Journal Reviews

Kapur AK, Tenenbein M. Vaccination of emergency department patients at high risk for influenza. Acad Emerg Med 2000; 7:354-358.

More than half of ED patients at risk for increased morbidity from influenza had not been vaccinated, and over half of these were willing to be vaccinated during an ED visit, reports this study from the University of Manitoba in Winnipeg, Canada. Here are key findings:

• Of 231 patients who met the high-risk criteria, 123 (53.2%) had not received the vaccine.

• 73 (59.3%) were willing to be vaccinated during an ED visit.

• Of the 50 high-risk patients unwilling to be vaccinated, 36 believed they did not need the vaccine, 30 were concerned about side effects, and 11 wanted to discuss the vaccine with their own physicians.

Even patients who refused vaccination could be educated during the ED visit, according to the researchers, who note that most of the high-risk patients who were not willing to be vaccinated believed that they did not need it. "It is unknown how many of these people would agree to vaccination if informed that it is recommended for them," they add.

Although most emergency physicians rarely or never offer influenza vaccinations, 76% of them were willing to do this during an ED visit, according to a survey of 54 ED physicians. ED physicians can increase the proportion of high-risk ED patients who are vaccinated by more than two-thirds, the study found.

The study’s results are evidence that ED vaccination for influenza would be considered as a strategy to increase vaccination among high-risk groups, say the researchers. (For more information about successful ED vaccine programs, see ED Management, February 2000, p. 13.)

Sun BC, Adams J, Orav EJ, et al.Determinants of patient satisfaction and willingness to return with emergency care.Ann Emerg Med2000; 35:426-434.

Communication and education are critical factors that determine how satisfied patients are with ED care and how willing they are to return to an ED, according to this study from Brigham and Women’s Hospital, Harvard Medical School, and Beth Israel Deaconess Medical Center, all based in Boston.

A total of 2,899 patients were surveyed on-site, and 2,333 patients were interviewed via telephone. The following problems were reported by patients, which affected their willingness to return to the ED:

• help not received when needed;

• poor explanation for potential causes of problem;

• not told about potential wait time;

• not told when to resume normal activity;

• poor explanation of test results;

• not told when to return to the ED;

• unable to leave a message for family.

The study also found that the actual wait time to see a physician and total length of stay are not significant predictors of patient satisfaction. "Managing the perception of waiting time, by communicating an expected wait time to patients, seems to be more important for satisfaction than the actual wait time," they say.

Improvements in communication must be systems-based, the researchers recommend, and suggest the following:

• Develop systems that build patient communication and education into the process of care.

• Don’t rely solely on the individual efforts of busy physicians and nurses, who are distracted by a constant demands and tasks.

• Give caregivers time to communicate with patients.

• Redesign the process of care to reduce distractions to the patient-physician relationship.

Arslanian-Engoren C.Gender and age bias in triage decisions. J Emerg Nurs2000; 26:117-124.

ED nurses fail to associate middle-aged women’s symptoms with myocardial infarction (MI), which might contribute to increased morbidity and mortality in these patients, according to this study from the University of Michigan in Ann Arbor. The study looked at whether triage nurses made different decisions for men and women with symptoms that suggested MI.

Four focus groups were conducted with 12 ED nurses about the way they handled triage of patients with MI symptoms. Nurses acknowledged they were less likely to suspect MI in middle-aged women and admitted that MI wasn’t the first diagnosis considered for middle-aged women, even if the patients had symptoms consistent with MI.

Women are less likely than men to be diagnosed with an MI and to receive early or aggressive treatment, and are more likely than men to die of an MI, the researcher notes.

"In the event that a young woman has an MI and it is missed, the outcome may be deadly," she writes. "Even though young women may not be having a coronary event, this possibility must be excluded before noncoronary causes are considered for the symptoms, because of the potential seriousness of missing this event."

The following solutions are offered:

• ED nurses must critically assess their own triage practices for the influence of gender bias.

• Nurses should watch for gender bias regarding patient signs and symptoms, suspected cause, and the need for emergent triage.

• ED nurses should be current with literature on women with heart disease to better understand how the disease presents in women.

• Clinical preparation of ED nurses should include gender bias recognition strategies.