ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome): A Study of Cross-System Implementation of a National Clinical Pathway.

BACKGROUND: Efforts to safely reduce length of stay for emergency department patients with symptoms suggestive of acute coronary syndrome (ACS) have had mixed success. Few system-wide efforts affecting multiple hospital emergency departments have ever been evaluated. We evaluated the effectiveness of a nationwide implementation of clinical pathways for potential ACS in disparate hospitals. METHODS: This was a multicenter pragmatic stepped-wedge before-and-after trial in 7 New Zealand acute care hospitals with 31 332 patients investigated for suspected ACS with serial troponin measurements. The implementation was a clinical pathway for the assessment of patients with suspected ACS that included a clinical pathway document in paper or electronic format, structured risk stratification, specified time points for electrocardiographic and serial troponin testing within 3 hours of arrival, and directions for combining risk stratification and electrocardiographic and troponin testing in an accelerated diagnostic protocol. Implementation was monitored for >4 months and compared with usual care over the preceding 6 months. The main outcome measure was the odds of discharge within 6 hours of presentation RESULTS: There were 11 529 participants in the preimplementation phase (range, 284-3465) and 19 803 in the postimplementation phase (range, 395-5039). Overall, the mean 6-hour discharge rate increased from 8.3% (range, 2.7%-37.7%) to 18.4% (6.8%-43.8%). The odds of being discharged within 6 hours increased after clinical pathway implementation. The odds ratio was 2.4 (95% confidence interval, 2.3-2.6). In patients without ACS, the median length of hospital stays decreased by 2.9 hours (95% confidence interval, 2.4-3.4). For patients discharged within 6 hours, there was no change in 30-day major adverse cardiac event rates (0.52% versus 0.44%; P=0.96). In these patients, no adverse event occurred when clinical pathways were correctly followed. CONCLUSIONS: Implementation of clinical pathways for suspected ACS reduced the length of stay and increased the proportions of patients safely discharged within 6 hours. CLINICAL TRIAL REGISTRATION: URL: https://www.anzctr.org.au/ (Australian and New Zealand Clinical Trials Registry). Unique identifier: ACTRN12617000381381.

In situ simulation training in emergency departments: what patients really want to know.

Objectives: Despite the use of in situ simulation in the emergency department (ED) for training staff to better manage critical events, little is known about how such training is experienced by patients in the ED during these simulations. We therefore aimed to explore ED patient knowledge and perceptions about staff training for emergencies, as well as their views about simulation generally, and in the ED setting specifically. Methods: In this qualitative study, we used an interpretive approach involving video elicitation and semistructured interviews with patients who were waiting for treatment in the ED. Patients who agreed to participate were asked about their knowledge of simulation and were then shown a short video of a simulated resuscitation from cardiac arrest. We asked participants open-ended questions about their perspectives on the film and their views and about simulation training in the ED. Interviews were audio recorded, transcribed and analysed using thematic analysis. Results: We interviewed 15 participants. Most had little or no prior knowledge of simulation training. Watching the video elicited emotional responses in some participants, and pragmatic responses concerning staff training in others, with most participants viewing simulation training as useful and necessary. Participants said that to avoid unnecessary stress, they would prefer to be notified of when simulations were occurring, and what they could expect to see and hear during simulations. Most participants predicted that they would be willing to wait slightly longer (approximately 30 min) to see a doctor while simulation training was conducted, provided they did not require urgent medical attention. Conclusions: Patient-centred care and care partnerships between patients and healthcare professionals underpin New Zealand healthcare and medical education ideologies. This requires effective communication between all parties, as evident in our study of in situ simulation training in the ED.

Using a template in fracture clinic leads to a sustained improvement in clinical notes.

Changes in shift work patterns have meant that patients presenting to a hospital fracture clinic for follow-up may see a different doctor on each visit. Clear clinical notes are essential in this setting, for both clinical and medico-legal reasons. We tried to improve documentation in the fracture clinic by using an education intervention followed by the introduction of a fracture clinic template. Audits were performed at baseline in January 2002, then in July 2002 after the education intervention, in October 2002 after the template introduction, and finally in March 2005. The combined approach of education and involving staff in design of the template followed by introduction of the template, resulted in a significant and sustained improvement in fracture clinic documentation.

Re-presentation and suicide rates in emergency department patients who self-harm.

OBJECTIVE: To investigate adult presentations to North Shore Hospital, Auckland, New Zealand, following deliberate self-harm, determine re-presentation and suicide rates and investigate the characteristics of those patients who re-present. METHODS: Retrospective review of a cohort of adult patients presenting to North Shore Hospital Emergency Care Centre in Auckland, New Zealand, with deliberate self-harm between 1 January 2001 and 31 August 2002, using data from the National Minimum Data Set and Hospital Discharge Database. The re-presentation rate was calculated as the percentage of patients presenting a second time within 1 year of their index presentation. The suicide rate was calculated as the percentage of patients with a coroner's verdict of suicide within 1 year of their index presentation of deliberate self-harm. RESULTS: There were 1055 presentations by 754 people during the presentation period. Of these 754 people, 136 presented for a second time within a year of the index case (136/754 [18.0%, 95% CI 15.5-21.0]). Eight of the seven hundred and fifty-four people went on to commit suicide within 1 year (8/754 [1.1%, 95% CI 0.5-2.1]). Self-poisoning was the most common method of self-harm. Minor tranquillizers were used more commonly in the group who re-presented. CONCLUSION: Re-presentation and suicide rates in our study were similar to previously published rates. Further research is needed to identify strategies to reduce re-presentations and excess mortality in all people who deliberately self-harm.

Use of information technology in New Zealand emergency departments.

OBJECTIVES: To determine previous computer training and current computer confidence of emergency medicine (EM) specialists and trainees, and to determine the accessibility of computer and Internet resources in New Zealand ED. METHODS: A prospective, cross-sectional study of all New Zealand EM specialists and trainees between July 2005 and October 2005, using a 47-item postal questionnaire. Descriptive statistics with 95% confidence intervals were compiled. Fisher's exact test was used to compare proportions, with t-test and Mann-Whitney U-test to compare continuous variables. RESULTS: A total of 226 EM specialists and trainees were sent questionnaires. In total, 144 (62 specialists and 82 trainees) out of 224 were analysed (response rate 64.3%). The majority of respondents (136, 94.4% (95% CI 89.4-97.6)) had access to a computer at home. Almost all respondents (143, 99.3% (95% CI 96.2-100.0)) also had computer access in the ED 24 h/day. The vast majority (140, 97.2% (95% CI 93.0-99.2)) had access to medical educational materials via the Internet in the ED 24 h/day. Most respondents had limited prior computer training. Respondents felt most confident using word processing and e-mail/communications applications, and least confident using statistical and graphics programs. Compared with specialists, trainees were significantly less confident with spreadsheets (P = 0.002), literature searching (P = 0.034), and e-mail/communications (P = 0.040). CONCLUSIONS: Increased access to computer technology has not been parallelled by increased confidence in the use of computers among EM specialists and trainees. Training must address gaps in computer literacy if computer technology is to be used to its full potential.

Accidental poisoning in New Zealand.

OBJECTIVE: To examine mortality and morbidity associated with accidental poisoning in New Zealand for the period of 1993-97, and make comparisons with international trends. METHODS: Poison Centre call data, and mortality and public hospital discharge data from the New Zealand Health Information Service were examined. Mortality and hospitalization rates were calculated. Statistical trends were examined using Poisson regression. RESULTS: Poison Centre calls regarding household agents and therapeutics were most frequent. Accidental poisoning with analgesics, antipyretics and antirheumatics (18%) was a common cause of hospitalization. Children under 5 years had the highest hospitalization rates, but were less at risk of death by accidental poisoning than other age groups. Common causes of death from accidental poisoning included utility gas/carbon monoxide (16%), psychotropic agents (16%), and analgesics, etc. (15%). Mortality rates varied between 0.54 and 0.72/100,000 population. CONCLUSION: Mortality rates in New Zealand are lower than in many countries, but hospitalization rates are higher. Possible explanations and prevention implications are discussed.