Barriers to and facilitators of the development and utilization of context appropriate evidence based clinical algorithms to optimize clinical care and patient outcomes in the Tikur Anbessa emergency department: a multi-component qualitative study

BACKGROUND Painful vaso-occlusive crises (VOC) are the most common reason for acute care utilization in patients with sickle cell disease (SCD), and the emergency department (ED) is often the site of initial management and treatment. Treatment guidelines recommend initiation of analgesia with parenteral opioids within 30 minutes of presentation, timely reassessment of pain, and additional opioids as needed every 15-30 minutes. These targets are infrequently met, resulting in uncontrolled pain, increased likelihood of hospital admission, and deterioration of physician-patient relationships. METHODS We undertook a multidisciplinary effort to improve the management of VOC in the ED, by development and implementation of an evidence-based clinical care pathway. The clinical pathway was implemented at the Hospital of the University of Pennsylvania in December 2018, with direct education of hematology and ED providers around the content of the clinical pathway, and availability of the pathway on the institutional intranet. Specific areas of focus in the pathway included appropriate triaging of patients as emergency severity index 2, timely administration of initial opioid dose, rapid reassessment and administration of additional opioid doses as needed, as well as appropriate laboratory evaluation and evaluation for other common and/or serious complications of SCD. Outcome measures included time from ED registration to administration of first opioid dose, time between administration of first opioid dose and second opioid dose, and proportion of patients discharged from the ED. Balance measures included rate of ED readmission and length of stay. RESULTS There were 602 ED visits from 103 unique patients in the study period, with 256 visits in the six-month period prior to pathway implementation and 346 visits in the six-month period after implementation. Following pathway implementation, time from registration to first opioid dose fell from 114 minutes to 93 minutes (p = 0.003). The proportion of patients receiving their first opioid dose within 60 minutes of registration increased from 19% to 33%. Time from administration of the first opioid dose to the second opioid dose improved from 117 minutes to 94 minutes (p = 0.002). The proportion of patients receiving their second opioid dose within 60 minutes of the first opioid dose increased from 27% to 37%. There was no change in the rate of hospital admission from the ED, or in the proportion of patients who left without being seen (p = 0.710). There was also no change in rate of ED readmissions (p = 0.138) or length of stay (p = 0.483). CONCLUSION Implementation of an evidence-based clinical care pathway in the ED for SCD patients presenting with VOC led to significant improvement in outcomes, with decreased time to first opioid dose and decreased time from first to second opioid dose. Nevertheless, very few patients received guideline-based care, particularly with the goal of time to first opioid dose of less than 30 minutes. While our data demonstrate that provider education and clinical pathways clearly improve the management of VOC in the ED, additional interventions will be required to target other barriers to optimal management, including implicit biases, negative provider attitudes, and social stigma surrounding SCD. Disclosures No relevant conflicts of interest to declare.

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Emergency Department Response to Chemical, Biological, Radiological, Nuclear, and Explosive Events: A Systematic Review

Prehospital and Disaster Medicine ◽

10.1017/s1049023x18000900 ◽

2018 ◽

Vol 33 (5) ◽

pp. 543-549 ◽

Cited By ~ 5

Author(s):

Saydia Razak ◽

Sue Hignett ◽

Jo Barnes

Keyword(s):

Systematic Review ◽

Emergency Department ◽

Systems Approach ◽

Clinical Care ◽

Evidence Based ◽

Key Factors ◽

Publication Type ◽

Organizational Policies ◽

Response Planning ◽

Explosive Events

AbstractIntroductionA Chemical, Biological, Radiological, Nuclear, and explosive (CBRNe) event is an emergency which can result in injury, illness, or loss of life. The emergency department (ED) as a health system is at the forefront of the CBRNe response with staff acting as first receivers. Emergency departments are under-prepared to respond to CBRNe events - recognizing key factors which underlie the ED CBRNe response is crucial to provide evidence-based knowledge to inform policies and, most importantly, clinical practice.ProblemChallenges in detection, decontamination, and diagnosis are associated with the ED CBRNe response when faced with self-presenting patients.MethodsA systematic review was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). An in-depth search strategy was devised to identify studies which focused on the ED and CBRNe events. The inclusion criteria were stringent in terms of the environment (ED), participants (first receivers), situation (CBRNe response), and actions (detection, decontamination, and diagnosis). Fifteen databases and topic-specific journals were searched. Studies were critically appraised using the Mixed Methods Appraisal Tool (MMAT). Papers were thematically coded and synthesized using NVivo 10 (QSR International Ltd, Melbourne, Australia).ResultsSixty-seven full-text papers were critically appraised using the MMAT; 70% were included (n = 60) as medium- or high-quality studies. Data were grouped into four themes: preparedness, response, decontamination, and personal protective equipment (PPE) problems.DiscussionThis study has recognized the ED as a system which depends on four key factors - preparedness, response, decontamination, and PPE problems - which highlight challenges, uncertainties, inconsistencies, and obstacles associated with the ED CBRNe response. This review suggests that response planning and preparation should be considered at three levels: organizational (policies and procedures); technological (decontamination, communication, security, clinical care, and treatment); and individual (willingness to respond, PPE, knowledge, and competence). Finally, this study highlighted that there was a void specific to detection and diagnosis of CBRNe exposure on self-presenting patients in the ED.Conclusion:The review identified concerns for both knowledge and behaviors which suggests that a systems approach would help understand the ED response to CBRNe events more effectively. The four themes provide an evidence-based summary for the state of science in ED CBRNe response, which can be used to inform future policies and clinical procedures.RazakS,HignettS,BarnesJ.Emergency department response to chemical, biological, radiological, nuclear, and explosive events: a systematic review.Prehosp Disaster Med.2018;33(5):543–549.

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Review of implementation strategies to change healthcare provider behaviour in the emergency department

CJEM ◽

10.1017/cem.2017.432 ◽

2018 ◽

Vol 20 (3) ◽

pp. 453-460 ◽

Cited By ~ 4

Author(s):

Kerstin de Wit ◽

Janet Curran ◽

Brent Thoma ◽

Shawn Dowling ◽

Eddy Lang ◽

...

Keyword(s):

Emergency Department ◽

Implementation Research ◽

Best Practice ◽

Clinical Care ◽

Intervention Strategy ◽

Implementation Strategies ◽

Evidence Based ◽

Medicine Research ◽

Canadian Association ◽

New Evidence

AbstractObjectivesAdvances in emergency medicine research can be slow to make their way into clinical care, and implementing a new evidence-based intervention can be challenging in the emergency department. The Canadian Association of Emergency Physicians (CAEP) Knowledge Translation Symposium working group set out to produce recommendations for best practice in the implementation of a new science in Canadian emergency departments.MethodsA systematic review of implementation strategies to change health care provider behaviour in the emergency department was conducted simultaneously with a national survey of emergency physician experience. We summarized our findings into a list of draft recommendations that were presented at the national CAEP Conference 2017 and further refined based on feedback through social media strategies.ResultsWe produced 10 recommendations for implementing new evidence-based interventions in the emergency department, which cover identifying a practice gap, evaluating the evidence, planning the intervention strategy, monitoring, providing feedback during implementation, and desired qualities of future implementation research.ConclusionsWe present recommendations to guide future emergency department implementation initiatives. There is a need for robust and well-designed implementation research to guide future emergency department implementation initiatives.

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Abstract 253: Abstract: Self-advocacy in the Diagnostic Process Among Emergency Department Patients: A Qualitative Study

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/hcq.13.suppl_1.253 ◽

2020 ◽

Vol 13 (Suppl_1) ◽

Author(s):

Paula Emille C Bondal ◽

Mariel Villanueva ◽

Kelly T Gleason

Keyword(s):

Decision Making ◽

Emergency Department ◽

Qualitative Study ◽

Clinical Care ◽

Diagnostic Process ◽

Self Awareness ◽

Self Advocacy ◽

Emergency Department Patients ◽

High Level ◽

Health Situation

Background: Evidence suggests that including the patient in the decision-making process leads to better health outcomes. The objective of this qualitative study is to explore barriers and facilitators to self-advocacy among patients during the diagnostic process in the emergency department (ED). Methods: ED patients (n=16) completed 15-30 minute semi-structured phone interviews 2 weeks to 3 months following an ED visit. Patients were eligible who had at least one chief complaint linked to common, dangerous cardiovascular conditions that are often misdiagnosed (chest pain, dizziness, headache, abdominal pain, and/or cough). Interviews were transcribed verbatim and coded by two independent reviewers using an inductive thematic analysis approach. Findings: The participants’ average age was 51 years-old (range 26-73 years-old). 62.5% of participants identified their race as White, 37.5% Black or African American, and 6.2% Asian. Interviews centered on the patients’ experience with the diagnostic process in the ED, including expectations, communication with clinical care team, and satisfaction and understanding of follow-up plans. The analysis revealed three common themes: (1) Doctors perceived as having total authority. Patients voiced that they must do as prescribed and not question the explanation given for their health problems by the doctors, who were the experts. (2) Satisfaction without a thorough assessment. Patients reported an acceptance of being “rushed” from the ED without thorough diagnosis or explanation because they expect doctors to be busy. Patients are satisfied with being told their diagnosis is unknown but not life-threatening. (3) Patients reported a high-level of self-awareness of their baseline health status, and used their intuition to seek medical care. Three of the sixteen patients reported developing a dangerous cardiovascular condition, including a stroke and a venous thromboembolism, after discharge that potentially could have been identified in the ED. They each reported a self-awareness that a dangerous health situation may be developing, but a trust in providers’ decision-making to discharge them. Conclusions: The interviews shared common themes of reduced self-advocacy in the setting of the ED and trust in providers’ opinions over patients’ own intuition. In three cases, patients reported developing a dangerous cardiovascular condition shortly after discharge that may have been identified earlier with increased self-advocacy.Implications for Practice: The fast-paced ED system may exacerbate patient vulnerability and impede their willingness to assert themselves. Empowering patients to provide input in the diagnostic process may contribute valuable information that leads to more accurate diagnoses.

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Managing clinical uncertainty in older people towards the end of life: a systematic review of person-centred tools

BMC Palliative Care ◽

10.1186/s12904-021-00845-9 ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

Clare Ellis-Smith ◽

India Tunnard ◽

Marsha Dawkins ◽

Wei Gao ◽

Irene J. Higginson ◽

...

Keyword(s):

Older People ◽

End Of Life ◽

Integrated Care ◽

Patient Outcomes ◽

Clinical Care ◽

Logic Model ◽

Evidence Based ◽

Clinical Uncertainty ◽

Causal Pathways ◽

Care And Treatment

Abstract Background Older people with multi-morbidities commonly experience an uncertain illness trajectory. Clinical uncertainty is challenging to manage, with risk of poor outcomes. Person-centred care is essential to align care and treatment with patient priorities and wishes. Use of evidence-based tools may support person-centred management of clinical uncertainty. We aimed to develop a logic model of person-centred evidence-based tools to manage clinical uncertainty in older people. Methods A systematic mixed-methods review with a results-based convergent synthesis design: a process-based iterative logic model was used, starting with a conceptual framework of clinical uncertainty in older people towards the end of life. This underpinned the methods. Medline, PsycINFO, CINAHL and ASSIA were searched from 2000 to December 2019, using a combination of terms: “uncertainty” AND “palliative care” AND “assessment” OR “care planning”. Studies were included if they developed or evaluated a person-centred tool to manage clinical uncertainty in people aged ≥65 years approaching the end of life and quality appraised using QualSyst. Quantitative and qualitative data were narratively synthesised and thematically analysed respectively and integrated into the logic model. Results Of the 17,095 articles identified, 44 were included, involving 63 tools. There was strong evidence that tools used in clinical care could improve identification of patient priorities and needs (n = 14 studies); that tools support partnership working between patients and practitioners (n = 8) and that tools support integrated care within and across teams and with patients and families (n = 14), improving patient outcomes such as quality of death and dying and satisfaction with care. Communication of clinical uncertainty to patients and families had the least evidence and is challenging to do well. Conclusion The identified logic model moves current knowledge from conceptualising clinical uncertainty to applying evidence-based tools to optimise person-centred management and improve patient outcomes. Key causal pathways are identification of individual priorities and needs, individual care and treatment and integrated care. Communication of clinical uncertainty to patients is challenging and requires training and skill and the use of tools to support practice.

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Nurse-Initiated Protocols for Chest Pain in the Emergency Department

10.46409/sr.dbar8053 ◽

2020 ◽

Author(s):

◽

Matthew Hodges

Keyword(s):

Emergency Department ◽

Chest Pain ◽

Length Of Stay ◽

Patient Outcomes ◽

Evidence Based ◽

Safe Patient Care ◽

Practice Problem ◽

Clinically Significant ◽

Effective Use ◽

Pain Patients

Practice Problem: Emergency department crowding inhibits the ability to provide safe patient care to chest pain patients and negatively impact patient outcomes. A Veteran Affairs emergency department has identified a similar concern and implemented a nurse-initiated protocol to decrease the length of stay and improve patient outcomes. PICOT: This evidence-based practice (EBP) project was guided by the following PICOT question: In the emergency department (ED), how does a nurse-initiated protocol (NIP) for chest pain (CP) patients compared to no protocol use influence length of stay (LOS) in the ED over 8 weeks? Evidence: The reviewed literature supported the evidence of effective use of a nurse-initiated protocol in reducing the length of stay in the emergency department. Eleven articles met the inclusion criteria and were used for this literature review. Intervention: The evidence-based nurse-initiated protocol is an intervention to provide objective clinical practice guidelines for chest pain patients resulting in improved earlier diagnostic results and decreased length of stay in the emergency department. Outcome: Post-implementation conclusions revealed no reduction in length of stay after using the protocol but achieved a clinically significant decrease in the time of completion for 12-lead EKGs. Conclusion: Staff education and the implementation of an evidence-based NIP for CP established positive outcomes on reducing EKG times. The results were also clinically significant to validate the implementation of nursing protocols in the ED for decreasing LOS and improving patient outcomes.

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Interventions to change clinician behaviour in relation to suicide prevention care in the emergency department: A scoping review protocol

10.31219/osf.io/f3gdr ◽

2020 ◽

Author(s):

Hwayeon Danielle Shin ◽

Christine Cassidy ◽

Janet Curran ◽

Lori Weeks ◽

Leslie Anne Campbell ◽

...

Keyword(s):

Emergency Department ◽

Suicide Prevention ◽

Behaviour Change ◽

Clinical Care ◽

Grey Literature ◽

Allied Health Professionals ◽

Wide Range ◽

Knowledge And Attitude ◽

Clinician Behaviour ◽

Google Search

Objective: This review aims to explore, characterize, and map the literature on interventions implemented to change emergency department (ED) clinicians’ behaviour related to suicide prevention using the Behaviour Change Wheel (BCW) as a guiding theoretical framework. Introduction: An ED is a critical place for suicide prevention. Yet, many patients who present with suicide-related thoughts and behaviours are discharged without proper assessment or appropriate treatment. Supporting clinicians (who provide direct clinical care, including nurses, physicians, allied health professionals) to make the desired behaviour change following evidence-based suicide prevention care is an essential step toward improving patient outcomes. However, reviews to date have yet to take a theoretical approach to investigate interventions implemented to change clinicians’ behaviour. Inclusion criteria: This review will consider literature that includes interventions that target ED clinicians’ behaviour change related to suicide prevention. Behaviour change refers to observable practice changes as well as proxy measures of behaviour change including knowledge and attitude. There are many ways in which an intervention can change clinicians’ behaviour (e.g., education, altering service delivery). This review will include a wide range of interventions that target behaviour change regardless of the type but exclude interventions that exclusively target patients.Methods: Multiple databases will be searched: PubMed, PsycInfo, CINAHL and Embase. We will also include grey literature, including Google search, ProQuest Dissertations and Theses Global, and Scopus conference papers. Full text of included studies will be reviewed, critically appraised and extracted. Extracted data will be coded to identify intervention functions using the BCW. Findings will be summarized in tables accompanied by narrative reports.

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Faculty Opinions recommendation of Undergraduate medical student perceptions and use of Evidence Based Medicine: a qualitative study.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.9113958.9697057 ◽

2011 ◽

Author(s):

Chad Whelan ◽

Elizabeth Schulwolf

Keyword(s):

Medical Student ◽

Qualitative Study ◽

Student Perceptions ◽

Evidence Based Medicine ◽

Undergraduate Medical Student ◽

Evidence Based ◽

Based Medicine

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The Red Legs RATED tool to improve diagnosis of lower limb cellulitis in the emergency department

British Journal of Nursing ◽

10.12968/bjon.2021.30.12.s22 ◽

2021 ◽

Vol 30 (12) ◽

pp. S22-S29

Author(s):

Gillian O'Brien ◽

Patricia White

Keyword(s):

Emergency Department ◽

Lower Limb ◽

Treatment Guidelines ◽

Positive Impact ◽

Data Gathering ◽

Pilot Project ◽

Accurate Diagnosis ◽

Evidence Based ◽

Significant Burden ◽

User Friendly

Background: Lower limb cellulitis poses a significant burden for the Irish healthcare system. Accurate diagnosis is difficult, with a lack of validated evidence-based tools and treatment guidelines, and difficulties distinguishing cellulitis from its imitators. It has been suggested that around 30% of suspected lower limb cellulitis is misdiagnosed. An audit of 132 patients between May 2017 and May 2018 identified a pattern of misdiagnosis in approximately 34% of this cohort. Objective: The aim of this pilot project was to develop a streamlined service for those presenting to the emergency department with red legs/suspected cellulitis, through introduction of the ‘Red Leg RATED’ tool for clinicians. Method: The tool was developed and introduced to emergency department clinicians. Individuals (n=24) presenting with suspected cellulitis over 4 weeks in 2018 were invited to participate in data gathering. Finally, clinician questionnaire feedback regarding the tool was evaluated. Results: Fourteen participants consented, 6 female and 8 male with mean age of 65 years. The tool identified 50% (n=7) as having cellulitis, of those 57% (n=4) required admission, 43% (n=3) were discharged. The remainder who did not have cellulitis (n=7) were discharged. Before introduction of the tool, all would typically have been admitted to hospital for further assessment and management of suspected lower limb cellulitis. Overall, 72% (n=10) of patients who initially presented with suspected cellulitis were discharged, suggesting positive impact of the tool. Clinician feedback suggested all were satisfied with the tool and contents. Conclusion: The Red Leg RATED tool is user friendly and impacts positively on diagnosis treatment and discharge. Further evaluation is warranted.

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Perspectives and experiences of patients and healthcare professionals with geriatric assessment in chronic kidney disease: a qualitative study

BMC Nephrology ◽

10.1186/s12882-020-02206-9 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Carlijn G. N. Voorend ◽

Noeleen C. Berkhout-Byrne ◽

Yvette Meuleman ◽

Simon P. Mooijaart ◽

Willem Jan W. Bos ◽

...

Keyword(s):

Kidney Disease ◽

Qualitative Study ◽

Clinical Outcomes ◽

Geriatric Assessment ◽

Clinical Care ◽

Treatment Options ◽

Routine Care ◽

Treatment Team ◽

Dutch Hospital ◽

Additional Support

Abstract Background Older patients with end-stage kidney disease (ESKD) often live with unidentified frailty and multimorbidity. Despite guideline recommendations, geriatric assessment is not part of standard clinical care, resulting in a missed opportunity to enhance (clinical) outcomes including quality of life in these patients. To develop routine geriatric assessment programs for patients approaching ESKD, it is crucial to understand patients’ and professionals’ experiences with and perspectives about the benefits, facilitators and barriers for geriatric assessment. Methods In this qualitative study, semi-structured focus group discussions were conducted with ESKD patients, caregivers and professionals. Participants were purposively sampled from three Dutch hospital-based study- and routine care initiatives involving geriatric assessment for (pre-)ESKD care. Transcripts were analysed inductively using thematic analysis. Results In six focus-groups, participants (n = 47) demonstrated four major themes: (1) Perceived characteristics of the older (pre)ESKD patient group. Patients and professionals recognized increased vulnerability and (cognitive) comorbidity, which is often unrelated to calendar age. Both believed that often patients are in need of additional support in various geriatric domains. (2) Experiences with geriatric assessment. Patients regarded the content and the time spent on the geriatric assessment predominantly positive. Professionals emphasized that assessment creates awareness among the whole treatment team for cognitive and social problems, shifting the focus from mainly somatic to multidimensional problems. Outcomes of geriatric assessment were observed to enhance a dialogue on suitability of treatment options, (re)adjust treatment and provide/seek additional (social) support. (3) Barriers and facilitators for implementation of geriatric assessment in routine care. Discussed barriers included lack of communication about goals and interpretation of geriatric assessment, burden for patients, illiteracy, and organizational aspects. Major facilitators are good multidisciplinary cooperation, involvement of geriatrics and multidisciplinary team meetings. (4) Desired characteristics of a suitable geriatric assessment concerned the scope and use of tests and timing of assessment. Conclusions Patients and professionals were positive about using geriatric assessment in routine nephrology care. Implementation seems achievable, once barriers are overcome and facilitators are endorsed. Geriatric assessment in routine care appears promising to improve (clinical) outcomes in patients approaching ESKD.

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