Introduction: From the patient and staff perspective, care delivery for patients experiencing a mental health problem in ambulance and emergency department (ED) settings is challenging. There is no uniform and internationally accepted concept to reflect people with a mental health problem who require emergency care, be it for, or as a result of, a mental health or physical health problem. On initial presentation to the emergency service provider (ambulance or ED), the cause of their healthcare condition/s (mental health and/or physical health) is often initially unknown. Due to this (1) the prevalence and range of underlying causes (mental and/or physical) of the patients presenting condition is unknown; (2) misattribution of physical symptoms to a mental health problem can occur and (3) diagnosis and treatment of the initial somatic complaint and cause(s) of the mental/physical health problem may be hindered.This study will name and define a new concept: 'mental dysregulation' in the context of ambulance and ED settings. Methods and analysis: A Delphi study, informed by a rapid literature review, will be undertaken. For the literature review, a steering group (ie, persons with lived experience, ED and mental health clinicians, academics) will systematically search the literature to provide a working definition of the concept: mental dysregulation. Based on this review, statements will be generated regarding (1) the definition of the concept; (2) possible causes of mental dysregulation and (3) observable behaviours associated with mental dysregulation. These statements will be rated in three Delphi rounds to achieve consensus by an international expert panel (comprising persons with lived experience, clinicians and academics). Ethics and dissemination: This study has been approved by the Medical Ethical Committee of the University of Applied Sciences Utrecht (reference number: 258-000-2023_Geurt van der Glind). Results will be disseminated via peer-reviewed journal publication(s), scientific conference(s) and to key stakeholders.
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Designers move more and more in the direction of Service Design, in which frequently a participatory or co-design approach is used to involve service providers in the design process. The designerprovider relationship in such Service Design processes differs in four aspects from traditional client-relationships: The relationship is 1) more dynamic and interactive, 2) based on collaboratively evolving ideas and ambitions, 3) focusing on the process of innovation, rather than on the outcome, and 4) frequently based on extrinsic motivation for innovation or on fuzzy starting points. Designers experience difficulties in persuading service providers of the importance of such a collaborative approach, while providers are not familiar with this kind of approach and their organizations are not ready for such a kind of collaboration. This paper positions designer-provider relationship in Service Design processes in literature and describes a research proposal for the development of an efficient and effective participatory design intervention that stimulates collaboration between designers and service providers.
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Introduction: Worldwide, there is an increase in the extent and severity of mental illness. Exacerbation of somatic complaints in this group of people can result in recurring ambulance and emergency department care. The care of patients with a mental dysregulation (ie, experiencing a mental health problem and disproportionate feelings like fear, anger, sadness or confusion, possibly with associated behaviours) can be complex and challenging in the emergency care context, possibly evoking a wide variety of feelings, ranging from worry or pity to annoyance and frustration in emergency care staff members. This in return may lead to stigma towards patients with a mental dysregulation seeking emergency care. Interventions have been developed impacting attitude and behaviour and minimising stigma held by healthcare professionals. However, these interventions are not explicitly aimed at the emergency care context nor do these represent perspectives of healthcare professionals working within this context. Therefore, the aim of the proposed review is to gain insight into interventions targeting healthcare professionals, which minimise stigma including beliefs, attitudes and behaviour towards patients with a mental dysregulation within the emergency care context. Methods and analysis: The protocol for a systematic integrative review is presented, using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols recommendations. A systematic search was performed on 13 July 2023. Study selection and data extraction will be performed by two independent reviewers. In each step, an expert with lived experience will comment on process and results. Software applications RefWorks-ProQuest, Rayyan and ATLAS.ti will be used to enhance the quality of the review and transparency of process and results. Ethics and dissemination: No ethical approval or safety considerations are required for this review. The proposed review will be submitted to a relevant international journal. Results will be presented at relevant medical scientific conferences.
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Background: There is an increase in the number of frail elderly patients presenting to the emergency department. Diagnosis and treatment for this patient group is challenging due to multimorbidity, a-typical presentation and polypharmacy and requires specialised knowledge and competencies from healthcare professionals. We aim to explore the needs and preferences regarding emergency care in frail older patients based on their experiences with received care during Emergency Department admission. Method: A qualitative study design was used, and semi-structured interviews were conducted after discharge with twelve frail older patients admitted to emergency departments in the Netherlands. Data collection and analysis were performed iteratively, and data were thematically analysed. Results: The analysis enfolded the following themes; feeling disrupted, expecting to be cared for, suppressing their needs and wanting to be seen. These themes indicated a need for situational awareness by healthcare professionals when taking care of the participants and were influenced by the participants' life experiences. Conclusion: Frail older patients feel disrupted when admitted to the emergency department. Because of this, they expect to be cared for, lessen their own needs and want to be seen as human beings. The impact of the admission is influenced by the extent to which healthcare professionals show situational awareness.
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In 2016, a selective preventive spinal immobilization protocol for emergency medical service (EMS) nurses was introduced in the Netherlands. This protocol leaves more room for autonomous decision-making in the pre-hospital phase regarding preventive spinal immobilization (PSI), compared to the previous strict protocol. In this study, we explored the experiences and perspectives of EMS nurses on decision making about PSI after the change from a strict to a selective PSI protocol. Methods: We used a qualitative design with semi structured face-to-face interviews. Thematic analysis was applied. The capability-opportunity-motivation behavior-model was used to interpret the experiences and perspectives. Results: Thirteen EMS nurses from three emergency medical services were interviewed. Respondents appreciated autonomous decision-making as there was more room for patient-centered informed decision-making. However, autonomous decision-making required optimized knowledge and skills and elicited the need to receive feedback on their decision not to apply PSI. When nurses anticipated resistance to selective PSI from receiving hospitals, they were doubtful to apply it. Conclusion: Nurses appreciate the increased autonomy in decision-making, encouraging them to focus on patient-centered care. Increased autonomy also places higher demands on knowledge and skills, calling for training and feedback. Anticipated resistance to receiving hospitals based on mutual protocol discrepancies could lead to PSI application by EMS nurses while not deemed necessary. Recommendations: To enhance PSI procedures, optimizing the knowledge and skills of EMS nurses that facilitate on-scene decision-making may be indicated. A learning loop for feedback between the EMS nurses and the involved hospitals may add to their professional performance. More efforts are needed to create support for the changed Emergency Medical Services strategy in PSI to prevent unnecessary PSI and practice variation.
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Introduction: Retrospective studies suggest that a rapid initiation of treatment results in a better prognosis for patients in the emergency department. There could be a difference between the actual medication administration time and the documented time in the electronic health record. In this study, the difference between the observed medication administration time and documentation time was investigated. Patient and nurse characteristics were also tested for associations with observed time differences. Methods: In this prospective study, emergency nurses were followed by observers for a total of 3 months. Patient inclusion was divided over 2 time periods. The difference in the observed medication administration time and the corresponding electronic health record documentation time was measured. The association between patient/nurse characteristics and the difference in medication administration and documentation time was tested with a Spearman correlation or biserial correlation test. Results: In 34 observed patients, the median difference in administration and documentation time was 6.0 minutes (interquartile range 2.0-16.0). In 9 (26.5%) patients, the actual time of medication administration differed more than 15 minutes with the electronic health record documentation time. High temperature, lower saturation, oxygen-dependency, and high Modified Early Warning Score were all correlated with an increasing difference between administration and documentation times. Discussion: A difference between administration and documentation times of medication in the emergency department may be common, especially for more acute patients. This could bias, in part, previously reported time-to-treatment measurements from retrospective research designs, which should be kept in mind when outcomes of retrospective time-to-treatment studies are evaluated.
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This paper presents the design and the results of a comparative study of multidisciplinary on-scene command teams at work in virtual emergency training exercises. The principal goals of the study were to understand how "on-scene command teams" coordinate on multidisciplinary objectives and tasks, and how the manner in which this is done affects their performance. The study involved 20 on-scene command teams consisting of various individuals, such as police, fire and medical services personnel, municipal officers and infrastructure operators, drawn from a Safety Region in The Netherlands. Integrated video recordings by five synchronized cameras captured the coordination processes during the virtual exercises. The integrated and synchronized video recordings were then transformed into numerical data for analysis. Performance was operationalized by scoring the progress and completion of emergency management tasks for which individual members and/or teams as a whole were responsible. Team coordination was operationalized using network centrality and density measures. The significant findings are the following: (i) emergency management performance and coordination patterns within and among on-scene command teams have considerable variation; and (ii) teams that use less coordination during the intermediate phases of emergency management perform significantly better than teams that do not, moreover, actors who have central positions in a network are better able to achieve their performance goals.
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With age, people often develop multiple health problems, chronic illnesses, and frailty. For geriatric adults with frailty, there is a complex interplay of medical, psychological, cognitive, functional, and social issues. As a result, even a minor medical event can disrupt the delicate balance of their condition, often leading to admission to the emergency department. However, frailty can lead to an unpredictable course of symptoms and treatment. Emergency care professionals, including emergency medical services providers and ED staff, are the first to interact with and assess these patients. Therefore, this study aimed to explore the challenges that emergency medical services and ED professionals encounter when caring for geriatric patients with frailty and how they experience these challenges.
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ObjectiveIn 2016, a selective preventive spinal immobilization protocol for emergency medical service (EMS) nurses was introduced in the Netherlands. This protocol leaves more room for autonomous decision-making in the pre-hospital phase regarding preventive spinal immobilization (PSI), compared to the previous strict protocol. In this study, we explored the experiences and perspectives of EMS nurses on decisionmaking about PSI after the change from a strict to a selective PSI protocol. Methods: We used a qualitative design with semi-structured face-to-face interviews. Thematic analysis was applied. The capability-opportunity-motivation-behavior-model was used to interpret the experiences and perspectives. Results: Thirteen EMS nurses from three emergency medical services were interviewed. Respondents appreciated autonomous decision-making as there was more room for patient-centered informed decision-making. However, autonomous decision-making required optimized knowledge and skills and elicited the need to receive feedback on their decision not to apply PSI. When nurses anticipated resistance to selective PSI from receiving hospitals, they were doubtful to apply it. Conclusion: Nurses appreciate the increased autonomy in decision-making, encouraging them to focus on patient-centered care. Increased autonomy also places higher demands on knowledge and skills, calling for training and feedback. Anticipated resistance to receiving hospitals based on mutual protocol discrepancies could lead to PSI application by EMS nurses while not deemed necessary. Recommendations: To enhance PSI procedures, optimizing the knowledge and skills of EMS nurses that facilitate on-scene decision-making may be indicated. A learning loop for feedback between the EMS nurses and the involved hospitals may add to their professional performance. More efforts are needed to create support for the changed Emergency Medical Services strategy in PSI to prevent unnecessary PSI and practice variation.
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Emergency care (from ambulance to emergency room) is focused on somatic care: fixing the body. When a patient with mental dysregulation who experiences ‘disproportionate feelings like fear, anger, sadness or confusion, possibly with associated behaviours’ (Van de Glind et al. 2023) does not get appropriate attention, this can result in the disruption of treatment and even psychological trauma upon trauma. To improve the emergency care process, the authors of this paper - health researchers and design researchers engaged in a project based on the experience-based co-design (EBCD) approach (Donetto et al. 2015; Bate and Robert 2007). EBCD is a method used to design better experiences in healthcare settings, in cooperation with (former) patients and healthcare professionals. The process of EBCD involves partnerships between stakeholders and the discovery and sensemaking of experiences through specialized methods to gain an understanding of the interface between user and service, to design new experiences (Bate and Robert 2007, 31). There is, however, an interesting challenge in bringing patients and care professionals together. In emergency care, patients depend greatly on their healthcare providers. The patients in this study had existing mental vulnerabilities and may have been traumatized by previous visits. We needed to enable these stakeholders to be equal partners with ownership and power, one of the characteristics of co-design in EBCD (Donetto et al. 2015). In this paper, we describe how we adapted and applied the EBCD method, with a focus on creating equal partnerships. We also reflect on the extent of our success and the diBiculties we encountered in attaining this objective.
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