Young female with abdominal pain and intra-abdominal free fluid: The risk of confirmation bias associated with point-of-care ultrasound.

Confirmation bias is an ever-present risk to the rapid decision-making required in emergency departments (EDs). We present a case of a young woman who was brought to ED by ambulance with hypotension, syncope and vaginal bleeding, with a presumptive pre-hospital diagnosis of ruptured ectopic pregnancy. On arrival in ED, she was found to have intra-abdominal free fluid on bedside ultrasound. This finding could have been used by clinicians to confirm their suspicion of a ruptured ectopic; however, with further investigations, it was found that anaphylaxis was the most likely cause of the patient's symptoms. This case highlights that point-of-care ultrasound findings can play a potentially dangerous role in confirmation bias and that we should maintain an open mind when making a diagnosis by treating the patient, rather than the ultrasound picture.

Reducing Patient Risk and Enhancing Care Through the Development and Implementation of a New Chest Pain Pathway, Expedited by and for the COVID-19 Era.

The COVID-19 pandemic raised major concerns relating to hospital capacity and cross-infection patients and staff in the Emergency Department (ED) of a metropolitan hospital servicing a population of ~500,000. We determined to reduce length of stay and admissions in patients presenting with symptoms of possible myocardial infarction; the most common presentation group. After establishing stakeholder consensus, the existing accelerated diagnostic pathway (ADP) based on the ED Assessment of Chest-pain Score (EDACS), electrocardiogram, and troponin measurements with a high-sensitivity assay (hs-cTn) on presentation and two hours later (EDACS-ADP) was modified to stream patients following an initial troponin measure as follows: (i) to a very-low risk group who could be discharged home without follow-up or further testing, and (ii) to a low-risk group who could be discharged with next-day follow-up community troponin testing. Simulations were run in an extensive research database to determine appropriate hs-cTnI and EDACS thresholds for risk classification. This COVID-ADP was developed in ~2-weeks and was implemented in the ED within a further 3-weeks. A comparison of all chest pain presentations for the 3 months prior to implementation of the COVID-ADP to 3 months following implementation showed that there was a 64.7% increase in patients having only one troponin test in the ED, a 30-minute reduction of mean length of stay of people discharged home from the ED, and a 24.3% reduction in hospital admissions of patients ultimately diagnosed with non-cardiac chest pain.

Visualising emergency department capacity in an 'Emergency Department Capacity Clock': A novel tool to assess and communicate overcrowding and access block.

Hospital-wide engagement is required to alleviate the problem of ED crowding and its associated adverse effects. To this end, the article describes a novel visualisation termed 'the ED Capacity Clock', which can be formatted using business intelligence software. This radial diagram represents ED capacity and its consumption in a format that can be understood intuitively and at a glance. The ED Capacity Clock is designed to promote common understanding and discussion between relevant hospital services and also acts as an auditing tool to monitor processes implemented to alleviate ED crowding.