Patient satisfaction in emergency medicine.

A systematic review was undertaken to identify published evidence relating to patient satisfaction in emergency medicine. Reviewed papers were divided into those that identified the factors influencing overall satisfaction in emergency department patients, and those in which a specific intervention was evaluated. Patient age and race influenced satisfaction in some, but not all, studies. Triage category was strongly correlated with satisfaction, but this also relates to waiting time. The three most frequently identified service factors were: interpersonal skills/staff attitudes; provision of information/explanation; perceived waiting times. Seven controlled intervention studies were found. These suggested that increased information on ED arrival, and training courses designed to improve staff attitudes and communication, are capable of improving patient satisfaction. None of the intervention studies looked specifically at the effect of reducing the perceived waiting time. Key interventions to improve patient satisfaction will be those that develop the interpersonal and attitudinal skills of staff, increase the information provided, and reduce the perceived waiting time. Future research should use a mixture of quantitative and qualitative methods to evaluate specific interventions

Can patients apply the Ottawa ankle rules to themselves?

ABSTRACT Objective: To determine whether patients with an ankle injury obtained the same results as clinicians when applying the Ottawa ankle rules (a validated clinical decision rule) to themselves. Methods: Patients aged .15 years presenting to an inner city emergency department within 48 h of an ankle injury were asked to assess their own injury using the Ottawa ankle rules. The results of their self-assessment were compared with those of a treating clinician. Results: Poor interobserver agreement was found between patients and clinicians. Conclusions: Making the Ottawa ankle rule more widely available to the general public is unlikely to reduce healthcare demand. Indeed, given the apparently low specificity of the rule, demand could actually increase as a result. The Ottawa ankle rules have been extensively validated as a clinical decision rule for use by healthcare professionals in detecting possible bony injury-and therefore the need for radiography-in patients with a recent ankle injury. 2 The Ottawa ankle rules can be reliably applied by a range of healthcare professionals, including emergency nurse practitioners. 3 If they could also be reliably applied by patients to their own ankle injuries, there is the potential to reduce healthcare consultations following ankle sprain with consequent resource savings, particularly if the rules were widely publicised. The aim of this pilot study was to determine the agreement between patients and clinicians when applying the Ottawa ankle rules, and therefore whether adult patients with a recent ankle injury are potentially able to accurately apply the Ottawa ankle rules to themselves. METHODS A convenience sample of 50 patients attending a single inner city emergency department with a recent (within 48 h) ankle injury were asked if they wished to participate in the study by a researcher triaging the patient. All patients were offered analgesia. Patients who elected not to enter the study were examined by a researcher and treated according to usual practice. If the patient entered the study, informed written consent was obtained and they were then given an information sheet and pictorial questionnaire describing the Ottawa ankle rules (see online Appendix 1). Participants were asked to examine their own ankle and to enter the results on the questionnaire before formal clinical assessment. The patient was then seen by an emergency department clinician (doctor, emergency nurse practitioner or extended scope physiotherapist) who was blind to the patient's assessment of his or her own injury. The clinician made an independent assessment of the injury and arranged radiographs as appropriate. The clinician then completed a study questionnaire giving details of his/her assessment and an interpretation of any radiographs. The formal radiology report was also reviewed and, where any disagreement occurred, the radiology report was taken as the reference standard. If radiography was not performed, the emergency and radiology department records were checked to see if the patient presented in the following month with a lower limb injury. The kappa statistic was used to determine the level of agreement between the patient and clinician, with x 2 testing to compare their overall opinion. RESULTS Fifty patients (25 men, 25 women) of mean age 32 years (range 16-63) were recruited to the study. The mean duration from injury to presentation was 17 h. All 50 patients rated themselves as positive on at least one of the five Ottawa criteria, and therefore all patients concluded that they required a radiograph. On examination by the clinician, 45 of the 50 patients were positive on at least one of the Ottawa criteria and therefore required a radiograph. Of the remaining five patients, one had a ruptured Achilles tendon and one underwent radiography for other reasons. None of the other three patients who did not undergo radiography returned to the emergency department or had lower limb radiographs at the same hospital during the following month. Of the patients who underwent radiography, seven (14%) had fractures identified by both the clinician and the reporting radiologist. Three (6%) had fractures suspected by the clinician but not confirmed by the radiologist. The remaining 36 patients (72%) who had radiographs did not have a fracture. No fractures were missed by an ED clinician. Agreement between the patient and clinician in relation to each of the five Ottawa criteria is shown in tables 1 and 2. There was very little agreement between patients and clinicians on whether they could walk initially or in the emergency department, but greater agreement regarding local tenderness. Overall, 90% of clinicians and 100% of patients rated the rule as positive, demonstrating a statistically significant difference between the final opinions of the two groups (p = 0.02, x 2 test). The kappa values show

CacheZoom: How SGX Amplifies The Power of Cache Attacks

In modern computing environments, hardware resources are commonly shared, and parallel computation is widely used. Parallel tasks can cause privacy and security problems if proper isolation is not enforced. Intel proposed SGX to create a trusted execution environment within the processor. SGX relies on the hardware, and claims runtime protection even if the OS and other software components are malicious. However, SGX disregards side-channel attacks. We introduce a powerful cache side-channel attack that provides system adversaries a high resolution channel. Our attack tool named CacheZoom is able to virtually track all memory accesses of SGX enclaves with high spatial and temporal precision. As proof of concept, we demonstrate AES key recovery attacks on commonly used implementations including those that were believed to be resistant in previous scenarios. Our results show that SGX cannot protect critical data sensitive computations, and efficient AES key recovery is possible in a practical environment. In contrast to previous works which require hundreds of measurements, this is the first cache side-channel attack on a real system that can recover AES keys with a minimal number of measurements. We can successfully recover AES keys from T-Table based implementations with as few as ten measurements.Comment: Accepted at Conference on Cryptographic Hardware and Embedded Systems (CHES '17

How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals

Background: Hospital emergency admissions have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical units. These pressures have an adverse impact on patient experience and potentially lead to suboptimal clinical decision-making. In response, a variety of innovations have been developed, but whether or not these reduce inappropriate admissions or improve patient and clinician experience is largely unknown. Aims: To investigate the interplay of service factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners. Methods: The project used a multiple case study design for a mixed-methods analysis of decision-making about admissions in four acute hospitals. The primary research comprised two parts: value stream mapping to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers and 282 practitioners of different specialties and levels. Additional data were collected through a clinical panel, learning sets, stakeholder workshops, reading groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources. Findings: Patients’ experiences of emergency care were positive and they often did not raise concerns, whereas carers were more vocal. Staff’s focus on patient flow sometimes limited time for basic care, optimal communication and shared decision-making. Practitioners admitted or discharged few patients during the first hour, but decision-making increased rapidly towards the 4-hour target. Overall, patients’ journey times were similar, although waiting before being seen, for tests or after admission decisions, varied considerably. The meaning of what constituted an ‘admission’ varied across sites and sometimes within a site. Medical and social complexity, targets and ‘bed pressure’, patient safety and risk, each influenced admission/discharge decision-making. Each site responded to these pressures with different initiatives designed to expedite appropriate decision-making. New ways of using hospital ‘space’ were identified. Clinical decision units and observation wards allow potentially dischargeable patients with medical and/or social complexity to be ‘off the clock’, allowing time for tests, observation or safe discharge. New teams supported admission avoidance: an acute general practitioner service filtered patients prior to arrival; discharge teams linked with community services; specialist teams for the elderly facilitated outpatient treatment. Senior doctors had a range of roles: evaluating complex patients, advising and training juniors, and overseeing ED activity. Conclusions: This research shows how hospitals under pressure manage complexity, safety and risk in emergency care by developing ‘ground-up’ initiatives that facilitate timely, appropriate and safe decision-making, and alternative care pathways for lower-risk, ambulatory patients. New teams and ‘off the clock’ spaces contribute to safely reducing avoidable admissions; frontline expertise brings value not only by placing senior experienced practitioners at the front door of EDs, but also by using seniors in advisory roles. Although the principal limitation of this research is its observational design, so that causation cannot be inferred, its strength is hypothesis generation. Further research should test whether or not the service and care innovations identified here can improve patient experience of acute care and safely reduce avoidable admissions. Funding: The National Institute for Health Research (NIHR) Health Services and Delivery Research programme (project number 10/1010/06). This research was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula

The 3D Grazing Collision of Two Black Holes

We present results for two colliding black holes (BHs), with angular momentum, spin, and unequal mass. For the first time gravitational waveforms are computed for a grazing collision from a full 3D numerical evolution. The collision can be followed through the merger to form a single BH, and through part of the ringdown period of the final BH. The apparent horizon is tracked and studied, and physical parameters, such as the mass of the final BH, are computed. The total energy radiated in gravitational waves is shown to be consistent with the total mass of the spacetime and the final BH mass. The implication of these simulations for gravitational wave astronomy is discussed.Comment: 4 pages, 7 figures, revte

PAin SoluTions In the Emergency Setting (PASTIES)--patient controlled analgesia versus routine care in emergency department patients with non-traumatic abdominal pain: randomised trial

© Smith et al 2015. OBJECTIVE: To determine whether patient controlled analgesia (PCA) is better than routine care in providing effective analgesia for patients presenting to emergency departments with moderate to severe non-traumatic abdominal pain.DESIGN: Pragmatic, multicentre, parallel group, randomised controlled trialSETTING: Five English hospitals.PARTICIPANTS: 200 adults (66% (n=130) female), aged 18 to 75 years, who presented to the emergency department requiring intravenous opioid analgesia for the treatment of moderate to severe non-traumatic abdominal pain and were expected to be admitted to hospital for at least 12 hours.INTERVENTIONS: Patient controlled analgesia or nurse titrated analgesia (treatment as usual).MAIN OUTCOME MEASURES: The primary outcome was total pain experienced over the 12 hour study period, derived by standardised area under the curve (scaled from 0 to 100) of each participant's hourly pain scores, captured using a visual analogue scale. Pre-specified secondary outcomes included total morphine use, percentage of study period in moderate or severe pain, percentage of study period asleep, length of hospital stay, and satisfaction with pain management.RESULTS: 196 participants were included in the primary analyses (99 allocated to PCA and 97 to treatment as usual). Mean total pain experienced was 35.3 (SD 25.8) in the PCA group compared with 47.3 (24.7) in the treatment as usual group. The adjusted between group difference was 6.3 (95% confidence interval 0.7 to 11.9). Participants in the PCA group received significantly more morphine (mean 36.1 (SD 22.4) v 23.6 (13.1) mg; mean difference 12.3 (95% confidence interval 7.2 to 17.4) mg), spent less of the study period in moderate or severe pain (32.6% v 46.9%; mean difference 14.5% (5.6% to 23.5%)), and were more likely to be perfectly or very satisfied with the management of their pain (83% (73/88) v 66% (57/87); adjusted odds ratio 2.56 (1.25 to 5.23)) in comparison with participants in the treatment as usual group.CONCLUSIONS: Significant reductions in pain can be achieved by PCA compared with treatment as usual in patients presenting to the emergency department with non-traumatic abdominal pain. Trial registration European Clinical Trials Database EudraCT2011-000194-31; Current Controlled Trials ISRCTN25343280