Early identification and management of the unstable adult patient in the emergency department.

AIMS AND OBJECTIVES: The focus of this research was to standardise an emergency observation chart, the Adult Emergency Department Flow Chart, which incorporates elements designed to allow clinicians to more readily recognise the trends of patient deterioration. BACKGROUND: Patients present to the Emergency Department with some form of instability. Core skills and principles of Emergency Department care are to rapidly and continually assess the clinical condition of the patient, prioritise their care and treat accordingly. Often, however, deterioration of these patients is missed. The incidence of missed deterioration is set within a background of increasing presentations to Emergency Departments, greater complexity of the patient health status, longer length of stay within the Emergency Department and an ageing population. DESIGN: This quantitative research study comprised a retrospective medical record audit. Only those records containing notes relating to an Emergency Department admission were included. METHODS: An online data collection tool based on the Adult Emergency Department Flow Chart was developed. A total of 181 medical records were reviewed: 80 during the pre-implementation audit and 101 during the post-implementation audit. RESULTS: The Adult Emergency Department Flow Chart enabled clinicians to better identify deteriorating patients, with a higher number of abnormal vital signs being identified at the post-implementation audit. Identification of pain also dramatically increased at the post-implementation audit. Documentation of notification to Medical Officers also increased, as did documentation of the number of patients receiving medication to help treat the abnormal vital sign. CONCLUSION: The introduction of the Adult Emergency Department Flow Chart facilitated the essential role of nurses in the identification, documentation and monitoring of the unstable or deteriorating patient in the Emergency Department. Further research is required with larger samples to determine the impact of the Adult Emergency Department Flow Chart on the timely management of abnormal vital signs. RELEVANCE TO CLINICAL PRACTICE: The Adult Emergency Flow Chart provides a valuable tool for the early identification and subsequent management of an unstable / deteriorating adult in the emergency department, particularly for clinicians with limited experience.

The inaccuracy of automatic devices taking postural measurements in the emergency department.

Automatic devices are used to take postural blood pressures in the emergency department despite research proving their inaccuracy in taking single blood pressures. This study assessed the accuracy of an automatic device compared with a manual aneroid reference standard for determining orthostatic hypotension and postural drops at triage. Supine and standing blood pressures were taken with an automatic and a manual device in a sequential and random order, and postural drops were calculated. The manual device indicated 10/150 emergency department patients had orthostatic hypotension (7%) and the automatic device detected this with a sensitivity of 30% and a specificity of 91%. The automatic-manual differences were clinically significant in 13% of systolic drops and 37% of diastolic drops. Findings suggest that automatic devices cannot reliably detect or rule out orthostatic hypotension, indicating that triage nurses need to use manual devices to take accurate postural blood pressures for optimal patient care.