When less is more: Emergency department staffing in Greece

338 Provider Opinions of Emergency Department HIV Testing Before and After Program Implementation

BackgroundPatient health-related social needs (HRSN) complicate care and drive poor outcomes in emergency department (ED) settings. This study sought to understand what HRSN information is available to ED physicians and staff, and how HRSN-related clinical actions may or may not align with patient expectations.MethodsWe conducted a qualitative study using in-depth semi-structured interviews guided by HRSN literature, the 5 Rights of Clinical Decision Support (CDS) framework, and the Contextual Information Model. We asked ED providers, ED staff, and ED patients from one health system in the mid-Western United Stated about HRSN information availability during an ED encounter, HRSN data collection, and HRSN data use. Interviews were recorded, transcribed, and analyzed using modified thematic approach.ResultsWe conducted 24 interviews (8 per group: ED providers, ED staff, and ED patients) from December 2022 to May 2023. We identified three themes: (1) Availability: ED providers and staff reported that HRSNs information is inconsistently available. The availability of HRSN data is influenced by patient willingness to disclose it during an encounter. (2) Collection: ED providers and staff preferred and predominantly utilized direct conversation with patients to collect HRSNs, despite other methods being available to them (e.g., chart review, screening questionnaires). Patients’ disclosure preferences were based on modality and team member. (3) Use: Patients wanted to be connected to relevant resources to address their HRSNs. Providers and staff altered clinical care to account for or accommodate HRSNs. System-level challenges (e.g., limited resources) limited provider and staff ability to address patients HRSNs.ConclusionsIn the ED, HRSNs information was inconsistently available, collected, or disclosed. Patients and ED providers and staff differed in their perspectives on how HSRNs should be collected and acted upon. Accounting for such difference in clinical and administrative decisions will be critical for patient acceptance and effective usage of HSRN information.

Background Limited information is available on the extent of Emergency Department (ED) staff knowledge of frailty and frailty screening tools. Educational challenges unique to the ED environment are also little researched. This multi-site staff survey explores frailty knowledge and use of frailty screening tools in Irish emergency departments, as well as detailing educational challenges faced in the ED environment Methods A mixed-methods multi-site survey of twenty-five Irish adult emergency departments, aimed at all grades of ED staff. An anonymous online survey consisting of twenty-five statements across five categories was distributed via staff email at these sites. Five free-text sections were included after each category. Quantitative data were managed and analysed using IBM SPSS Statistics software. Qualitative results were analysed using reflexive thematic analysis Results 181 ED staff (nursing, medical and allied health) across all grades responded to the survey. ED nursing staff made up the largest staff category (n=80, 44%). Less than half of respondents had received training on frailty identification (n=88, 48%,p=0.028), yet the majority felt confident of identifying frailty (n=99, 54%, p=0.007). ED staff aged under 35 years felt nursing staff were the most appropriate group to screen for frailty in ED (N=88, 87%, P=0.017). Most respondents felt overwhelmed by time pressures in ED, which left little opportunity for dedicated teaching (n=77, 45%). A thematic map was created to explore obstacles to frailty screening in ED. Conclusion The opinion of ED staff surveyed was that frailty screening is feasible to undertake in ED but quick, user-friendly frailty screening instruments are lacking. Most ED staff surveyed relied on clinical judgement rather than frailty teaching experience to diagnose frailty syndromes. The provision of inclusive education in ED is challenging. Learning strategies in ED should reflect the demands of the acute care environment and incorporate a flexible, hybrid multi-disciplinary teaching model

A Survey of Staff Perceptions of an Emergency Medicine Pharmacist Program in a Community Hospital: A Brief Report

The purpose of this study was to identify the role of emergency department (ED) design on ED staff satisfaction and performance. High patient volume, surging workloads, and violent behaviors are expected pressures for ED staff. Literature suggests the substantial role of the physical environment in the delivery of care and its role in staff and patient experiences. Nevertheless, limited studies have explored simultaneous interactions between ED physical design elements, attributes (security, wayfinding, visibility, privacy, and efficiency), and staff satisfaction or performance. Interviews, surveys, visibility graph analysis, and agent simulations were employed to understand the connection between ED physical design, attributes, performance, and staff satisfaction. Enhanced security, effective wayfinding, team visibility, noise reduction, adequate privacy, and accessible supplies and equipment were significant predictors of staff satisfaction and performance. Unobstructed views in waiting and triage and controlled entrances were critical for improving security. To improve wayfinding, eye-level signage, reducing surveillance obstacles, and creating direct public routes were recommended. Rectangular units with multiple perpendicularly connected corridors and linear pod arrangements enhanced movement. Including team rooms and enclosed ERs were recommended for privacy improvements. Visibility was critical for team communication and improved by including short-distanced perpendicular corridors and eliminating columns. Enhancing access to supplies or equipment and reducing noise levels improved the perception of staff efficiency. The findings contribute to the general body of knowledge on the impact of ED physical design on attributes that potentially improve staff satisfaction and work performance.

Blood culture contamination is a common problem in the emergency department (ED) that leads to unnecessary patient morbidity and health care costs. The study objective was to develop and evaluate the effectiveness of a quality improvement (QI) intervention for reducing blood culture contamination in an ED. The authors developed a QI intervention to reduce blood culture contamination in the ED and then evaluated its effectiveness in a prospective interrupted times series study. The QI intervention involved changing the technique of blood culture specimen collection from the traditional clean procedure to a new sterile procedure, with standardized use of sterile gloves and a new materials kit containing a 2% chlorhexidine skin antisepsis device, a sterile fenestrated drape, a sterile needle, and a procedural checklist. The intervention was implemented in a university-affiliated ED and its effect on blood culture contamination evaluated by comparing the biweekly percentages of blood cultures contaminated during a 48-week baseline period (clean technique) and 48-week intervention period (sterile technique), using segmented regression analysis with adjustment for secular trends and first-order autocorrelation. The goal was to achieve and maintain a contamination rate below 3%. During the baseline period, 321 of 7,389 (4.3%) cultures were contaminated, compared to 111 of 6,590 (1.7%) during the intervention period (p < 0.001). In the segmented regression model, the intervention was associated with an immediate 2.9% (95% confidence interval [CI] = 2.2% to 3.2%) absolute reduction in contamination. The contamination rate was maintained below 3% during each biweekly interval throughout the intervention period. A QI assessment of ED blood culture contamination led to development of a targeted intervention to convert the process of blood culture collection from a clean to a fully sterile procedure. Implementation of this intervention led to an immediate and sustained reduction of contamination in an ED with a high baseline contamination rate.

To assess the opinion of Belgian Emergency Department (ED) staff regarding family-witnessed resuscitation (FWR). All 142 Belgian EDs were sent a questionnaire on hospital-related data and personal questionnaires for the ED staff concerning their opinion on FWR. Opinions of physicians, nurses and other emergency care providers were compared and related with hospital or sociodemographic data. Eighty-five ED services (60%) responded with a total of 1143 personal questionnaires: of these 79% were nurses, and 19% physicians. Eighty percent of the hospitals had a prehospital intervention team. Only two departments (2.5%) practiced structured FWR; 21% put the relatives in the corridor. Eleven percent did not give any information at all to relatives. Fourteen percent organized 'training in coping with relatives'. Forty-one percent of the staff members had been asked for FWR but only 33% were positive about it. Fifty-six percent thought that relatives could be of use in the shock room. Sixty-six percent experienced it as a burden. Sixty-five percent thought that FWR helps in grieving but 93% feared traumatic distress. Sixty-four percent would like to attend the resuscitation of their own relatives. Thirty-five percent fear a high risk of complaints. Prehospital experience, higher workload, seniority and male staff are significant advantages towards FWR. Emergency physicians are more positive towards FWR, nurses less so, followed by other physicians. The Belgian ED staff is still unconvinced about FWR. Despite evidence-based data they still think that resuscitation is traumatizing for relatives. Experience, both in as well as out of hospital, is a positive factor.

The level of expertise and degree of training in neonatal resuscitation (NNR) of emergency physicians is not standardized and has not been measured. We sought to determine the self-reported comfort with, knowledge of, and experience with NNR of emergency department (ED) staff in a general ED prior to the opening of a new neonatal intensive care unit (NICU) and to explore factors associated with NNR comfort. Using Dillman methodology, we electronically surveyed full-time emergency physicians and nurses. Participants rated knowledge, comfort, and experience on 5-point Likert scales. We used logistic regression to explore factors associated with NNR comfort. The response rate was 67.3% (n = 107). Only 4.2% of staff reported ever participating in a NNR, and only 38.7% reported any previous NNR training. Between 75 and 85% of participants rated their comfort level in caring for neonates, sense of preparedness, and knowledge of managing a sick neonate as poor or very poor. A recent neonatal clinical encounter was the strongest predictor of perceived comfort in NNR (OR = 22.2, 95% CI 5.0-98.7), as was completion of the Neonatal Resuscitation Provider (NRP) course (OR = 3.1, 95% CI 1.4-7.0). Perceived comfort with, knowledge of, and preparedness for NNR were poor in an urban, general ED prior to the opening of an NICU. Recent neonatal clinical encounter and participation in the NRP course were the strongest predictors of improved NNR comfort. In future work, we intend to assess the impact of simulation-based training on comfort with NNR among ED staff who primarily treat adults.

IntroductionAdvance Care Planning (ACP) refers to a process that includes Advance Care Directives (ACD) and Goals of Care (GOC), a practice widely used for over three decades. Following the findings of an audit and a cross-sectional study in 2019 and 2021 respectively, we implemented several educational and other interventional strategies aimed at enhancing staff awareness and emphasizing the importance of recognizing and documenting of ACD/GOC. The aim of this study was to evaluate the acknowledgement and use of ACD and GOC by Emergency Department (ED) staff following these interventions.MethodWe used a mixed methods approach, incorporating both observational and cross-sectional designs with reflexive thematic analysis. Data extraction for the observational study took place between 1st April and 30th June 2023 focusing on a target population of randomly sampled adults aged ≥ 65 years. Demographics and other ACD and GOC related patients’ clinical data were collected. Data collection for the cross-sectional study occurred between 19th July and 13th September 2023 targeting all ED staff. Information gathered included demographics, awareness about ACD and GOC, including storage location and implementation, as well as knowledge of Medical Treatment decision Makers (MTDM), a jurisdictional term identifying a person legally appointed to make healthcare decisions on behalf of someone who lacks decision-making capacity and other Victorian State legislative requirements were collected.ResultsIn the observational period, 22,335 patients attended the ED and 19% (n = 6546) qualified for inclusion from which a sample of 308 patients were randomly extracted. We found ACD documents were noted in the medical records of 6.5% of the sample, fewer than 8% identified in our previous study. There was no correlation between ACD record availability and age (p = 0.054; CI ranging from − 0.065 to 7.768). The response rate for the cross-sectional survey was 12% (n = 340) in contrast to earlier study with 28% (n = 476) respondents. Staff knowledge and familiarity with ACD was 25% and GOC 45%.ConclusionAfter implementing interventions in staff education and ACP awareness, we found that ACD documentation did not improve. However, GOC documentation increased in the context of heightened institutional awareness and integration into the Electronic Medical Records (EMR).

The aim of the review is to synthesize the best available evidence on interventions targeting occupational stress and burnout among emergency department (ED) staff. The specific review questions are.

BackgroundTraining emergency medical services (EMS) workforce is challenging in rural and remote settings. Moreover, critical access hospitals (CAHs) struggle to ensure continuing medical education for their emergency department (ED) staff. This project collected information from EMS and ED providers across Nebraska to identify gaps in their skills, knowledge, and abilities and thus inform curriculum development for the mobile simulation-based training program.MethodsThe needs assessment used a three-step process: (1) four facilitated focus group sessions were conducted in distinct geographical locations across Nebraska to identify participants’ perceived training gaps; (2) based on the findings from the focus group, a needs assessment survey was constructed and sent to all EMS and ED staff in Nebraska; and (3) 1395 surveys were completed and analyzed.ResultsThematic areas of training gaps included cardiopulmonary conditions, diabetes management, mass casualty incidents (MCI), maternal health and child delivery, patient assessment, pediatric care (PC), and respiratory emergency care. Gaps in non-clinical skills were related to crisis management such as maintaining effective teamwork. Participants frequently identified cardiopulmonary care, PC, and MCI as highly needed trainings. Other needs included life support-related retaining courses, sessions informing protocol updates, the availability of retraining tailored for rural areas, substance use-related emergencies, and farming-related injuries.ConclusionEMS and ED staff identified several skill gaps and training needs in the provision of emergency services in rural communities. These results allow for the development of customized training curricula and, with the help of an on-site simulation-based program, can identify gaps in health professionals’ skills, knowledge, and abilities and thus help them respond to acute healthcare needs of rural communities.

&#x0D; This review used a rapid best-fit framework analysis approach to synthesize 9 included studies exploring how people who engage with emergency department (ED) services experience and understand the impacts of ED overcrowding, access block, and boarding on quality of care, patient safety, and the well-being of health care professional learners and staff working in the ED. None of the included studies were conducted in Canada.&#x0D; The included studies detailed how people who engage with ED services understand the ED as a location that is appropriate for providing short-term treatment to people requiring critical or emergent care, but inappropriate for providing care to patients for extended lengths of time. Study participants described experiencing ED overcrowding, boarding, and access block as transforming the ED into an unsafe environment where the risk of avoidable patient harm increased due to the accelerated depletion of available equipment, space, and human resources. They observed that this unsafe environment led to patients experiencing delayed, missed, and inappropriate care, resulting in potential or actual physical harm, threats to their human rights and dignity, exposures to secondary suffering, reduced satisfaction, and worsening emotional and psychological states.&#x0D; Participants reported that ED overcrowding, access block, and boarding had, for the most part, negative impacts on health care professional learners and staff working in the ED. Some ED staff reported that these phenomena led them to experience increased exposure to violence and physical harm, emotional and moral distress, dimensions of burnout, and/or missed learning opportunities for health care professional learners. Some ED staff reported experiences of camaraderie and collaboration necessarily forged as a coping mechanism to manage adversity in the context of overcrowding. Amid the challenges experienced within their practice setting, some experienced staff also perceived overcrowding as providing opportunities to exercise and expand their existing knowledge and skills.&#x0D; Considering these findings, decision-makers seeking to address the adverse impacts of ED overcrowding, access block, and boarding on quality of care and patient safety may explore facilitating the integration of routine preventive care into ED processes; enhancing communication within the ED; optimizing available equipment and space; giving patients information before and during their stay to manage their expectations; and enhancing staff’s access to education and resources necessary to better address the needs of patients who frequently experience extended stays in the ED and require specialized care beyond that which ED staff typically have the training and experience to provide. They may prioritize interventions that alleviate, rather than add to, the workload of ED staff. Additionally, they may assess and explore working conditions in the ED with a lens of promoting the well-being and retention of ED staff. By drawing on the findings of this review, they may, for example, consider exploring how to incentivize senior staff to remain in their positions, enhance learning opportunities for health care professional learners, and promote interprofessional collaboration. They may also consider investigating and addressing systemic factors contributing to overcrowding, access block, and the recruiting and retaining of health care providers in their jurisdictions.&#x0D; Decision-makers may also further explore how proposed interventions might address or exacerbate ethical and equity issues raised by ED overcrowding, including: the fair and equitable allocation of scarce resources; harms and forgone benefits to patients, health care providers, and other hospital staff; and inequitable access to and experience of ED care by patients, including impacts on patients’ dignity, relationships with care providers, and trust in EDs or health care systems. They may consider providing targeted support to groups identified as disproportionately at risk of harm in overcrowded EDs, including but not limited to: those requiring extended lengths of stay, those with limited agency to self-advocate or gain appropriate attention and care, those who are unable to perform activities of daily living, or those experiencing mental health emergencies. They also may consider that the included studies provided limited or no insight into the perspectives of people belonging to equity-deserving groups with a history of harm and lack of agency in the ED, including but not limited to: Indigenous people, Black people, and other people of colour; people with disabilities; people experiencing houselessness; those experiencing language barriers without access to a professional interpreter; and members of the 2SLGBTQ+ community. More research is needed to understand how these and other equity-deserving groups experience overcrowding, access block, and boarding as impacting their quality of care and safety.&#x0D;

Factors influencing violence at emergency departments: Patients’ relatives’ perspectives

OBJECTIVES Misuse of opioid medications was associated with 75% of drug-related deaths in 2020. Although emergency departments (EDs) frequently prescribe opioids, no preventive interventions have been implemented to educate adolescents and their families on safe opioid use. This study aimed to characterize ED staff’s perspectives on implementing the MedSMA℞T Families intervention in the ED to improve opioid education and safety among adolescents. METHODS ED staff played the MedSMA℞T game, completed a survey, and were asked open-ended questions regarding their experience interfacing with the technology. Transcripts were coded using NVivo to conduct content analysis. The analysis integrated the Systems Engineering Initiative for Patient Safety 3.0 model into the intervention. RESULTS A total of 23 ED staff were recruited. Staff reported that the game was more interactive and age-appropriate for adolescents compared with other educational materials in the ED. Reflecting on the care team, nurses and child life specialists were identified as appropriate roles for delivering the game to patients. Moreover, staff buy-in, training, and ED workflows were recognized as important factors within the organizational conditions allowing for game implementation. Space, loudness, and allocated resources in the ED were perceived as challenges to game implementation. Lastly, waiting room gameplay was thought to be the most efficient setting of game implementation. CONCLUSIONS MedSMA℞T Families can be efficiently implemented into ED settings. It is one of the first serious games to target opioid education and to engage and better retain the attention of younger patients and was well received by ED staff.

OBJECTIVE: To determine whether emergency department staff met the needs of the next of kin and close friends ("survivors") of patients dying in an emergency department and to assess the effectiveness of a program to improve care of survivors. DESIGN: Mail survey before and after program implementation. SETTING: Emergency department of a tertiary care, adult teaching hospital. PARTICIPANTS: Two groups of survivors, identified through a review of emergency department records of deaths during two 6-month periods. In the first group, surveyed in 1987, before program implementation, 26 (53%) of 49 responded; in the second group, surveyed in 1990, after program implementation, 40 (70%) of 57 responded. INTERVENTIONS: A structured, multidisciplinary protocol for notifying next of kin of death and supporting the survivors was implemented. An educational program was provided to all emergency department staff. An information pamphlet was created and provided to survivors. MAIN OUTCOME MEASURES: Questionnaire responses regarding the adequacy and timeliness of information provided, the support and actions by emergency department staff and the survivors9 desire to be present during resuscitation efforts. RESULTS: Comparison of responses before and after program implementation showed that adequate information was provided before notification of death in 32% and 83% of cases respectively (p &lt; 0.001), lengthy delays in receiving medical information occurred in 60% and 15% of cases (p &lt; 0.01), adequate medical information concerning the events of death was provided in 53% and 88% (p &lt; 0.05), the presence of emergency department staff was sufficient in 40% and 79% (p &lt; 0.01), survivors spent less than 2 hours in the emergency department in 50% and 81% (p &lt; 0.05), and survivors expressed a desire to be present during resuscitation efforts in 95% and 11% of cases (p &lt; 0.001). CONCLUSION: The grievous experience of learning that a loved one has suddenly and unexpectedly died in the emergency department can be alleviated somewhat by a structured, multidisciplinary approach combined with staff sensitization and education.