Senior doctor triage (SDT), a qualitative study of clinicians' views on senior doctors' involvement in triage and early assessment of emergency patients

INTRODUCTION: Despite the focus during the last decade on introducing interventions such as senior doctor initial assessment or senior doctor triage (SDT) to reduce emergency department (ED) crowding, there has been little attempt to identify the views of emergency healthcare professionals on such interventions. The aim of this study was to gain an understanding of SDT from the perspective of emergency hospital staff. A secondary aim of this study was to develop a definition of SDT based on the interview findings and the available literature on this process. METHODS: Qualitative semi-structured telephone interviews were conducted with participants of different backgrounds including senior doctors, nurses, paramedics and ED managers. Textual data were analysed using a template analysis approach. RESULTS: 27 participants from 13 EDs across England were interviewed. SDT was viewed as a safety mechanism and a measure to control patient flow. The most prominent positive aspect was the ability to initiate early investigations and treatment. Various shortcomings of SDT were described such as the lack of standardisation of the process and its cost implications. Participants identified a number of barriers to this process including insufficient resources and exit block, and called for solutions focused on these issues. A proposed definition of an 'ideal' SDT was developed where it is described as a systematic brief assessment of patients arriving at the ED by a senior doctor-led team, which takes place in a dedicated unit. The aim of this assessment is to facilitate early investigation and management of patients, early patient disposition and guide junior staff to deliver safe and high-quality clinical care. CONCLUSION: This is the first national study to explore the opinions of various emergency and managerial staff on the SDT model. It revealed variable interpretations of this model and what it can and cannot offer. This has led to a standard definition of the SDT process, which can be useful for clinicians and researchers in emergency care

Understanding better how emergency doctors work. Analysis of distribution of time and activities of emergency doctors: A systematic review and critical appraisal of time and motion studies

Background: Optimising the efficiency and productivity of senior doctors is critical to ED function and delivery of safe patient care. Time and motion studies (TMS) can allow quantification of how these doctors spend their working time, identify inefficiencies in the current work processes and provide insights into improving working conditions, and enhancing productivity. Three questions were addressed: (1) How do senior emergency doctors spend their time in the ED? (2) How much of their time is spent on multitasking? (3) What is the number of tasks completed per hour? Methods: The literature was systematically searched for TMS of senior emergency doctors. We searched for articles published in peer-reviewed journals in English language from 1998 to 2018 in the following databases: MEDLINE, EMBASE, Scopus, Web of Science and Cochrane. Studies were assessed for methodological quality using evidence-based quality criteria relevant for TMS including duration of observation, observer bias, Hawthorne effect and whether the task classification acknowledged any previous existing schemes. A narrative synthesis approach was followed. Results: Fourteen TMS were included. The studies were liable to several biases including observer and Hawthorne bias. Overall, the time spent on direct face-to-face contact with the patient accounted for at least around 25%-40% of the senior doctors' time. The remaining time was mostly spent on indirect clinical care such as communication (8%-44%), documentation (10%-28%) and administrative tasks (2%-20%). The proportion of time spent on multitasking ranged from 10% to 23%. When reported, the number of tasks performed per hour was generally high. Conclusion: The review revealed that senior doctors spent a large percentage of their time on direct face-to-face contact with patients. The review findings provided a grounded understanding of how senior doctors spent their time in the ED and could be useful in implementing improvements to the emergency care system

The impact of senior doctor assessment at triage on emergency department performance measures: systematic review and meta-analysis of comparative studies.

STUDY QUESTION: To determine if placing a senior doctor at triage versus standard single nurse in a hospital emergency department (ED) improves ED performance by reviewing evidence from comparative design studies using several quality indicators. DESIGN: Systematic review. DATA SOURCES: Cochrane Library, MEDLINE, EMBASE, CINAHL, Cochrane Effective Practice and Organisation of Care (EPOC), Web of Science, Clinical Trials Registry website. In addition, references from included studies and citation searches were used to identify relevant studies. REVIEW METHODS: Databases were searched for comparative studies examining the role of senior doctor triage (SDT), published from 1994 to 2014. Senior doctor was defined as a qualified medical doctor who completed high specialty training in emergency medicine. Articles with a primary aim to investigate the effect of SDT on ED quality indicators such as waiting time (WT), length of stay (LOS), left without being seen (LWBS) and left without treatment complete (LWTC) were included. Articles examining the adverse events and cost associated with SDT were also included. Only studies with a control group, either in a randomised controlled trial (RCT) or in an observational study with historical controls, were included. The systematic literature search was followed by assessment of relevance and risk of bias in each individual study fulfilling the inclusion criteria using the Effective Public Health Practice Project (EPHPP) bias tool. Data extraction was based on a form designed and piloted by the authors for dichotomous and continuous data. DATA SYNTHESIS: Narrative synthesis and meta-analysis of homogenous data were performed. RESULTS: Of 4506 articles identified, 25 relevant studies were retrieved; 12 were of the weak pre-post study design, 9 were of moderate quality and 4 were of strong quality. The majority of the studies revealed improvements in ED performance measures favouring SDT. Pooled results from two Canadian RCTs showed a significant reduction in LOS of medium acuity patients (weighted means difference (WMD) -26.26 min, 95% CI -38.50 to -14.01). Another two RCTs revealed a significant reduction in WT (WMD -26.17 min, 95% CI -31.68 to -20.65). LWBS was reduced in two Canadian RCTs (risk ratio (RR)=0.79, 95% CI 0.66 to 0.94). This was echoed by the majority of pre-post study designs. SDT did not change the occurrence of adverse events. No clear benefit of SDT in terms of patient satisfaction or cost effectiveness could be identified. CONCLUSIONS: This review demonstrates that SDT can be an effective measure to enhance ED performance, although cost versus benefit analysis is needed. The potential high risk of bias in the evidence identified, however, mandates more robust multicentred studies to confirm these findings

Fabrication of alternating copolymers based on cyclopentadithiophene-benzothiadiazole dicarboxylic imide with reduced optical band gap: synthesis, optical, electrochemical, thermal, and structural properties

A series of alternating copolymers containing cyclopentadithiophene (CPDT) flanked by thienyl moieties as electron-donor units and benzothiadiazole dicarboxylic imide (BTDI) as electron-acceptor units were designed and synthesized for solar cell applications. Different solubilizing side chains, including 2-ethylhexyl chains and n-octyl chains were attached to CPDT units, whereas 3,7-dimethyloctyl chains and n-octyl chains were anchored to the BTDI moieties. The impact of these substituents on the solubilities, molecular weights, optical and electrochemical properties, and thermal and structural properties of the resulting polymers was investigated. PCPDTDTBTDI-EH, DMO was synthesized via Suzuki polymerization, whereas PCPDTDTBTDI-8, DMO, and PCPDTDTBTDI-EH, 8 were prepared through direct arylation polymerization. PCPDTDTBTDI-8, DMO has the highest number average molecular weight (Mn = 17,400 g mol−1) among all polymers prepared. The PCPDTDTBTDI-8, DMO and PCPDTDTBTDI-8, 8 which have n-octyl substituents on their CPDT units have comparable optical band gaps (Eg ~ 1.3 eV), which are around 0.1 eV lower than PCPDTDTBTDI-EH, DMO analogues that have 2-ethylhexyl substituents on their CPDT units. The polymers have their HOMO levels between −5.10 and −5.22 eV with PCPDTDTBTDI-EH, DMO having the deepest highest occupied molecular orbital (HOMO) energy level. The lowest unoccupied molecular orbital (LUMO) levels of the polymers are between −3.4 and −3.5 eV. All polymers exhibit good thermal stability with decomposition temperatures surpassing 350 °C. Powder X-ray diffraction (XRD) studies have shown that all polymers have the amorphous nature in solid state

Influence of fluorine substitution on the optical, thermal, electrochemical and structural properties of carbazole-benzothiadiazole dicarboxylic imide alternate copolymers

In this work four novel donor-acceptor copolymers, PCDTBTDI-DMO, PCDTBTDI-8, P2F-CDTBTDI-DMO and P2F-CDTBTDI-8, were designed and synthesised via Suzuki polymerisation. The first two copolymers consist of 2,7-carbazole flanked by thienyl moieties as the electron donor unit and benzothiadiazole dicarboxylic imide (BTDI) as electron acceptor units. In the structures of P2F-CDTBTDI-DMO and P2F-CDTBTDI-8 copolymers, two fluorine atoms were incorporated at 3,6-positions of 2,7-carbazole to investigate the impact of fluorine upon the optoelectronic, structural and thermal properties of the resulting polymers. P2F-CDTBTDI-8 possesses the highest number average molecular weight (Mn = 24,200 g mol−1) among all the polymers synthesised. PCDTBTDI-DMO and PCDTBTDI-8 show identical optical band gaps of 1.76 eV. However, the optical band gaps of fluorinated copolymers are slightly higher than non-fluorinated counterparts. All polymers have deep-lying highest occupied molecular orbital (HOMO) levels. Changing the alkyl chain substituents on BTDI moieties from linear n-octyl to branched 3,7-dimethyloctyl groups as well as substituting the two hydrogen atoms at 3,6-positions of carbazole unit by fluorine atoms has negligible impact on the HOMO levels of the polymers. Similarly, the lowest unoccupied molecular orbital (LUMO) energy levels are almost comparable for all polymers. Thermogravimetric analysis (TGA) has shown that all polymers have good thermal stability and also confirmed that the fluorinated copolymers have higher thermal stability relative to those non-fluorinated analogues. Powder X-ray diffraction (XRD) studies proved that all polymers have an amorphous nature in the solid state

Tea from the drinking to the synthesis of metal complexes and fabrication of PVA based polymer composites with controlled optical band gap

In the present study black tea extract (BTE) solution which is familiar for drinking was used to prepare cerium metal-complexes (Ce(III)-complex). The prepared Ce(III)-complex was characterized by Fourier transform infrared spectroscopy (FTIR), X-ray diffraction (XRD), and UV–Vis spectroscopy. The results indicate that BTE solution is a novel green coordination chemistry approach for the synthesis of metal complexes. The outcomes signify that coordination occurs between cerium cations and polyphenols. The synthesis of metal-complexes with superior absorption performance in the visible region is a challenge for optoelectronic device applications. The suspended Ce(III)-complex in distilled water was mixed with poly (vinyl alcohol) (PVA) polymer to fabricate PVA/ Ce(III)-complex composites with controlled optical properties. The PVA/Ce(III)-complexes composite films were characterized by FTIR, XRD, and UV–Vis spectroscopy. The XRD findings confirms the amorphous structure for the synthesized Ce(III)-complexes. The addition of Ce(III)-complex into the PVA host polymer led to the growth of polymer composites with controllable small optical band gaps. It is shown by the FTIR spectra of the composite films that the functional groups of the host PVA have a vigorous interaction with the Ce(III)-complex. The XRD deconvolution on PVA composites reveals the amorphous phase enlargement with increasing Ce(III)-complex concentration. It is indicated in the atomic force microscopy (AFM) that the surface roughness in the doped PVA films increases with the increase of the Ce(III)-complex. There is a decrease in absorption edge from 5.7 to 1.7 eV. It becomes possible to recognize the type of electron transition by studying both the Tauc's model and optical dielectric loss (ɛi) parameter

The study of EDLC device with high electrochemical performance fabricated from proton ion conducting PVA-based polymer composite electrolytes plasticized with glycerol

In the present work, a novel polymer composite electrolytes (PCEs) based on poly(vinyl alcohol) (PVA): ammonium thiocyanate (NH4SCN): Cd(II)-complex plasticized with glycerol (Gly) are prepared by solution cast technique. The film structure was examined by XRD and FTIR routes. The utmost ambient temperature DC ionic conductivity (σDC) of 2.01 × 10−3 S cm−1 is achieved. The film morphology was studied by field emission scanning electron microscopy (FESEM). The trend of σDC is further confirmed with investigation of dielectric properties. Transference numbers of ions (tion) and electrons (tel) are specified to be 0.96 and 0.04, respectively. Linear sweep voltammetry (LSV) displayed that the PCE potential window is 2.1 V. The desired mixture of activated carbon (AC) and carbon black was used to fabricate the electrodes of the EDLC. Cyclic voltammetry (CV) was carried out by sandwiching the PCEs between two carbon-based electrodes, and it revealed an almost rectangular shape. The EDLC exhibited specific capacitance, energy density, and equivalent series resistance with average of 160.07F/g, 18.01Wh/kg, and 51.05Ω, respectively, within 450 cycles. The EDLC demonstrated the initial power density as 4.065 × 103 W/Kg