Training clinicians to become leaders of complex change: Lessons from Scotland.

Clinicians are trained to diagnose disease and recommend treatments or procedures. This is the focus of much of undergraduate training, but delivery of healthcare depends on so much more than theoretical knowledge and technical skill. It is a complex environment where professionals from different backgrounds have to work together to deliver safe pathways of care to patients who have very varied backgrounds. This can lead to inefficiency and variation in provision of care and clinical outcomes. In turn, this can negatively impact on the experience of patients and staff. Attempting to change this complex environment requires a unique set of skills. This article describes an international fellowship that creates a network of individuals skilled in quality improvement, human factors, service design and leadership.

Multi-method evaluation of a national clinical fellowship programme to build leadership capacity for quality improvement.

BACKGROUND: This paper reports the results of the evaluation of the Scottish Quality and Safety Fellowship (SQSF)-a 10-month, lead-level international educational programme established in 2008 with the overarching aim of developing clinicians with advanced quality improvement knowledge, technical ability and essential leadership skills. The evaluation explores four levels of educational and practice outcomes associated with (1) the reaction of fellows to SQSF participation, (2) learning gained, (3) subsequent behaviour changes and (4) the overall impact on national and international level capability and capacity building. METHODS: A theory-informed multi-method design was applied using (1) a search and review of the SQSF organisational database to tabulate personal, professional and demographic characteristics; (2) semi-structured telephone interviews with 16 participants using purposive and self-selected sampling; and (3) a cross-sectional online evaluation survey across all 10 cohorts involving 222 fellows RESULTS: SQSF was positively perceived as a high-quality learning experience containing a well-balanced mix of theory and practice, with a majority of respondents reporting career changing benefits. Most participants reported improved social, behavioural and emotional skills, knowledge and attitudes and, with sustained support of their host organisations, were able to apply and share learning in their workplace. The impact of the SQSF on a wider national and international level capability and capacity was both mediated and moderated by a wide range of interrelated contextual factors. CONCLUSIONS: This multi-method evaluation demonstrates that SQSF has achieved significant positive outcomes for the great majority of participants. Some tentative recommendations are provided with the aim of further enhancing fellowship content, delivery, transfer and future evaluations of wider impacts at regional, national and international health system levels.

Improving door to CT scanner times for potential stroke thrombolysis candidates - The Emergency Department's role.

Stroke thrombolysis is an important treatment in the management of acute strokes. Its' effectiveness is reliant on prompt administration after stroke onset. Disability free survival at 3-6 months increases by 10% when administered within 3 hours. There is also an economic benefit from early administration with reduced institutional care. New Scottish care standards have been introduced which suggest a target that 50% of suitable patients should receive thrombolysis within 30 minutes, and 80% within one hour 6. Processes in the Emergency Department play a key role in determining the time a patient waits between arrival and reaching the CT scanner. The project team looked at Ninewells Emergency Department times to CT scanner between May and August 2015 and found that only 20% of patients had their scan within 20 minutes, and 70% within 45 minutes. The team went on to conduct a quality improvement project. This involved initial patient mapping and short interviews with staff. A multi action approach was developed involving education in the form of emails, presentations and visual charts, and the final step was to simplify the paperwork involved. The project was conducted over 11 months and successfully reduced the times to CT, with 60% having had their CT scan within 20 minutes, and 100% within 45 minutes, with a very noticeable reduction in variation around the mean. It is hoped to take this approach forward and apply it to other processes in the department.

Emergency Department redirection to primary care: a prospective evaluation of practice.

Background and aim Non-urgent Emergency Department presentations contribute to overcrowding, which can adversely affect patient care. Redirecting patients to a more appropriate service is an option to help address this. We conducted a prospective evaluation of a major Scottish hospital's Emergency Department redirection policy to assess its safety. Methods and results Over two months, 620 patients triggered senior assessment for redirection with 444 (72%) redirected to primary care. Information on presentation was collected with subsequent management and outcome of redirection provided by the patient's general practitioner. Those who required admission within seven days of redirection triggered review. This was carried out independently by an Emergency Department Consultant and a GP Principal to assess the incidence of sub-optimal care or harm as a consequence of redirection. Most patients presented during daytime hours with no significant variation between days. 'Patient factors' accounted for 74% of presentations with 'convenience' (20%) cited as the most common reason. Twenty-two patients were subsequently admitted, with one case of sub-optimal care (incidence 0.23%) and no cases of harm. Conclusions Our redirection policy provides a safe and effective means of directing patients to more appropriate care. The authors believe this to be in the patient s best interest as Emergency Department clinicians are not specifically trained to manage primary care issues.

A change of culture: reducing blood culture contamination rates in an Emergency Department.

Blood cultures are an important investigation to help tailor effective management for patients with severe sepsis. Frequent contaminated samples increase laboratory workload and can delay or cause incorrect changes to patient management. This can prolong patient hospitalisation, increase the risk of harm and increase cost to health boards. Current guidelines advocate a contamination rate of 2-3%. From January 2013 to November 2014 inclusive, the contamination rate was 4.74% in our Emergency Department, responsible for initial management and investigation of over 40 cases of sepsis per month. A Quality Improvement team was created to try to reduce contamination rates to the recommended target. An initial baseline survey of local staff showed good understanding of when to obtain a blood culture but there was variability in the methods and equipment used. A project was then conducted which focused on rationalising and standardising equipment and technique for blood culture sampling along with staff education to support this change. A simple department target of 30 days free from a contaminated blood culture was created which, if achieved, would ensure a contamination rate of less than 3%. This was supported by ongoing surveillance of contamination rates and investigation of contaminated sample cases. We were able to then identify high risk patients and factors which increased the chance of blood culture contamination. This allowed us to formulate solutions to help reduce the risks of contamination. Department achievements and learning points to help prevent further contamination were fed back positively to all staff. This project operated for 12-months and successfully reduced local contamination rates to 2.0%.

Seeking Sepsis in the Emergency Department- Identifying Barriers to Delivery of the Sepsis 6.

The Sepsis 6 is an internationally accepted management bundle that, when initiated within one hour of identifying sepsis, can reduce morbidity and mortality. This management bundle was advocated by the Scottish Patient Safety Programme as part of its Acute Adult campaign launched in 2008 and adopted by NHS Tayside in 2012. Despite this, the Emergency Department (ED) of Ninewells Hospital, a tertiary referral centre and major teaching hospital in Scotland, was displaying poor success in the Sepsis 6. We therefore set out to improve compliance by evaluating the application of all aspects of the NHS Tayside Sepsis 6 bundle within one hour of ED triage time, to identify what human factors may influence achieving the one hour The Sepsis 6 bundle. This allowed us to tailor a number of specific interventions including educational sessions, regular audit and personal feedback and check list Sepsis 6 sticker. These interventions promoted a steady increase in compliance from an initial rate of 51.0% to 74.3%. The project highlighted that undifferentiated patients create a challenge in initiating the Sepsis 6. Pyrexia is a key human factor-trigger for recognising sepsis with initial nursing assessment being vital in recognition and identifying the best area (resus) of the department to manage severely septic patients. EDs need to recognise these challenges and develop educational and feedback plans for staff and utilise available resources to maximise the Sepsis 6 compliance.

Reducing inappropriate emergency department attendances--a review of ambulance service attendances at a regional teaching hospital in Scotland.

INTRODUCTION: Emergency Departments (ED) in the UK have seen increasing attendance rates in recent years. Departments are now seeking strategies to reduce their attendances. A review of all ambulance attendances to the ED at Ninewells Hospital was conducted to identify if patients presenting by ambulance could be seen and treated more appropriately in other parts of the health service. METHOD: A retrospective review of ambulance attendances to the ED at Ninewells Hospital over 7 non-consecutive days. The ambulance patient report form and the ED notes were reviewed by the duty consultant to deem whether it was appropriate for the patient to be presented to the ED. If inappropriate, an alternative destination was suggested. Additional data was collected on the source of the ambulance call. RESULTS: There were 910 attendances in the 7 days. 295 (32%) presented by ambulance. 32 had incomplete data and were excluded. 185 (70%) and 179 (68%) of the 263 were deemed appropriate from review of the patient report form and notes respectively. Of the inappropriate, 74.4% and 79.7% had primary care suggested as an alternative. Patients who call for their own ambulance and NHS24 had higher rates of inappropriate attendances. DISCUSSION: The ambulance services present one-third of the patients to the ED at Ninewells Hospital. 30%-32% were found to be attending inappropriately and 74%-80% of these could have been managed in primary care. Reducing inappropriate ambulance attendances could reduce the departmental patient load by 11%.

Impact of senior clinical review on patient disposition from the emergency department.

INTRODUCTION: The delivery of high quality emergency medicine ideally involves input from senior doctors 24 h a day. This study aims to assess the influence of 'real-time' senior clinician supervision on patient disposition from a UK emergency department. METHODS: The study was set in a UK teaching hospital with 24 h senior cover. Patients were initially seen by a junior doctor who completed a plan for the patient before seeking senior advice. Primary outcome measures were a change in patient outcome of discharge, admit, telephone speciality for opinion or outpatient follow-up. RESULTS: 556 patients underwent senior review during the study period. Review reduced inpatient admissions by 11.9% (95% CI 7.2% to 18.2%) and specifically reduced admissions to the acute medical assessment unit by 21.2% (95% CI 13.5% to 30.8%). Inappropriate discharge was prevented in 9.4% (95% CI 6.2% to 13.7%) and appropriate use of outpatient facilities resulted in a rise of 34.6% in appointments. CONCLUSIONS: Senior doctor input in patient care in the ED adds accuracy to disposition decisions, impacting on patient safety and improving departmental flow.

To ED or not to ED: NHS 24 referrals to the emergency department.

INTRODUCTION: This study aimed to compare the opinions of consultants in emergency medicine and general practitioners (GPs) on the appropriateness of NHS 24 referrals to the emergency department (ED). METHODS: 170 NHS 24 referrals to the ED were reviewed by six GPs and six emergency consultants who were asked their opinion as to which out-of-hours service would be most appropriate for the patient. Modal responses from both groups were calculated for each referral. Consensus within groups and levels of agreement were calculated. RESULTS: Modal responses agreed with an ED disposal in 59.2% of cases in the emergency consultant group with a 90% consensus rate. The GP group agreed with an ED disposal in only 47% of cases with a 75.9% consensus rate. A primary care referral response was the mode in 20.8% of the emergency consultant group compared with 35.7% in the GP group. Consensus was reached in 76.3% of the emergency consultant responses and 81.7% of GP responses. The difference in opinion between the two study groups was statistically significant. CONCLUSIONS: GPs and consultants in emergency medicine both believe a high proportion of NHS 24 referrals to the ED should be handled by primary care services. This would suggest that, compared with previous out-of-hours practice, NHS 24 favours an ED outcome. The results indicate a large proportion of primary care patients are being handled inappropriately and uneconomically in the ED setting. There is a need for ongoing improvement of the telephone triage service provided by NHS 24.

Reduced productivity among junior trainees in the emergency department and the impact on senior clinicians.

UNLABELLED: Emergency medicine has recently undergone significant changes, with training, staffing and service delivery attracting particular attention. Senior doctors are under increased pressure to ensure the prompt delivery of service and to provide a smooth patient journey. It has been suggested that junior trainees see fewer patients than their predecessors, resulting in the burden of clinical work being transferred to senior clinicians, representing a shift away from the traditional model of service delivery. This study charts the work rate trends among junior doctors and the proportion of work performed by senior doctors over a 3-year period. RESULTS: The number of patients seen by junior trainees fell by 4% and was associated with a statistically significant 16.6% reduction in the mean number of patients seen per hour. The number of patients seen purely by senior clinicians increased to over 35%, in addition to reviewing those seen by junior trainees. This highlights reduced clinical exposure and productivity among juniors, but also shows the significant knock-on effect on the workload of senior clinicians. CONCLUSIONS: There will need to be an increase in the number of trained clinicians within emergency medicine to continue to deliver effective training and supervision and ensure a safe, good quality service to patients.

Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department.

BACKGROUND: Decreased consciousness is a common reason for presentation to the emergency department (ED) and admission to acute hospital beds. In trauma, a Glasgow Coma Scale score (GCS) of 8 or less indicates a need for endotracheal intubation. Some advocate a similar approach for other causes of decreased consciousness, however, the loss of airway reflexes and risk of aspiration cannot be reliably predicted using the GCS alone. STUDY OBJECTIVE: A survey of all poisoned patients with a decreased GCS who were admitted to an ED short-stay ward staffed by experienced emergency physicians, to establish the incidence of clinically significant aspiration or other morbidities and endotracheal intubation. METHODS: A prospective, observational study was conducted of all patients admitted to the ED short-stay ward with a decreased level of consciousness (GCS < 15). RESULTS: The study included 73 patients with decreased consciousness as a result of drug or alcohol intoxication. The GCS ranged from 3 to 14, and 12 patients had a GCS of 8 or less. No patient with a GCS of 8 or less aspirated or required intubation. There was one patient who required intubation; this patient had a GCS of 12 on admission to the ward. CONCLUSIONS: This study suggests that it can be safe to observe poisoned patients with decreased consciousness, even if they have a GCS of 8 or less, in the ED.

Paediatric analgesia in the emergency department, are we getting it right?

OBJECTIVES: To measure the dose discrepancy in prescribing simple paediatric analgesia, in the emergency department, by comparing age and actual weight-based dosing. To establish the accuracy of the weight-estimation formula for children [weight kg=2 (age years+4)]. METHODS: A prospective survey conducted in the emergency departments of a UK teaching hospital and district general hospital. Two hundred and forty-seven children were prescribed simple analgesia in the form of paracetamol and ibuprofen or both. The dose prescribed was based on age. All children were weighed and a maximum dose based on the child's weight was calculated. The individual child's weight was also compared with the weight calculated using the estimation formula. RESULTS: A total of 247 patients were included. Two hundred and thirty-three patients were prescribed paracetamol. Fifteen patients were prescribed ibuprofen. The paracetamol group was administered a mean dose that was 67% (P<0.001) of the optimal dose that was based on weight. Ibuprofen dosage was 51% (P<0.001) of optimal dose. The weight-estimation formula underestimated weight by 16% (P<0.001). CONCLUSIONS: Prescribing analgesia by age often results in significant underdosing in the paediatric population. Predicting a child's weight using the calculation may result in underdosing.

Best evidence topic report. Role of flexion/extension radiography in paediatric neck injuries.

A short cut review was carried out to establish the potential utility of flexion/extension views of the cervical spine in children with neck injuries. Using the reported search, 51 papers were found, of which three presented the best evidence to answer the clinical question. The author, date, and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Best evidence topic report. Role of flexion/extension radiography in neck injuries in adults.

A short cut review was carried out to establish whether flexion-extension radiography is indicated in the investigation of a neurologically intact adult patient with midline neck tenderness and normal 3-view cervical spinal radiographs. Altogether 101 papers were found using the reported search, of which five presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Emergency physicians and rapid sequence intubation: a survey of Scottish teaching hospitals.

OBJECTIVES: Emergency definitive airway management is a fundamental skill for physicians in the emergency department. The aim of this survey was to determine the perceived confidence in the assessment and control of the emergency airway, including rapid sequence intubation, among physicians in Scottish teaching hospital emergency departments. METHODS: A postal survey of senior and middle-grade physicians in seven Scottish teaching hospital emergency departments. RESULTS: The response rate was 78% (47/60). A total of 98% of physicians rated their confidence at assessing the difficult airway as 'reasonable' to 'very high'; 79% were confident concerning their ability to administer drugs to facilitate emergency intubation; 47% had used drugs for emergency intubation within the month preceding the survey, and 72% had done so within the 6 months before the survey. Consultants were more confident than trainees, as were those possessing the Fellow of the Royal College of Anaesthetists qualification or a Diploma in Anaesthetics (UK). Those possessing the Fellowship of the Royal College of Anaesthetists qualification had all performed a rapid sequence intubation within the past month. CONCLUSION: Physicians in Scottish teaching hospital emergency departments have high levels of self-rated confidence in assessment and their ability to secure the emergency airway utilizing drugs to facilitate emergency intubation. Consultants and those with anaesthetic qualifications are more confident than trainees and those without such a qualification.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Venous blood gas in adult patients with diabetic ketoacidosis.

A short cut review was carried out to establish whether venous blood gas measurement accurately demonstrates the degree of acidosis in patients with diabetic ketoacidosis. A total of 27 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.