ED Assembly: Introducing a Simple Method of Bringing Emergency Department Staff Together to Facilitate Improvement; A Report of a Real Experience

Introduction: The emergency department (ED) at Ashford and St Peter’s Hospitals NHS Foundation Trust (ASPH) is a medium size department which sees around 260-300 patients per day.  As a result of sustained demand, we continue to struggle to meet the four hour waiting target and face similar challenges of those of ED’s nationally. Working in a busy ED is challenging and demanding. specific challenges around communication and risks arise directly from the unique contextual demands of the ED environment. Objective: Aim being to improve the productivity of the ED team and find a mechanism to create a more supportive and enjoyable working environment within the department. Method: Our clinical leadership started looking for answer to improve communication among team members and to create a platform where there was no hierarchy and all team members could be directly involved in problem solving.  With the support of the quality improvement (QI) team, ED assembly was born. The assembly is a simple method of regularly bringing together staff to facilitate improvement and better team working. It is a platform for effective communication and innovation, in which there is no hierarchy and everyone is encouraged to contribute. Results: The assembly runs to a routine; every other Wednesday at 11am, the team come together for just half an hour. The agenda is set by the team in advance and everyone is encouraged to contribute their ideas and items they wish to contribute to others. Here are some examples of the quality improvement initiatives that have been born out of ED assembly: ED board rounds, coding information, overdose proforma, timely completion of standard investigations, access to fracture clinic appointments, nil-by-mouth communication, safety huddles, patient safety and sepsis, inclusive improvement, adoption of the ED assembly model by other teams and etc. Conclusion: ED assembly has supported many small but effective QI initiatives and regular communications support timely feedback on progress and update on plan-do-study-act (PDSA) cycles, resulting in changes in the everyday practice and improved pathways of patient care

ED Assembly: Introducing a Simple Method of Bringing Emergency Department Staff Together to Facilitate Improvement; A Report of a Real Experience

Introduction: The emergency department (ED) at Ashford and St Peter’s Hospitals NHS Foundation Trust (ASPH) is a medium size department which sees around 260-300 patients per day.  As a result of sustained demand, we continue to struggle to meet the four hour waiting target and face similar challenges of those of ED’s nationally. Working in a busy ED is challenging and demanding. specific challenges around communication and risks arise directly from the unique contextual demands of the ED environment. Objective: Aim being to improve the productivity of the ED team and find a mechanism to create a more supportive and enjoyable working environment within the department. Method: Our clinical leadership started looking for answer to improve communication among team members and to create a platform where there was no hierarchy and all team members could be directly involved in problem solving.  With the support of the quality improvement (QI) team, ED assembly was born. The assembly is a simple method of regularly bringing together staff to facilitate improvement and better team working. It is a platform for effective communication and innovation, in which there is no hierarchy and everyone is encouraged to contribute. Results: The assembly runs to a routine; every other Wednesday at 11am, the team come together for just half an hour. The agenda is set by the team in advance and everyone is encouraged to contribute their ideas and items they wish to contribute to others. Here are some examples of the quality improvement initiatives that have been born out of ED assembly: ED board rounds, coding information, overdose proforma, timely completion of standard investigations, access to fracture clinic appointments, nil-by-mouth communication, safety huddles, patient safety and sepsis, inclusive improvement, adoption of the ED assembly model by other teams and etc. Conclusion: ED assembly has supported many small but effective QI initiatives and regular communications support timely feedback on progress and update on plan-do-study-act (PDSA) cycles, resulting in changes in the everyday practice and improved pathways of patient care

DRESS syndrome: carbamazepine induced anaphylactic shock

A 51-year-old female of Southeast Asian ethnicity was referred to our Neurosurgery service for a newly diagnosed intracranial meningioma. She underwent surgical excision of the tumor and was discharged home on Carbamazepine. Four weeks later, she presented back to our Emergency Department (ED) with fever, generalized rash, and altered mental status. The rash appeared a week prior to the patient’s presentation to the ED, and she complained of spikes of fever for two days. On arrival, her temperature was 41 °C. She was tachypneic at 24 breaths/min, and hypotensive at 95/55 mm Hg, with a heart rate of 120 beats per minute (BPM). Soon after triage, she was moved to the resuscitation room for further assessment and management. On examination, the patient appeared to be in moderate distress, anxious, and slightly confused with a Glasgow Coma Scale (GCS) of 14/15. She had a generalized, macular, pruritic, urticarial rash with irregular confluent margins that was consistent with an allergic reaction. Apart from the above-detailed findings, her examination was unremarkable. There was no mucosal surfaces involvement. Her chest was clear on auscultation. Her abdomen was soft, non-tender, with no organomegaly. No focal neurological deficits were detected. Her investigations included a full septic panel. Laboratory workup revealed elevated Liver Function Tests {Alkaline Phosphatase (ALP) of 120 IU/L (Normal range 35 – 104), Aspartate Transaminase (AST) of 65 IU/L (Normal Range > 32), Alanine Aminotransferase (ALT) of 82 IU/L (Normal Range > 33)}, Lactate Dehydrogenase (LDH) of 367 IU/L (Normal Range 135 – 214), Procalcitonin of 1.01 ng/mL (Normal Range < 0.5), and C-Reactive Protein (CRP) of 150.2 mg/L (Normal Range < 0.5). Of note, she had no Leukocytosis nor eosinophilia. The patient’s empirical treatment plan in the ED included the administration of Intravenous (IV) Fluids, antihistamines, and Ceftriaxone. Upon admission, she was commenced on IV Dexamethasone 4 mg twice a day. Additionally, Carbamazepine was stopped immediately. The day following her admission, the patient’s lab work was repeated, and it showed an improvement in CRP, but most notably, her differential complete blood count revealed eosinophilia of 0.73x10^9/L (Normal Range > 0.7), which further went up to 1.33x10^9/L two days later. She was also reviewed by the dermatologist who agreed with the diagnosis of DRESS. A skin biopsy was proposed. However, the patient did not consent to the procedure. On day 3 of her admission, the patient clinically improved on treatment and remained afebrile and vitally stable. She was therefore discharged home with a follow-up clinic appointment. Written patient consent for publishing the case with no identifiable personal information was obtained

Barbicidal overdose

Acute severe methemoglobinaemia is an uncommon but life-threatening condition caused by a variety of oxidizing agents commonly used in both health care and industrial settings. Thus, recognition is important as it is readily treatable. The oxygen transport is compromised as a result of abnormal levels of oxidized haemoglobin, and this leads to skin discolouration and a variety of symptoms. Diagnostic confusion occurs as the oxygen saturations (SpO2) on the pulse oximeter are unreliable (Sharma V, Haber A. Acquired methaemoglobinaemia: a case report of benzocaine-induced methaemoglobinaemia and a review of the literature. Clin Pul Med. 2002;9(1):53–8). A case of severe methaemoglobinaemia due to self poisoning with barbicide is presented with a brief discussion of the patho-physiology and an overview of the treatment. A barbicidal overdose has never been reported before

Academic Research International THE DETERMINANTS OF INFLATION AND ITS IMPACT ON ECONOMIC GROWTH: A CASE STUDY OF PAKISTAN (2002-2010)

ABSTRACT Attempt is made to identify the determinants of fresh inflation i