Julia Crilly

Clinical handover of patients arriving by ambulance to the emergency department – A literature review

AIM To provide a critical review of research on clinical handover between the ambulance service and emergency department (ED) in hospitals. METHOD Data base and hand searches were conducted using the keywords ambulance, handover, handoff, emergency department, emergency room, ER, communication, and clinical handover. Data were extracted, summarised and critically assessed to provide evidence of current clinical handover processes. RESULTS From 252 documents, eight studies fitted the inclusion criteria of clinical handover and the ambulance to ED patient transfer. Three themes were identified in the review: (1) important information may be missed during clinical handover; (2) structured handovers that include both written and verbal components may improve information exchange; (3) multidisciplinary education about the clinical handover process may encourage teamwork, a shared common language and a framework for minimum patient information to be transferred from the ambulance service to the hospital ED. CONCLUSION Knowledge gaps exist concerning handover information, consequences of poor handover, transfer of responsibility, staff perception of handovers, staff training and evaluation of recommended strategies to improve clinical handover. Evidence of strategies being implemented and further research is required to examine the ongoing effects of implementing the strategies.

Clinical handover of patients arriving by ambulance to a hospital emergency department: a qualitative study.

AIM The aims of this study were to (1) explore the clinical handover processes between ambulance and ED personnel of patients arriving by ambulance at one hospital and (2) identify factors that impact on the information transfer to ascertain strategies for improvement. METHODS A focused ethnographic approach was used that included participant observation, conversational interviews and examination of handover tools. Participants included ambulance paramedics, nurses and medical practitioners from an ambulance service and regional hospital located in South East Queensland, Australia. Grounded theory methods of constant comparative data analyses were used to generate categories of findings. FINDINGS Two types of clinical handover were identified: (1) for non-critical patients and (2) for critical patients. Quality of handover appears to be dependent on the personnels expectations, prior experience, workload and working relationships. Lack of active listening and access to written information were identified issues. CONCLUSION Clinical handover between two organisations with different cultures and backgrounds may be improved through shared training programmes involving the use of guidelines, tools such as a whiteboard and a structured communication model such as MIST. Future participatory research to evaluate new handover strategies is recommended.

An outcomes evaluation of an Australian Hospital in the Nursing Home admission avoidance programme

AIMS AND OBJECTIVES To undertake an outcomes evaluation of a Hospital in the Nursing Home (HINH) admission avoidance programme. BACKGROUND Admission avoidance type services such as Hospital in the Home have a place in improving service delivery for certain population groups. Research related to HINH has been limited, derived from various different health care systems internationally and results are varied. DESIGN A quasi-experimental study was conducted at one regional hospital. Routinely collected health information system data from two separate data sources were linked to undertake analysis. METHODS Those in the intervention group were matched to a comparison group of patients on the basis of three characteristics (age, gender and diagnostic category). Other factors that could affect a patients hospital outcomes and length of stay (LOS) were statistically controlled for. Participants were aged care facility residents enrolled in a HINH programme (n = 62) and a matched group receiving usual in-hospital care (n = 115). Emergency department (ED) outcome measures included LOS and re-presentation. Hospital admission-related outcome measures included episode of care LOS, in-hospital LOS and hospital readmission. RESULTS A significant independent relationship between HINH programme enrolment and shorter in-hospital LOS was identified even after adjusting for other characteristics OR 0·16 (95% CI 0·28, 0·99 p < 0·001). CONCLUSION The HINH model evaluated, with its focus on delivering acute care for aged care facility residents, can impact on health service delivery. RELEVANCE TO CLINICAL PRACTICE With a demonstrated reduction in in-hospital LOS, the available bed space created can be used for other patients perhaps waiting in the ED or waiting for surgery.

The haemodynamic response to pre-hospital RSI in injured patients ☆

BACKGROUND Laryngoscopy and tracheal intubation provoke a marked sympathetic response, potentially harmful in patients with cerebral or cardiovascular pathology or haemorrhage. Standard pre-hospital rapid sequence induction of anaesthesia (RSI) does not incorporate agents that attenuate this response. It is not known if a clinically significant response occurs following pre-hospital RSI or what proportion of injured patients requiring the intervention are potentially at risk in this setting. METHODS We performed a retrospective analysis of 115 consecutive pre-hospital RSIs performed on trauma patients in a physician-led Helicopter Emergency Medical Service. Primary outcome was the acute haemodynamic response to the procedure. A clinically significant response was defined as a greater than 20% change from baseline recordings during laryngoscopy and intubation. RESULTS Laryngoscopy and intubation provoked a hypertensive response in 79% of cases. Almost one-in-ten patients experienced a greater than 100% increase in mean arterial pressure (MAP) and/or systolic blood pressure (SBP). The mean (95% CI) increase in SBP was 41(31-51) mmHg and MAP was 30(23-37) mmHg. Conditions leaving the patient vulnerable to secondary injury from a hypertensive response were common. CONCLUSIONS Laryngoscopy and tracheal intubation, following a standard pre-hospital RSI, commonly induced a clinically significant hypertensive response in the trauma patients studied. We believe that, although this technique is effective in securing the pre-hospital trauma airway, it is poor at attenuating adverse physiological effects that may be detrimental in this patient group.

Safety and effectiveness of high-dose midazolam for severe behavioural disturbance in an emergency department with suspected psychostimulant-affected patients.

Objectives:  To trial high‐dose midazolam sedation protocol for uncooperative patients with suspected psychostimulant‐induced behavioural disorders. End‐points were effectiveness and safety.

A structure and process evaluation of an Australian hospital admission avoidance programme for aged care facility residents

AIM To describe and evaluate the structures and processes involved in a hospital in the Nursing Home programme. BACKGROUND Older Australians are the largest consumers of healthcare, and as a result of the ageing process are at risk of developing hospital acquired iatrogenic complications. Hospital admission avoidance programmes that aim to provide care for patients in their own environment include Hospital in the Home and, more recently, Hospital in the Nursing Home. METHODS In 2006, a qualitative evaluation of a nurse-led Hospital in the Nursing Home programme using semi-structured interviews with 19 stakeholders was undertaken. Data analysis involved using start codes and content analysis. FINDINGS Effective referral and communication strategies were important for Hospital in the Nursing Home implementation. Furthermore, the Hospital in the Nursing Home programme manager had acute care and community experience and worked in an advanced practice role. These elements were integral to the programmes operation. CONCLUSION As the population ages, reducing hospital admissions for aged-care facility residents has the potential to improve patient outcomes. A structurally and procedurally sound programme is a key element in achieving this aim.

Review article: Staff perception of the emergency department working environment: Integrative review of the literature

Employees in EDs report increasing role overload because of critical staff shortages, budgetary cuts and increased patient numbers and acuity. Such overload could compromise staff satisfaction with their working environment. This integrative review identifies, synthesises and evaluates current research around staff perceptions of the working conditions in EDs. A systematic search of relevant databases, using MeSH descriptors ED/EDs, Emergency room/s, ER/s, or A&E coupled with (and) working environment, working condition/s, staff perception/s, as well as reference chaining was conducted. We identified 31 key studies that were evaluated using the mixed methods assessment tool (MMAT). These comprised 24 quantitative‐descriptive studies, four mixed descriptive/comparative (non‐randomised controlled trial) studies and three qualitative studies. Studies included varied widely in quality with MMAT scores ranging from 0% to 100%. A key finding was that perceptions of working environment varied across clinical staff and study location, but that high levels of autonomy and teamwork offset stress around high pressure and high volume workloads. The large range of tools used to assess staff perception of working environment limits the comparability of the studies. A dearth of intervention studies around enhancing working environments in EDs limits the capacity to recommend evidence‐based interventions to improve staff morale.

Review article: systematic review of three key strategies designed to improve patient flow through the emergency department.

To explore the literature regarding three key strategies designed to promote patient throughput in the ED. CINAHL, Medline, PubMed, Scopus and Australian Government databases were searched for articles published between 1980 and 2014 using the key search terms ED flow/throughput, ED congestion, crowding, overcrowding, models of care, physician‐assisted triage, medical assessment units, nurse practitioner, did not wait (DNW) and ED length of stay (LOS). Abstracts and articles not published in English and articles published before 1980 were excluded from the review. Quantitative and qualitative studies were considered for inclusion. The National Health Medical Research Council (NHMRC) Level of Evidence Hierarchy (2009) was applied to included studies. Twenty‐one articles met criteria for review. The level of evidence assessed using the NHMRC guidelines of studies ranged from I to IV, with the majority falling into the Level II‐2 (n = 6) and III‐3 (n = 9) range. ED LOS was the outcome most often reported. Study quality was limited with few studies adjusting for confounding factors. Only one level I systematic review was included in this review. Advanced practice nursing roles, physician‐assisted triage and medical assessment units are models of care that can positively impact ED throughput. They have been shown to decrease ED LOS and DNW rates. Confounding factors, such as site specific staffing requirements, patient acuity and rest‐of‐hospital processes, can also impact on patient throughput through the ED.

Effect of the increase in "alcopops" tax on alcohol-related harms in young people: a controlled interrupted time series.

Objective: To measure alcohol‐related harms to the health of young people presenting to emergency departments (EDs) of Gold Coast public hospitals before and after the increase in the federal government “alcopops” tax in 2008.

Paramedic rapid sequence induction (RSI) in a South African emergency medical service: A retrospective observational study

BACKGROUND Early access to critical care interventions may improve outcomes for severely ill and injured patients. South Africa (SA) faces the unique challenges of prolonged pre-hospital times and limited access to physicians. In 2008, the Health Professions Council of SA introduced paramedic rapid sequence induction (RSI), the gold standard critical care intervention for emergency airway management; however, the risk to benefit ratio in this context is unclear. OBJECTIVE We conducted a pilot study to identify if paramedic RSI in the SA pre-hospital care setting is effective and safe. METHODS We undertook a retrospective observational study of paramedic RSI performed by an emergency medical service, between 12 December 2009 and 12 December 2011. RESULTS Eighty-six RSIs were performed during the study period. No failed intubations were reported. Heart rate was significantly reduced from a median baseline value of 112 to 90 bpm, and oxygen saturations improved from 92% to 99% at handover following RSI. Nineteen patients (22%), however, had an adverse event (AE). Female patients (odds ratio (OR) 18.3; 95% confidence interval (CI) 3.46 - 99.38; p=0.001) and patients subsequently transported by helicopter (OR 7.24; 95% CI 1.44 - 36.32; p=0.016) remained independently associated with AEs after adjusting for confounders. CONCLUSIONS RSI performed by specially trained paramedics is effective in terms of self-reported success. However, the 1 in 5 AE rate highlights safety concerns. The importance of a robust clinical governance programme to identify problems, refine practice and improve the quality of care is underscored.