The growing worldwide use of clinician-performed ultrasound (CPU) marks a dramatic change in bedside medicine and patient care. With steadily improving portability, accessibility and technology, ultrasound use continues to grow amongst many medical specialties. Likewise, the application of CPU in emergency medicine is increasing. Emergency Medicine (EM) is a medical specialty “based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury…” (International Federation for Emergency Medicine, 1991). Increasingly, emergency physicians are using emergency department ultrasound (ED U/S) to enhance their assessment of critically-ill patients (American College of Emergency Physicians, 2008). The purpose of this study was to evaluate and describe those aspects of ultrasound simulation (during HFS) that contribute to the development of critical care ED U/S skills. Secondly, it was of interest to assess how a novel ultrasound simulator (edus2) compared to video playback on a laptop in terms of the above-mentioned aspects. The population of interest included both EM trainees and faculty. This investigation was a randomized, prospective, crossover study with two intervention treatments for all participants. In Phase I, EM trainees and faculty from London, UK, were invited to participate in one of four day-long critical-care HFS sessions during which they participated in four critical-care scenarios. Faculty were involved in assisting with session debriefing and feedback. All participants completed two cases with each intervention. In Phase II, faculty in Saskatoon, SK, Canada, were invited to review video recordings of the sessions from Phase I and evaluate the educational merits of the two ED U/S simulation interventions. iii This study produced both quantitative and qualitative data. As this study looked at two interventions and how they could contribute to the development of ED U/S skills, pre- and postintervention changes were analysed for statistically significant differences between them. T-test analyses were used for comparisons. Effect sizes (Cohen’s d) were calculated where statistically significant findings were observed. Qualitative data was assessed through emergent thematic analysis and triangulation. The findings of the study support the integration of ED U/S simulation into HFS. Integration was found to be of value to both trainees and faculty by allowing trainees to demonstrate knowledge of indications as well as correct image interpretation and general integration of ED U/S into critical care (p<0.05). Trainees described an increased motivation to develop their ED U/S skills as well as greater desire to use ED U/S in everyday practice. Furthermore, the edus2 was identified as being the preferred training intervention. The edus2 met functional fidelity through its real time and hands-on applicability. Faculty preferred the edus2 as it allowed for better assessment of trainee skills that then influenced session debriefing and formative feedback. Faculty in Phase II found the edus2 intervention sufficient in offering basic insights into trainee ED U/S skills and mastery (p<0.05). Implications of the study include support for the use of ultrasound simulation during HFS for the development of critical care ED U/S skills amongst EM trainees. Further study on the effects of such hybrid simulation on clinical performance is warranted.

A hand-off represents the transfer of patient information and care responsibility between a sending and receiving provider. Hand-offs occur in single locations such as inpatient wards and across care settings like from primary care offices to emergency departments. This care transition quality improvement (QI) project was created to improve patient hand-off communication from a primary care office to a hospital based emergency department within the greater Phoenix, AZ metropolitan area. No uniform hand-off process existed before the QI project. The purpose of the QI project was to demonstrate process necessary to achieve desired outcomes, in this case, a superior patient hand-off. The QI project goal was to develop a standardized hand-off protocol and tool. The aim of this QI project was to replace existing hand-off methods with a formalized new hand-off process and tool used during care transition from a primary care office to an emergency department. QI project methods followed two (2) plan-do-study-act (PDSA) cycles involving QI team meetings and end-user feedback that iteratively led to the adoption of a standardized hand-off process and tool. PDSA cycle one identified the best handoff tool. PDSA cycle two established an efficient process for conducting hand-offs. The new hand-off tool consistently demonstrated superior information transfer. Program participant satisfaction increased and was reflected by positive feedback as most nurses and doctors embraced the new process.

This study qualitatively explored the practice of domestic violence (DV) intervention in the emergency department (ED) from the distinct perspectives of service users, service providers and co-ordinators of DV voluntary organisations. The research participant group was made up of eight survivors of domestic abuse, fourteen staff members from an ED (including their manager) and eight co-ordinators from a voluntary organisation offering services for DV issues. The study was informed by the dearth of evidence regarding pragmatic intervention for the specific context of emergency departments (EDs), a need to develop system level interventions and a solid theoretical base to inform implementation of a more effective interventional strategy (Feder et al., 2009; Thurston and Eisener, 2006; Ramsay et al., 2002).The study utilised constructivist grounded theory and feminist perspectives to elicit unique viewpoints from interviews with the three separate groups. A range of meanings and conceptualisations were found which contribute to a more complex understanding of the issues involved and the responses to them. These included how women experience DV, the way DV is rendered invisible by ED culture and, perhaps most importantly, how a lack of policy implementation has influenced the practice of ED staff with regard to DV. Adopting a perspective that takes into account the sensitivity and gendered nature of DV made visible the socio-political and personal influences that affect both health providers' and health users' attitudes to seeking help. System-wide barriers to intervention ranged from personal to situational levels within the context of EDs. They included deep-seated ambivalence, fear and trust issues located within the constructs of both service users and providers regarding identifying and assessing the problem, seeking help, and providing support. Three overarching concepts were identified: 1) meanings and complex realities relating to DV and its intervention 2) barriers to seeking and providing help and 3) strategies for overcoming barriers and developing DV intervention within ED. Using rigorous, inductive, comparative and interpretive attributes of grounded theory procedures, conclusions were reached about the development of DV interventions in the department. These informed the propositions made for a comprehensive and integrated DV intervention including universal interventions which can be helpful irrespective of service user's disclosure and stage of abuse, providing resources within the ED to enhance DV intervention; improving the ED environment so that it is more favourable for DV intervention; implementing policies that make the experience of psychological abuse visible; and promoting DV awareness. Areas of concern were highlighted for practice, policy, and research relevant to DV intervention in EDs.

Aim: The aim of this study was to describe the nurse’s work at an emergency department trough a perspective of caring. Method: A literature review has been made of twelve studies published between the years of 2002 – 2012. The focus of all the studies was on Swedish emergency departments.   Results: The researchers found four themes that they choose to use as a way of describing the nurses work in the emergency room as detailed as possible. These themes were: ‘The emergency room’, ‘the nurse’s job assignments at an emergency department’, ‘the patient’s experiences’ and ‘lifeworld and communication’. This study shows that it is problematic for the nurses to give a caring nursing. The emergency department is more focused on medicine than caring, as there are certain parameters to follow as a nurse at an emergency department.  Lack of time and manpower has been a consistent factor in this study to explain the inability to give good caring at the emergency department. Conclusion: High workload leads to short time with each patient. This leads to a lack of patient care in the emergency room. In the short meetings with patients, important information could get lost and this could lead to inferior nursing. This study shows that some nurses developed strategies to make a fast and correct assessment of the patient. Other nurses developed strategies to make the patients feel more comfortable. Examples were to make eye contact, touch the patient in a comforting way and take the time to really listen to the patient during the short time they had with each patient.

More than 6 million people present to emergency departments (EDs) across the US annually with chief complaints of chest pain or other symptoms suggestive of acute myocardial infarction (AMI). Of the million who are diagnosed with AMI, 350,000 die during the acute phase. Accurate triage in the ED can reduce mortality and morbidity, yet accuracy rates are low and delays in patient care are high. The purpose of this study was to explore the relationship between (a) patient characteristics, registered nurse (RN) characteristics, symptom presentation, and accuracy of ED RN triage level designations and (b) delay of care of patients with symptoms suggestive of AMI. Constructs from Donabedian’s Structure-Process-Outcome model were used to guide this study. Descriptive correlational analyses were performed using retrospective triage data from electronic medical records. The sample of 286 patients with symptoms suggestive of AMI comprised primarily Caucasian, married, non-smokers, of mean age of 61 with no prior history of heart disease. The sample of triage nurses primarily comprised Caucasian females of mean age of 45 years with an associate’s degree in nursing and 11 years’ experience in the ED. RNs in the study had an accuracy rate of 54% in triage of patients with symptoms suggestive of AMI. The older RN was more accurate in triage level designation. Accuracy in triage level designations was significantly related to patient race/ethnicity. Logistic regression results suggested that accuracy of triage level designation was twice as likely (OR 2.07) to be accurate when the patient was non-Caucasian. The patient with chest pain reported at triage was also twice as likely (OR 2.55) to have an accurate triage than the patient with no chest pain reported at triage. Electrocardiogram (ECG) delay was significantly greater in the patient without chest pain and when the RN had more experience in ED nursing. Triage delay was significantly related to patient gender and race/ethnicity, with female patients and non-Caucasian patients experiencing greater delay. An increase in RN years of experience predicted greater delay in triage. Further studies are necessary to understand decisions at triage, expedite care, improve outcomes, and decrease deaths from AMI.

Background: The demand for hospice palliative care (HPC) services is expected to grow due to the increasing number of seniors living into advanced old age, the changing nature of death, and the changing family structure. HPC is a philosophy of care that aims to relieve suffering and improve the quality of life for clients with life-threatening illnesses or end of life issues. The goals of HPC are not only to ameliorate clients’ symptoms but also to reduce unneeded or unwanted medical interventions such as emergency room visits or hospitalizations (ERVH). Hospitals are considered a setting ill-prepared for end of life issues. Therefore, use of such acute care services has to be considered an indicator of poor quality end of life care. It is important to understand the factors that contribute to ERVH in order to determine how to minimize the number of avoidable hospital visits. Objectives: The objectives of this study were to report the proportion of palliative home care clients with ERVH, describe the characteristics of clients with ERVH, and identify the predisposing, enabling, and need-for-care variables associated with ERVH. Methods: Analysis of secondary data was performed on a palliative home care dataset from the Hamilton Community Care Access Centre (CCAC). All palliative home care clients receiving services from the Hamilton branch were assessed using the interRAI Palliative Care (interRAI PC), which is a comprehensive, standardized instrument. One assessment for each client assessed between April 2008 and July 2010 was used, for a final sample size of 764. Results: Half of the palliative home care clients had one or more ERVH. Visits to the emergency department by time of the day and day of the week were relatively stable. Logistic regression and Cox regression analyses showed that wish to die at home and advance care directives are protective against ERVH. Unstable health, identified by a Changes in Health End stage disease and Signs and Symptoms scale (CHESS) score of 3 or higher, was associated with reduced odds of ERVH, while infections such as prior pneumonia and prior urinary tract infections increased odds of ERVH. Conclusions: Predisposing characteristics (i.e., wish to die at home and advance care directives) are nearly as important as need variables (i.e., CHESS and prior urinary tract infection) in determining ERVH among palliative home care clients, which challenges the assumption that need variables are the most important determinants of ERVH. There was a lack of significant association between many assessed needs and ERVH, perhaps due to the fluctuating health status among such clients and the stability of measurements. Ongoing assessment of palliative home care clients is essential in reducing ERVH, as reassessments at specified intervals will allow care and service plans to be adjusted with clients’ changing health needs and end of life preferences.

In light of the competitions of different medical services and the National Health Insurance¡¦s patient-oriented goal, the quality of medical care in the emergency room has been a top priory for improvement in many major medical centers. The purpose of this research is to evaluate the differences of medical quality after adjustment of physician manpower in three emergency departments of three separate hospitals. We will attempt to suggest ways to improve medical quality and make good use of medical resources. This is a retrospective survey using data from three emergency departments of three separate hospitals. The date ranged from March to April of 2002 and March to April of 2003. A total of 66,025 cases were gathered, minus 311 cases with incomplete data, the total valid data were 65,714 cases. The three hospitals A, B, C have 24,010 cases, 17,690 cases, and 24,014 cases, respectively. The result of this study showed that hospital A had increased the number of medical staff when comparing 2003 to 2002 data, however, the quality of care did not improve. Hospital B had increased the number of physicians on duty, decreased the waiting time for the patients, and the number of patients taken care per doctor had been increased too. However, within the 72-hour clinic follow-up patient numbers have increased. Hospital C have decreased the number of physicians on duty, but the waiting time have also decreased. The number of patients being taken care of by physicians, and 72-hour clinic follow-up are all increased. When compare the month between March and April of 2002, the highest ratio of 72-hour clinic follow-up is hospital A, followed by hospital B and C, in descending order. When compare the two study period of March and April of 2002 and 2003, waiting time and the ratio of waiting time in emergency department more than 6 hours is hospital A more than hospital C more than hospital B; the ratio of waiting time less than 2 hours is hospital C more than hospital B more than hospital A. The ratio of waiting time more than 2 hour but less than or equal to 4 hours and waiting time more than 4 hours but less than or equal to 6 hours is hospital A more than hospital B more than hospital C. This study suggests that the hospitals must establish a complete quality indicators, and must conduct periodic evaluation. At the same time, we must incorporate these indicators into our hospital information system and monitoring the effectiveness, in order to promote the quality of care.

The medical quality becomes a very important issue of a scholar and the public opinion. The high quality medical service of patients center and customer direction already has been necessarily prepare conditions to get the best competition advantage of all levels hospital in Taiwan, now.¡CTherefore, all hospital manager believe that promote medical quality is the very important issue¡CThe medical service quality of Emergency Department plays the very important role in the whole hospital. The medical service quality indicator is acknowledged well trusty medical quality measurement tool. Donabedian point out that medical quality measurement is compose of structure¡Bprocess and outcome, and that the outcome quality indicator measurement is the trend¡CAsthma is one of the most common diseases among children. Because of rising morbidity, mortality and medical costs all over the world, asthma becomes a very important issue. So, The purpose of this study is to identify the key factors associated with the of outcomes quality. The example of Pediatric Asthma in a Teaching Hospital. Data take from the Teaching Hospital¡¦s TQIP database through 2003. There are 534 Pediatric asthma patients who are research samples and care take by 25 physicians. The research analyze patient¡¦s and physician¡¦s characteristic to described data, Correlation and Regression with SPSS software. Look for the characteristic what influence the outcome quality of Emergency Department. The outcome quality include that patient¡¦s state after the treatment, patient¡¦s stay time and unscheduled revisit to Emergency Department.¡CRegression analysis showed that. 1.patient¡¦s state after the treatment trend to be inpatient who care by experienced physician, younger, illness serious and reach on day shift. 2.patient¡¦s stay time longer who care by experienced physician, so that the consultations effectiveness should promote to reduce .patient¡¦s stay time¡C3.patient¡¦s stay time longer who younger, so that the staff take care more careful and pay attention to patient¡¦s condition change frequently¡Ato reduce uneasy of long-term stay in Emergency Department. 4.unscheduled revisit ratio in the study is 4.7%¡Abut not discover the correlation factor¡C Integrate above-mentioned¡Athe study find that ¡Aphysician¡¦s and patient¡¦s characteristic will influence medical outcome quality. The project hospital should with different influence factor to draw quality manage policy and stratagem, and improve Emergency Department quality will raise the satisfied degree.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Background and Significance: The i‐STAT point of care blood analyzer is a handheld device used for a variety of laboratory analyses in medical settings. Much research has been performed to evaluate its validity, but it has not been exhaustively tested in real‐world emergency department settings, despite its increasingly popular use in such settings. Methods: We retrospectively examined medical records at the Maricopa Integrated Health Systems Emergency Department to find 100 instances between February 2014 and September 2014 in which a patient had electrolyte testing performed on both the i‐STAT and in the central laboratory within a 60 minute timeframe. These data were examined using variance of means and Bland‐Altman graphing for equivalency. Results: We set the clinical equivalence threshold for each lab to be 5% of the mean normal value. That is, if the i‐STAT differed from central lab by less than 5% of the middle of the normal range (137‐145 for sodium, 5% of which is 7) then we consider them to be clinically equivalent. At this level we were unable to show clinical equivalence. In additional, all electrolytes tested showed small but significant bias between the i‐STAT and the central laboratory. Re‐examination of the data excluding all measurements more than 15 minutes apart showed similar findings. Conclusions: At this time we cannot show equivalency between the i‐STAT device and the central laboratory when used under real‐life emergency department conditions. More research is needed is to support or refute these findings.

Emergency departments (EDs) are often thought of solely as places where life-saving interventions occur. However, EDs are also places where dying patients receive end of life care. Though research examining expert nurse behaviours in care of the dying has been conducted in a variety of care settings, little is known about this topic as it relates to care of the dying adult in the ED. A descriptive exploratory study was conducted with registered nurse experts (n = 6) in two urban EDs in Western Canada. Five expert nurse behaviours deemed essential in care of the dying adult patient in the ED were identified: 1) providing comfort; 2) honouring the personhood of the patient; 3) responding to the family; 4) responding after the death of the patient; and 5) responding to colleagues. These findings contribute to the empirical evidence concerning expert nursing care of the dying.