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In command of guardians : executive servant leadership for the community of responders
\"In Command of Guardians: Executive Servant Leadership for the Community of Responders, Second Edition spotlights the philosophy of servant leadership and offers a pathway for strengthening first responder organizations. Responders work in high-risk, critical situations under the pressure of time and consequence. Being a responder means one must become an active player in the tragedies of others. Because these situations can change the responder over time, a special type of leader is needed to walk beside them while they navigate the realities of public safety and emergency service operations. This book illustrates how being a servant leader to these guardians allows the community of responders to strengthen their resiliency, foster individual growth, and perform at peak levels. \" --Amazon.
Book
Strategic planning and response to COVID-19 in a London emergency department
For many of us in emergency medicine, rising to the challenge of the COVID-19 crisis will be the single most exciting and challenging episode of our careers. Lessons have been learnt on how to make quick and effective changes without being hindered by the normal restraints of bureaucracy. Changes that would normally have taken months to years to implement have been successfully introduced over a period of several weeks. Although we have managed these changes largely by command and control, compassionate leadership has identified leaders within our team and paved the way for the future. This article covers the preparation and changes made in response to COVID-19 in a London teaching hospital.
Journal Article
Emergency medicine patient wait time multivariable prediction models: a multicentre derivation and validation study
ObjectivePatients, families and community members would like emergency department wait time visibility. This would improve patient journeys through emergency medicine. The study objective was to derive, internally and externally validate machine learning models to predict emergency patient wait times that are applicable to a wide variety of emergency departments.MethodsTwelve emergency departments provided 3 years of retrospective administrative data from Australia (2017–2019). Descriptive and exploratory analyses were undertaken on the datasets. Statistical and machine learning models were developed to predict wait times at each site and were internally and externally validated. Model performance was tested on COVID-19 period data (January to June 2020).ResultsThere were 1 930 609 patient episodes analysed and median site wait times varied from 24 to 54 min. Individual site model prediction median absolute errors varied from±22.6 min (95% CI 22.4 to 22.9) to ±44.0 min (95% CI 43.4 to 44.4). Global model prediction median absolute errors varied from ±33.9 min (95% CI 33.4 to 34.0) to ±43.8 min (95% CI 43.7 to 43.9). Random forest and linear regression models performed the best, rolling average models underestimated wait times. Important variables were triage category, last-k patient average wait time and arrival time. Wait time prediction models are not transferable across hospitals. Models performed well during the COVID-19 lockdown period.ConclusionsElectronic emergency demographic and flow information can be used to approximate emergency patient wait times. A general model is less accurate if applied without site-specific factors.
Journal Article
Exploring parents’ reasons for attending the emergency department for children with minor illnesses: a mixed methods systematic review
BackgroundThe number of EDs visit is on the increase, and the pressure on EDs is of significant concern worldwide. The usage of EDs by parents of children with minor illness is an important and still unresolved problem causing a burden to healthcare services. The aim of this study was to review the literature to summarise parental reasons for visiting ED for children with minor illness.MethodSeven electronic databases (Medline, Embase, PsycINFO, CINAHL, PubMed, Web of Science and Scopus) were comprehensively searched during a 2-week period in August 2016 and updated between 11 and 20 June 2018. The study selection process was undertaken independently by two authors. Qualitative and quantitative studies that focused on the reasons for parents of children with minor illness to attend an ED were included. Studies were assessed for quality and data were analysed by means of narrative synthesis.ResultsTwenty-four studies were included. Eleven studies employed quantitative methods, eleven studies used qualitative methods and two studies used mixed methods. Parental reasons for using ED included perceived urgency, ED advantages (eg, faster service, superior ED resources and efficiency), difficulties with getting a general practitioner appointment, lack of facilities in primary healthcare services, lack of health insurance, reassurance, convenience and access.ConclusionThis review identified some of the reasons why parents bring their children to the ED for minor illnesses highlighting the multifaceted nature of this problem. Understanding parental reasons behind their choice to use the ED may help us better design targeted interventions to reduce unnecessary ED visits and alleviate the burden on overstretched healthcare services. This review may help inform emergency care policy makers, researchers and healthcare staff to understand parents’ reasons for visiting the ED, to better meet their healthcare needs.
Journal Article
Emergency department treatment of the psychiatric patient : policy issues and legal requirements
Many hospital emergency departments are overcrowded and short-staffed, with a limited number of available hospital beds. It is increasingly hard for emergency departments and their staff to provide the necessary level of care for medical patients. Caring for people with psychiatric disabilities raises different issues and calls on different skills. In Emergency Department Treatment of the Psychiatric Patient, the author uses research, surveys, and statutory and litigation materials to examine problems with emergency department care for clients with psychiatric disorders. She relies on interviews with emergency department nurses, doctors and psychiatrists, as well as surveys of people with psychiatric disabilities in order to present the perspectives of both the individuals seeking treatment, and those providing it. This book explores the structural pressures on emergency departments and identifies the burdens and conflicts that undermine their efforts to provide compassionate care to people in psychiatric crisis. In addition to presenting a new analysis of the source of these problems, the author also suggests alternatives to emergency department treatment for people in psychiatric crisis. Moreover, she proposes standards for treatment of these individuals when they do inevitably end up in a hospital emergency department.
eBook
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 s 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.
Journal Article
Retention of doctors in emergency medicine: a scoping review of the academic literature
IntroductionWorkforce issues prevail across healthcare; in emergency medicine (EM), previous work improved retention, but the staffing problem changed rather than improved. More experienced doctors provide higher quality and more cost-effective care, and turnover of these physicians is expensive. Research focusing on staff retention is an urgent priority.MethodsThis study is a scoping review of the academic literature relating to the retention of doctors in EM and describes current evidence about sustainable careers (focusing on factors influencing retention), as well as interventions to improve retention. The established and rigorous JBI scoping review methodology was followed. The data sources searched were MEDLINE, Embase, Cochrane, HMIC and PsycINFO, with papers published up to April 2020 included. Broad eligibility criteria were used to identify papers about retention or related terms, including turnover, sustainability, exodus, intention to quit and attrition, whose population included emergency physicians within the setting of the ED. Papers which solely measured the rate of one of these concepts were excluded.ResultsEighteen papers met the inclusion criteria. Multiple factors were identified as linked with retention, including perceptions about teamwork, excessive workloads, working conditions, errors, teaching and education, portfolio careers, physical and emotional strain, stress, burnout, debt, income, work–life balance and antisocial working patterns. Definitions of key terms were used inconsistently. No factors clearly dominated; studies of correlation between factors were common. There were minimal research reporting interventions.ConclusionMany factors have been linked to retention of doctors in EM, but the research lacks an appreciation of the complexity inherent in career decision-making. A broad approach, addressing multiple factors rather than focusing on single factors, may prove more informative.
Journal Article
A longitudinal, retrospective registry-based validation study of RETTS©, the Swedish adult ED context version
Background
Triage and triage related work has been performed in Swedish Emergency Departments (EDs) since the mid-1990s. The Rapid Emergency Triage and Treatment System (RETTS©), with annual updates, is the most applied triage system. However, the national implementation has been performed despite low scientific foundation for triage as a method, mainly related to the absence of adjustment to age and gender. Furthermore, there is a lack of studies of RETTS© in Swedish ED context, especially of RETTS© validity. Hence, the aim the study was to determine the validity of RETTS©.
Methods
A longitudinal retrospective register study based on cohort data from a healthcare region comprising two EDs in southern Sweden. Two editions of RETTS© was selected; year 2013 and 2016, enabling comparison of crude data, and adjusted for age-combined Charlson comorbidity index (ACCI) and gender. All patients ≥ 18 years visiting either of the two EDs seeing a physician, was included. Primary outcome was ten-day mortality, secondary outcome was admission to Intensive Care Unit (ICU). The data was analysed with descriptive, and inferential statistics.
Results
Totally 74,845 patients were included. There was an increase in patients allocated red or orange triage levels (unstable) between the years, but a decrease of admission, both to general ward and ICU. Of all patients, 1031 (1.4%) died within ten-days. Both cohorts demonstrated a statistically significant difference between the triage levels, i.e. a higher risk for ten-day mortality and ICU admission for patients in all triage levels compared to those in green triage level. Furthermore, significant statistically differences were demonstrated for ICU admission, crude as well as adjusted, and for adjusted data ten-day mortality, indicating that ACCI explained ten-day mortality, but not ICU admission. However, no statistically significant difference was found for the two annual editions of RETTS© considering ten-day mortality, crude data.
Conclusion
The annual upgrade of RETTS© had no statistically significant impact on the validity of the triage system, considering the risk for ten-day mortality. However, the inclusion of ACCI, or at least age, can improve the validity of the triage system.
Graphical Abstract
Journal Article
Does the physician in triage strategy improve door-to-balloon time for patients with STEMI?
BackgroundThe physician in triage (PIT) strategy was implemented in the emergency department (ED) of the Soroka University Medical Center (SUMC) to improve overcrowding and waiting time. Our objective in the current study was to assess the impact of the PIT strategy on door-to-balloon time for the treatment of acute ST-elevation myocardial infarction (STEMI).MethodsThe PIT programme began on January 2016, working weekdays between 8:00 and 23:00 hours. We included patients who visited the ED and were diagnosed with STEMI, from November 2014 to February 2018. The primary outcome was improvement in door-to-balloon (D2B) time <90 min between the preintervention and postintervention period. The analysis included a comparison between the two time periods using univariate tests, a time trend analysis illustrated by the locally weighted scatterplot smoothing curves and a regression analysis using generalised estimating equation models. To determine the impact of the PIT, as opposed to other changes in the department, we stratified the population arriving after January 2016 to patients arriving during PIT hours versus patients arriving on weekends and at nights (23:00–8:00 hours).ResultsIn all, 415 patients met all the inclusion criteria of which 237 (57.1%) visited on weekdays 8:00–23:00 hours. The per cent of patients with D2B <90 min was 13.9% higher for postintervention versus preintervention visits (p=0.006). D2B time was significantly shorter by 9 min for postintervention visits (p=0.001). In the postintervention period, patients arriving between 8:00 and 23:00 hours on weekdays were more likely to have D2B <90 min than those arriving nights and weekends; 90/146 (61.6%) vs 47.2% (51/108), respectively, p=0.02. ORs for D2B <90 min was 2.04 (95% CI 1.06 to 3.91) for weekday visits, and 1.90 (0.88 to 4.12) for weekend and night visits.ConclusionThe PIT model in SUMC is associated with D2B reduction for patients with STEMI. To achieve further reduction, both targeted interventions should be performed and PIT strategy should be applied for full time, including nights and weekends.
Journal Article