Teams under pressure in the emergency department: an interview study

ABSTRACT Objective To identify key stressors for emergency department (ED) staff, investigate positive and negative behaviours associated with working under pressure and consider interventions that may improve how the ED team functions. Methods This was a qualitative study involving semistructured interviews. Data were collected from staff working in the ED of a London teaching hospital

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

Background: Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. Methods: We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124. Findings: Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). Interpretation: We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial

The Assessment of Registrars’ Non-technical Skills in the Emergency Department

In recent years safety in medicine has been high on the agenda, both for government and for healthcare providers. This thesis starts by describing the evolution of patient safety and then goes on to explore error specifically in the Emergency Department (ED). Focus is drawn to the role of non-technical skills for improving safety. The initial broad aim of this research was to learn how the ED team could function better to improve patient care. An interview study is developed to investigate how ED staff change their behaviour during periods of high demand and to determine the direction of future research. This study highlights that staff would benefit from increased awareness of the nontechnical skills that contribute to effective teamwork and enhanced patient safety. The interviews also reveal the leadership role of the registrar is of particular importance. Therefore, a series of studies are developed to identify and describe the non-technical skills required by Emergency Medicine trainees, with a specific focus on leadership. The process of developing a provisional assessment tool for assessing non-technical skills in the ED is described. This draws on published literature and curricula as well as considering existing methods of assessment. The assessment tool is revised using re-analysis of staff interviews and a series of preliminary observations in the ED. Content validity of the tool is measured using a survey of expert opinion and this helps to further refine the tool components. An experimental study reveals that whilst adequate levels of inter-rater reliability are achievable, rater accuracy appears to be more problematic. Various sources or rater error are also explored and this leads onto a larger, multicentre observational study investigating use of the tool in the workplace. Further data for reliability is collected and field notes are analysed to provide a detailed description of the non-technical skills displayed by ED registrars. Findings of the studies are summarised and limitations, applications and further research are discussed

The assessment of registrars' non-technical skills in the Emergency Department

In recent years safety in medicine has been high on the agenda, both for government and for healthcare providers. This thesis starts by describing the evolution of patient safety and then goes on to explore error specifically in the Emergency Department (ED). Focus is drawn to the role of non-technical skills for improving safety. The initial broad aim of this research was to learn how the ED team could function better to improve patient care. An interview study is developed to investigate how ED staff change their behaviour during periods of high demand and to determine the direction of future research. This study highlights that staff would benefit from increased awareness of the nontechnical skills that contribute to effective teamwork and enhanced patient safety. The interviews also reveal the leadership role of the registrar is of particular importance. Therefore, a series of studies are developed to identify and describe the non-technical skills required by Emergency Medicine trainees, with a specific focus on leadership. The process of developing a provisional assessment tool for assessing non-technical skills in the ED is described. This draws on published literature and curricula as well as considering existing methods of assessment. The assessment tool is revised using re-analysis of staff interviews and a series of preliminary observations in the ED. Content validity of the tool is measured using a survey of expert opinion and this helps to further refine the tool components. An experimental study reveals that whilst adequate levels of inter-rater reliability are achievable, rater accuracy appears to be more problematic. Various sources or rater error are also explored and this leads onto a larger, multicentre observational study investigating use of the tool in the workplace. Further data for reliability is collected and field notes are analysed to provide a detailed description of the non-technical skills displayed by ED registrars. Findings of the studies are summarised and limitations, applications and further research are discussed.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

BackgroundTranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding.MethodsWe did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124.FindingsBetween July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98).InterpretationWe found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial.</div