Unprecedented times in the emergency department: are "board rounds" and leadership the missing links to improve patient flow?

PURPOSE: National Health Service (NHS) Emergency Department (ED) attendances are at the second highest level ever recorded, (RCEM, 2021a) and as they soar, performance plummets, putting patient safety at risk (RCEM, 2021b). Managing patient flow in the ED is critical to reduce patient safety incidents and crowding, however, this needs effective leadership (Jensen and Crane, 2014). This paper aims to introduce an innovative form of managing patient flow in ED, which is a two hourly "Board Rounds", providing a managed process to pull patients through the system meeting pre-determined time critical standards and preventing patient harm. Board Rounds combined with effective leadership can play a contributory role preventing crowding in the ED. DESIGN/METHODOLOGY/APPROACH: An evaluation of two hourly ED Board Rounds was undertaken using the hospitals' ED Board Round Standard Operating Procedure to develop a series of short questions. As leadership is the responsibility of all clinicians (Darzi, 2008; Moscrop, 2012), a separate survey was undertaken for clinicians of all grades and managers to self-assess their own leadership styles using the Path-Goal Leadership Theory (House and Mitchell, 1974; Indvik, 1985; Northhouse, 2013). Findings were reported to the team to explore ideas for improvement not only to develop more effective leadership in the ED but also to raise awareness of how to optimise leadership in Board Rounds. FINDINGS: In total, 27 (n = 27) clinicians and managers reported support for a 2 hourly Board Round, for a period of 15 min, in both minor and major injuries departments in ED. A multi-disciplinary Board meeting, led by the lead nurse with support from the Emergency Physician in Charge, was preferred, locating it at the nurse's station. A validated Path-Goal Leadership survey instrument was returned (n = 24). The findings reveal that leaders and managers are using a high level of the directive leadership style, where there is more potential to use the supportive, participative and achievement approaches to leadership. RESEARCH LIMITATIONS/IMPLICATIONS: This was a small sample, returned from a Hospital ED located in a semi-rural location, department requiring "improvement" from the Health Regulator. This research would benefit from being undertaken in a medium/large NHS ED department to identify if the findings report on a wider leadership culture in the NHS ED. The implications for this study are that improvement interventions such as a "Board Round" can be usefully evaluated alongside a review of leadership styles and approaches to understand the wider implications for continuous improvement and change in the ED. ORIGINALITY/VALUE: NHS EDs are facing unprecedented challenges and require innovative evidence-based solutions combined with leadership at this time. The evidence base for improving patient flow is limited, however, this study provides some initial findings on the positive perception and experience of staff to Board Rounds. Board Rounds combined with leadership has the potential to contribute to the wider strategy to prevent crowding in ED. This paper is the first of its kind to evaluate perceptions of Board Rounds in the ED and to engage clinicians and managers in a self-assessment of their own leadership styles to reflect on optimum leadership styles for use in ED.

Intussusception in children aged under two years in India: Retrospective surveillance at nineteen tertiary care hospitals.

OBJECTIVE: Intussusception has been linked with rotavirus vaccine (RVV) as a rare adverse reaction. In view of limited background data on intussusception in India and in preparation for RVV introduction, a surveillance network was established to document the epidemiology of intussusception cases in Indian children. METHODS: Intussusception in children 2-23 months were documented at 19 nationally representative sentinel hospitals through a retrospective surveillance for 69 months (July 2010 to March 2016). For each case clinical, hospital course, treatment and outcome data were collected. RESULTS: Among the 1588 intussusception cases, 54.5% were from South India and 66.3% were boys. The median age was 8 months (IQR 6, 12) with 34.6% aged 2-6 months. Seasonal variation with higher cases were documented during March-June period. The most common symptoms and signs were vomiting (63.4%), bloody stool (49.1%), abdominal pain (46.9%) and excessive crying (42.8%). The classical triad (vomiting, abdominal pain, and blood in stools) was observed in 25.6% cases. 96.4% cases were diagnosed by ultrasound with ileocolic location as the commonest (85.3%). Management was done by reduction (50.8%) and surgery (41.1%) and only 1% of the patients' died. 91.1% cases met Brighton criteria level 1 and 3.3% Level 2. Between 2010 and 2015, the case load and case ratio increased across all regions. CONCLUSION: Intussusception cases have occurred in children across all parts of the country, with low case fatality in the settings studied. The progressive rise cases could indicate an increasing awareness and availability of diagnostic facilities.

Intrauterine Arrow Injury.

Injury of a pregnant lady risks both mother and fetus. Various modes of injuries are possible. But arrow injury is not usually heard of in today's world. We have reported a male child delivered with a cut injury on the face. It was caused by a penetrating arrow hitting his mother in her lower abdomen at term. The injury of the baby was repaired successfully.