Background: Emergency Department (ED) overcrowding is a national healthcare problem, and despite awareness and efforts to alleviate excessive patient volume, it continues to be an epidemic. One improvement technique proposed is to increase employment of independently licensed APRNs in the ED. Objective: The objective of this study was to determine if LMC and USACS physicians are willing and ready to implement and collaborate with NPs in the ED. Design and Methods: A non-experimental descriptive study design was employed, and sixty emergency medicine providers were surveyed. Eighteen participants (14 MDs, 4 DOs) completed an online questionnaire which consisted of 21 Likert-style questions, an open-ended question, and six demographic questions. Research questions: 1) What are physician perceptions regarding the tasks and resources required for NPs to practice in emergency medicine? 2) What are physician perceptions regarding the need, importance, and benefits of NPs in the ED? 3) What are physician perceptions of contextual factors regarding NPs’ working in the organization? Results: Entire Questionnaire: Mean = 2.02 (SD = .35); Subscale 1: Mean = 2.13 (SD = .33); Subscale 2: Mean = 1.79 (SD = .48); Subscale 3: Mean = 2.06 (SD = .49). Conclusion: This study concludes that, overall, there is a readiness to change among the USACS physicians. Evaluation of subscale 2 and 3 from this study indicates that USACS physicians are willing and ready to implement an NP service in LMC's ED. Furthermore, while discrepancies occurred in subscale 1, these differences can be mitigated through education, credentialing requirements, and policy development.

Class of 2016 Abstract / Objectives: Pain management in the pediatric population is crucial when providing emergency medical care, as inadequate pain control is a significant cause of morbidity and mortality. The use of adjunctive therapy can potentially decrease opioid requirements, thereby reducing potential opioid related adverse effects. The purpose of this study was to evaluate the use of adjunctive therapy and impact on morphine dose requirements for pediatric pain management in the emergency department (ED). Methods: This study was an IRB approved retrospective review of pediatric patients ages 1 to 18 years, who received intravenous (IV) morphine therapy in the ED. Patients were excluded based on opioid-tolerance (using opioids prior to ED visit), diagnosis of sickle cell disease, and oncologic disorders. Data collection included baseline demographics, medical diagnoses and comorbidities, morphine total dose by weight, type, dose by weight and frequency of adjunctive analgesia agents, and pain scores. Results: The use of adjunctive analgesia in addition to morphine did not reduce the total morphine doses given, repeat morphine dose requirements, admission rates, or length of stay but did increase the time to a repeat dose of morphine. In those patients who received adjunctive analgesia before morphine, we saw a statistically significant decrease in the total amount of morphine received, total morphine doses given, repeat morphine dose requirements, and admission rates. Conclusions: In pediatric patients who require pain management in the ED, adjunctive analgesia should be given before morphine to reduce the amount of morphine required.

Magister Artium - MA / Staff members of a district hospital experience various challenges in managing psychotic patients in the emergency department. Psychosis can result from the use of illicit drugs. Persons presenting in a psychotic state due to use of illicit substances are common at emergency departments of district hospitals. In terms of the South African legislation, mental health services are accessible at general district hospitals with the 72-hour observation period being mandatory. Emergency departments are the first area where behaviourally disturbed and psychotic persons are assessed and managed in terms of the Mental Health Care Act of South Africa (Act No. 17 of 2002). Emergency staff members render a 24-hour service to all public users requiring emergency services, and should have the skills, training and resources necessary to manage any public user presenting for emergency services. A large proportion of the patients presenting with psychosis at the hospital where the study was done, were reported as using illicit substances. This study sought to discover and understand: What are the challenges experienced by staff members in managing substance-induced psychotic patients in the emergency department of a district hospital? In an attempt to answer the research question, the aim of this study was to explore and describe the challenges experienced by emergency department staff members in managing substance-induced psychotic patients in a district hospital in the Western Cape. An explorative and descriptive research design was used, grounded in the qualitative research approach. Ten staff members managing or assisting with managing substance-induced psychotic patients in the emergency department were purposefully sampled. This sample comprised doctors, nurses, and other support staff members, such as security guards, porters and general workers. An interview schedule guided the face-toface semi-structured interviews as the method of data collection. The digitally recorded data from these interviews were transcribed verbatim, and analysed into six themes as well as sub-themes. Data were analysed according to Tesch, as cited in Creswell (2009). Measures to ensure trustworthiness were adhered to, such as neutrality, consistency, truth value, and applicability. Ethical considerations were closely followed, such as obtaining permission from the Senate Higher Degrees of the University of the Western Cape and the Provincial Health Ethics Committee, participants’ gave voluntary written consent to partake in the study, aware of the right to withdraw at any time, and of their anonymity and confidentiality being maintained through the use of pseudo names. The findings of the study were that the emergency department was inappropriate for the managing of acutely psychotic or behaviourally disturbed patients such as these, particularly if these staff members were not adequately trained, and where there were staff shortages. Though there was recognition of these patients’ rights to obtain medical care, fear and resentment accompanied by stress on the part of staff presented throughout the themes. The study yielded recommendations such as the need for training and debriefing of staff members and support by hospital management, as well as services such as groupwork and supportive services to patients and family. Recommendations were also made for a review of staffing, infrastructure, facilities and legislation. These recommendations are considered important to assist in the planning, and implementation of healthcare services to mental healthcare users, with specific reference to substance-induced psychotic patients.

Altered mental status (AMS), a common and serious entity in elderly Emergency Department patients, is not well recognized by physicians. Our prospective cohort study evaluated the implementation, by nurses and physicians, of the Ottawa 3DY Scale, a cognitive screening tool. We enrolled 260 patients (60.0% female, mean age 83.7). Screening rates were: overall - 78.3%; physician - 51.8%; and nurse - 64.2%. Interrater reliability was 0.65. Physician and nurse sensitivity was 78.9, 84.6% and specificity was 39.4, 54.2%, respectively, compared with the Mini-Mental State Exam. Patient living situation, educational level, triage location, hospitalization, admission location and 30 day mortality were associated with AMS. Implementation of the Ottawa 3DY Scale increased screening for AMS in elderly Emergency Department patients. It was feasible, sensitive, specific and had good interrater reliability. Use will lead to increased identification of cognitive impairment and ultimately result in improved care and outcomes in this vulnerable patient population.

Class of 2006 Abstract / Objectives: To evaluate the use of the numerical pain scale at the Sierra Vista Regional Health Center Emergency Department in adult patients presenting with a chief complaint of pain. Methods: A retrospective chart review was performed on 299 charts of patients presenting to the emergency department with a chief complaint of pain. Results: Pain was assessed in 86.2% of 299 patients at triage, 26.4% post-intervention, and 58.2% at discharge. The average pain value reported by patients at triage was 6.3. Subsequent average pain value post-intervention was 4.1 and 2.9 at discharge. The average pain value at triage compared to the average pain value at discharge was statistically different (p<0.05). Conclusions: Pain assessment using the NRS is not being performed adequately in all patients presenting to the emergency department at SVRHC with a chief complaint of pain.

The emergency department of Lions Gate Hospital was studied both in regard to the patients' current visit to this facility and in regard to the patients' other sources of ambulatory medical care. The objectives of the study were: (1) to understand why patients seek care at Lions Gate's emergency department; (2) to discover how this facility fits into the patients' overall patterns of medical care; and (3) on the basis of the above data, to propose any appropriate changes in the organization of the emergency department. The study was conducted during 14 days in September, 1974; the sampling frame covered all hours of the day and all days of the week. Data were gathered by questionnaires administered in the emergency department, with 85.60 percent of the sample responding. The increase in demand for emergency department services has been attributed to a variety of factors. The present study determined that private physicians and their non-availability are the predominant factors contributing to emergency department usage at Lions Gate Hospital, indicating that this facility is substituting for the wider primary care system. Data pertaining to the patients' overall patterns of medical care provided further evidence that the emergency department has gained wide acceptance by the patients as a source of primary medical care. Moreover, the emergency department was identified as an important and continuing source of care in the medical care patterns of many of its patients. As a result of the above findings, it was recommended that future plans for either the modification or expansion of Lions Gate's emergency department should include the establishment within the department of a walk-in ambulatory clinic. The proposed ambulatory care department, consisting of an emergency centre and primary care clinic, would assist Lions Gate Hospital to fit its services to the medical care needs which its patients exhibit. / Business, Sauder School of / Graduate

Background: Kidney stones are a common, painful disorder that can affect as many as one of 11 people in the United States (Goldfarb & Arowojolu, 2013). The gold standard for diagnosing kidney stones is currently computed tomography (CT). However, because CT scans emit radiation during the exam, they could be causing more harm than good. According to recent research, ultrasound may be used to diagnose kidney stones with close to similar accuracy and reliability. Ultrasounds are also safer and more cost effective for patients and the healthcare system. Purpose: The purpose of this project is to describe nurse practitioners (NPs) use of ultrasound to diagnose kidney stones in the emergency department (ED). The information from this project was compared with the recent literature and used to develop an evidence-based practice recommendation for diagnosing suspected kidney stones in the ED. Methods: A 15-item survey was mailed to emergency department NPs across the United States. Descriptive statistics were used to analyze the quantitative results. One open-ended question was also posed, and findings were grouped by commonalities of clinical experiences. Results: Analysis of survey responses indicates that all of the respondents use CT scan to diagnose kidney stones. However, the majority of the respondents also feel that ultrasound could be used in the ED to diagnose kidney stones. The results also demonstrate that even though there is no nationally or internationally accepted standardized guideline for diagnosing kidney stones in the ED, many EDs across the country are instituting their own protocols.

Emergency department (ED) nurses exposed to pediatric resuscitations are at a high risk of developing posttraumatic stress (Adriaenssens et al., 2012; Lavoie et al., 2016). This may be especially true in community hospital EDs where nurses have less exposure to, knowledge about, and resources for managing these events (Gangadharan et al., 2018; Gilleland et al., 2014; Goldman et al., 2018). Interventions to proactively prevent nurse trauma in these contexts remain uninvestigated. To inform such interventions, this study aimed to understand the largely unknown lived experiences of these nurses. In-depth, semi-structured interviews were conducted with four registered nurses who experienced at least one pediatric resuscitation while working in a community hospital ED in Ontario. Data analyzed using Smith et al.’s (2009) interpretive phenomenological analysis revealed three superordinate themes (i.e., “Conceptualizing Pediatric Resuscitations,” “Seeing What I See,” and “Making Sense of What I Saw”) and nine corresponding subthemes. This study provides insight into the infrequent but profound experiences of nurses resuscitating children in community hospital EDs. Participants, who conceptualized these events as unnatural, emotional, and chaotic, were comforted by those who understood their experiences and distressed by those who could not see what they saw. To reconcile what they saw, the nurses reflected and ruminated on the event, ultimately restructuring their experiences of themselves, others, and the world to make room for a new reality where the safety of childhood is not certain. The findings of this study have implications for nursing practice, education, leadership, and research that may enhance nurse coping following these events.

Presently, extensive research supporting the overcrowding of emergency departments (EDs) and behavior disorder patients presenting to EDs are prevalent. There exists a knowledge gap between specific behavior disorders diagnoses associated to repeated visits to the ED. The purpose of this quantitative study was to address whether a relationship exists between patients with psychotic and/or substance abuse disorders and the repeated ED visits within 72 hours. The Andersen Behavioral framework model and the secondary data were used in the study. The cross-sectional archival data from the 2016 National Ambulatory Medical Care Survey was analyzed by using cross-tabulation with the 2 test followed by multiple logistic regression analysis. The author found that the primary independent variables were not significant in (un)weighted multivariate results. However, the primary independent variables were statistically significant in the unweighted cross tabulation analyses, along with the covariates of homelessness, geographical region, and gender. The findings also showed a strong likelihood of return to the ED for the primary independent variables and covariates. The implications of this study with regard to social change and health care practices are providing proper outpatient resources through behavior disorder urgent care facilities, behavior disorder travel clinics, follow-up communications directly to the patients’ care managers, and creating a treatment team, which will decrease future financial effects on the healthcare system.

BACKGROUND: Approximately one-third of community dwelling elderly people (age ≥65 years) falls each year contributing to over 2 million elderly emergency department (ED) visits for falls annually. The cost of care for fatal falls by elderly patients in the US was $179 million in 2000, and was $19 billion for non-fatal falls. The risk of falling increases with various risk factors including advancing age. Despite the frequency and costs associated with elderly falls, it is not clear what evaluation elderly fallers receive in the ED, after the ED, and the outcomes of the care provided. OBJECTIVES: We sought to examine the ED and post-ED workup of elderly fallers, and to compare this evaluation to that recommended by published ED fall evaluation and treatment guidelines. We also examined the disposition of these patients and the rate of adverse events which occurred within 1 year of discharge. METHODS: This study was a retrospective chart review of elderly ED fall patients from one urban teaching hospital with >90,000 visits per year. Patients aged ≥65 years who had an ED visit in 2012 with fall related ICD-9 codes E880-886, E888 and who had been seen by a primary care physician (PCP) within our hospital network during the past 3 years were included. We excluded patients who were transferred to our hospital and subsequent visits related to the original fall. We randomly selected 350 eligible patients for chart review. We adapted our data collection instrument from published fall evaluation recommendations including the American Geriatric Society. Categorical data were presented as percentages and continuous data were recorded as mean with standard deviation (SD) if normally distributed or medians with inter-quartile ranges (IQR) if non-normally distributed. RESULTS: A random sample of 450 charts were taken, 100 were subsequently excluded for erroneous identification. The average age was 80 (SD±9) years; 124 (35%) were male, with an average Charlson comorbidity index of 7.6 (SD 2.9). In terms of history, 251/350 (72%) took 5 or more medications, 144/350 (41%) had their visual acuity checked in the past 12 months, and 34/350 (10%) had fallen two or more times in the past 3 months. In the physical exam, only 43/350 (12%) had orthostatics done. 168/350 (48%) patients had their extremity strength recorded, of these 16/168 (10%) had decreased muscle strength. Only 128/350 (37%) patients had their gait recorded, of which 108/128 (84%) were noted to have an abnormal gait. Basic chemistry laboratory tests and hematology were sent on 199/350 (57%) of patients in the ED. X-rays were taken of 275/350 (79%) patients, and CTs were taken of 184/350 (53%) patients in the ED. 277/350 (79%) patients were discharged to their place of preadmission residence from the ED, ED observation unit, or hospital while 70/350 (20%) were discharged to a skilled rehab facility, all after being admitted to the hospital. 196/350 (56%) patients returned to the ED for any reason within 1 year of discharge, averaging 2.4 ± 1.9 visits. 161/350 (46%) patients were hospitalized within 1 year after discharge, averaging 2 ± 1.4 hospital admissions. 23 (7%) of patients died within 1 year after discharge. CONCLUSION: The comprehensive evaluation of falls for well-established risk factors and causes appears to be poor in this academic medical center ED. While results may not be generalizable to other EDs, the results suggest that standardized evaluation and treatment guidelines are needed.