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

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

Chiral corrections to the axial charges of the octet baryons from quenched QCD

We calculate one-loop correction to the axial charges of the octet baryons using quenched chiral perturbation theory, in order to understand chiral behavior of the axial charges in quenched approximation to quantum chromodynamics (QCD). In contrast to regular behavior of the full QCD chiral perturbation theory result, $c_0+c_{l2}m_\pi^2\,\ln{m_\pi^2}+\cdots$, we find that the quenched chiral perturbation theory result, $c_0^Q+(c_{l0}^Q+c_{l2}^Qm_\pi^2)\ln{m_\pi^2}+c_2^Q m_\pi^2+\cdots$, is singular in the chiral limit.Comment: standard LaTeX, 16 pages, 4 epsf figure

Measurement of the vector and tensor analyzing powers for dp- elastic scattering at 880 MeV

The vector Ay and tensor analyzing powers Ayy and Axx for dp- elastic scattering were measured at Td = 880 MeV over the c.m. angular range from 60 to 140 degrees at the JINR Nuclotron. The data are compared with predictions of different theoretical models based on the use of nucleon-nucleon forces only. The observed discrepancies of the measured analyzing powers from the calculations require the consideration of additional mechanisms.Comment: 5 pages,3 figure

Influence of Cation Substitution on Cycling Stability and Fe-Cation Migration in Li3Fe3–xMxTe2O12 (M = Al, In) Cathode Materials

Li3Fe3Te2O12 adopts a crystal structure, described in space group Pnnm, related to that of LiSbO3, in which Te6+, Fe3+, and Li+ cations reside in a partially ordered configuration within an hcp array of oxide ions. Chemical or electrochemical insertion of lithium is accompanied by a fully reversible migration of some of the Fe cations with an initial capacity of 120 mA h g-1 (2.85 Li per formula unit). Long-term cycling stability is limited by the facile reduction of Te6+ to elemental Te, which leads to cathode decomposition. Partial substitution of Fe by In suppresses Te6+ reduction, such that Li3Fe2InTe2O12 shows no sign of this cathode decomposition pathway, even after 100 cycles. In contrast, Al-for-Fe substitution is chemically limited to Li3Fe2.6Al0.4Te2O12 and appears to have almost no influence on cathode longevity. These features of the Li3Fe3-xMxTe2O12 system are discussed on the basis of a detailed structural analysis performed using neutron and synchrotron X-ray diffraction

Characterisation of the muon beams for the Muon Ionisation Cooling Experiment

A novel single-particle technique to measure emittance has been developed and used to characterise seventeen different muon beams for the Muon Ionisation Cooling Experiment (MICE). The muon beams, whose mean momenta vary from 171 to 281 MeV/c, have emittances of approximately 1.2–2.3 π mm-rad horizontally and 0.6–1.0 π mm-rad vertically, a horizontal dispersion of 90–190 mm and momentum spreads of about 25 MeV/c. There is reasonable agreement between the measured parameters of the beams and the results of simulations. The beams are found to meet the requirements of MICE

Leptonic and Semileptonic Decays of Charm and Bottom Hadrons

We review the experimental measurements and theoretical descriptions of leptonic and semileptonic decays of particles containing a single heavy quark, either charm or bottom. Measurements of bottom semileptonic decays are used to determine the magnitudes of two fundamental parameters of the standard model, the Cabibbo-Kobayashi-Maskawa matrix elements $V_{cb}$ and $V_{ub}$. These parameters are connected with the physics of quark flavor and mass, and they have important implications for the breakdown of CP symmetry. To extract precise values of $|V_{cb}|$ and $|V_{ub}|$ from measurements, however, requires a good understanding of the decay dynamics. Measurements of both charm and bottom decay distributions provide information on the interactions governing these processes. The underlying weak transition in each case is relatively simple, but the strong interactions that bind the quarks into hadrons introduce complications. We also discuss new theoretical approaches, especially heavy-quark effective theory and lattice QCD, which are providing insights and predictions now being tested by experiment. An international effort at many laboratories will rapidly advance knowledge of this physics during the next decade.Comment: This review article will be published in Reviews of Modern Physics in the fall, 1995. This file contains only the abstract and the table of contents. The full 168-page document including 47 figures is available at http://charm.physics.ucsb.edu/papers/slrevtex.p