ROYAL ACADEMY OF MEDICINE IN IRELAND IRISH JOURNAL OF MEDICAL SCIENCE
ANNUAL SCIENTIFIC MEETING (ASM) OF THE Irish Association for EMERGENCY MEDICINE (IAEM) Thursday 16th October - Saturday 18th October 2014
Royal Marine Hotel, Dun Laoghaire, Dublin
Irish Journal of Medical Science Volume 183 Supplement 10 DOI 10.1007/s11845-014-1203-3
123 123
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Ir J Med Sci (2014) 183 (Suppl 10):S473–S481
THANK YOU TO OUR ABSTRACT JUDGES
Abstract Judges: Dr. Niamh Collins, Connolly Hospital, Blanchardstown, Dublin. Professor Conor Deasy, Cork University Hospital. Dr. Peadar Gilligan, Beaumont Hospital, Dublin. Mr. Aidan Gleeson, Beaumont Hospital, Dublin. Mr. Fergal Hickey, Sligo Regional Hospital. Ms. Patricia Houlihan, Beaumont Hospital, Dublin. Dr. David Menzies, St. Vincent’s University Hospital, Dublin. Dr. Sinead O’Gorman, Letterkenny General Hospital, Co. Donegal. Professor Ronan O’Sullivan, Cork University Hospital. Dr. Damien Ryan, University Hospital Limerick. Professor John Ryan, St. Vincent’s University Hospital, Dublin. On behalf of the IAEM Academic & Research Committee, a special thanks to the abstract judges for taking the time to painstakingly review and score the 121 abstracts submitted to IAEM ASM 2014. Abel Wakai, MD, FCEM Chair IAEM Academic & Research Committee
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Ir J Med Sci (2014) 183 (Suppl 10):S473–S481
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Disclosure Statement The Annual Scientific Meeting (ASM) of the Irish Association for Emergency Medicine (IAEM) from the 16th to 18th October 2014 is funded with the support of commercial bodies. These bodies are: SP Services, Pharmed Limited, Oxygen Care, Astra Zeneca, LEO Laboratories Ltd, Grunenthal Pharma, Boehringer, Pre-Hospital Emergency Care Council, Alere Limited, Cardiac Services, Global Medics, Amdipharm, Fannin Healthcare, Eli Lilly and Company (Ireland) Ltd, Innovection, MDI Medical, Bayer, Safety Ireland, OLM, Archimedes.
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Ir J Med Sci (2014) 183 (Suppl 10):S473–S481 DOI 10.1007/s11845-014-1203-3
Listed below are the title, presenter name (underlined) and author(s) affiliation(s) for the top-10 ranked abstracts selected for presentation, from 121 abstract submissions, at the 2014 IAEM Annual Scientific Meeting. These abstracts are presented as they were received, with minimal proofreading and copyediting. Any questions related to the content of the abstracts should be directed to the authors Feasibility analysis of emergency department key performance indicators in Ireland: an interim analysis 2
3
4
Aileen McCabe, Gloria Crispino , Sinead Nally , Ronan O’Sullivan , Abel Wakai5 1
Emergency Care Research Unit (ECRU), Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland and National Children’s Research Centre, Our Lady’s Children’s Hospital, Crumlin, 2StatisticaMedica Ltd, Dublin, Ireland, 3National Children’s Research Centre (NCRC), Dublin, Ireland; 4Paediatric Emergency Research Unit (PERU), National Children’s Research Centre, Dublin, Ireland, 5Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland and Emergency Care Research Unit (ECRU), Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland Introduction: Despite its limitations, use of medical records as a source of data for quality of care indicators is common. The primary objective of this study was to measure the completeness (availability) of Emergency Department (ED) medical records as a source of minimum data set (MDS) elements for a feasibility analysis of 10 potential ED key performance indicators (KPIs) in Ireland. Methods: MDS elements relevant to 10 potential ED KPIs were studied in six EDs. Relevant MDS elements were independently abstracted by two investigators in each of the six participating EDs. Reproducibility of the data abstraction process was measured by using inter-observer and intra-observer agreement (kappa scores). Internal consistency of the MDS elements was measured by using Cronbach’s alpha. Mokken scaling was used to assess dimensionality. Uniformity of the MDS elements in the medical records was measured using Gini coefficient and described by Lorenz curves. Results: Overall 42,929 MDS elements relevant to the 10 KPIs were collected and analysed from 4,202 patient records in 6 EDs. The proportion of MDS elements available for each of the KPI examined ranged from 61 % to 85 %. Inter-observer kappa values ranged from 0.6 to 0.8. Intra-observer kappa values ranged from 0.8 to 0.9. Cronbach’s alpha showed unacceptable to poor internal consistency, ranging from 0.3 to 0.6. Gini coefficient ranged from 0.1 to 0.9. Mokken scaling formed moderate to strong multidimensional scales. Conclusion: Many MDS elements relevant to the KPIs examined are absent in current medical records. Documentation of the relevant MDS elements is poorly inter-related and the MDS elements are variably distributed in current medical records. The Mokken scaling illustrates that, in terms of documentation, not all of the MDS elements being examined correlate with each other. The findings of this study highlight the importance of performing a feasibility analysis before implementing KPIs for ED performance monitoring.
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Table: Availability of MDS elements/KPI for all EDs KPI
No. of EDs included in interim analysis
MDS elements per KPI
Totals (n/N)
%
KPI1
5
13
4160/6474
64.2
KPI 2
2
13
1770/2600
68.1
KPI 3 KPI 4
3 5
13 13
2678/3965 4552/6500
67.5 70
KPI 5
1
15
998/1500
66.5
KPI 6
5
12
4261/6500
65.6
KPI 7
3
12
2484/3600
69
KPI 8
6
7
2823/4200
67.2
KPI 9
6
11
5634/6600
85
KPI 10
6
10
3680/5990
61.4
Totals
6
33040/42929
68.9
Peripheral blood RNAs may differentiate bacterial from viral febrile illness in infants SM O’Donnell1,2,5, J Pollock1, P O’Connor3, P Baranov3, G Crispino-O’Connell1, S Walsh2, A Wakai4, RG O’Sullivan1,5 1 National Children’s Research Centre, Dublin; 2Our Lady’s Children’s Hospital, Crumlin; 3Dept. of Biochemistry, University College Cork (UCC); 4Emergency Care Research Unit (ECRU), Royal College of Surgeons in Ireland; 5School of Medicine, UCC
Introduction: Infants presenting to the Emergency Department (ED) with undifferentiated febrile illness pose a diagnostic and management challenge. Current strategies for diagnosing serious bacterial infection in this vulnerable population are suboptimal. RNAs (including microRNAs (miRNAs)) are involved in regulating multiple cell processes including those central to immune functioning, and RNA biosignatures potentially allow us to identify the aetiology of infection by observing the host response to different types of infection. We hypothesised that RNA, isolated from the blood of febrile infants, could potentially differentiate between febrile cases and non-febrile controls and within the cases, between bacterial and non-bacterial disease. Methods: We prospectively collected whole blood samples from 20 febrile infants, aged less than 1 year, and 5 matched controls for miRNA microarray analysis and messenger RNA (mRNA) whole genome sequencing. Study participants also had blood, urine, respiratory and stool microbiological and PCR samples collected to aid with specific organism identification. Results: Eight (40 %) of the febrile infants had a positive bacterial culture from sterile sites. Cluster analysis of microarray data revealed significant differences in expression of multiple miRNA transcripts between controls and cases (p \ 0.05) (Figure 1) and between bacterial and non-bacterial cases (p \ 0.01). Analysis of mRNA sequencing revealed marked similarity of gene expression profiles of both types of infected samples in comparison to controls. A number of genes exhibited large differences in expression depending on the infectious agents. Eighty genes had a greater than 4-fold change of RNA expression. Sixty of these allowed for separation of the majority of the samples based on their infectious agents.
Ir J Med Sci (2014) 183 (Suppl 10):S473–S481
Conclusion: Analysis of this discovery set using miRNA microarray data and mRNA sequence data shows potential in differentiating infected cases from controls and bacterial from non-bacterial cases. Figure 1: Heat map of miRNA expression between controls and cases; columns are individual controls or cases: Controls are the 5 columns from left to right, from PERU_UFI_C001 to PERU_UFI_C005, while cases are the 20 columns from right to left, from PERU_UFI_021 to PERU_UFI_001; rows are miRNA transcripts statistically significantly expressed (p \ 0.05) between controls and cases.
A Baseline Study of Procedural Sedation Practices in Paediatric Emergency Medicine: A Paediatric Emergency Research United Kingdom & Ireland (PERUKI) Network Study Siobha´n McCoy1, Mark D Lyttle2, Stuart Hartshorn3, Philip Larkin4, Maria Brenner5, Ronan O’Sullivan6 1 Department of Emergency Medicine, Cork University Hospital, Cork, Ireland, 2Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI), Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8BJ, England, 3Department of Emergency Medicine, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH, England, 4School of Nursing, Midwifery and Health Systems & Our Lady’s Hospice and Care Services, Health Sciences Centre, University College Dublin, Dublin 4, Ireland, 5School of Nursing, Midwifery and Health
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Systems, University College Dublin, Dublin 4, Ireland, 6Department of Emergency Medicine, Cork University Hospital, Cork, Ireland Introduction: There is an extensive literature on paediatric procedural sedation and its clinical applications in Emergency Departments (EDs). While numerous guidance and policy documents exist from international bodies such as the College of Emergency Medicine (CEM) and American College of Emergency Physicians (ACEP), there remains a lack of uniformity and consistency of sedation practices within EDs. Procedural sedation for paediatric patients in the UK and Ireland is now gaining traction and this study aimed to describe existing paediatric sedation practices and identify any barriers and enablers to ED-based paediatric procedural sedation. Methods: A qualitative approach was employed to capture data through a focus group interview. A total of 9 specialists in Emergency Medicine (EM) participated, varying in years of experience, clinical settings (mixed adult and paediatric ED or paediatric only) and geographical location (UK and Ireland). The focus group, conducted at the CEM annual meeting in London in 2013, was audio-recorded, transcribed verbatim and analysed using Attride-Stirling’s framework for thematic network analysis. Ethical approval was not required for this study. Results: The global theme ‘The Future of Paediatric Procedural Sedation (PPS) in Emergency Medicine–A UK and Ireland perspective’ emerged from three organising themes as follows: 1) training and education of ED staff; 2) current realities of PPS in EDs and 3) procedural sedation and the wider hospital community (see figure). The main findings were: there is a significant variability in ED sedation practice throughout the UK and Ireland; lack of formal training in PPS at a trainee level is a barrier to the implementation of
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sedation as a standard treatment; and the lack of recognition of procedural sedation at a college/training level as a specialised emergency medicine skill. Conclusion: Emergency Medicine must take ownership of PPS as a core competency through embedding procedural sedation training into general and paediatric EM training and EM-led research and audit of sedation practice.
Optimal oropharyngeal airway sizing using facial surface markings correlated with teeth to vallecula distance in the adult population Sarah-Jane Yeung1,2, Farrukh Suhail3, David John Cagney4, Patrick O’Kelly5, Gabriella Iohom6,7 1 Department of Emergency Medicine, Cork University Hospital, Cork, 2SHO, Department of Anaesthesia, Intensive Care and Pain Medicine, Cork University Hospital, Cork, 3Department of Anaesthesia, Intensive Care and Pain Medicine, Cork University Hospital, Cork, 4Department of Anaesthesia, Intensive Care and Pain Medicine, Cork University Hospital, Cork, 5Department of Nephrology Beaumont Hospital, Dublin, 6Department of Anaesthesia, Intensive Care and Pain Medicine, Cork University Hospital, Cork, 7University College Cork, Cork, Ireland
Ir J Med Sci (2014) 183 (Suppl 10):S473–S481
malocclusion or mandibular fracture were excluded. Measurements included corner of mouth to angle of jaw (CM-AJ), corner of mouth to base of tragus of ear (CM-TE), mid-incisor point to angle of jaw (MIP-AJ), mid-incisor point to base of tragus of ear (MIP-TE), incisor plane to angle of jaw (IP-AJ), incisor plane to base of tragus of ear (IP-TE), and teeth to vallecula distance (T-V). Gender, height and weight were recorded. Univariate ANOVA and multifactorial analysis were performed. P \ 0.05 was deemed significant. Results: Mean age was 41.8 years (SD 15.3) with 53 % male participants. One-way ANOVA models show all surface markings to be significantly associated with T-V. A strong confounding variable was gender: T-V was 11.4 cm (SD 0.7) for males versus 10.6 cm (SD 0.7) for females. Multi-variable ANOVA models demonstrate CM-TE and MIP-TE retaining significance in the presence of confounders. Conclusion: Distances corner of mouth to tragus of ear (CM-TE) and midincisor point to tragus of ear (MIP-TE) may be best suited to sizing an OPA.
Accuracy and Concordance of Emergency Department Nurses’ Acuity Ratings to Adult Emergency Department Patient Scenarios using the Manchester Triage System Caitriona McGarrell1, Kathleen Neenan2 1
Department of Emergency Medicine, St James Hospital, Dublin; Trinity College, Dublin
2
Introduction: The oropharyngeal airway (OPA) is utilised to maintain a patent airway in unresponsive patients. Sizing an OPA utilises patient’s facial surface markings.(1, 2) The objective was to determine optimal oropharyngeal airway sizing using facial surface markings correlated with teeth to vallecula distance in adults. Methods Methodology: Having obtained ethical committee approval and written informed consent from each, 100 patients aged over 18, scheduled to undergo general anaesthesia were enrolled in this prospective observational study. Edentulous patients, those with dental
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Introduction: The National Emergency Medicine Program (2012) recommends the use of the Manchester Triage System (MTS) in Emergency Departments (ED) in the Republic of Ireland. The fundamental characteristic of triage is when patients presenting to an ED with a specific issue, the patient should be assigned the same triage category each time irrespective of the time of day or the nurse in triage. Inaccurate triage assessment places the patients’ health at risk if assigned a triage category below their level of acuity and prioritises care unnecessarily if triaged above their acuity level.
Ir J Med Sci (2014) 183 (Suppl 10):S473–S481 Methods: A descriptive survey of nurses trained in MTS (n = 44) from two Irish urban ED’s was conducted. Using the Manchester Triage System, Nurses allocated an acuity rating to 20 ED adult patient scenarios. Descriptive and inferential statistics were used. Accuracy is defined as the ability of targeting the expected triage score, while concordance is defined as the agreement between the staff nurses’ rating. Ethical approval was obtained to conduct the study. Results: The accuracy of ED nurses acuity rating to adult ED scenarios using the MTS was 58 % (r = 0.32, p \ 0.001 un-weighted) which paired with a concordance rate of 65 % in relation to the expected triage score shows a significant disagreement between ED nurses. Accuracy peaked (67 %) in those who received training within [ 12-36 months. There was no statistical significance between length of nursing experience and accuracy in assigning acuity ratings. Conclusion: The accuracy and concordance of ED nurses application of acuity ratings to ED patient scenarios using the MTS shows higher levels of disagreement than previous research. Accuracy of 67 % was achieved by participants that received training in the MTS in the previous 12-36 months, which may suggest that update training sessions within this timeframe may improve ED nurses accuracy in the application of acuity ratings to scenarios.
Have new changes to prehospital practice addressed the barriers and difficulties that Irish Advanced Paramedics have identified to pain management? Ian Brennan National Ambulance Service, Ireland. Research undertaken during MSc Emergency Medical Sciences in University College Dublin, UCD Centre for Emergency Medical Science Introduction: Effective pain management must be at the forefront of any ambulance services priority. The author’s 2009 study identified difficulties and barriers that Irish Advanced Paramedics (APs) had to pain management. Since then newer medications and guidelines have been introduced. This review of the study will examine if the barriers and difficulties identified have been addressed. Methods: The barriers and difficulties were identified by a two part study. Part one was a survey to all APs (response rate 77 %) and part two was a clinical element that involved 145 patients. Seven key barriers and difficulties were identified. Recommendations from this study were reviewed against the new clinical practice guidelines and practises. Results:
Barriers and difficulties identified 2009
Changes made up to 2014
Morphine IV only for children
PO & IO morphine available Increase in IV morphine dose IN Fentanyl now available for children
Pain assessment for children Routes of administration of medication
Increase in pain assessment education given to APs Morphine now available in IV, IO, PO & IM IN Fentanyl now available to both adult and children
Access to medical oversight
S479 Table continued Barriers and difficul- Changes made up to 2014 ties identified 2009 Range of analgesics
Paracetamol (adult), ibuprofen (adult), and fentanyl (adult & child) have been introduced since 2008
Dose of morphine
Dose of morphine increased to 16 mg
Contraindications to morphine
Wording of contraindications changed
Conclusion: Many of the common barriers and difficulties to pain management identified by this 2009 study have been acted upon. Guidelines have changed, more pain education has been given, a greater range of analgesia is now available and medical oversight is available. More research is needed to find out if these changes are having an impact on current prehospital pain management.
Making Emergency Care semi-elective Emergency Care Maura Grummell, James Carroll, Joseph Bonham, Niamh O Gorman, Olive Buckley, Peadar Gilligan Department of Emergency Medicine, Beaumont Hospital, Beaumont Road, Dublin Introduction: Emergency Departments have done much work to align service provision with demand. Long waits out of hours are a particular issue for those with lower acuity injuries. An innovative solution used by the research hospital was to put in place an advanced nurse practioner (ANP) clinic to provide care the following morning for selected patients with minor injuries. Methods: Over a three year period from Jan 1st 2010 to Dec 31st 2013, patients with minor injuries were seen at triage. Suitable patients were then offered the opportunity of going home and a fixed appointment time at the ANP Clinic for the following morning. The data was collected retrospectively from a chart reveiw of patients age/sex/day/time of presentation and final diagnosis. Data was merged onto an excel spread sheet and analysed. Results: 1922 were deemed suitable for reveiw in the ANP Clinic. 101 patients were excluded due to insufficent data. Of the 1821 remaining there was an equal male to female distribution. The patients ranged in age from 1 to 93, with an average age 33 years. Patients most commonly presented between the hours of 20:00 to 00:00. Soft tissue injuries at 71 % were the most common condition seen, followed by Lacerations at 14 % and Fractures at 11 %. Of those whom were offered and agreed to an ANP Clinic appointment, 91 % attended. Conclusion: This prospective study revealed that for selected patients presenting to the emergency department out of hours and following initial first aid being offered the option of going home and returning the following day for an ANP clinic is a safe and acceptable way to deliver emergency care on a semi elective basis and provides a welcome alternative to prolonged waits.
24-hour access to medical oversight now available
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For a patient requiring psychiatric admission do routine mandatory screening studies in the ED affect morbidity and mortality? Tom Mc Mahon, Nigel Salter Department of Emergency Medicine, St. Vincent’ University Hospital, Elm Park, Dublin 4. Introduction: Amongst the many challenges in the acute assessment and management of psychiatric patients in the ED is the issue of the potential need to screen such patients for acute medical illnesses. Controversy exists regarding the need for such comprehensive ‘‘medical clearance’’ in the ED. Such screening is associated with longer delays for patients, more HCP time, and a higher cost with limited yield. A limited research base of varying quality has lead to a haphazard approach to such medical assessment with wide variation in practice observed across and within institutions. Arguments advocating for such screening strategies point to patient safety, with rates of medical illness being identified in some studies in as high as 63 % of patients. The aim of this study was to establish whether or not the use of routine mandatory screening studies in the ED affects morbidity and mortality in patients requiring psychiatric admission. Methods: A literature search was conducted using the search strategy: Medline 1966-12/98 using the OVID interface. ((Emergency) AND Psychiatric patients) AND Medical Clearance LIMIT to human AND english language. The identified papers were then manually reviewed for relevance and quality. Results: 32 papers were identified of which 21 were considered irrelevant or of insufficient quality for inclusion. Of the 11 relevant studies, 8 were retrospective and based on observational chart reviews. Of the three prospective studies, all were observational opportunistic studies. There were no observational cohort studies. None of the studies looked at mortality as primary outcome measure; no study reported any deaths during their study period. Both retrospective and prospective data show a general trend of there being no difference in morbidity or disposition with the use of routine medical screening tests. Four of the studies looked at patients who were cleared medically through clinical gestault alone by the Emergency Medicine Physician; these studies showed no benefit to further lab screening in those medically cleared patients. Conclusion: The routine use of mandatory screening studies for psychiatric patients with a normal medical history or examination in the ED does not affect morbidity, mortality or subsequent clinical disposition.
Ir J Med Sci (2014) 183 (Suppl 10):S473–S481 further data acquisition is required to meet international standards for an injury database. Methods: The clinical notes of patients presenting to the ED with an injury within a 7-day period were mined using Symphony ED information system. A modified version of the Bi-National Trauma Minimum Dataset for Australia and New Zealand was used to record injury type, mechanism, intent, location and activity when injured, the role of alcohol/drugs, protective devices used, referrals and discharge status. Data capture and analysis were performed via Microsoft Excel. Results: Within the study period, 145 patients presented with an injury (55 % male, median age 34). Ankle sprains were statistically most common (p = 0.0001). Sprains were more likely to arise during Sport and Exercise (p = 0.030). 40.7 % of injures were due to falls and 44 % of falls occurred at home. 13.8 % of injuries were associated with a motor vehicle collision and 90 % of those injured as a result were male. The activity when injured was not specified in the clinical notes in 28.3 % and location was not specified in 11.0 %. Conclusion: Injury accounted for 21.2 % of ED attendances in the study period. Since there are 1.2 million annual ED attendances nationally, this could be extrapolated to over a quarter of a million injury attendances to Irish EDs annually. In order for injury surveillance to be feasible, a minimum dataset must be defined and this data needs to be documented and analysed. This study shows that further information on activity and location is required.
Blood Flow Mc Ardle S.1, Gaffney P.2, Boran G.3, Condell S.4, Moran M.5, Tierney C.1, Rochford M.1 1
Department of Emergency Medicine, Adelaide & Meath Hospital (AMNCH), Tallaght, 2Biochemistry Department, AMNCH, Tallaght, 3 Diagnostic department, AMNCH, Tallaght, 4Nursing & Midwifery Research Deparment, AMNCH, Tallaght, 5Information Technology Dept, AMNCH, Tallaght.
Introduction: Studies have shown that one third of tests ordered in the acute hospital setting are inappropriate for contribution to patient diagnosis and treatment1. Despite this, up to two-thirds of Emergency Department (ED) patients undergo phlebotomy as part of their workup2. We undertook a quality improvement project to reduce inappropriate testing and improve efficiency in requesting blood samples. Methods: •
•
Is Injury Surveillance in Irish Emergency Departments Feasible? Juliet Veens1, Niamh Collins2 Royal College of Surgeons in Ireland, 2 Department of Emergency Medicine, Connolly Hospital, Blanchardstown
1
Introduction: There has never been a national injury database in Ireland, thereby limiting the capacity for strategic injury prevention. A feasibility study was undertaken in the Emergency Department (ED) of a University teaching hospital to determine if current documentation is adequate for reliable injury surveillance or whether
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•
We introduced ‘‘Lab profiles’’ for the top 12 diagnoses attending ED, which recommend specific blood tests for each presenting complaint. We implemented a generic ED log-on for the OSC Key Computer System. Only tests relevant to ED practice are now available to order. We constucted process maps to identify obstacles in achieving efficient transit of bloods to the labratory.
Results: With the exception of Troponin (which increased by 11 %), there was a reduction in all biochemistry tests requested: Renal profile (1 %), C- reactive protein (11 %), Amylase (19 %), Bone profile (49 %), Glucose (98 %) and a 50 % reduction in Coagulation testing. An estimated saving of €100,000 has been made to date by these changes. To tackle transit times, ED was upgraded to a priority on the pneumatic tube system (PTS) used to transport samples to the laboratory. 24 additional ED pods were obtained and launched into circulation. Initially there was a marked improvement in transit times, with those samples taking greater than 20 min to reach the laboratory having
Ir J Med Sci (2014) 183 (Suppl 10):S473–S481
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been reduced from 60 % to approximately 25 %- 30 % but this unfortunately has not been sustainable due to hoarding of pods by different departments (Figure 1).
Conclusion: Focused guidance and education on phlebotomy requests can reduce inappropriate orders and is a cost effective method of reducing ED expenditure without compromising patient care.
100%
% > 20 mins from OCS to Lab 90% % > 20mins
Monitoring Started
80%
Target > 20mins Median
Additional canisters put into circulation
70%
60%
Priority on PTS given to ED New canisters labelled for Adult ED
50%
40%
30% PTS line 1 down twice this week
20%
10%
08 to
11
08
14
14 07 28
14
14 17
03
07
to
20 to 14
07 14
08
14
14 07
14 to
30
06
14
to 16 06 16
06
06
15
22
06
14 08 to 14 06 02
05
14
to
25
05
14
14
05
14 19
05 05
21
04
14
to
to
11
27
13 to
07
04
14
to 14 03
04
14
14
04
03
14 30
03
14 24
03
14
to
16
03
14 10
24
02
14
to
02
02
14 16
02 10
02
14
to
02 to
14 01 27
14 01 13
30
12
13
to
to
19
05
01
01
14
14
0%
Graph 1: Blood samples Taking >20 minutes to reach Lab; January 2014 to present
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ANNUAL SCIENTIFIC MEETING (ASM) OF THE Irish Association for EMERGENCY MEDICINE (IAEM) Thursday 16th October - Saturday 18th October 2014
Royal Marine Hotel, Dun Laoghaire, Dublin
Irish Journal of Medical Science Volume 183 Supplement 10 DOI 10.1007/s11845-014-1203-3
123 123
S474
Ir J Med Sci (2014) 183 (Suppl 10):S473–S481
THANK YOU TO OUR ABSTRACT JUDGES
Abstract Judges: Dr. Niamh Collins, Connolly Hospital, Blanchardstown, Dublin. Professor Conor Deasy, Cork University Hospital. Dr. Peadar Gilligan, Beaumont Hospital, Dublin. Mr. Aidan Gleeson, Beaumont Hospital, Dublin. Mr. Fergal Hickey, Sligo Regional Hospital. Ms. Patricia Houlihan, Beaumont Hospital, Dublin. Dr. David Menzies, St. Vincent’s University Hospital, Dublin. Dr. Sinead O’Gorman, Letterkenny General Hospital, Co. Donegal. Professor Ronan O’Sullivan, Cork University Hospital. Dr. Damien Ryan, University Hospital Limerick. Professor John Ryan, St. Vincent’s University Hospital, Dublin. On behalf of the IAEM Academic & Research Committee, a special thanks to the abstract judges for taking the time to painstakingly review and score the 121 abstracts submitted to IAEM ASM 2014. Abel Wakai, MD, FCEM Chair IAEM Academic & Research Committee
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Ir J Med Sci (2014) 183 (Suppl 10):S473–S481
S475
Disclosure Statement The Annual Scientific Meeting (ASM) of the Irish Association for Emergency Medicine (IAEM) from the 16th to 18th October 2014 is funded with the support of commercial bodies. These bodies are: SP Services, Pharmed Limited, Oxygen Care, Astra Zeneca, LEO Laboratories Ltd, Grunenthal Pharma, Boehringer, Pre-Hospital Emergency Care Council, Alere Limited, Cardiac Services, Global Medics, Amdipharm, Fannin Healthcare, Eli Lilly and Company (Ireland) Ltd, Innovection, MDI Medical, Bayer, Safety Ireland, OLM, Archimedes.
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Ir J Med Sci (2014) 183 (Suppl 10):S473–S481 DOI 10.1007/s11845-014-1203-3
Listed below are the title, presenter name (underlined) and author(s) affiliation(s) for the top-10 ranked abstracts selected for presentation, from 121 abstract submissions, at the 2014 IAEM Annual Scientific Meeting. These abstracts are presented as they were received, with minimal proofreading and copyediting. Any questions related to the content of the abstracts should be directed to the authors Feasibility analysis of emergency department key performance indicators in Ireland: an interim analysis 2
3
4
Aileen McCabe, Gloria Crispino , Sinead Nally , Ronan O’Sullivan , Abel Wakai5 1
Emergency Care Research Unit (ECRU), Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland and National Children’s Research Centre, Our Lady’s Children’s Hospital, Crumlin, 2StatisticaMedica Ltd, Dublin, Ireland, 3National Children’s Research Centre (NCRC), Dublin, Ireland; 4Paediatric Emergency Research Unit (PERU), National Children’s Research Centre, Dublin, Ireland, 5Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland and Emergency Care Research Unit (ECRU), Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland Introduction: Despite its limitations, use of medical records as a source of data for quality of care indicators is common. The primary objective of this study was to measure the completeness (availability) of Emergency Department (ED) medical records as a source of minimum data set (MDS) elements for a feasibility analysis of 10 potential ED key performance indicators (KPIs) in Ireland. Methods: MDS elements relevant to 10 potential ED KPIs were studied in six EDs. Relevant MDS elements were independently abstracted by two investigators in each of the six participating EDs. Reproducibility of the data abstraction process was measured by using inter-observer and intra-observer agreement (kappa scores). Internal consistency of the MDS elements was measured by using Cronbach’s alpha. Mokken scaling was used to assess dimensionality. Uniformity of the MDS elements in the medical records was measured using Gini coefficient and described by Lorenz curves. Results: Overall 42,929 MDS elements relevant to the 10 KPIs were collected and analysed from 4,202 patient records in 6 EDs. The proportion of MDS elements available for each of the KPI examined ranged from 61 % to 85 %. Inter-observer kappa values ranged from 0.6 to 0.8. Intra-observer kappa values ranged from 0.8 to 0.9. Cronbach’s alpha showed unacceptable to poor internal consistency, ranging from 0.3 to 0.6. Gini coefficient ranged from 0.1 to 0.9. Mokken scaling formed moderate to strong multidimensional scales. Conclusion: Many MDS elements relevant to the KPIs examined are absent in current medical records. Documentation of the relevant MDS elements is poorly inter-related and the MDS elements are variably distributed in current medical records. The Mokken scaling illustrates that, in terms of documentation, not all of the MDS elements being examined correlate with each other. The findings of this study highlight the importance of performing a feasibility analysis before implementing KPIs for ED performance monitoring.
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Table: Availability of MDS elements/KPI for all EDs KPI
No. of EDs included in interim analysis
MDS elements per KPI
Totals (n/N)
%
KPI1
5
13
4160/6474
64.2
KPI 2
2
13
1770/2600
68.1
KPI 3 KPI 4
3 5
13 13
2678/3965 4552/6500
67.5 70
KPI 5
1
15
998/1500
66.5
KPI 6
5
12
4261/6500
65.6
KPI 7
3
12
2484/3600
69
KPI 8
6
7
2823/4200
67.2
KPI 9
6
11
5634/6600
85
KPI 10
6
10
3680/5990
61.4
Totals
6
33040/42929
68.9
Peripheral blood RNAs may differentiate bacterial from viral febrile illness in infants SM O’Donnell1,2,5, J Pollock1, P O’Connor3, P Baranov3, G Crispino-O’Connell1, S Walsh2, A Wakai4, RG O’Sullivan1,5 1 National Children’s Research Centre, Dublin; 2Our Lady’s Children’s Hospital, Crumlin; 3Dept. of Biochemistry, University College Cork (UCC); 4Emergency Care Research Unit (ECRU), Royal College of Surgeons in Ireland; 5School of Medicine, UCC
Introduction: Infants presenting to the Emergency Department (ED) with undifferentiated febrile illness pose a diagnostic and management challenge. Current strategies for diagnosing serious bacterial infection in this vulnerable population are suboptimal. RNAs (including microRNAs (miRNAs)) are involved in regulating multiple cell processes including those central to immune functioning, and RNA biosignatures potentially allow us to identify the aetiology of infection by observing the host response to different types of infection. We hypothesised that RNA, isolated from the blood of febrile infants, could potentially differentiate between febrile cases and non-febrile controls and within the cases, between bacterial and non-bacterial disease. Methods: We prospectively collected whole blood samples from 20 febrile infants, aged less than 1 year, and 5 matched controls for miRNA microarray analysis and messenger RNA (mRNA) whole genome sequencing. Study participants also had blood, urine, respiratory and stool microbiological and PCR samples collected to aid with specific organism identification. Results: Eight (40 %) of the febrile infants had a positive bacterial culture from sterile sites. Cluster analysis of microarray data revealed significant differences in expression of multiple miRNA transcripts between controls and cases (p \ 0.05) (Figure 1) and between bacterial and non-bacterial cases (p \ 0.01). Analysis of mRNA sequencing revealed marked similarity of gene expression profiles of both types of infected samples in comparison to controls. A number of genes exhibited large differences in expression depending on the infectious agents. Eighty genes had a greater than 4-fold change of RNA expression. Sixty of these allowed for separation of the majority of the samples based on their infectious agents.
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Conclusion: Analysis of this discovery set using miRNA microarray data and mRNA sequence data shows potential in differentiating infected cases from controls and bacterial from non-bacterial cases. Figure 1: Heat map of miRNA expression between controls and cases; columns are individual controls or cases: Controls are the 5 columns from left to right, from PERU_UFI_C001 to PERU_UFI_C005, while cases are the 20 columns from right to left, from PERU_UFI_021 to PERU_UFI_001; rows are miRNA transcripts statistically significantly expressed (p \ 0.05) between controls and cases.
A Baseline Study of Procedural Sedation Practices in Paediatric Emergency Medicine: A Paediatric Emergency Research United Kingdom & Ireland (PERUKI) Network Study Siobha´n McCoy1, Mark D Lyttle2, Stuart Hartshorn3, Philip Larkin4, Maria Brenner5, Ronan O’Sullivan6 1 Department of Emergency Medicine, Cork University Hospital, Cork, Ireland, 2Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI), Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8BJ, England, 3Department of Emergency Medicine, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH, England, 4School of Nursing, Midwifery and Health Systems & Our Lady’s Hospice and Care Services, Health Sciences Centre, University College Dublin, Dublin 4, Ireland, 5School of Nursing, Midwifery and Health
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Systems, University College Dublin, Dublin 4, Ireland, 6Department of Emergency Medicine, Cork University Hospital, Cork, Ireland Introduction: There is an extensive literature on paediatric procedural sedation and its clinical applications in Emergency Departments (EDs). While numerous guidance and policy documents exist from international bodies such as the College of Emergency Medicine (CEM) and American College of Emergency Physicians (ACEP), there remains a lack of uniformity and consistency of sedation practices within EDs. Procedural sedation for paediatric patients in the UK and Ireland is now gaining traction and this study aimed to describe existing paediatric sedation practices and identify any barriers and enablers to ED-based paediatric procedural sedation. Methods: A qualitative approach was employed to capture data through a focus group interview. A total of 9 specialists in Emergency Medicine (EM) participated, varying in years of experience, clinical settings (mixed adult and paediatric ED or paediatric only) and geographical location (UK and Ireland). The focus group, conducted at the CEM annual meeting in London in 2013, was audio-recorded, transcribed verbatim and analysed using Attride-Stirling’s framework for thematic network analysis. Ethical approval was not required for this study. Results: The global theme ‘The Future of Paediatric Procedural Sedation (PPS) in Emergency Medicine–A UK and Ireland perspective’ emerged from three organising themes as follows: 1) training and education of ED staff; 2) current realities of PPS in EDs and 3) procedural sedation and the wider hospital community (see figure). The main findings were: there is a significant variability in ED sedation practice throughout the UK and Ireland; lack of formal training in PPS at a trainee level is a barrier to the implementation of
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sedation as a standard treatment; and the lack of recognition of procedural sedation at a college/training level as a specialised emergency medicine skill. Conclusion: Emergency Medicine must take ownership of PPS as a core competency through embedding procedural sedation training into general and paediatric EM training and EM-led research and audit of sedation practice.
Optimal oropharyngeal airway sizing using facial surface markings correlated with teeth to vallecula distance in the adult population Sarah-Jane Yeung1,2, Farrukh Suhail3, David John Cagney4, Patrick O’Kelly5, Gabriella Iohom6,7 1 Department of Emergency Medicine, Cork University Hospital, Cork, 2SHO, Department of Anaesthesia, Intensive Care and Pain Medicine, Cork University Hospital, Cork, 3Department of Anaesthesia, Intensive Care and Pain Medicine, Cork University Hospital, Cork, 4Department of Anaesthesia, Intensive Care and Pain Medicine, Cork University Hospital, Cork, 5Department of Nephrology Beaumont Hospital, Dublin, 6Department of Anaesthesia, Intensive Care and Pain Medicine, Cork University Hospital, Cork, 7University College Cork, Cork, Ireland
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malocclusion or mandibular fracture were excluded. Measurements included corner of mouth to angle of jaw (CM-AJ), corner of mouth to base of tragus of ear (CM-TE), mid-incisor point to angle of jaw (MIP-AJ), mid-incisor point to base of tragus of ear (MIP-TE), incisor plane to angle of jaw (IP-AJ), incisor plane to base of tragus of ear (IP-TE), and teeth to vallecula distance (T-V). Gender, height and weight were recorded. Univariate ANOVA and multifactorial analysis were performed. P \ 0.05 was deemed significant. Results: Mean age was 41.8 years (SD 15.3) with 53 % male participants. One-way ANOVA models show all surface markings to be significantly associated with T-V. A strong confounding variable was gender: T-V was 11.4 cm (SD 0.7) for males versus 10.6 cm (SD 0.7) for females. Multi-variable ANOVA models demonstrate CM-TE and MIP-TE retaining significance in the presence of confounders. Conclusion: Distances corner of mouth to tragus of ear (CM-TE) and midincisor point to tragus of ear (MIP-TE) may be best suited to sizing an OPA.
Accuracy and Concordance of Emergency Department Nurses’ Acuity Ratings to Adult Emergency Department Patient Scenarios using the Manchester Triage System Caitriona McGarrell1, Kathleen Neenan2 1
Department of Emergency Medicine, St James Hospital, Dublin; Trinity College, Dublin
2
Introduction: The oropharyngeal airway (OPA) is utilised to maintain a patent airway in unresponsive patients. Sizing an OPA utilises patient’s facial surface markings.(1, 2) The objective was to determine optimal oropharyngeal airway sizing using facial surface markings correlated with teeth to vallecula distance in adults. Methods Methodology: Having obtained ethical committee approval and written informed consent from each, 100 patients aged over 18, scheduled to undergo general anaesthesia were enrolled in this prospective observational study. Edentulous patients, those with dental
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Introduction: The National Emergency Medicine Program (2012) recommends the use of the Manchester Triage System (MTS) in Emergency Departments (ED) in the Republic of Ireland. The fundamental characteristic of triage is when patients presenting to an ED with a specific issue, the patient should be assigned the same triage category each time irrespective of the time of day or the nurse in triage. Inaccurate triage assessment places the patients’ health at risk if assigned a triage category below their level of acuity and prioritises care unnecessarily if triaged above their acuity level.
Ir J Med Sci (2014) 183 (Suppl 10):S473–S481 Methods: A descriptive survey of nurses trained in MTS (n = 44) from two Irish urban ED’s was conducted. Using the Manchester Triage System, Nurses allocated an acuity rating to 20 ED adult patient scenarios. Descriptive and inferential statistics were used. Accuracy is defined as the ability of targeting the expected triage score, while concordance is defined as the agreement between the staff nurses’ rating. Ethical approval was obtained to conduct the study. Results: The accuracy of ED nurses acuity rating to adult ED scenarios using the MTS was 58 % (r = 0.32, p \ 0.001 un-weighted) which paired with a concordance rate of 65 % in relation to the expected triage score shows a significant disagreement between ED nurses. Accuracy peaked (67 %) in those who received training within [ 12-36 months. There was no statistical significance between length of nursing experience and accuracy in assigning acuity ratings. Conclusion: The accuracy and concordance of ED nurses application of acuity ratings to ED patient scenarios using the MTS shows higher levels of disagreement than previous research. Accuracy of 67 % was achieved by participants that received training in the MTS in the previous 12-36 months, which may suggest that update training sessions within this timeframe may improve ED nurses accuracy in the application of acuity ratings to scenarios.
Have new changes to prehospital practice addressed the barriers and difficulties that Irish Advanced Paramedics have identified to pain management? Ian Brennan National Ambulance Service, Ireland. Research undertaken during MSc Emergency Medical Sciences in University College Dublin, UCD Centre for Emergency Medical Science Introduction: Effective pain management must be at the forefront of any ambulance services priority. The author’s 2009 study identified difficulties and barriers that Irish Advanced Paramedics (APs) had to pain management. Since then newer medications and guidelines have been introduced. This review of the study will examine if the barriers and difficulties identified have been addressed. Methods: The barriers and difficulties were identified by a two part study. Part one was a survey to all APs (response rate 77 %) and part two was a clinical element that involved 145 patients. Seven key barriers and difficulties were identified. Recommendations from this study were reviewed against the new clinical practice guidelines and practises. Results:
Barriers and difficulties identified 2009
Changes made up to 2014
Morphine IV only for children
PO & IO morphine available Increase in IV morphine dose IN Fentanyl now available for children
Pain assessment for children Routes of administration of medication
Increase in pain assessment education given to APs Morphine now available in IV, IO, PO & IM IN Fentanyl now available to both adult and children
Access to medical oversight
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Paracetamol (adult), ibuprofen (adult), and fentanyl (adult & child) have been introduced since 2008
Dose of morphine
Dose of morphine increased to 16 mg
Contraindications to morphine
Wording of contraindications changed
Conclusion: Many of the common barriers and difficulties to pain management identified by this 2009 study have been acted upon. Guidelines have changed, more pain education has been given, a greater range of analgesia is now available and medical oversight is available. More research is needed to find out if these changes are having an impact on current prehospital pain management.
Making Emergency Care semi-elective Emergency Care Maura Grummell, James Carroll, Joseph Bonham, Niamh O Gorman, Olive Buckley, Peadar Gilligan Department of Emergency Medicine, Beaumont Hospital, Beaumont Road, Dublin Introduction: Emergency Departments have done much work to align service provision with demand. Long waits out of hours are a particular issue for those with lower acuity injuries. An innovative solution used by the research hospital was to put in place an advanced nurse practioner (ANP) clinic to provide care the following morning for selected patients with minor injuries. Methods: Over a three year period from Jan 1st 2010 to Dec 31st 2013, patients with minor injuries were seen at triage. Suitable patients were then offered the opportunity of going home and a fixed appointment time at the ANP Clinic for the following morning. The data was collected retrospectively from a chart reveiw of patients age/sex/day/time of presentation and final diagnosis. Data was merged onto an excel spread sheet and analysed. Results: 1922 were deemed suitable for reveiw in the ANP Clinic. 101 patients were excluded due to insufficent data. Of the 1821 remaining there was an equal male to female distribution. The patients ranged in age from 1 to 93, with an average age 33 years. Patients most commonly presented between the hours of 20:00 to 00:00. Soft tissue injuries at 71 % were the most common condition seen, followed by Lacerations at 14 % and Fractures at 11 %. Of those whom were offered and agreed to an ANP Clinic appointment, 91 % attended. Conclusion: This prospective study revealed that for selected patients presenting to the emergency department out of hours and following initial first aid being offered the option of going home and returning the following day for an ANP clinic is a safe and acceptable way to deliver emergency care on a semi elective basis and provides a welcome alternative to prolonged waits.
24-hour access to medical oversight now available
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For a patient requiring psychiatric admission do routine mandatory screening studies in the ED affect morbidity and mortality? Tom Mc Mahon, Nigel Salter Department of Emergency Medicine, St. Vincent’ University Hospital, Elm Park, Dublin 4. Introduction: Amongst the many challenges in the acute assessment and management of psychiatric patients in the ED is the issue of the potential need to screen such patients for acute medical illnesses. Controversy exists regarding the need for such comprehensive ‘‘medical clearance’’ in the ED. Such screening is associated with longer delays for patients, more HCP time, and a higher cost with limited yield. A limited research base of varying quality has lead to a haphazard approach to such medical assessment with wide variation in practice observed across and within institutions. Arguments advocating for such screening strategies point to patient safety, with rates of medical illness being identified in some studies in as high as 63 % of patients. The aim of this study was to establish whether or not the use of routine mandatory screening studies in the ED affects morbidity and mortality in patients requiring psychiatric admission. Methods: A literature search was conducted using the search strategy: Medline 1966-12/98 using the OVID interface. ((Emergency) AND Psychiatric patients) AND Medical Clearance LIMIT to human AND english language. The identified papers were then manually reviewed for relevance and quality. Results: 32 papers were identified of which 21 were considered irrelevant or of insufficient quality for inclusion. Of the 11 relevant studies, 8 were retrospective and based on observational chart reviews. Of the three prospective studies, all were observational opportunistic studies. There were no observational cohort studies. None of the studies looked at mortality as primary outcome measure; no study reported any deaths during their study period. Both retrospective and prospective data show a general trend of there being no difference in morbidity or disposition with the use of routine medical screening tests. Four of the studies looked at patients who were cleared medically through clinical gestault alone by the Emergency Medicine Physician; these studies showed no benefit to further lab screening in those medically cleared patients. Conclusion: The routine use of mandatory screening studies for psychiatric patients with a normal medical history or examination in the ED does not affect morbidity, mortality or subsequent clinical disposition.
Ir J Med Sci (2014) 183 (Suppl 10):S473–S481 further data acquisition is required to meet international standards for an injury database. Methods: The clinical notes of patients presenting to the ED with an injury within a 7-day period were mined using Symphony ED information system. A modified version of the Bi-National Trauma Minimum Dataset for Australia and New Zealand was used to record injury type, mechanism, intent, location and activity when injured, the role of alcohol/drugs, protective devices used, referrals and discharge status. Data capture and analysis were performed via Microsoft Excel. Results: Within the study period, 145 patients presented with an injury (55 % male, median age 34). Ankle sprains were statistically most common (p = 0.0001). Sprains were more likely to arise during Sport and Exercise (p = 0.030). 40.7 % of injures were due to falls and 44 % of falls occurred at home. 13.8 % of injuries were associated with a motor vehicle collision and 90 % of those injured as a result were male. The activity when injured was not specified in the clinical notes in 28.3 % and location was not specified in 11.0 %. Conclusion: Injury accounted for 21.2 % of ED attendances in the study period. Since there are 1.2 million annual ED attendances nationally, this could be extrapolated to over a quarter of a million injury attendances to Irish EDs annually. In order for injury surveillance to be feasible, a minimum dataset must be defined and this data needs to be documented and analysed. This study shows that further information on activity and location is required.
Blood Flow Mc Ardle S.1, Gaffney P.2, Boran G.3, Condell S.4, Moran M.5, Tierney C.1, Rochford M.1 1
Department of Emergency Medicine, Adelaide & Meath Hospital (AMNCH), Tallaght, 2Biochemistry Department, AMNCH, Tallaght, 3 Diagnostic department, AMNCH, Tallaght, 4Nursing & Midwifery Research Deparment, AMNCH, Tallaght, 5Information Technology Dept, AMNCH, Tallaght.
Introduction: Studies have shown that one third of tests ordered in the acute hospital setting are inappropriate for contribution to patient diagnosis and treatment1. Despite this, up to two-thirds of Emergency Department (ED) patients undergo phlebotomy as part of their workup2. We undertook a quality improvement project to reduce inappropriate testing and improve efficiency in requesting blood samples. Methods: •
•
Is Injury Surveillance in Irish Emergency Departments Feasible? Juliet Veens1, Niamh Collins2 Royal College of Surgeons in Ireland, 2 Department of Emergency Medicine, Connolly Hospital, Blanchardstown
1
Introduction: There has never been a national injury database in Ireland, thereby limiting the capacity for strategic injury prevention. A feasibility study was undertaken in the Emergency Department (ED) of a University teaching hospital to determine if current documentation is adequate for reliable injury surveillance or whether
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•
We introduced ‘‘Lab profiles’’ for the top 12 diagnoses attending ED, which recommend specific blood tests for each presenting complaint. We implemented a generic ED log-on for the OSC Key Computer System. Only tests relevant to ED practice are now available to order. We constucted process maps to identify obstacles in achieving efficient transit of bloods to the labratory.
Results: With the exception of Troponin (which increased by 11 %), there was a reduction in all biochemistry tests requested: Renal profile (1 %), C- reactive protein (11 %), Amylase (19 %), Bone profile (49 %), Glucose (98 %) and a 50 % reduction in Coagulation testing. An estimated saving of €100,000 has been made to date by these changes. To tackle transit times, ED was upgraded to a priority on the pneumatic tube system (PTS) used to transport samples to the laboratory. 24 additional ED pods were obtained and launched into circulation. Initially there was a marked improvement in transit times, with those samples taking greater than 20 min to reach the laboratory having
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been reduced from 60 % to approximately 25 %- 30 % but this unfortunately has not been sustainable due to hoarding of pods by different departments (Figure 1).
Conclusion: Focused guidance and education on phlebotomy requests can reduce inappropriate orders and is a cost effective method of reducing ED expenditure without compromising patient care.
100%
% > 20 mins from OCS to Lab 90% % > 20mins
Monitoring Started
80%
Target > 20mins Median
Additional canisters put into circulation
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Priority on PTS given to ED New canisters labelled for Adult ED
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30% PTS line 1 down twice this week
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Graph 1: Blood samples Taking >20 minutes to reach Lab; January 2014 to present
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