Prompt cards in the Emergency Department

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Human factors are a well recognised cause of discrepancies in patient care that can lead to adverse outcomes. In a busy Emergency Department (ED) setting, when dealing with the sickest patients at all hours and with a rotating workforce, there is an increased potential for inconsistent care despite clear evidence based protocols and guidelines on emergency conditions.

To ensure a standardised approach to procedures and medical emergencies, Brighton and Sussex University Hospitals NHS Trust developed a number of prompt cards. These do not aim to be a set of box-ticking checklists but instead provide a list of simple step-by-step instructions and considerations aimed to guide the clinical team and reduce the opportunities for human factors errors and therefore improving patient safety.

The prompt cards were formed in discussion with both the junior and senior clinicians in the ED as well as the resus nurses to formulate a list of conditions and procedures for which there are clear ‘best evidence’ guidelines. Once created, the prompt cards were reviewed with the relevant specialty clinical leads (for example the respiratory consultants were consulted about the noninvasive ventilation [NIV] guideline) to ensure those who will be continuing the care of the patient following admission agreed with the initial management being carried out in the ED.

The cards are updated yearly to ensure they comply with current guidelines, and current cards undergo constant improvement following suggestions by the staff using them. The prompt cards cover a wide scope of scenarios and are split into five headings:
  1. Trauma, Transfers, Briefings – including pre-transfer checks and initial treatment of severe burns
  2. Medical Emergencies – including sepsis, life threatening asthma and severe pre-eclampsia
  3. Anaesthetics and Resuscitation guidance – including newborn life support, anaphylaxis, code red
  4. Haemorrhage and Sedation Procedures – including chest drains and organ donation
  5. Medications- including salbutamol and starting vasoactive medication
The proposal was met with some resistance at first, with colleagues feeling they knew what they were doing and that the prompt cards were unnecessary. However, since introducing the sedations prompt card, 100% have been compliant with best practice, and out of 500 procedures, there has been only one minor complication. 

In time, and through repeated audits, we believe this positive effect will become apparent throughout the conditions and procedures covered in the prompt cards, greatly improving patient safety.

Alice Edmondson, Senior Sister, Resus and Trauma, has, along with her team of nurses, been the driving force behind the introduction of the prompt cards. She said: “As the lead nurse for resus I see the prompt cards as a tool that has empowered nursing staff to be comfortable and confident to challenge and discuss prescribed and potential treatment with their medical colleagues. “The presence of the prompt cards has resulted in a more consistent approach when treating the sickest patients in the emergency department.”

Staff feedback has also been extremely positive, with one ED Charge Nurse saying: ““I used the prompt card to challenge a doctor to stop the incorrect rate and dosage of a naloxone infusion”. And an anaesthetic SHO adding: “The intubation Prompt Card creates a minute to communicate with the team and check everyone is clear on the plan. It helps me signify we are about to begin and I find that helpful.” A staff nurse also said: “By me showing the prompt card the doctor went through the sedation checks and we identified equipment was missing before we started.” The prompt cards have been so successful, multiple other hospitals are adopting them, and the BSUH ED team is developing an app that will enable teams in hospitals all over the country to benefit from the innovation. 

The Prompt Cards were developed by Dr Rob Galloway, Dr Duncan Bootland, Dr Rob Greenhalgh and Dr James Green at Brighton and Sussex University Hospitals NHS Trust.

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Published on : Thu, 23 Aug 2018

emergency department, Brighton and Sussex University Hospitals NHS Trust Human factors are a well recognised cause of discrepancies in patient care that can lead to adverse outcomes. In a busy Emergency Department (ED) setting,...

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