resident wellness was recommended. Discussion is included regarding the appropriate length of EM training programs if clinical experiences were limited by new duty hour regulations. Finally, this report presents a review of the financing issues associated with any changes.

P EDIATRIC C RITICAL C ARE T RANSPORT —T HE S AFETY OF THE J OURNEY : A F IVE-YEAR R EVIEW OF V EHICULAR C OLLISIONS I NVOLVING P EDIATRIC AND N EONATAL T RANSPORT T EAMS

Objective. To determine the frequency and consequences of vehicular crashes among dedicated pediatric and neonatal transport teams. Methods. A three-page questionnaire was sent to the transport teams of National Association of Childrens Hospitals and Related Institutions (NACHRI) member hospitals. The survey instrument consisted of three sections. The first section requested demographic information about the team and asked the team to report any vehicular collisions or incidents in the previous five years. The second section was directed at teams that did not report collisions or incidents and asked the team to identify potential reasons for their safety record. The third section was directed to those teams reporting collisions or incidents and asked about the causes and consequences of these events. Results. Ninety of 153 (59%) surveys were returned. Thirty-eight of the 90 teams (42%) reported at least one collision in the previous five years. A total of 66 collisions were reported (nine aircraft crashes and 57 ambulance collisions). The number of collisions was not related to the total number of transports performed by the team. Most teams attributed the collisions to errors on the part of a team member or to the actions of a third party. Collisions resulted in eight deaths, ten cases of moderate to severe injury, and 28 minor injuries to patients, health care workers, and/or the ambulance crew. All deaths resulted from aircraft crashes. Additionally, there were operational impacts upon the teams. These included missed workdays and disability on the part of team members and changes in team practices. Collision-free teams attributed their safety record to specific policies of the team and/or the vehicle owner or vendor and to luck. Conclusions. Collisions/crashes among pediatric transport teams are unusual. However, they have resulted in deaths, injuries, and disability. Collisions/crashes appear to be caused by the actions of a team member and/or those of third parties. Specific safety policies on the part of the team and/or vehicle owner or provider may prevent or decrease collisions/crashes.

The Future of Emergency Medicine

BACKGROUND The specialty of emergency medicine (EM) continues to experience a significant workforce shortage in the face of increasing demand for emergency care. SUMMARY In July 2009, representatives of the leading EM organizations met in Dallas for the Future of Emergency Medicine Summit. Attendees at the Future of Emergency Medicine Summit agreed on the following: 1) Emergency medical care is an essential community service that should be available to all; 2) An insufficient emergency physician workforce also represents a potential threat to patient safety; 3) Accreditation Council for Graduate Medical Education/American Osteopathic Association (AOA)-accredited EM residency training and American Board of Medical Specialties/AOA EM board certification is the recognized standard for physician providers currently entering a career in emergency care; 4) Physician supply shortages in all fields contribute to-and will continue to contribute to-a situation in which providers with other levels of training may be a necessary part of the workforce for the foreseeable future; 5) A maldistribution of EM residency-trained physicians persists, with few pursuing practice in small hospital or rural settings; 6) Assuring that the public receives high quality emergency care while continuing to produce highly skilled EM specialists through EM training programs is the challenge for EMs future; 7) It is important that all providers of emergency care receive continuing postgraduate education.

Duty Hours in Emergency Medicine: Balancing Patient Safety, Resident Wellness, and the Resident Training Experience: A Consensus Response to the 2008 Institute of Medicine Resident Duty Hours Recommendations

BACKGROUND Representatives of emergency medicine (EM) were asked to develop a consensus report that provided a review of the past and potential future effects of duty hour requirements for EM residency training. In addition to the restrictions made in 2003 by the Accreditation Council for Graduate Medical Education, the potential effects of the 2008 Institute of Medicine (IOM) report on resident duty hours were postulated. DISCUSSION The elements highlighted include patient safety, resident wellness, and the resident training experience. Many of the changes and recommendations did not affect EM as significantly as other specialties. Current training standards in EM have already emphasized patient safety by requiring continuous onsite supervision of residents. Resident fatigue has been addressed with restrictions of shift lengths and limitation of consecutive days worked. CONCLUSION One recommendation from the IOM was a required 5-h rest period for residents on call. Emergency department (ED) patient safety becomes an important concern with the decrease in the availability and in the patient load of a resident consultant that may result from this recommendation. Of greater concern is the already observed slower throughput time for admitted patients waiting for resident care, which will increase ED crowding and decrease patient safety in academic institutions. A balance between being overly prescriptive with duty hour restrictions and trying to improve resident wellness was recommended. Discussion is included regarding the appropriate length of EM training programs if clinical experiences were limited by new duty hour regulations. Finally, this report presents a review of the financing issues associated with any changes.

Haemophilus influenzae type b bacteremia in older children.

Haemophilus influenzae type b (HIB) is a well-recognized cause of serious infection in infants and toddlers. However, little information exists regarding HIB infections in older children. This report describes serious HIB infections in 23 children (eight immunocompromised; 15 immunocompetent) older than 59 months of age. Data were collected over an 11-year period. The mean age of the children was 7.6 years (range, 5–15 years), and 14 were male. While three of the eight immunocompromised children had HIB pneumonia, none of the immunocompetent group had this diagnosis. Eleven of the 15 immunocompetent children had epiglottitis or meningitis. HIB bacteremia without focal infection occurred in four children, two immunocompromised and two immunocompetent.This study supports the recommendation of empiric HIB antibiotic therapy for children up to 12 years of age who have serious infections. Antibiotics effective against HIB should be included in the presumptive antibiotic therapy of seriously ill immunocompromised children, regardless of age.

The future of emergency medicine.

Physician shortages are being projected for most medical specialties. The specialty of emergency medicine continues to experience a significant workforce shortage in the face of increasing demand for emergency care. The limited supply of emergency physicians, emergency nurses, and other resources is creating an urgent, untenable patient care problem. In July 2009, representatives of the leading emergency medicine organizations met in Dallas, TX, for the Future of Emergency Medicine Summit. This consensus document, agreed to and cowritten by all participating organizations, describes the substantive issues discussed and provides a foundation for the future of the specialty.