Canadian Journal of Emergency Nursing (CJEN)
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Geriatric Recovery and Enhancement Alliance in Trauma (GREAT) multidisciplinary quality improvement initiative: improving rates of successful resuscitation, rehabilitation and reintegration of geriatric trauma patients across the trauma spectrum of care
Full text linkGeriatric Recovery and Enhancement Alliance in Trauma (GREAT) multidisciplinary quality improvement initiative: improving rates of successful resuscitation, rehabilitation and reintegration of geriatric trauma patients across the trauma spectrum of care.
Sandy Widder, Kristin E. Morch, Nori L Bradley, Lauren Ternan, Ni Thuyen Lam
Background: Traumatic injuries are a significant cause of morbidity and mortality in the elderly, with the risk of poor outcomes increasing with advanced age. Using a multidisciplinary geriatric trauma care approach, led by a dedicated nursing coordinator, standardized order sets were implemented to reduce in-hospital complications and screening tools applied early to identify patient specific care needs. Specifically, early trauma consult, identification of injuries, appropriate opioid ordering, polypharmacy avoidance, delirium prevention, mental health issues, and mobility needs were addressed
The goal was to improve geriatric trauma awareness, decrease in-hospital complications and improve the likelihood of return to home and baseline function
Implementation: Through stakeholder consultation process, it was recognized that the hospital needed a coordinated, geriatric trauma team process. The geriatric trauma navigator (GTN) role was created to lead these quality improvement initiatives. This included the development of educational strategies for frontline staff and physicians to highlight the unique challenges of trauma patient management and to introduce the GREAT study for optimized patient care. Patients 65 years of age or older with a traumatic mechanism were enrolled. GREAT patients then followed a protocol designed for tracking and implementing standardized processes, including early ED and in-patient order sets, engagement of trauma services, and the application of screening tools and specialty consultations. Screening tools (Identification of Seniors At Risk (ISAR), Confusion Assessment Method (CAM), Mini-Cog, Patient Health Questionnaire (PHQ-2), Geriatric Depression Scale (GDS-15), Alcohol Use Disorders Identification Test- Concise (AUDIT-C), Canadian Nutrition Screening Tool (CNST), Clinical Frailty Scale, ADL/IDLs) were administered to identify at-risk patients and to inform consultation with geriatrics and psychiatry, and allied health services (occupation therapy, physical therapy, nutrition services, pharmacy). The study team evaluated data on a monthly basis and met quarterly to evaluate and implement changes.
Evaluation Methods: Data was prospectively collected and compared to control data from the Alberta Trauma Registry and Trauma Quality Improvement Program (American College of Surgeons). Data tabulation and statistical analysis was performed using Stat59 (STAT59 Services Ltd, Edmonton, AB, Canada).
Outcome measures-provision of timely and comprehensive care: rates of trauma team activations, emergencydepartment and in-hospital length of stay-reduction of hospital complications: UTI, DVT/PE, pneumonia, pressure ulcers, ICUadmission, unexpected readmission to hospital-improvement of functionality upon discharge: in-hospital and 30 day mortality rates,return to function, disposition (home versus long term care)
Process measures-time to diet and ambulation-tracking of number of days of urinary catheter in situ-compliance with GOC discussions-use of assessment screening tools-spinal clearance <24 hours
Results: Enrollment of patients into GREAT based on study criteria lowered the threshold for triggering a trauma team consult, improving the recognition rate of geriatric trauma. This was reflected in the decreased average ISS scores and higher rate of trauma consults. Ground level falls, which previously did not typically activate a trauma consult, are now be recognized as major trauma. With the GTN, we determined that gaps exist in the current monitoring of key performance measures. Through the GREAT data collection process, we were able to establish baseline data and target PDSA changes to address these gaps.
Advice and Lessons Learned: This quality initiative was designed as a proof of concept model for early identification of the geriatric trauma patient and a collaborative team approach to optimize care processes, and in turn minimize complications. The GTN role was vital to identify patients, implement screening tools, and coordinate care. With limited resources and increasing work loads for all programs, the additional GTN role required site leadership and stakeholder support. Ideally, a protocolized geriatric trauma team activation and admission process would ensure all patients receive screening tools as part of their in-patient orders for early assessments and interventions. Further educational campaigns will need to be developed to increase awareness of the importance of geriatric trauma. Additionally, processes need to be streamlined for data gathering and monitoring of performance measures. Access to screening tools and order sets need to be user friendly, built into currently existing workflows, and evaluated for optimization
Le Traumatisme de Suspension: Un tueur silencieux
Full text linkFall harnesses have become much more prevalent for those that work at heights. Safety harnesses and fall arrest systems are commonly used by the construction industry, mountain climbers and other recreational activities where fall risks are a concern. Through the efforts of occupational health and safety legislation, job site safety programming and workplace harm reduction culture, there is a growing understanding of how and when to don these safety devices and the potential perils associated with their use. However, there is a paucity of information within the healthcare community in how to clinically manage a patient who has suffered a pattern of injury that can arise from these devices - known as suspension trauma. This condition may also be termed as harness-induced pathology, orthostatic shock while suspended and harness hang syndrome. This article helps to increase awareness and understanding of what suspension trauma is and how to pragmatically manage this condition from both a prehospital and emergency department perspective.Dans un monde où les exigences de sécurité sont omniprésentes, les harnais antichute sont devenus monnaie courante pour les personnes qui travaillent en hauteur. Les harnais et dispositifs antichute sont aujourd’hui fréquemment utilisés dans l’industrie de la construction, l’alpinisme et les autres activités récréatives comportant un risque de chute. Grâce à la législation sur la santé et la sécurité au travail, aux programmes de prévention sur les lieux de travail et à la culture de réduction des risques au travail, on comprend mieux quand et comment porter les dispositifs antichute, ainsi que les dangers potentiels associés à leur utilisation. Le milieu de la santé manque toutefois de connaissances sur la prise en charge clinique des patients qui, blessés par ce type d’équipement, subissent un traumatisme de suspension, aussi appelé « syndrome du harnais » ou « choc orthostatique par suspension ». Cet article aide à accroître la sensibilisation et la compréhension de ce qu\u27est un traumatisme de suspension et comment gérer de manière pragmatique cette condition à la fois du point de vue préhospitalier et du service d\u27urgence
The utility of telemedicine in pediatric emergency care: a scoping review.
Full text linkThe utility of telemedicine in pediatric emergency care: a scoping review.
Owen Robinson, Shaelynn Zouboules, Hailey Lafave, Roger Galbraith, Eddy Lang
Background: Widespread public health measures to combat COVID-19 and escalated parental fear in seeking medical care have compromised access to acute healthcare, leading clinicians to search for alternative methods of delivery. Pediatric emergency departments (ED) have seen significant reductions in documented visits without evidence of a reduction in needs. In Alberta, average daily visits to pediatric emergency and urgent care departments decreased 69.6%, from 952.2 in December 2019 to 289.6 in April 2020. While pediatric emergency telemedicine (PET) programs have the potential to alleviate said gaps in care, it is critical that these technologies are evaluated to ensure patient safety and efficacy.
Implementation: This study aimed to serve as an implementation framework for future PET programs. A scoping review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analysis extension for scoping reviews (PRISMA-ScR). The primary objective was to map the existing literature and identify research gaps pertaining to the use of telemedicine in pediatric emergency departments. Primary areas of focus included direct-to-consumer (DTC) telemedicine, rural/regional applications, general ED utility, transfer of care and specialist consultation. This presentation focused on the aspects of DTC telemedicine, and its ability to potentially alleviate the present barriers to in-person presentations to EDs for acute pediatric health concerns. Our team consisted of two University of Calgary affiliated emergency physicians, three University of Calgary medical students, Canadian Agency for Drugs and Technology in Health research consultants, and a university librarian.
Evaluation Methods: The outcomes of interest that we used to evaluate the relevant literature included: prevalence of PET; current applications; patient outcomes; patient satisfaction; provider satisfaction; and feasibility, challenges and barriers to implementation. In addition, we aimed to determine the proportion of literature focusing on DTC telemedicine, as this would be the desirable telemedicine application that could be used to supplement the gap in pediatric ED visits during the pandemic and mitigate the resulting health impacts. Lastly, we aimed to characterize both successes and challenges associated with DTC telemedicine in order to provide guidance for future research and policy.
Results: Searches of the electronic databases returned 1617 studies. Following the two-step screening process, 37 studies met our inclusion criteria and six focused on DTC telemedicine. Study designs were all observational with all published in 2015 or later. The number of studies reporting data on the outcomes of interest were as follows: patient satisfaction (N=0); prevalence (N=1); provider satisfaction (N=1); patient outcomes (N=2); current applications (N=6); feasibility, challenges and barriers (N=6). Respiratory presentations were the most prevalent application. Three of six studies demonstrated agreement between telemedicine and in-person providers during acute assessments, demonstrating reliability of telemedicine. Conversely, two studies conveyed antimicrobial stewardship with conflicting results. Overall, results were largely positive with important challenges identified.Advice and Lessons Learned: Based on the lessons learned from our research, we recommend the following:
1) Implentation of a DTC telemedicine program can provide timely access to care, whileminimizing the health risks associated with visting the ED during the COVID-19 pandemic.
2) Respiratory complaints were among the most common presentations and thus we recommenddeveloping diagnostic and management algorithms to standardize the virtual care provided.
3) Continue quality improvement measures upon implementing a telemedicine program throughtimely feedback regarding physicians’ experiences and challenges in order to addressconcerns early and optimize efficacy of the program
Artist Profile
No full textHeather Patterson is an Emergency Physician who believes that providing care for patients is a shared experience of humanity. Telling authentic stories of patients and front-line workers during the COVID-19 pandemic, the photographs provide a visual voice for those battling this invisible enemy and highlight the common themes of teamwork, vulnerability, resilience, empathy, joy and suffering. She hopes that her photography will validate the experiences of front-line workers and will inspire hopefulness during these challenging times. Her work can be found on Instagram @heather.l.patterson and will be published in a book available to the public later this year
The clinical effects of CPR meter on chest compression quality: a QI project
Full text linkThe clinical effects of CPR meter on chest compression quality: a QI project.
Christopher Picard, Richard Drew, Domhnall O’Dochartaigh, Matthew J Douma, Candice Keddie, Colleen Norris.
Background: High-quality chest compressions are the cornerstone of resuscitation. Training guidelines require CPR feedback, and pre-clinical data shows that feedback devices improve chest compression quality; but devices are not being used in many emergency departments, and their impact on clinical care is less well understood. Some services use defibrillator generated reports for quality improvement, but these measurements may be limited in scope and have not been rigorously compared to other tools.
Methods: Laerdal CPRMeter 2 chest compression feedback devices were purchased using funds made available by a zone QI initiative. Initial training for implementation consisted of staff performing one minute of blinded chest compression using the feedback device, followed by one minute of chest compression unblinded. Staff were shown the raw percentage of chest compressions meeting target depth, release, and rate under both conditions as well as overall improvement. Following initial orientation, devices were incorporated into clinical care and all subsequent staff simulation and training. Clinically, use of the feedback device and completion or QI tracking forms was not mandated but was encouraged by drawing code participant names from completed forms for a free ACLS or PALS course. Data from all codes were automatically collected by the LifePak 20, data from any resuscitation using the Laerdal CPRmeter 2 were also automatically recorded when the device was used: these data were downloaded weekly. Completed questionnaire forms were submitted to the Clinical Educators and extracted as received.
Evaluation Methods: Chest compression quality data was collected in two ways: first, using a Laerdal CPRMeter2, second, by downloading and analyzing cardiac arrest data from a LifePak20 defibrillator using CodeStatTM software. Device data were matched and synthesized by an emergency department CNE using Microsoft excel and IBM SPSS 26. Descriptive statistics (mean and standard deviations) are used to describe the data. Differences in chest compression quality and duration of resuscitations between resuscitation that did or did not use a feedback device or a backboard were compared using independent t-testing. Differences in chest compressions at the target depth, release, and rate between the numbers of staff involved were assessed using ANOVA. Agreement between devices (CPRMeter2 and LifePak) used during the resuscitations were evaluated using paired t-testing, Pearson correlations, and Bland-Altman plots. All tests were two-tailed with predetermined significance levels set at a=0.05.
Results: Data collection occurred between August 2019 and December 2020. There were a total of 50 cardiac arrests included, 36 had questionnaire data returned, 36 had data collected from the CPR meter 2, 24 had data collected from the LifePak, and 10 had data collected using all three methods. The average duration of resuscitation (number of chest compressions) was 1079.56 (SD=858.25); there was no difference in the duration of resuscitation (number of chest compressions) between resuscitations using versus not using CPR feedback devices (p=0.673). Resuscitations utilizing chest compression feedback had a higher percentage of chest compressions at the target rate compared to resuscitations not using feedback (74.08% vs 42.18%, p=0.007). Resuscitations that utilized a backboard had a higher percentage of chest compressions at target depth (72.92% vs 48.73%, p=0.048). There were no differences noted in the duration of resuscitation attempt (p=0.167) or percentages of chest compressions at the target depth (p=0.181), release (p=0.538), or rate (p=0.656) between resuscitations with different sized teams (4-5, 6-7, 8-9, >10 staff involved). There was a strong positive correlation (r=0.771, p=0.005, n=11) between the two measurement methods and chest compression rates, and no statistically significant difference in measured scores (p=0.999), with 100% of values falling within the Bland-Altman confidence intervals of 36.72 and -36.72, n=11. Interpretation of the levels of agreement between these two device measures methods should be done cautiously however, given the small sample size and wide confidence intervals.
Implications
1) Incorporation of visual chest compression feedback and use of a backboard are fast andaffordable and significantly improved the percentage of chest compression at the target rateand depth.
2) There was no correlation between the size of the resuscitation team and the percentage ofchest compressions at the target depth, release or rate; nor was the feedback device useassociated with the duration of the resuscitation attempt.
3) The implications of improvement with the CPR meter suggests that areas or service not usingfeedback should consider implementing its use to achieve the target compression rate.
4) Compared to LifePak feedback alone the CPRMeter2 will also allow services to target depthand release targets as well as rate
Stratégies éducatives pour le déploiement de l’occlusion aortique endovasculaire par ballonnet (REBOA) comme mesure de réanimation dans une salle d’urgence de soins tertiaires canadiens
Full text linkResuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is not a novel intervention in the trauma literature. However, the incorporation of this intervention into the Canadian emergency department setting is recent in onset. This healthcare setting is dynamic and the nurses who practice in the emergency setting must be efficient care providers for an infinitely diverse set of potential patient presentations. The introduction of this complex procedure was accompanied by a variety of educational strategies to enhance the uptake of this new knowledge. The usage of small groups, didactic teaching, hands-on practice, establishing unit champions, coordinating in-situ simulations, and creating workflow documents were strategies used by the education team at this academic center for this particular knowledge dissemination exercise.L’occlusion aortique endovasculaire par ballonnet(REBOA) comme mesure de réanimation n’est pas unsujet nouveau dans la littérature sur les traumatismes.Toutefois, l’intégration de cette mesure d’interventionen salle d’urgence est récente au Canada. Ce milieu desoins est dynamique et les infirmières qui exercent dansle cadre des urgences doivent être des prestataires desoins efficaces pour un ensemble infiniment varié desituations cliniques. L’introduction de cette procédurecomplexe s’est accompagnée d’une série de stratégieséducatives visant à favoriser l’assimilation de ces nouvellesconnaissances. L’utilisation de petits groupes, l’enseignementdidactique, la pratique, l’établissement dechampions d’unité, la coordination de simulations in situet la création de documents de flux de travail ont été lesstratégies utilisées par l’équipe éducative de ce centreuniversitaire pour cet exercice particulier de diffusiondes connaissances
The patient journey map: Improving the emergency department communication experience for patients and their family and friends
Full text linkThe patient journey map: Improving the emergency department communication experience for patients and their family and friends.
Stephanie VandenBerg, Heather Hair, Gillian Harvey, Eddy Lang, David Stringer
Background: The 2013 Urban and Regional Emergency Department (ED) Patient Experience Report indicates that the most important factor influencing a patients’ ED experience is a combination of staff care and communication. Lack of communication in the emergency room experience can be addressed by design methods and processes. The Emergency Strategic Care NetworkTM assembled an interdisciplinary team of experts from various clinical, academic, and information design backgrounds to engage patients, families and providers to improve the ED intake experience. This innovative partnership resulted in the development of a graphic information system that directs, informs and educates patients in EDs in Alberta.
Implementation: Using the Plan-Do-Study-Act (PDSA) framework, focus groups were conducted to understand the communication needs of emergency department patients. An information design specialist co-created a graphic information system (the patient journey map) and worked with AHS communications to ensure it met AHS guidelines. Patients were then approached to participate in a 14-question survey about the usability and accuracy of the journey map as well as the impact it had on their ED visit. Our team consisted of Heather Hair, Executive Director of the (ESCN) who provided leadership in identifying communication as a key area for improvement and coordinating ED partners and patient involvement. Gillian Harvey is an assistant professor of Design Studies at the University of Alberta. She used the data collected in focus groups to design a 2-D communication map. David Stringer acted as project manager for the implementation and evaluation of the journey map. Stephanie Vandenberg is an emergency physician and was responsible for designing the evaluation strategy including research methods and data analysis. An official journey map is now available to print for emergency departments across Alberta.
Evaluation Methods: The objective was to understand what information ED patients require during their visit to better understand the process by which they are triaged and receive care. Data collection consisted of a 10-minute, 14 question interview. Each question allowed for positive, neutral or negative feedback to capture unintended consequences of the journey map. Quantitative demographic and journey map-specific variables were collected and reported as frequencies. Qualitative data was analyzed using thematic analysis with thematic codes developed and assigned to the qualitative responses. Both quantitative and qualitative analysis was undertaken by two members of the research team. Responses were analyzed against the demographic variable of age category to determine if age impacts communication needs and desired medium of communication in the ED.
Results: Seven hospitals took part in this survey, conducted between September 1, 2019 and May 5, 2020. 162 emergency department patients participated. Most people agreed that the journey map clarified the ED patient process and accurately reflected their experience of the ED journey. The journey map did not seem to make the wait less confusing. Participants reported the journey map was good at helping them understand the overall emergency department intake process and did a good job of helping them understand the reason for waiting/delays. The journey map was excellent at helping the participant understand why specific tests/treatments were needed but was poor at helping them to understand the total time it would take them to be seen