Objectives Hand hygiene is effective in preventing healthcare-associated infections. Environmental conditions in the emergency department (ED), including crowding and the use of nontraditional patient care areas (i.e. hallways), may pose barriers to hand hygiene compliance. We examined the relationship between these environmental conditions and proper hand hygiene. Methods This was a single-site, observational study. From October 2013 to January 2014, trained observers recorded hand hygiene compliance among staff in the ED according to the World Health Organization “My 5 Moments for Hand Hygiene.” Multivariable logisitic regression was used to analyze the relationship between environmental conditions and hand hygiene compliance, while controlling for important covariates (e.g., hand hygiene indication, glove use, shift, etc.). Results A total of 1,673 hand hygiene opportunities were observed. In multivariable analyses, hand hygiene compliance was significantly lower when the ED was at its highest level of crowding than when the ED was not crowded and lower among hallway care areas than semi-private care areas (OR=0.39, 95% CI 0.28-0.55; OR= 0.73, 95% CI 0.55-0.97). Conclusions Unique environmental conditions pose barriers to hand hygiene compliance in the ED setting and should be considered by ED hand hygiene improvement efforts. Further study is needed to evaluate the impact of these environmental conditions on actual rates of infection transmission.

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Background: The United States Agency for Healthcare Research and Quality endorses the importance of a clinician's accurate diagnosis of skin and soft tissue infection as a way to improve patient safety especially with the nation wide emergence of community-acquired methicillin resistant Staphylococcus aureus. A reliable and accurate bedside ultrasound imaging classification approach to skin and soft tissue infection may assist the emergency department (ED) triage nurse in safely identifying those patients with skin and soft tissue infection in both light-skinned and darkskinned patients and help the ED triage nurse stratify those patients who need medical versus surgical therapy. Study Objectives: To assess the reliability of ED triage nurse-performed bedside ultrasound imaging (inter-rater reliability testing) for the detection and classification of skin and soft tissue infections into surgical vs non-surgical levels of skin and soft tissue infection in patients with light skin and dark skin (Fitzpatrick Skin Color Classification stratification). Methods: Prospective, blinded, convenience sample, in urban teaching hospital ED. Adult volume approximately 120,000 patients/year. All enrolled patients received bedside ultrasound by an ED triage nurse who underwent point-of-care ultrasonography training and criterion standard image review (experienced RDMS, RMSK ED attending physician) assessed for possible skin and soft tissue infection. Groups were compared via a two-rater linear weighted kappa statistic. A total sample size of 160 patients was determined to attain a desired kappa of > 0.6 in each group. Results: ED triage nurse pre-ultrasound versus post-ultrasound assessment of patients changed clinical management in 19/163 ¼11.7% cases. Conclusion: ED triage nurses can reliably use bedside utrasound imaging to evaluate for skin and soft tissue infection. Substantial inter-rater agreement for light skinned and dark-skinned patients was revealed. Substantial inter-rater agreement was found overall. ED triage nurse-performed bedside point of care ultrasonography can reliably assist the emergency physician to initiate medical vs. surgical therapy for patients with skin and soft tissue infections. Table. Reliability of ED Nurse Ultrasound for Detecting Skin-ST Infection in Light & Dark Skin Patients.

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Background and Purpose The literature demonstrates how utilizing evidence-based, standardized stroke care can improve patient outcomes; however, the contribution of electronic medical record (EMR) systems may also impact outcomes by ensuring utilization and compliance with established stroke performance measures, facilitating and improving documentation requirements, and standardizing approach to care. In 2008, documentation in patients’ medical records was done in combination of paper and a template free EMR. Originally, the EMR was used for order entry, then transitioned to full electronic documentation in 2009. At that time we implemented our stroke templates and performance measures based on regulatory standards. We hypothesized that the stroke template implementation would help us achieve performance measure criteria above state benchmarks as set out by the New York State Department of Health (NYS DOH). Methods Implementation was phased in [over 18 months], initially using a template that only included neurological assessment and free text fields for stroke measures. By July 2010, existing templates were modified and additional stroke templates were implemented to meet new regulatory requirements and meaningful use criteria. Retrospective data review was conducted for performance comparison between 2008 -- one year prior to EMR/template implementation -- and 2010. In Quarter 1 of 2011 EMR was also implemented in the Emergency Department (ED). Data was reviewed for compliance with stroke measures. Results Documentation compliance substantially improved between 2008 and Quarter 1 2011: Compliance for these measures has been maintained ≥ 85% since November 2010, ≥ 90% Q1 2011 Conclusions The EMR implementation of stroke templates and performance measures can produce substantial improvement in performance measure compliance. Future steps will include automated documentation alerts to retrieve information and real time discovery of missing documentation for concurrent quality review and improvement