{"id":5038,"date":"2011-07-14T20:22:51","date_gmt":"2011-07-14T20:22:51","guid":{"rendered":"http:\/\/crashtext.org\/misc\/emergency-department-logistics.htm\/"},"modified":"2014-08-08T16:28:51","modified_gmt":"2014-08-08T20:28:51","slug":"emergency-department-logistics","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/philosophy\/emergency-department-logistics.htm\/","title":{"rendered":"Emergency Department Logistics"},"content":{"rendered":"

<\/h2>\n

<\/span>Ambient Noise<\/span><\/h2>\n

EDs are way too load and this contributes to stress in ED workers (Pediatr Emer Care 2011;27:826)<\/p>\n

 <\/p>\n

<\/span>Cell Phones<\/span><\/h2>\n

Cell Phones are probably fine in the ED unless right next to 1 in 20 pieces of medical equipment. (BMJ 326:460, March 2002)<\/p>\n

They may interfere with vents if less than 30cm away (CCM 2004 32:4)<\/p>\n

 <\/p>\n

Case report of infusion pump intereference (Annal Emerg Med 2005;46(3):298)<\/p>\n

 <\/p>\n

Mayo Clin Proc. 2005;80:1286-1290 \u00a9 2005 Mayo Foundation for Medical Education and Research ORIGINAL ARTICLE Cellular Telephone Interference With Medical Equipment JEFFREY L. TRI, MSEE; RODNEY P. SEVERSON, CBET; ALLEN R. FIRL, AS; DAVID L. HAYES, MD; JOHN P. ABENSTEIN, MD OBJECTIVE: To assess the potential electromagnetic interference (EMI) effects that new or current-generation cellular telephones have on medical devices. MATERIAL AND METHODS: For this study, performed at the Mayo Clinic in Rochester, Minn, between March 9, 2004, and April 24, 2004, we tested 16 different medical devices with 6 cellular telephones to assess the potential for EMI. Two of the medical devices were tested with both new and old interface modules. The 6 cellular telephones chosen represent the different cellular technology protocols in use: Code Division Multiple Access (2 models), Global System for Mobile communications, Integrated Digital Enhanced Network, Time Division Multiple Access, and analog. The cellular telephones were tested when operating at or near their maximum power output. The medical devices, connected to clinical simulators during testing, were monitored by observing the device displays and alarms. RESULTS: Of 510 tests performed, the incidence of clinically important interference was 1.2%; EMI was induced in 108 tests (21.2%). Interference occurred in 7 (44%) of the 16 devices tested. CONCLUSIONS: Cellular telephones can interfere with medical equipment. Technology changes in both cellular telephones and medical equipment may continue to mitigate or may worsen clinically relevant interference. Compared with cellular telephones tested in previous studies, those currently in use must be closer to medical devices before any interference is noticed. However, periodic testing of cellular telephones to determine their effects on medical equipment will be required. Mayo Clin Proc. 2005;80(10):1286-1290<\/p>\n

<\/span>Medical Error<\/span><\/h2>\n

Annals Emerg Med Dec 2003 42:6<\/p>\n

<\/span>Scrubs worn outside OR<\/span><\/h2>\n

Bacterial contamination of surgical scrub suits worn outside the operating theatre: a randomised crossover study (<\/span>DOI:\u00a010.1111\/anae.12633)<\/p>\n

<\/span>Laundering of Scrubs<\/span><\/h2>\n

MCN Am J Matern Child Nurs. 2004 Mar-Apr;29(2):106-10. Home- versus hospital-laundered scrubs: a pilot study-no difference<\/p>\n

<\/span>Masks<\/span><\/h2>\n

Masks prob don’t matter (American Journal of Infection Control<\/b><\/a>
\nVolume 29, Issue 1<\/a>, February 2001, Pages 58-64)<\/p>\n

<\/span>Point of Care Testing<\/span><\/h2>\n

There is a whole lot of obfuscation out there saying that we cannot perform certain tests (such as urine dipsticks, HCGs, wet preps, and even guaiac testing for rectal exams) because of CLIA and JCAHO. A few years back, John Patrick forwarded a letter to the list that he received from the eastern regional JCAHO czar, debunking the rumor that JCAHO prohibited physicians from testing stool for blood at the bedside. (I still have a copy of this letter somewhere, and am sure the Dr. Patrick does as well.)<\/p>\n

At Massachusetts General Hospital, a major center where our EM residents rotate, the lab is so set in these rumors that physicians cannot even perform fingerstick glucose testing at the bedside. Worse yet, these same residents cannot perform vaginal wet preps at any of their hospital rotations (except ours), because of the belief that “doctors are no longer allowed [by JCAHO or CLIA] to use microscopes at work.”<\/p>\n

Both of these beliefs, (1) that simple tests such as urines, HCGs, rapid streps, and the like are disallowed from ED bedside use, and (2) that provider performed microscopy is prohibited are FALSE.<\/p>\n

A good summary of the actual law is provided on the American Academy of Family Physicians site: http:\/\/www.aafp.org\/x2255.xml<\/a>. Note that the regulatory discussion of provider performed microscopy (PPM) applies not to physicians doing wet preps in the ER, but to laboratories that perform such tests for physicians. (The laboratories, but not the physicians, must demonstrate QA and control procedures to be allowed to do these tests. Physicians can just do them.)<\/p>\n

A **17 page** list of CLIA-waived bedside tests is periodically published by CMS (Medicare\/Medicaid) at http:\/\/www.cms.hhs.gov\/clia\/waivetbl.pdf. What was most surprising when I first read this a few years ago (in an unsuccessful attempt to get fingersticks installed at Massachusetts General Hospital), was that CLIA has waived much more than the simple rapid strep, HCG, and urine dip tests. If an ER is ambitious, it can do bedside monospots, cholesterol screening, H. pyloris, prothrombins, blood ketones, urine toxicologies, and much much more. All without the QA burden of the lab that performed CLIA-regulated testing.<\/p>\n

I hope this helps.<\/p>\n

James Li, M.D. Assistant Professor of Medicine Division of Emergency Medicine Harvard Medical School<\/p>\n

www.remotemedicine.org<\/a><\/p>\n

<\/span>Resident Apparel<\/span><\/h2>\n

No Difference between shirt\/tie and scrubs.\u00a0 No difference with or without tie (The American Journal of Emergency Medicine Volume 22, Issue 1 , January 2004, Pages 61-62)<\/p>\n

 <\/p>\n

 <\/p>\n

Academic Emergency Medicine Volume 11, Number 5 450 Patient Attitudes toward Emergency Physician Attire: A Randomized Trial Siu Fai Li and Marc Haber Jacobi Medical Center: Bronx, NY ABSTRACT BACKGROUND: Previous studies have suggested that ED patient satisfaction is unaffected by physician attire. In a previous unrandomized study, we found no difference in patient evaluation of physician performance between different styles of dress. We now follow up our original study with a randomized trial to confirm this hypothesis. METHODS:We surveyed a convenience sample of ED patients during a two-week period. In the first week, emergency physicians wore white coats and formal attire. In the second week, the same physicians wore scrubs. Patients were asked to indicate on a 100-mm visual analog scale (VAS) their ratings of physician appearance, satisfaction, and professionalism. The primary outcome was the difference in VAS scores between the two dress styles. Secondary outcomes included difference in VAS scores between the two dress styles stratified by patient age, sex, and race, and physician sex. We estimated that 55 patients were needed in each group. RESULTS: 111 patients were surveyed. There were no significant differences between patients’ evaluation of appearance ( = \u00960.68, 95% CI \u00965.5 to 4.1), satisfaction ( = 0.83, 95% CI \u00963.0 to 4.6), or professionalism ( = \u00960.46, 95% CI \u00963.6 to 2.6) between the two dress styles. There were no differences in preference of physician attire based on patient age, sex, or race, or physician sex. CONCLUSIONS: Emergency physician attire does not affect patient satisfaction.<\/p>\n

Recommended attire from ID perspective for resuscitation<\/a><\/p>\n

<\/span>Difference between ED and Medicine Admit Decisions<\/span><\/h2>\n

Abstract 4 of 12 Academic Emergency Medicine Volume 11, Number 5 573, \u00a9 2004 Society for Academic Emergency Medicine ——————————————————————————– CLINICAL DECISION GUIDELINES Concordance of Disposition for Hypothetical Medical Patients in the Emergency Department Jason B. Hack and Nicholas Benson East Carolina University: Greenville, NC ABSTRACT INTRODUCTION: Emergency physicians are charged with making dispositions for every emergency department (ED) patient. They often require agreement from in-patient services to admit patients. Sometimes disagreements arise. To the best of our knowledge, no previously published study has examined this interaction. OBJECTIVE:To determine disposition concordance between emergency physicians and admitting medical services of hypothetical patients presenting to the ED. Also, to determine differences in additional information requested by each service. METHODS: Within a 2-week period resident and attending physicians from emergency medicine (EM), family practice (FP), and internal medicine (IM) voluntarily completed anonymous questionnaires asking them to disposition hypothetical patients in the ED. The 11 case scenarios were each followed by three disposition choices\u0097Admit, Discharge, Cannot Tell\u0097 from given information (with a free-text area for listing information they required to make a disposition). The dispositions were compared between groups using Pearson chi-square test for homogeneity. RESULTS: 105 questionnaires were returned\u0097EM 42 (12\/30) (attending\/resident, respectively); FP 33 (14\/19); IM 30 (4\/26). Admission rates were statistically different (P < .001) for EM (68%\/65%\/66% (attendings\/residents\/total)) when compared to FP (42%\/54%\/49%) and IM (36%\/53%\/51%). Discharge rates were also statistically different (P < .001) for EM (8%\/19%\/16%) vs FP (29%\/29%\/28%) and IM (27%\/28%\/28%). Cannot Tell rates were not significantly different between groups (P > .05)\u0097EM (23%\/16%\/18%) vs. FP (25%\/14%\/19%) and IM (36%\/16%\/18%). However, the rate of additional testing requested in the free-text area by EM was about half that of FP or IM (0.45 vs. 0.92 and 1.0). Dispositions between FP and IM were not different at any level. CONCLUSION: When presented with identical hypothetical ED patients, emergency physicians admit more, discharge less, and ask for fewer tests than their FP or IM counterparts. FP and IM doctors disposition patients in a similar manner.<\/p>\n

 <\/p>\n

<\/span>ED Metrics and Differences between EDs<\/span><\/h2>\n

ed-metrics-on-wait-time-satisfaction<\/a><\/p>\n

<\/span>Overcrowding<\/span><\/h2>\n

Critically ill that have to board have higher mortality, LOS, and higher costs (Acad Emerg Med 2006;12(5):suppl 1 9)<\/p>\n

 <\/p>\n

Review of crit ill boarding in the ED (Crit Care 2005;9:291)<\/p>\n

 <\/p>\n

Vicellio’s incredible piece<\/a><\/p>\n

 <\/p>\n

<\/span>Patient Satisfaction<\/span><\/h2>\n

Ann Intern Med. 2006 May 2;144(9):665-72. Related Articles, Links Patients’ global ratings of their health care are not associated with the technical quality of their care. Chang JT, Hays RD, Shekelle PG, MacLean CH, Solomon DH, Reuben DB, Roth CP, Kamberg CJ, Adams J, Young RT, Wenger NS. the David Geffen School of Medicine at UCLA and Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California; RAND Health, Santa Monica, California; and RAND Health, Arlington, Virginia. BACKGROUND: Patient global ratings of care are commonly used to assess health care. However, the extent to which these assessments of care are related to the technical quality of care received is not well understood. OBJECTIVE: To investigate the relationship between patient-reported global ratings of health care and the quality of providers’ communication and technical quality of care. DESIGN: Observational cohort study. SETTING: 2 managed care organizations. PATIENTS: Vulnerable older patients identified by brief interviews of a random sample of community-dwelling adults 65 years of age or older who received care in 2 managed care organizations during a 13-month period. MEASUREMENTS: Survey questions from the second stage of the Consumer Assessment of Healthcare Providers and Systems program were used to determine patients’ global rating of health care and provider communication. A set of 236 quality indicators, defined by the Assessing Care of Vulnerable Elders project, were used to measure technical quality of care given for 22 clinical conditions; 207 quality indicators were evaluated by using data from chart abstraction or patient interview. RESULTS: Data on the global rating item, communication scale, and technical quality of care score were available for 236 vulnerable older patients. In a multivariate logistic regression model that included patient and clinical factors, better communication was associated with higher global ratings of health care. Technical quality of care was not significantly associated with the global rating of care. LIMITATIONS: Findings were limited to vulnerable elders who were enrolled in managed care organizations and may not be generalizable to other age groups or types of insurance coverage. CONCLUSIONS: Vulnerable elders’ global ratings of care should not be used as a marker of technical quality of care. Assessments of quality of care should include both patient evaluations and independent assessments of technical quality.<\/p>\n

\"\"<\/a><\/p>\n

 <\/p>\n

Patient handovers and formula 1 racing (Pediatric Anesthesia 2007;17:470)<\/p>\n

Emergency Department Crowding is Associated with Reduced Satisfaction Scores in Patients
\nDischarged from the Emergency Department\u00a0 ([West J Emerg Med.2013;14(1):11-15)<\/p>\n

<\/span>Task Interruptions<\/span><\/h2>\n

Acad Emerg Med 2000;7(11):1239<\/p>\n

Ann Emerg Med 2001;38(2):146<\/p>\n

ACADEMIC EMERGENCY MEDICINE 2011; 18:1246\u20131254<\/p>\n

AM J Emerg Med 2005;23(3):332<\/p>\n

Acoust Soc Am 2007;121(4):1996<\/p>\n

Momentary interruptions can derail the train of thought. Altmann, Erik M.; Trafton, J. Gregory; Hambrick, David Z. Journal of Experimental Psychology: General, Vol 143(1), Feb 2014, 215-226. doi: 10.1037\/a0030986<\/p>\n

The impact of interruptions on clinical task completion (Qual Saf Health Care 2009.039255)<\/p>\n

Qual Saf Health Care.<\/a> 2010 May 12. [Epub ahead of print] The impact of interruptions on clinical task completion. Westbrook JI<\/a>, Coiera E<\/a>, Dunsmuir WT<\/a>, Brown BM<\/a>, Kelk N<\/a>, Paoloni R<\/a>, Tran C<\/a>. Health Informatics Research & Evaluation Unit, Faculty of Health Sciences, University of Sydney, Sydney, Australia. Abstract Background Interruptions and multitasking are implicated as a major cause of clinical inefficiency and error. Objective The aim was to measure the association between emergency doctors’ rates of interruption and task completion times and rates. Methods The authors conducted a prospective observational time and motion study in the emergency department of a 400-bed teaching hospital. Forty doctors (91% of medical staff) were observed for 210.45 h on weekdays. The authors calculated the time on task (TOT); the relationship between TOT and interruptions; and the proportion of time in work task categories. Length-biased sampling was controlled for. Results Doctors were interrupted 6.6 times\/h. 11% of all tasks were interrupted, 3.3% more than once. Doctors multitasked for 12.8% of time. The mean TOT was 1:26 min. Interruptions were associated with a significant increase in TOT. However, when length-biased sampling was accounted for, interrupted tasks were unexpectedly completed in a shorter time than uninterrupted tasks. Doctors failed to return to 18.5% (95% CI 15.9% to 21.1%) of interrupted tasks. Conclusions It appears that in busy interrupt-driven clinical environments, clinicians reduce the time they spend on clinical tasks if they experience interruptions, and may delay or fail to return to a significant portion of interrupted tasks. Task shortening may occur because interrupted tasks are truncated to ‘catch up’ for lost time, which may have significant implications for patient safety.<\/p>\n

 <\/p>\n

<\/span>Rudeness<\/span><\/h2>\n

rudeness doesn’t only affect the immediate encouneter but subsequent encounters that day and also people not directly involved in the incident (BMJ 2010;340:c2480)<\/p>\n

<\/span>The Need to Urinate<\/span><\/h2>\n
\n

Neurourol Urodyn.<\/a> 2011 Jan;30(1):183-7.<\/p>\n<\/div>\n

The magnitude of
\ndecline in cognitive function associated with an extreme urge to void
\nwas as large and equivalent or greater than the cognitive deterioration
\nobserved for conditions known to be associated with increased accident
\nrisk.<\/p>\n

<\/span>Dehydration<\/span><\/h2>\n

\u00a0A.C. Grandjean and N.R. Grandjean, Dehydration and cognitive performance.\u00a0<\/span>J Am Coll Nutr<\/i>,\u00a0<\/span>\u00a026\u00a0<\/b>\u00a0(2007), pp. 549S\u2013554S.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

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