M. Howlett

Burnout in emergency department healthcare professionals is associated with coping style: a cross-sectional survey.

Introduction Ineffective coping may lead to impaired job performance and burnout, with adverse consequences to staff well-being and patient outcomes. We examined the relationship between coping styles and burnout in emergency physicians, nurses and support staff at seven small, medium and large emergency departments (ED) in a Canadian health region (population 500 000). Methods Linear regression with the Coping Inventory for Stressful Situations (CISS) and Maslach Burnout Inventory (MBI) was used to evaluate the effect of coping style on levels of burnout in a cross-sectional survey of 616 ED staff members. CISS measures coping style in three categories: task-oriented, emotion-oriented and avoidance-oriented coping; MBI, in use for 30 years, assesses the level of burnout in healthcare workers. Results Task-oriented coping was associated with decreased risk of burnout, while emotion-oriented coping was associated with increased risk of burnout. Discussion Specific coping styles are associated with varied risk of burnout in ED staff across several different types of hospitals in a regional network. Coping style intervention may reduce burnout, while leading to improvement in staff well-being and patient outcomes. Further studies should focus on building and sustaining task-oriented coping, along with alternatives to emotion-oriented coping.

A Method for Reviewing the Accuracy and Reliability of a Five-Level Triage Process (Canadian Triage and Acuity Scale) in a Community Emergency Department Setting: Building the Crowding Measurement Infrastructure

Objectives. Triage data are widely used to evaluate patient flow, disease severity, and emergency department (ED) workload, factors used in ED crowding evaluation and management. We defined an indicator-based methodology that can be easily used to review the accuracy of Canadian Triage and Acuity Scale (CTAS) performance. Methods. A trained nurse reviewer (NR) retrospectively triaged two separate months ED charts relative to a set of clinical indicators based on CTAS Chief Complaints. Interobserver reliability and accuracy were compared using Kappa and comparative statistics. Results. There were 2838 patients in Trial 1 and 3091 in Trial 2. The rate of inconsistent triage was 14% and 16% (Kappa 0.596 and 0.604). Clinical Indicators “pain scale, chest pain, musculoskeletal injury, respiratory illness, and headache” captured 68% and 62% of visits. Conclusions. We have demonstrated a system to measure the levels of process accuracy and reliability for triage over time. We identified five key clinical indicators which captured over 60% of visits. A simple method for quality review uses a small set of indicators, capturing a majority of cases. Performance consistency and data collection using indicators may be important areas to direct training efforts.

Advanced Practice Nursing: Parameters for Successful Integration:

This article analyzes advanced practice nursing roles through a literature review and a pilot stakeholder survey in relation to five strategic areas: (1) definitions and scope of practice; (2) education, credentialing and regulation; (3) new roles in healthcare; (4) costs and benefits in health reform; and (5) implementation and relationships. The Canadian health services environment is best served by a multifaceted APN role, defined by a nursing paradigm that invokes collaborative relationships with physicians, and education and credentialing that is based on national standardization.

Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With Undifferentiated Hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators

Study objective Point‐of‐care ultrasonography protocols are commonly used in the initial management of patients with undifferentiated hypotension in the emergency department (ED). There is little published evidence for any mortality benefit. We compare the effect of a point‐of‐care ultrasonography protocol versus standard care without point‐of‐care ultrasonography for survival and clinical outcomes. Methods This international, multicenter, randomized controlled trial recruited from 6 centers in North America and South Africa and included selected hypotensive patients (systolic blood pressure <100 mm Hg or shock index >1) randomized to early point‐of‐care ultrasonography plus standard care versus standard care without point‐of‐care ultrasonography. Diagnoses were recorded at 0 and 60 minutes. The primary outcome measure was survival to 30 days or hospital discharge. Secondary outcome measures included initial treatment and investigations, admissions, and length of stay. Results Follow‐up was completed for 270 of 273 patients. The most common diagnosis in more than half the patients was occult sepsis. We found no important differences between groups for the primary outcome of survival (point‐of‐care ultrasonography group 104 of 136 patients versus standard care 102 of 134 patients; difference 0.35%; 95% binomial confidence interval [CI] –10.2% to 11.0%), survival in North America (point‐of‐care ultrasonography group 76 of 89 patients versus standard care 72 of 88 patients; difference 3.6%; CI –8.1% to 15.3%), and survival in South Africa (point‐of‐care ultrasonography group 28 of 47 patients versus standard care 30 of 46 patients; difference 5.6%; CI –15.2% to 26.0%). There were no important differences in rates of computed tomography (CT) scanning, inotrope or intravenous fluid use, and ICU or total length of stay. Conclusion To our knowledge, this is the first randomized controlled trial to compare point‐of‐care ultrasonography to standard care without point‐of‐care ultrasonography in undifferentiated hypotensive ED patients. We did not find any benefits for survival, length of stay, rates of CT scanning, inotrope use, or fluid administration. The addition of a point‐of‐care ultrasonography protocol to standard care may not translate into a survival benefit in this group.

A comparative study of patient characteristics, opinions, and outcomes, for patients who leave the emergency department before medical assessment

OBJECTIVE The emergency department (ED) left-without-being-seen (LWBS) rate is a performance indicator, although there is limited knowledge about why people leave, or whether they seek alternate care. We studied characteristics of ED LWBS patients to determine factors associated with LWBS. METHODS We collected demographic data on LWBS patients at two urban hospitals. Sequential LWBS patients were contacted and surveyed using a standardized telephone survey. A matched group of patients who did not leave were also surveyed. Data were analysed using the Fisher exact test, chi-square test, and student t-test. RESULTS The LWBS group (n=1508) and control group (n=1504) were matched for sex, triage category, recorded wait times, employment and education, and having a family physician. LWBS patients were younger, more likely to present in the evening or at night, and lived closer to the hospital. A long wait time was the most cited reason for leaving (79%); concern about medical condition was the most common reason for staying (96%). Top responses for improved likelihood of waiting were shorter wait times (LWBS, 66%; control, 31%) and more information on wait times (41%; 23%). A majority in both groups felt that their condition was a true emergency (63%; 72%). LWBS patients were more likely to seek further health care (63% v. 28%; p<0.001) and sooner (median time 1 day v. 2-4 days; p=0.002). Among patients who felt that their condition was not a true emergency, the top reason for ED attendance was the inability to see their family doctor (62% in both groups). CONCLUSION LWBS patients had similar opinions, experiences, and expectations as control patients. The main reason for LWBS was waiting longer than expected. LWBS patients were more likely to seek further health care, and did so sooner. Patients wait because of concern about their health problem. Shorter wait times and improved communication may reduce the LWBS rate.

Adapting Prehospital Care to a Large Rural Geographic Area: A Review of the Emergency Health Services Nova Scotia Implementation

Nova Scotia is building a system of prehospital care based on four principles: “Fail Safe” government ownership; “Full Service” advanced life support capable; “High Performance” resource efficiency; and “Fiscally Responsible” performance goals, incentives and penalties. Emergency Health Services Nova Scotia exercises funding and regulatory control through service provided by a private contractor. Benefits include improved fleet and equipment management, information systems, 911 dispatch and performance tracking, medical control and paramedic care, and public accountability. Problems include rural dispatch, budget costs, labour issues and stakeholder communication.

Evaluation of BD Vacutainer® Barricor™ blood collection tubes for routine chemistry testing on a Roche Cobas® 8000 Platform

INTRODUCTION Barricor™ Vacutainers® are a novel non-gel separator blood collection tube. These tubes enable faster pre-analytical processing which could reduce turnaround time and be beneficial in an acute care setting. We sought to evaluate the bias, stability, and integrity of plasma generated from these tubes compared to Plasma Separator Tubes™ (PST) for 50 routine chemistry analytes on a Roche Cobas® 8000 analyzer. METHODS Paired samples were collected from 150 patients originating in the emergency department and outpatient collections at the Saint John Regional Hospital. Barricor™ vacutainers were centrifuged for 3 min at 4000g and PST™ vacutainers for 10 min at 1300 g within two hours of collection. Plasma samples (n = 126) were then analyzed for 50 chemistry analytes and bias determined between tubes. Ten-day stability of AST, glucose, potassium, phosphate, and LDH was also assessed in a subset of paired samples (n = 4). Lastly, the quality of plasma (n = 20) was assessed through measurement of cell counts on a DxH Hematology Analyzer. RESULTS All 50 analytes demonstrated comparable results across a broad concentration range between Barricor™ and PST™ vacutainers (average percent bias -1.5% to 6.1%; Deming linear regression slopes 0.933-1.041; correlation coefficients ≥ 0.9144). AST, potassium, glucose and LDH were stable for 10 days in Barricor™ vacutainers (change from baseline < 10%) but <5 days in PST™ vacutainers while phosphate was stable for 4 days in Barricor™ vs 2 days in PST™ vacutainers. Platelet counts were statistically lower in Barricor™ compared to PST™ vacutainers. CONCLUSION Our data suggest that Barricor™ vacutainers are an acceptable alternative to PST™ vacutainers while offering the added benefit of decreased pre-analytical processing time, increased stability of certain analytes, and possibly less cellular contamination.

A comparison of work stressors in higher and lower resourced emergency medicine health settings

OBJECTIVES The study compares experiences of workplace stressors for emergency medicine trainees and specialists in settings where the specialty is relatively well resourced and established (Canada), and where it is newer and less well resourced (South Africa, (SA)). METHODS We conducted an online cross-sectional survey of emergency medicine trainees and physicians in both countries for six domains (demands, role, support, change, control, and relationships) using the validated Management Standards Indicator Tool (MSIT, Health, and Safety Executive, United Kingdom). RESULTS 74 SA and 430 Canadian respondents were included in our analysis. SA trainees (n=38) reported higher stressors (lower MSIT scores) than SA specialists (n=36) for demands (2.2 (95%CI 2.1-2.3) vs. 2.7 (2.5-2.8)), control (2.6 (2.4-2.7) vs. 3.5 (3.3-3.7)) and change (2.4 (2.2-2.6) vs. 3.0 (2.7-3.3)). In Canada, specialists (n=395) had higher demands (2.6 (2.6-2.7) vs. 3.0 (2.8-3.1)) and manager support stressors (3.3 (3.3-3.4) vs. 3.9 (3.6-4.1)) than trainees (n=35). Canadian trainees reported higher role stressors (4.0 (95%CI 3.8-4.1) vs. 4.2 (4.2-4.3)) than Canadian specialists. SA trainees had higher stressors on all domains than Canadian trainees. There was one domain (control) where Canadian specialists scored significantly lower than SA specialists, whereas SA specialists had significantly lower scores on peer support, relationships and role. CONCLUSIONS Work related stressor domains were different for all four groups. Perceived stressors were higher in all measured domains among SA trainees compared with Canadian trainees. The differences between the SA and Canadian specialists may reflect the developing nature of the specialty in SA, although the Canadian specialists reported less control over their work than SA counterparts.

Does Elimination of a Laboratory Sample Clotting Stage Requirement Reduce Overall Turnaround Times for Emergency Department Stat Biochemical Testing

Introduction: Laboratory turnaround times (TAT) influence length of stay for emergency department (ED) patients. We studied biochemistry TATs around the implementation of a plasma separating tube (PST) that omitted a 20-minute clotting step in processing when compared to the standard serum separating tubes (SST). Methods: We compared laboratory TATs using PST vs SST in a prospective before-and-after study with a washout period. TATs for creatinine, urea, electrolytes, troponin, and N-terminal pro b-type natriuretic peptide (NT-proBNP), as well as hemolysis rates, were collected for all ED patients. Results were excluded if the TAT was four minutes or less (data entry error). We recorded the 90th percentile response times (TAT90; the time for 90% of the tests to be completed). Statistical analysis used survival analyses, Mann-Whitney U tests, and Chi-square tests of independence. Results: SST and PST groups were matched for days of the week, critical values, or hemolysis. There was a statistically significant reduction in median TAT and proportion completed by 60 minutes. However, the effect size was only two to four minutes in the In-Lab-TAT90 with the PST tubes for all tests, except B-type natriuretic peptide (BNP). Conclusions: Reducing the machine processing time for stat blood work with PST tubes did not produce a clinically meaningful reduction of TAT. Clinically important improvement for Lab TAT requires process analysis and intervention that is inclusive of the entire system. Fractile response times at a 90th percentile for TAT within 60 minutes may be an accurate benchmark for analysis.

Are Postgraduate Medical Residency Training Positions in Atlantic Canada Evenly Distributed

Background The distribution of postgraduate medical training (residency) positions in Canada is administered by medical schools and universities in conjunction with individual provinces. In Atlantic Canada, the Maritime provinces are considered a single unit under Dalhousie University in Nova Scotia (NS), although distributed medical undergraduate education through Dalhousie and Sherbrooke has enabled medical students to complete their entire course of study in New Brunswick (NB). It is unclear if postgraduate medical education has been distributed in a similar fashion in Atlantic Canada, particularly in New Brunswick and Prince Edward Island (PE). Methods Data on the number of R1 residency positions was obtained from the Canadian Resident Matching Service (CaRMS) database. The distribution of R1 positions was described and compared nationally and through the Atlantic provinces. The analysis was completed using MS Excel and Prism. Results Rates of R1 positions per million persons varied widely; the national median rate was 97 positions per million persons, with a range of 34 to 138. The combined Maritime provinces rate of R1 positions was 71 per million persons and the rate in Newfoundland (NL) was 138 positions per million. The NS rate was 106 positions per million while the NB rate was 54 per million and the PE rate 34 per million. Sixty-four percent of all residency training positions in Atlantic Canada were based in the two most urban areas of Halifax, NS or St John’s, NL. Royal College (specialty) positions were more likely to be based at the main university campus city than family medicine training positions (97 vs. 3%; 33 vs. 67%, respectively). Conclusion There is a high level of variation in available residency positions among the individual provinces, especially in Atlantic Canada. The lower prevalence of opportunities in NB and PE may influence the ability of these provinces to recruit and retain new physicians.