Misappropriation of medications and equipment in the emergency department.

OBJECTIVE: To determine the nature and extent of misappropriation of medications and equipment from the ED. METHODS: We undertook a retrospective audit of medications procured and administered, and equipment replaced, in 2016, within a tertiary referral ED. Medication procurement and administration data were obtained from our MERLIN® pharmacy system and CERNER® electronic prescribing system, respectively. A medication 'discrepancy rate' was defined as the percentage of a medication procured that could not be accounted for by electronic administrations. The study also comprised a nested intervention sub-study where, from July 1, 2016, all Panadeine Forte tablets were stored in a locked facility. Victorian Hospital Healthcare Equipment invoices were audited to determine which major non-disposable equipment items most commonly needed resupply. RESULTS: Discrepancy rates for paracetamol 500mg and 665mg tablets were 23.3% and 54.9%, respectively. Following the Panadeine Forte intervention, the discrepancy rate for this medication fell from 70.5% to 8.8%. Orally administered medications with the potential for misappropriation had high discrepancy rates: caffeine (90.6%), cephalexin (62.9%), ondansetron (50.1%), pantoprazole (42.9%), amoxicillin (41.1%), metoclopramide (41.0%) and the 'morning after pill' (levonorgestrel) (36.4%). Parenterally administered medications had lower discrepancy rates: ceftriaxone (7.9%) and ampicillin (3.4%). The largest equipment replacement rates were for tourniquets and crutches. CONCLUSION: Discrepancy rates for many medications, especially those administered orally, are high. Further research is required to determine how these medications 'go missing'. Placing a medication with a high discrepancy rate in a locked facility with a 'logbook' substantially reduces this rate. Misappropriation of non-disposable equipment items is uncommon.

Barriers to providing optimal management of psychiatric patients in the emergency department (psychiatric patient management).

BACKGROUND: We aimed to determine the barriers to optimal management of psychiatric patients in the emergency department (ED). METHODS: We undertook an observational study in a tertiary referral ED with a 24h acute psychiatric nursing service (February to April, 2017). Following patient discharge, the attending psychiatric nurse completed a validated questionnaire to determine the barriers they encountered with their patient. RESULTS: Data were collected on 104 patient encounters. The environmental/resource barriers included limited space (30.8% of cases), limited time (25.0%) and ED overcrowding (22.1%). The ED staff barriers included insufficient knowledge and education regarding psychiatric illness (25.0%), negative attitudes (17.3%) and avoidance of psychiatric patients (16.3%). The patient barriers included dual diagnoses (26.0%), difficulty differentiating between psychiatric illness and social disorganisation (25.0%), and presentation issues complicating management (22.1%). The day of presentation, patient diagnosis and place of disposition were associated with the total number of barriers for each patient. Most barriers were reported on weekdays, for patients with substance abuse disorders or psychosis and for those discharged to home or an inpatient psychiatric ward. CONCLUSION: Barriers to optimal psychiatric management are common and vary considerably. These findings will inform workplace reform and education strategies aimed at mitigating the observed barriers.

Our observations with cold calling: Patient anger and undesirable experiences.

Little is known about the effects of the 'cold calling' technique (telephone contact without prior warning) for patient follow up in ED research. Recently, we undertook a prospective, observational pain management study. Patients were cold called 48 h post-discharge and surveyed regarding their pain management satisfaction. We made contact with 778 patients. Among these, we observed 12 cases of patient anger: mistaken identity, disbelief that the hospital was calling, frustration that test results and appointment times could not be provided, abuse about ED management and outpourings of sadness. We also observed eight cases of an undesirable experience for either the patient, their family or the caller: five patients had died (including one 'at her last moments'), precipitation of patient distress and uncomfortable situations for the caller. Given our experience, we believe that cold calling should be avoided, where possible, and other techniques (e.g. limited disclosure) considered as alternatives.

Variables associated with completeness of medical record documentation in the emergency department.

OBJECTIVE: The completeness of ED medical record documentation is often suboptimal. We aimed to determine the variables associated with documentation completeness in a large, tertiary referral ED. METHODS: We audited 1200 randomly selected medical records of patients who presented with either abdominal pain, cardiac chest pain, shortness of breath or headache between May-July 2013 and May-July 2016. Data were collected on patient and treating doctor variables. Documentation completeness was assessed using a 0-10 point scoring tool designed for the study. A maximum score was achieved if each of 10 pre-determined important items, specific to the presenting complaint, were documented (five medical history items, five physical examination items). Data were analysed using multivariate regression. RESULTS: The presenting year, day and time, patient age and gender, preferred language, interpreter requirement, discharge destination and doctor gender were not associated with documentation completeness (P > 0.05). Patients with triage category 3 or pain score of 6-7 had higher documentation scores (P < 0.05). Compared to interns, registrars (effect size -0.72, 95% CI -1.02 to -0.42, P < 0.01) and consultants (-1.62, 95% CI -1.95 to -1.29, P < 0.01) scored significantly less. The headache patient subgroup scored significantly less than the other patient subgroups (-0.35, 95% CI -0.63 to -0.08, P = 0.01). For all presenting complaint subgroups, examination findings were less well documented than history items (P < 0.001). CONCLUSION: Documentation completeness is less among senior doctors, headache patients and for examination findings. Research should determine if the supervision responsibilities of senior doctors affects documentation and if medico-legal and patient care implications exist.