Evaluation of a new rapid assessment and treatment (RAT) tablet app for Emergency Department (ED) nurses: Is earlier identification of investigations and treatments feasible?

Although doctor-led RAT has advantages, serial processing (triage - investigation - treatment) still predominates in UK EDs. We have designed a RAT decision-support app to assist ED nurses to select investigations and treatments at initial patient assessment and aid acuity scoring. METHODS: Test nurses accompanied triage ('control') nurses in an observational study of 529 adult patients. Investigations, treatments and procedures, selected using the app, were compared with those selected later by ED clinicians. Acuities set by both nurses were re-evaluated blind by a consultant panel. RESULTS: Data capture and decision making using RAT-support took a median of 1.43 min (IQR 1.13-2.07). Odds ratios are reported for matching of test versus control investigation and treatment orders. The ability to predict, within minutes, control investigations which were ordered at median of 50 min (IQR 21-99) is encouraging. Median times to order treatments (analgesia 88 min, IV antibiotics 112 min) were also reduced. Acuity scores versus the consultant panel gave weighted kappa of 0.54 (CI 0.48-0.61) for study nurses and for controls 0.45 (CI 0.36-0.53). CONCLUSIONS: We conclude that nurse-led RAT for use in initial assessment is feasible given decision support. We also identified improvements required for the app.

Exercise associated hyponatraemia leading to tonic-clonic seizure.

A 34-year-old Filipino lady presented to the emergency department with breathlessness and muscle cramping following a Bikram yoga workout. The patient reported sweating excessively while performing 90 min of strenuous exertion in a humidified room heated to an ambient temperature of 40.6°C. After the workout she drank 3.5 litres of water before experiencing breathlessness, severe muscle cramps, nausea and general malaise. Initial investigations revealed severe hyponatraemia (120 mmol/l). Despite early sodium replacement the patient dropped her Glasgow coma scale to 9/15 and developed tonic clonic seizures, requiring intubation and admission to the intensive care unit. The hyponatraemia was slowly corrected on the intensive care unit and the patient made a full recovery over the course of 5 days. This case highlights the dangers of overzealous fluid replacement following severe exertion in a hot environment.