Katarina E. Göransson

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

BackgroundOvercrowding in emergency departments is a worldwide problem. A systematic literature review was undertaken to scientifically explore which interventions improve patient flow in emergency departments.MethodsA 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.ResultsThe 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.ConclusionsIntroducing 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.

Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival

AIMS To describe out-of-hospital cardiac arrest (OHCA) in Sweden from a long-term perspective in terms of changes in outcome and circumstances at resuscitation. METHODS AND RESULTS All cases of OHCA (n = 59,926) reported to the Swedish Cardiac Arrest Register from 1992 to 2011 were included. The number of cases reported (n/100,000 person-years) increased from 27 (1992) to 52 (2011). Crew-witnessed cases, cardiopulmonary resuscitation prior to the arrival of the emergency medical service (EMS), and EMS response time increased (P < 0.0001). There was a decrease in the delay from collapse to calling for the EMS in all patients and from collapse to defibrillation among patients found in ventricular fibrillation (P < 0.0001). The proportion of patients found in ventricular fibrillation decreased from 35 to 25% (P < 0.0001). Thirty-day survival increased from 4.8 (1992) to 10.7% (2011) (P < 0.0001), particularly among patients found in a shockable rhythm and patients with return of spontaneous circulation (ROSC) at hospital admission. Among patients hospitalized with ROSC in 2008-2011, 41% underwent therapeutic hypothermia and 28% underwent percutaneous coronary intervention. Among 30-day survivors in 2008-2011, 94% had a cerebral performance category score of 1 or 2 at discharge from hospital and the results were even better if patients were found in a shockable rhythm. CONCLUSION From a long-term perspective, 30-day survival after OHCA in Sweden more than doubled. The increase in survival was most marked among patients found in a shockable rhythm and those hospitalized with ROSC. There were improvements in all four links in the chain of survival, which might explain the improved outcome.

Interruptions in emergency department work: an observational and interview study

Objective Frequent interruptions are assumed to have a negative effect on healthcare clinicians’ working memory that could result in risk for errors and hence threatening patient safety. The aim of this study was to explore interruptions occurring during common activities of clinicians working in emergency departments. Method Totally 18 clinicians, licensed practical nurses, registered nurses and medical doctors, at two Swedish emergency departments were observed during clinical work for 2 h each. A semistructured interview was conducted directly after the observation to explore their perceptions of interruptions. Data were analysed using non-parametric statistics, and by quantitative and qualitative content analysis. Results The interruption rate was 5.1 interruptions per hour. Most often the clinicians were exposed to interruptions during activities involving information exchange. Calculated as percentages of categorised performed activities, preparation of medication was the most interrupted activity (28.6%). Face-to-face interaction with a colleague was the most common way to be interrupted (51%). Most common places for interruptions to occur were the nurses’ and doctors’ stations (68%). Medical doctors were the profession interrupted most often and were more often recipients of interruptions induced by others than causing self-interruptions. Most (87%) of the interrupted activities were resumed. Clinicians often did not regard interruptions negatively. Negative perceptions were more likely when the interruptions were considered unnecessary or when they disturbed the work processes. Conclusions Clinicians were exposed to interruptions most often during information exchange. Relative to its occurrence, preparation of medication was the most common activity to be interrupted, which might increase risk for errors. Interruptions seemed to be perceived as something negative when related to disturbed work processes.

Education in cardiopulmonary resuscitation in Sweden and its clinical consequences

AIM To describe the use of cardiopulmonary resuscitation (CPR) training programmes in Sweden for 25 years and relate those to changes in the percentage of patients with out of hospital cardiac arrest (OHCA) who receive bystander CPR. METHODS Information was gathered from (a) the Swedish CPR training registry established in 1983 and includes most Swedish education programmes in CPR and (b) the Swedish Cardiac Arrest Register (SCAR) established in 1990 and currently covers about 70% of ambulance districts in Sweden. RESULTS CPR education in Sweden functions according to a cascade principle (instructor-trainers who train instructors who then train rescuers in CPR). Since 1989, 5000 instructor-trainers have taught more than 50,000 instructors who have taught nearly 2 million of Swedens 9 million inhabitants adult CPR. This is equivalent to one new rescuer per 100 inhabitants every year in Sweden. In addition, since 1989, there are 51,000 new rescuers in Advanced Life Support (ALS), since 1996, 41,000 new Basic Life Support (BLS) rescuers with Automated External Defibrillation (AED) training, and since 1998, there are 93,000 new rescuers in child CPR. As a result of this CPR training the number of bystander CPR attempts for OHCA in Sweden increased from 31% in 1992 to 55% in 2007. CONCLUSION By using a cascade principle for CPR education nearly 2 million rescuers were educated in Sweden (9 million inhabitants) between 1989 and 2007. This resulted in a marked increase in bystander CPR attempts.

Validity of reported data in the Swedish Cardiac Arrest Register in selected parts in Sweden

AIM To describe differences and similarities between reported and non-reported data in the Swedish Cardiac Arrest Register in selected parts in Sweden. METHODS Prospective and retrospective data for treated OHCA patients in Sweden, 2008-2010, were compared in the Swedish Cardiac Arrest Register. Data were investigated in three Swedish counties, which represented one third of the population. The recording models varied. Prospective data are those reported by the emergency medical service (EMS) crews, while retrospective data are those missed by the EMS crews but discovered afterwards by cross-checking with the local ambulance register. RESULT In 2008-2010, the number of prospectively (n=2398) and retrospectively (n=800) reported OHCA cases was n=3198, which indicates a 25% missing rate. When comparing the two groups, the mean age was higher in patients who were reported retrospectively (69 years vs. 67 years; p=0.003). There was no difference between groups with regard to gender, time of day and year of OHCA, witnessed status or initial rhythm. Bystander cardiopulmonary resuscitation (CPR) was more frequent among patients who were reported prospectively (65% vs. 60%; p=0.023), whereas survival to one month was higher among patients who were reported retrospectively (9.2% vs. 11.9%; p=0.035). CONCLUSION Among 3198 cases of OHCA in three counties in Sweden, 800 (25%) were not reported prospectively by the EMS crews but were discovered retrospectively as missing cases. Patients who were reported retrospectively differed from prospectively reported cases by being older, having less frequently received bystander CPR but having a higher survival rate. Our data suggest that reports on OHCA from national quality registers which are based on prospectively recorded data may be influenced by selection bias.

Swedish emergency department triage and interventions for improved patient flows: a national update

BackgroundIn Scandinavia, emergency department triage and patient flow processes, are under development. In Sweden, the triage development has resulted in two new triage scales, the Adaptive Process Triage and the Medical Emergency Triage and Treatment System. Both these scales have logistic components, aiming to improve patient flows. The aim of this study was to report the development and current status of emergency department triage and patient flow processes in Sweden.MethodsIn 2009 and 2010 the Swedish Council on Health Technology Assessment sent out a questionnaire to the ED managers in all (74) Swedish hospital emergency departments. The questionnaire comprised questions about triage and interventions to improve patient flows.ResultsNearly all (97%) EDs in Sweden employed a triage scale in 2010, which was an increase from 2009 (73%). Further, the Medical Emergency Triage and Treatment System was the triage scale most commonly implemented across the country. The implementation of flow-related interventions was not as common, but more than half (59%) of the EDs have implemented or plan to implement nurse requested X-ray.ConclusionsThere has been an increase in the use of triage scales in Swedish EDs during the last few years, with acceleration for the past two years. Most EDs have come to use the Medical Emergency Triage and Treatment System, which also indicates regional co-operation. The implementation of different interventions for improved patient flows in EDs most likely is explained by the problem of crowding. Generally, more studies are needed to investigate the economical aspects of these interventions.

Medical errors and complaints in emergency department care in Sweden as reported by care providers, healthcare staff, and patients - a national review.

Objective Despite an increase in research, there is still a lack of knowledge about patient safety in emergency departments (EDs) in many European countries. The aim of this study was therefore to describe the incidence and types of reported medical errors and complaints in ED care in Sweden. Methods Data reported in 2009 were gathered from national authorities, including the National Board of Health and Welfare, the Medical Responsibility Board, the Patients Advisory Committees, and local incident-reporting systems. Data were analyzed by content analysis. Results Among 428 cases reported by care providers to the National Board of Health and Welfare, 64 (15.0%) were related to ED care. As several cases contained more than one medical error, 92 errors were identified, out of which 39 (42.4%) were related to diagnostic procedures. Among the 4628 cases of complaints reported by patients to the Medical Responsibility Board, 306 (6.6%) were related to ED care. In total, 437 complaints regarding perceived medical errors were identified (several cases contained more than one error), with 189 (43.2%) pertaining to diagnostic procedures. A total of 1341 complaints about ED care were made by patients to the Patients Advisory Committees (n=21), of which 655 (48.8%) were related to care and treatment. There were 7434 medical errors reported to local incident-reporting systems at the EDs (n=45). Of these, 1450 (19.5%) referred to care and treatment. Conclusion Medical errors and complaints at Swedish EDs, as reported by both patients and care providers, were related mainly to diagnostic procedures and treatments.

Patient experience of the triage encounter in a Swedish emergency department

UNLABELLED Emergency department triage is a prerequisite for the rapid identification of critically ill patients and for allocation of the correct acuity level which is pivotal for medical safety. The patients first encounter with a medical professional in the emergency department is often with the triage nurse. OBJECTIVES To identify patient experience of the triage encounter. METHODS A questionnaire focusing on the patient-triage nurse relationship in terms of satisfaction with the medical and administrative information, privacy and confidentiality in the triage area as well as triage nurse competence and attitude was answered by 146 participating patients. RESULTS The majority of patients perceived that while they were triaged immediately upon arrival to the emergency department, they were often given limited information about the waiting time. Although almost a quarter of the patients did not wish to have information about their medical condition from the triage nurse, 97% of the patients considered the triage nurse to be medically competent for the triage task. CONCLUSIONS Patients were generally satisfied with the reception and care given by the triage nurses, but less satisfied about information about expected waiting time. We suggest therefore, that patients should be routinely informed about their estimated waiting time to be seen by the doctor in addition to their triage level.

An observational study of activities and multitasking performed by clinicians in two Swedish emergency departments

Objectives To explore the type and frequency of activities and multitasking performed by emergency department clinicians. Methods Eighteen clinicians (licensed practical nurses, registered nurses and medical doctors), six from each occupational group, at two Swedish emergency departments were followed in their clinical work for 2 h each to observe all their activities and multitasking practices. Data were analysed using qualitative and quantitative content analysis. Results Fifteen categories of activities could be identified based on 1882 observed activities during the 36 h of observation. The most common activity was information exchange, which was most often performed face-to-face. This activity represented 42.1% of the total number of observed activities. Information exchange was also the most common activity to be multitasked. Registered nurses performed most activities and their activities were multitasked more than the other clinicians. The nurses’ and doctors’ offices were the most common locations for multitasking in the emergency department. Conclusion This study provides new knowledge regarding the activities conducted by clinicians in the emergency department. The most frequent activity was information exchange, which was the activity most often performed by the clinicians when multitasking occurred. Differences between clinicians were found for activities performed and multitasked, with registered nurses showing the highest frequencies for both.

Indication and usage of peripheral venous catheters inserted in adult patients during emergency care

Purpose The aim of this study was to identify the underlying decisions taken regarding the insertion of prehospital peripheral venous catheters in adult patients and, additionally, to ascertain peripheral venous catheter insertion rate and explore prehospital and hospital (within 24 hours of insertion) pharmaceutical treatment via peripheral venous catheters. Method This cross-sectional study gathered data through a study-specific questionnaire and patient record auditing. We distributed a study-specific questionnaire to be completed by ambulance crews, and carried out patient record auditing for 345 patients (median age 64 years, range 18–97 years) arriving at the emergency department at a Swedish level-1 trauma center in October 2008. Results Of 135 patients (39%) arriving at the emergency department with a peripheral venous catheter, 94 (70%) had received the device because the ambulance crews intended to use it for intravenous therapeutics (of which analgesics, intravenous fluids, and psycholeptics were most frequently used). In 30 patients (22%), the prehospital inserted device was not used by the ambulance crews or at hospital within 24 hours. The corresponding rate of unused peripheral venous catheters inserted in patients after arrival at the hospital was 35%. Conclusions We found that the main reason for the ambulance staff to insert a peripheral venous catheter in a prehospital setting was that they intended to use the device. Further, the rate of unused peripheral venous catheters was lower among prehospital peripheral venous catheters than hospital.