Canadian Journal of Emergency Nursing (CJEN)
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A multidisciplinary approach to treating low back pain in the ED: improving patient outcomes
Get PDFA multidisciplinary approach to treating low back pain in the ED: improvingpatient outcomesLesley Beique, Jason Martyn
Background: In collaboration with emergency physicians, the physiotherapy and pharmacy teams at the Rockyview General Hospital (RGH) implemented a novel, multidisciplinary, evidence-based pathway that functions by deploying a “rapid access back-care team” (RABT) to address low back pain (LBP) in urban emergency departments (EDs).
The pathway starts with having a physiotherapist (PT) conducting a neuromusculoskeletal exam, prior to the physician. They provide treatment and guidance including manual therapy, mobilization, education, home exercises and referral to community resources. The pharmacist then reviews medications, discusses pain management, prescribes analgesia and creates a plan for outpatient analgesia. This occurs while the patient awaits the physician (an average wait time of 2 hours at our site), avoiding increases to length of stay (LOS) and reducing burden on physicians.
Implementation: To operationalize this pathway successfully, a site requires dedicated PT and pharmacy services in the ED, as the unpredictable timing of LBP referrals requires a regular presence of the RABT. The selected PT and pharmacist must be confident, outgoing practitioners with a solid understanding of LBP, red-flags, and appropriate treatment. Our project team consisted of physiotherapists, pharmacists, nurses, physicians, managers, and QI leaders, formed to facilitate a collaborative approach to implementation. The Prosci® ADKAR model and Plan-Do-Study-Act (PDSA) cycles were used to implement the pathway and troubleshoot operational challenges.
Evaluation Methods: Front-line staff manually collected data on response time, treatments, adverse events, and resources provided. The investigators reviewed patient charts to record opioid prescriptions, DI referrals, and arrival/discharge times of the patients. We compared outcomes of patients seen by the RABT to historical site data of patients with a discharge diagnosis of LBP from the ED. We actively sought feedback from physicians, nurses, and the leadership group to ensure that unintended consequences or near-misses were identified early on. We reviewed interim data such as LOS and average time-to-assessment, to identify areas for improvement. This data and feedback were addressed via bimonthly PDSA cycles. We also administered patient and staff satisfaction surveys before and after site implementation of the pathway to develop an understanding of patient and staff thoughts, feelings and experiences with the service model.
Results: We studied these outcomes in 44 patients exposed to our RABT. Patients who saw a physiotherapist prior to the physician had shorter median ED LOS (3.2h vs. 4.0h), lower diagnostic imaging rates (36.4% vs. 49.4%) and less opioid prescribing (31.8% vs. 49.2%). No patients returned to the ED within 72 hours post evaluation, compared to the 7.6% historical recidivism. Not all patients were seen by a pharmacist. When performing a subgroup analysis of patients seen by both a pharmacist and physiotherapist prior tophysician, opioid prescriptions were found to drop significantly from a baseline of 49.2% to 16.7%.
Advice and Lessons Learned:1. Service hours are ideally aligned with higher patient demand times, but should ultimately be chosen to minimize service disruptions and maximize overlap between interdisciplinary members of the RABT team.2. Regular PDSA cycles (every 2-4 weeks) are useful to review interim data and address operational issues that arise during implementation. This ensures the pathway evolves to fit the contextual needs of the site. Reviewing early results motivates the team, and discussing practice issues allows clinicians to identify where improvements can be made.3. When this pathway was initially implemented, one unintended consequence was the increase in ED LOS for patients referred to the RABT following physician assessment. In addition, this subgroup did not show significant reductions in opioid prescriptions or DI referrals. Referrals were subsequently restricted to before the physician only and were ideally completed by the triage nurse to maximize time forthe RABT
The Emergency Strategic Clinical Network (ESCN) quality improvement and innovation forum
Get PDFThis is an introduction for a special issue publishing abstracts from the forum mentioned in the title, as requested by Christopher Picard.
 
Hemorrhage control, a fundamental skill: A review of direct pressure, dressings, wound packing and bandages for life-saving
Get PDFL’exactitude du volume de médicament administré à l’aide de seringues préremplies d’épinéphrine: Une étude de simulation
Get PDF‘One Health’ promotion in a model city for dog-aggression policy: A qualitative inquiry in the City of Calgary
Get PDFBackground
Dog-bite injuries remain a perennial problem, especially in pediatric emergency services. Nonetheless, few researchers have examined how local-level policies may contribute to primary prevention. We do so with qualitative research and an emphasis on implementation. This study highlights the potential benefit of coordination in Alberta between municipalities and emergency health services.
Implementation
This study mainly took place in the City of Calgary, which has earned a sterling reputation, in Canada and internationally, for the results of its animal-control policy in reducing dog-aggression incidents. We attribute part of this achievement to the high compliance of licensing in Calgary. The City estimates 80-90% of all dogs in Calgary have been licensed (by comparison, the City of Toronto estimates 35% compliance with mandatory licensing for dogs). The City of Calgary earmarks revenue from licensing for human-animal services, including public education, assessment of dogs’ behavior, and a state-of-the-art shelter oriented towards rehoming. Here, we frame the City of Calgary’s dog-aggression policy as a ‘One Health’ issue. This concept refers to human-animal-environment interdependencies as the basis for health. Whereas most One Health research has focused on preventing zoonotic infections or environmental toxins, our approach emphasizes health promotion, in which ‘caring for one’s self and others’ as the foundation for improving longevity and quality of life. Over the years, we have informed and learned from the City of Calgary’s implementation of its dog-aggression policy framework.
Evaluation Methods
Related research (Caffrey et al., 2019) has analyzed the City of Calgary’s administrative data on dog-bite incidents, statistically and spatially. Previously our team partnered with the Emergency Services Strategic Clinical Network on an analysis of emergency services utilization for dog-bite injuries across Alberta (Jelinski et al., 2016). We have also highlighted risks to occupational health and safety amongst officers who enforce dog-aggression policies, in Alberta and worldwide (Rault et al., 2018). In this presentation, we delve into how these officers act on municipal data when investigating dog-aggression incidents in the City of Calgary. Our main sources of information were semi-structured interviews and participant-observation.
Results
High compliance with dog-licensing bylaws in Calgary assists officers in efficiently locating dogs following a dog-aggression complaint. In turn, citizens lodge complaints because they view the City of Calgary’s human-animal services as effective and humane.
References
Caffrey, N., Rock, M., Schmidtz, O., Anderson, D., Parkinson, M., Checkley, S.L. Insights about the
epidemiology of dog bites in a Canadian city using a dog aggression scale and administrative data. Animals, 9(6). doi: 10.3390/ani9060324.
Jelinski, S.E., Phillips, C., Doehler, M., Rock, M. (May, 2016). The epidemiology of emergency department
visits for dog-related injuries in Alberta. Canadian Journal of Emergency Medicine, 18(S1). doi:
10.1017/cem.2016.68
Rault, D., Nowicki, S., Adams, C., Rock, M. (2018). To protect animals, first we must protect law
enforcement officers. Journal of Animal and Natural Resource Law, XIV, pp.1-33
iOAT in the ED – Lessons Learned: Abstract from the Emergency Department Strategic Clinical Network Quality and Innovation Forum, Red Deer, Alberta, February 2020
No full textEmergency Strategic Clinical NetworkTM
Quality and Innovation Forum Presentation Proposal
Name: xx
Position (e.g. patient care manager, professor): Manager
Primary Affiliation: (AHS) Other: AHS
Project Title: iOAT in the ED – Lessons Learned
Hospital: All adult sites in Calgary
Location: Calgary
Team Members: xx & xx
Background
Deaths related to opioid poisoning have continued to climb over the last few years. The Injectable Opioid Agonist Treatment program (iOAT) provides injectable hydromorphone to those individuals with moderate to severe opioid use disorder and a history of injection drug use who have been unsuccessful with oral OAT and continue to be at high risk for opioid poisoning. Working with the emergency departments (ED) was identified as a critical step in the initial roll out of iOAT.
Implementation
The iOAT program began operating in October 2018. The clinic provides prescribed hydromorphone to clients within the program. Additionally, the team is comprised of physicians, nurse practitioners, nurses, social worker, peer support workers and administrative support to provide comprehensive wrap around care to every client that is registered to the program. It was recognized early on that the clients that were being served by iOAT were also high users of the ED and UCCs. Being part of iOAT became a factor that needed to be considered when these clients presented to the ED due to their prescription of hydromorphone. Working with management, medical leadership, and nurse educators, support and education were provided to ensure that iOAT clients were provided with optimal care when in the ED. Ongoing communication has been the primary strategy that has been used.
Evaluation Methods
The evaluation for this project has been informal and ongoing. The medical team at iOAT has worked with the medical team for the Calgary EDs to develop a detailed treatment plan that is visible on SCM. Telephone and emails have been the primary mode of feedback for both parties, and the plan is adjusted as necessary along the way.
Results
Improving the knowledge and understanding for all staff involved to understand iOAT and the role of the ED has been demonstrated to be effective when clients stay in the ED and don’t leave against medical advice, which likely occurred before. Additionally, the trust that is built within the iOAT clinic is maintained when the ED is a partner in care and as appropriate, provides them with the dosing that they would normally receive at iOAT.
Advice and Lessons Learned
1) Involve the emergency department management in planning or initial implementation
2) Communicate, Communicate, Communicate
3) Use continuous feedback to adjust to find the best strategies to provide patient car
Spring 2020 artwork - artist bio and headshot
No full textSpring 2020 artwork - artist bio and headsho
The Continuity of Care: From Admission to the Recovery at Home
Get PDFThe treatment and support patients receive in their transition from the Emergency Department (ED) to the patient care unit (PCU), and eventually, the community, have clinical consequences, psycho-social outcomes, and financial ramifications. This quality improvement report provides recommendations intended to improve patient experiences and outcomes, in the context of ED crowding. The recommendations provided are informed by the findings of a master\u27s project that examined the transfer of patients from admission in a crowded ED, to a select PCU, and then to the community using process mapping and patient surveys. The purpose of this project was to examine the sequence of care beyond the walls of the ED and include the PCU (McHugh et al., 2011) using a systems approach (Villa, Prenestini, & Giusepi. 2014). We believe that by understanding process successes and failures, between EDs and PCUs, we can make improvements to ensure efficient, effective, and streamlined transitions to promote continuity of care