Eileen J. Carter

The relationship between emergency department crowding and patient outcomes: a systematic review.

PURPOSE Emergency department (ED) crowding is a significant patient safety concern associated with poor quality of care. The purpose of this systematic review is to assess the relationship between ED crowding and patient outcomes. DESIGN We searched the Medline search engine and relevant emergency medicine and nursing journals for studies published in the past decade that pertained to ED crowding and the following patient outcome measures: mortality, morbidity, patient satisfaction, and leaving the ED without being seen. All articles were appraised for study quality. FINDINGS A total of 196 abstracts were screened and 11 articles met inclusion criteria. Three of the eleven studies reported a significant positive relationship between ED crowding and mortality either among patients admitted to the hospital or discharged home. Five studies reported that ED crowding is associated with higher rates of patients leaving the ED without being seen. Measures of ED crowding varied across studies. CONCLUSIONS ED crowding is a major patient safety concern associated with poor patient outcomes. Interventions and policies are needed to address this significant problem. CLINICAL RELEVANCE This review details the negative patient outcomes associated with ED crowding. Study results are relevant to medical professionals and those that seek care in the ED.

Infection prevention and control in nursing homes: a qualitative study of decision-making regarding isolation-based practices

Background Isolation-based practices in nursing homes (NHs) differ from those in acute care. NHs must promote quality of life while preventing infection transmission. Practices used in NHs to reconcile these goals of care have not been characterised. Purpose To explore decision-making in isolation-based infection prevention and control practices in NHs. Methods A qualitative study was conducted with staff (eg, staff nurses, infection prevention directors and directors of nursing) employed in purposefully sampled US NHs. Semistructured, role-specific interview guides were developed and interviews were digitally recorded, transcribed verbatim and analysed using directed content analysis. The research team discussed emerging themes in weekly meetings to confirm consensus. Results We inferred from 73 interviews in 10 NHs that there was variation between NHs in practices regarding who was isolated, when isolation-based practices took place, how they were implemented, and how they were tailored for each resident. Interviewees’ decision-making depended on staff perceptions of acceptable transmission risk and resident quality of life. NH resources also influenced decision-making, including availability of private rooms, extent to which staff can devote time to isolation-based practices and communication tools. A lack of understanding of key infection prevention and control concepts was also revealed. Conclusions and implications Current clinical guidelines are not specific enough to ensure consistent practice that meets care goals and resource constraints in NHs. However, new epidemiological research regarding effectiveness of varying isolation practices in this setting is needed to inform clinical practice. Further, additional infection prevention and control education for NH staff may be required.

Environmental factors and their association with emergency department hand hygiene compliance: an observational study

Objectives Hand hygiene is effective in preventing healthcare-associated infections. Environmental conditions in the emergency department (ED), including crowding and the use of non-traditional patient care areas (ie, hallways), may pose barriers to hand hygiene compliance. We examined the relationship between these environmental conditions and proper hand hygiene. Methods This was a single-site, observational study. From October 2013 to January 2014, trained observers recorded hand hygiene compliance among staff in the ED according to the World Health Organization ‘My 5 Moments for Hand Hygiene’. Multivariable logistic regression was used to analyse the relationship between environmental conditions and hand hygiene compliance, while controlling for important covariates (eg, hand hygiene indication, glove use, shift, etc). Results A total of 1673 hand hygiene opportunities were observed. In multivariable analyses, hand hygiene compliance was significantly lower when the ED was at its highest level of crowding than when the ED was not crowded and lower among hallway care areas than semiprivate care areas (OR=0.39, 95% CI 0.28 to 0.55; OR=0.73, 95% CI 0.55 to 0.97). Conclusions Unique environmental conditions pose barriers to hand hygiene compliance in the ED setting and should be considered by ED hand hygiene improvement efforts. Further study is needed to evaluate the impact of these environmental conditions on actual rates of infection transmission.

Perceived barriers to infection prevention and control for nursing home certified nursing assistants: A qualitative study

Healthcare-associated infections, while preventable, result in increased morbidity and mortality in nursing home (NH) residents. Frontline personnel, such as certified nursing assistants (CNAs), are crucial to successful implementation of infection prevention and control (IPC) practices. The purpose of this study was to explore barriers to implementing and maintaining IPC practices for NH CNAs as well as to describe strategies used to overcome these barriers. We conducted a multi-site qualitative study of NH personnel important to infection control. Audio-recorded interviews were transcribed verbatim and transcripts were analyzed using conventional content analysis. Five key themes emerged as perceived barriers to effective IPC for CNAs: 1) language/culture; 2) knowledge/training; 3) per-diem/part-time staff; 4) workload; and 5) accountability. Strategies used to overcome these barriers included: translating in-services, hands on training, on-the-spot training for per-diem/part-time staff, increased staffing ratios, and inclusion/empowerment of CNAs. Understanding IPC barriers and strategies to overcome these barriers may better enable NHs to achieve infection reduction goals.

Common infection control practices in the emergency department: A literature review

Background Health care-associated infections (HAIs) are a major health concern, despite being largely avoidable. The emergency department (ED) is an essential component of the health care system and subject to workflow challenges, which may hinder ED personnel adherence to guideline-based infection prevention practices. Methods The purpose of this review was to examine published literature regarding adherence rates among ED personnel to selected infection control practices, including hand hygiene (HH) and aseptic technique during the placement of central venous catheters and urinary catheters. We also reviewed studies reporting rates of ED equipment contamination. PubMed was searched for studies that included adherence rates among ED personnel to HH during routine patient care, aseptic technique during the placement of central venous catheters and urinary catheters, and rates of equipment contamination. Results In total, 853 studies was screened, and 589 abstracts were reviewed. The full texts of 36 papers were examined, and 23 articles were identified as meeting inclusion criteria. Eight studies used various scales to measure HH compliance, which ranged from 7.7% to 89.7%. Seven articles examined central venous catheters inserted in the ED or by emergency medicine residents. Detail of aseptic technique practices during urinary catheterization was lacking. Four papers described equipment contamination in the ED. Conclusion Standardized methods and definitions of compliance monitoring are needed to compare results across settings.

Using Workflow Diagrams to Address Hand Hygiene in Pediatric Long-Term Care Facilities

Hand hygiene (HH) in pediatric long-term care settings has been found to be sub-optimal. Multidisciplinary teams at three pediatric long-term care facilities developed step-by-step workflow diagrams of commonly performed tasks highlighting HH opportunities. Diagrams were validated through observation of tasks and concurrent diagram assessment. Facility teams developed six workflow diagrams that underwent 22 validation observations. Four main themes emerged: 1) diagram specificity, 2) wording and layout, 3) timing of HH indications, and 4) environmental hygiene. The development of workflow diagrams is an opportunity to identify and address the complexity of HH in pediatric long-term care facilities.

Driven to distraction

OBJECTIVES To examine the apparent purpose of interruptions in a Pediatric Intensive Care Unit and opportunities to reduce their burden with informatics solutions. MATERIALS AND METHODS In this prospective observational study, researchers shadowed clinicians in the unit for one hour at a time, recording all interruptions participating clinicians experienced or initiated, their starting time, duration, and a short description that could help to infer their apparent purpose. All captured interruptions were classified inductively on their source and apparent purpose and on the optimal representational media for fulfilling their apparent purpose. RESULTS The researchers observed thirty-four one-hour sessions with clinicians in the unit, including 21 nurses and 13 residents and house physicians. The physicians were interrupted on average 11.9 times per hour and interrupted others 8.8 times per hour. Nurses were interrupted 8.6 times per hour and interrupted others 5.1 times per hour. The apparent purpose of interruptions included Information Seeking and Sharing (n=259, 46.3%), Directives and Requests (n=70, 12%), Shared Decision-Making (n=49, 8.8%), Direct Patient Care (n=36, 6.4%), Social (n=71, 12.7%), Device Alarms (n=28, 5%), and Non-Clinical (n=10, 1.8%); 6.6% were not classified due to insufficient description. Of all captured interruptions, 29.5% were classified as being better served with informational displays or computer-mediated communication. CONCLUSIONS Deeper understanding of the purpose of interruptions in critical care can help to distinguish between interruptions that require face-to-face conversation and those that can be eliminated with informatics solutions. The proposed taxonomy of interruptions and representational analysis can be used to further advance the science of interruptions in clinical care.

State focus on health care-associated infection prevention in nursing homes.

BACKGROUND Despite increased focus on health care-associated infections (HAI), between 1.6 and 3.8 million HAI occur annually among the vulnerable population residing in US nursing homes (NH). This study characterized state department of health (DOH) activities and policies intended to improve quality and reduce HAI in NH. METHODS We created a 17-item standardized data collection tool informed by 20 state DOH Web sites, reviewed by experts in the field and piloted by 2 independent reviewers (Cohens κ .45-.73). The tool and corresponding protocol were used to systematically evaluate state DOH Web sites and related links. RESULTS Three categories of data were abstracted: (1) consumer-directed information intended to increase accountability of and competition between NH, including mandatory HAI reporting and NH inspection reports; (2) surveyor training for federally-mandated NH inspections; and (3) guidance for NH providers to prevent HAI and monitor incidence. Only 5 states included HAI reporting in NH with differing HAI types and reporting requirements. CONCLUSION State DOH information and activities focused on NH quality and reducing HAI were inconsistent. Systematically characterizing state DOH efforts to reduce HAI in NH is important to interpret the effects of these activities.

Video-based Education to Reduce Distress and Improve Understanding among Pediatric MRI Patients: A Randomized Controlled Study

Purpose: Evaluate the effectiveness of an educational video vs. standard of care in improving relaxation and procedural understanding among pediatric patients undergoing a magnetic resonance imaging (MRI) procedure. Design and Methods: This pilot randomized controlled trial was conducted in a large, urban academic childrens hospital. Pediatric patients were randomized to receive either a 7‐minute educational video or standard of care. Standardized surveys, which consisted of a 1–10 visual analog scale and open‐ended questions were administered to patients to measure their level of relaxation, understanding of the procedure, and perceptions of the MRI education received. Bivariate statistics were used to compare changes in relaxation score and baseline understanding scores between study groups. Open‐ended questions were analyzed using content analysis. Results: A total of 50 pediatric patients completed the study. Improvements in relaxation scores and baseline procedural understanding scores were significantly higher among children 13–17 years of age who received the intervention compared to those that did not (P < 0.05). No statistically significant differences were noted in relaxation scores and procedural understanding scores among children < 13 years of age between study groups. A total of 26 patients, half from the control group and half from the intervention group responded to open‐ended survey questions. Content analysis revealed that nearly all respondents perceived the educational video to increase their understanding of the MRI procedure. Conclusions: Video‐based education effectively improved the relaxation and procedural understanding of children 13–17 years of age undergoing a MRI. Practice Implications: Nurses may use video‐based education to supplement existing MRI education among older children. HighlightsVideo‐based education improved the MRI procedural understanding of older children.Video‐based education decreased distress among older children undergoing MRI.Nurses may use video‐based education to improve MRI experiences among children.

Association of clinician burnout and perceived clinician-patient communication☆☆☆

Patient satisfaction in the emergency department (ED) has become increasingly important over the past decade [1]. Past work has found patient satisfaction associated with increased care compliance, [2,3] decreased litigation risk [4] and fiscal improvement for institutions [5]. In the context of this growing emphasis on patient satisfaction, a large body of work has attempted to identify ED stay factors associated with satisfaction. Previous work has examined the impact of environmental variables such as crowding [6] wait time [7] and analgesic use [8]. Another aspect of a patients ED stay that may play a significant role in patient satisfaction is clinician-patient communication. Strong clinicianpatient communication has been associated with multiple positive patient outcomes from medication compliance, [9] reduced stress, [10] and decreased litigation [11].While pastwork has noted that overall clinician-patient communication is associated with patient satisfaction, [11-13] less work has focused on individual provider level factors. In particular, clinician “burnout” may impact perceptions of clinician-patient communication. Burnout, defined by emotional exhaustion, physical fatigue, and cognitive weariness, [14] results from high and sustained levels of stress and is associatedwith feelings of irritability, fatigue, and cynicism [15]. In a sample of physicians across specialties adjusted for age, sex, hours worked, and years of practice, emergency physicians were at greatest risk for burnout (odds ratio [OR], 3.18; P b 0.001), with nearly 70% reporting burnout (the mean across specialties was under 50%) [16]. The negative impact of burnout on clinicians is broad including increased risk for depression, [17] anxiety, [18] and substance abuse [19]. However, clinician burnoutmay also affect patient care outcomes. Previous work has found clinician burnout associated with job absenteeism and increased medical errors [12]. The goal of this study was to build on this existing work and evaluate the association between clinician burnout and perceived clinician-patient communication in ED patients. We conducted a prospective observational study of 63 emergency staff (nurses and physicians) and 167 patients evaluated for potential acute coronary syndrome (ACS). We limited our patient cohort to potential ACS in order to attempt to account for variations in clinician-patient communication secondary tomedical illness. All patients receiving care in the ED and evaluated for ACSwere eligible. Clinician participants