Clinical pathways are used to support the management of patients in emergency departments. An existing document-based clinical pathway was used as the foundation on which to design and build a digital clinical pathway for acute chest pain, with the aim of improving clinical calculations, clinician decision-making, documentation, and data collection. Established principles of decision support system design were used to build an application within the existing electronic health record, before testing with a multidisciplinary team of doctors using a think-aloud protocol. Technical authoring was successful, however, usability testing revealed that the user experience and the flexibility of workflow within the application were critical barriers to implementation. Emergency medicine and acute care decision support systems face particular challenges to existing models of linear workflow that should be deliberately addressed in digital pathway design. We make key recommendations regarding digital pathway design in emergency medicine.
Hyponatraemia is among the more common electrolyte abnormalities encountered in the ED. Both the primary disturbance and its correction can result in life-threatening neurological sequelae. Osmotic myelinolysis syndrome is one such complication and is associated with the rapid correction of hyponatraemia. The present case report describes the mechanism of severe hyponatraemia in a patient taking deamino arginine vasopressin, and the subsequent development of both central pontine and extrapontine myelinolysis after rapid correction of sodium levels. Implications for the emergency management of such patients are discussed.
BACKGROUND AND CONTEXT
New Zealand is a largely rural nation. Despite the regionalisation of trauma services, rural hospitals continue to provide trauma and emergency care. A dedicated rural inter-professional team-based simulation course was designed, as part of a wider strategy of using simulation-based education to address the disparity in experience and training for rural hospital teams providing emergency and trauma care.
ASSESSMENT
A pre-course questionnaire identified learning needs. Post-course evaluation and a follow-up survey assessed participants’ perception of the course, and whether lasting changes in clinical or organisational practice occurred.
RESULTS
Three courses were provided over 2 years to 60 interprofessional participants from eight rural hospitals. The course employed an interprofessional faculty and used skill workshops and high-fidelity trauma simulations to address learning needs identified in pre-course research. Evaluation showed the course to be an effective learning experience for participants. The post-course survey indicated possible lasting changes in team performance and rural hospital protocols. This educational strategy also allowed the collection of research data for investigating rural team dynamics and interprofessional learning.
STRATEGIES FOR IMPROVEMENT
Further development of rural interprofessional simulation courses should include more diverse clinical content, including paediatric and medical scenarios. Participant access was sometimes limited by typical rural challenges such as hospital staffing and locum availability.
LESSONS
Rural simulation-based education is both effective for rural trauma team training and a vehicle for rural research; however, there are challenges to participant access and course sustainability, which echo the rural–urban disparity.
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