Impact of scribes on emergency medicine doctors' productivity and patient throughput: Multicentre randomised trial

Objectives To evaluate the changes in productivity when scribes were used by emergency physicians in emergency departments in Australia and assess the effect of scribes on throughput. Design Randomised, multicentre clinical trial. Setting Five emergency departments in Victoria used Australian trained scribes during their respective trial periods. Sites were broadly representative of Australian emergency departments: public (urban, tertiary, regional referral, paediatric) and private, not for profit. Participants 88 physicians who were permanent, salaried employees working more than one shift a week and were either emergency consultants or senior registrars in their final year of training; 12 scribes trained at one site and rotated to each study site. Interventions Physicians worked their routine shifts and were randomly allocated a scribe for the duration of their shift. Each site required a minimum of 100 scribed and non-scribed shifts, from November 2015 to January 2018. Main outcome measures Physicians’ productivity (total patients, primary patients); patient throughput (door-to-doctor time, length of stay); physicians’ productivity in emergency department regions. Self reported harms of scribes were analysed, and a cost-benefit analysis was done Results Data were collected from 589 scribed shifts (5098 patients) and 3296 non-scribed shifts (23838 patients). Scribes increased physicians’ productivity from 1.13 (95% confidence interval 1.11 to 1.17) to 1.31 (1.25 to 1.38) patients per hour per doctor, representing a 15.9% gain. Primary consultations increased from 0.83 (0.81 to 0.85) to 1.04 (0.98 to 1.11) patients per hour per doctor, representing a 25.6% gain. No change was seen in door-to-doctor time. Median length of stay reduced from 192 (interquartile range 108-311) minutes to 173 (96- 208) minutes, representing a 19 minute reduction (P<0.001). The greatest gains were achieved by placing scribes with senior doctors at triage, the least by using them in sub-acute/fast track regions. No significant harm involving scribes was reported. The cost-benefit analysis based on productivity and throughput gains showed a favourable financial position with use of scribes. Co nclusions Scribes improved emergency physicians’ productivity, particularly during primary consultations, and decreased patients’ length of stay. Further work should evaluate the role of the scribe in countries with health systems similar to Australia’s.The study was funded by Equity Trustees, the Phyllis Connor Memorial Fund, Cabrini Foundation, and Cabrini and supported by the Cabrini Institut

Adverse events associated with the use of intravenous epinephrine in emergency department patients presenting with severe asthma

Study objective: We determine the rate of adverse effects associated with the use of intravenous (IV) epinephrine by infusion for the treatment of severe asthma in the emergency department (ED). Methods: This retrospective, structured, medical record review included adult patients who presented to the ED of Western Hospital between 1998 and 2003 and who were triaged as category 1, 2, or 3, had a discharge diagnosis of asthma, and were administered IV epinephrine in the ED. Patients were excluded if they were older than 55 years or if a diagnosis of asthma was not confirmed. The primary outcome measures were occurrence of cardiac arrhythmia or ischemia, local tissue ischemia, hypotension or hypertension, neurologic injury, or death related to epinephrine infusion. Results: Two hundred twenty episodes of care met the inclusion criteria. Adverse events occurred in 67 episodes (30.5%; 95% confidence interval [CI] 24.5% to 37.1%); however, most were minor and self-limiting. There were no deaths. Major adverse events occurred in 3.6% of cases (8/220; 95% CI 1.7% to 7.3%), including 2 cases of supraventricular tachycardia, 1 case of chest pain with ECG changes, 1 case of incidental elevated troponin, and 4 cases of hypotension requiring intervention. Conclusion: IV epinephrine is associated with a low rate of major and a moderate rate of minor adverse events in patients with severe asthma; however, a causal relationship has not been established. Further research investigating effectiveness, as well as safety, is warranted

Differences in Coping Strategies and Help-Seeking Behaviours among Australian Junior and Senior Doctors during the COVID-19 Pandemic

Background: Throughout the COVID-19 pandemic, hospital medical staff (HMS) have faced significant personal, workplace, and financial disruption. Many have experienced psychosocial burden, exceeding already concerning baseline levels. This study examines the types and predictors of coping strategies and help-seeking behaviours utilised by Australian junior and senior HMS during the first year of the pandemic. Methods: A cross-sectional online survey of Australian frontline healthcare workers was conducted between 27 August and 23 October 2020. Data collected included demographics, personal and workplace disruptions, self-reported and validated mental health symptoms, coping strategies, and help-seeking. Results: The 9518 participants included 1966 hospital medical staff (62.1% senior, 37.9% junior). Both groups experienced a high burden of anxiety, depression, post-traumatic stress disorder, and burnout. Coping strategies varied by seniority, with maintaining exercise the most common strategy for both groups. Adverse mental health was associated with increased alcohol consumption. Engagement with professional support, although more frequent among junior staff, was uncommon in both groups. Conclusions: Junior and senior staff utilised different coping and help-seeking behaviours. Despite recognition of symptoms, very few HMS engaged formal support. The varied predictors of coping and help-seeking identified may inform targeted interventions to support these cohorts in current and future crises

Socioeconomic gradients in admission to coronary or intensive care units among Australians presenting with non-traumatic chest pain in emergency departments

Abstract Background Socioeconomic inequalities in cardiovascular morbidity have been previously reported showing direct associations between socioeconomic disadvantage and worse health outcomes. However, disagreement remains regarding the strength of the direct associations. The main objective of this panel design was to inspect socioeconomic gradients in admission to a coronary care unit (CCU) or an intensive care unit (ICU) among adult patients presenting with non-traumatic chest pain in three acute-care public hospitals in Victoria, Australia, during 2009–2013. Methods Consecutive adults aged 18 or over presenting with chest pain in three emergency departments (ED) in Victoria, Australia during the five-year study period were eligible to participate. A relative index of inequality of socioeconomic status (SES) was estimated based on residential postcode socioeconomic index for areas (SEIFA) disadvantage scores. Admission to specialised care units over repeated presentations was modelled using a multivariable Generalized Estimating Equations approach that accounted for various socio-demographic and clinical variables. Results Non-traumatic chest pain accounted for 10% of all presentations in the emergency departments (ED). A total of 53,177 individuals presented during the study period, with 22.5% presenting more than once. Of all patients, 17,579 (33.1%) were hospitalised over time, of whom 8584 (48.8%) were treated in a specialised care unit. Female sex was independently associated with fewer admissions to CCU / ICU, whereas, a dose-response effect of socioeconomic disadvantage and admission to CCU / ICU was found, with risk of admission increasing incrementally as SES declined. Patients coming from the lowest SES locations were 27% more likely to be admitted to these units compared with those coming from the least disadvantaged locations, p <  0.001. Men were significantly more likely to be admitted to such units than similarly affected and aged women among those diagnosed with angina pectoris, arrhythmia, myocardial infarction, heart failure, chest pain, and general signs and symptoms. Conclusions This study is the first to report socioeconomic gradients in admission to CCU / ICU in patients presenting with chest pain showing a dose-response effect. Our findings suggest increased cardiovascular morbidity as socioeconomic disadvantage increases

High levels of psychosocial distress among Australian frontline healthcare workers during the COVID-19 pandemic: a cross-sectional survey

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had a profound and prolonged impact on healthcare services and healthcare workers. AIMS: The Australian COVID-19 Frontline Healthcare Workers Study aimed to investigate the severity and prevalence of mental health issues, as well as the social, workplace and financial disruptions experienced by Australian healthcare workers during the COVID-19 pandemic. METHODS: A nationwide, voluntary, anonymous, single timepoint, online survey was conducted between 27 August and 23 October 2020. Individuals self-identifying as frontline healthcare workers in secondary or primary care were invited to participate. Participants were recruited through health organisations, professional associations or colleges, universities, government contacts and national media. Demographics, home and work situation, health and psychological well-being data were collected. RESULTS: A total of 9518 survey responses were received; of the 9518 participants, 7846 (82.4%) participants reported complete data. With regard to age, 4110 (52.4%) participants were younger than 40 years; 6344 (80.9%) participants were women. Participants were nurses (n=3088, 39.4%), doctors (n=2436, 31.1%), allied health staff (n=1314, 16.7%) or in other roles (n=523, 6.7%). In addition, 1250 (15.9%) participants worked in primary care. Objectively measured mental health symptoms were common: mild to severe anxiety (n=4694, 59.8%), moderate to severe burnout (n=5458, 70.9%) and mild to severe depression (n=4495, 57.3%). Participants were highly resilient (mean (SD)=3.2 (0.66)). Predictors for worse outcomes on all scales included female gender; younger age; pre-existing psychiatric condition; experiencing relationship problems; nursing, allied health or other roles; frontline area; being worried about being blamed by colleagues and working with patients with COVID-19. CONCLUSIONS: The COVID-19 pandemic is associated with significant mental health symptoms in frontline healthcare workers. Crisis preparedness together with policies and practices addressing psychological well-being are needed

Variation in CT use for paediatric head injuries across different types of emergency departments in Australia and New Zealand

Objectives: CT of the brain (CTB) for paediatric head injury is used less frequently at tertiary paediatric emergency departments (EDs) in Australia and New Zealand than in North America. In preparation for release of a national head injury guideline and given the high variation in CTB use found in North America, we aimed to assess variation in CTB use for paediatric head injury across hospitals types. Methods: Multicentre retrospective review of presentations to tertiary, urban/suburban and regional/rural EDs in Australia and New Zealand in 2016. Children age