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Why you should read this article: • To recognise that overcrowded emergency departments result in ambulance handover delays causing avoidable harm to patients awaiting assessment • To identify how forward planning and anticipatory escalation processes can reduce the potential for patients to experience avoidable harm • To learn how a strategic quality improvement project improved patient safety and the working lives of front-line healthcare professionals. Ambulance handover delays arise when emergency departments become overcrowded as patients waiting prolonged periods for admission occupy clinical cubicles designed to facilitate the assessment and treatment of emergency arrivals. In response, many organisations become reliant on temporarily lodging acutely unwell patients awaiting admission in undesignated areas for care such as corridors, to provide additional space. This results in a significant risk of avoidable harm, indignity and psychological trauma for patients and has a negative effect on the well-being of healthcare professionals, since unacceptable standards of care become normalised. A two-phase strategic quality improvement project was implemented at the authors’ acute trust. Ambulance handover data from between 2 November 2020 and 26 July 2021 provided a benchmark for the project. The first phase was implemented between 2 November 2021 and 26 July 2022 and aimed to reduce 60-minute ambulance handover delays. The second phase was implemented between 2 November 2022 and 26 July 2023 and aimed to eradicate 60-minute ambulance handover delays and improve overall performance. Phase one resulted in a 32% reduction in 60-minute ambulance handover delays. Phase two resulted in a 97% reduction in 60-minute ambulance handover delays. Over the course of the project there was a 24% increase in handovers completed within 15 minutes. This project demonstrates how strategic planning and collaboration between healthcare teams can reduce the potential for avoidable patient harm, while simultaneously promoting workforce well-being and retention. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To enhance your awareness and understanding of the Columbia-Suicide Severity Risk Scale • To learn about a project to improve suicide risk screening in three emergency departments in the US • To acknowledge the need to provide nurses with adequate training and tools on suicide risk assessment. Suicide is a significant and increasing public health concern. Research has shown that screening for suicide risk is inconsistent in acute care settings and that a variety of different tools are used for that purpose. The Columbia-Suicide Severity Risk Scale (C-SSRS) has emerged as a validated and recognised suicide risk screening tool. This article describes a quality improvement project designed to improve the screening of patients for suicide risk in a large hospital system in the Midwestern US. As part of the project, 97% of nurses working in the organisation’s emergency departments self-completed a 30-minute interactive learning module on the background, relevance and application of the C-SSRS. The C-SSRS enables nurses to classify the severity of suicide risk, which helps to provide interventions commensurate with patients’ level of risk. Following completion of the module, there was a significant increase in the percentage of patients screened for suicide risk. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To refresh your knowledge of the aims of and processes involved in triage • To enhance your understanding of the strategies you can use to make triage as safe and effective as possible for patients and staff • To contribute towards revalidation as part of your 35 hours of CPD (UK readers) • To contribute towards your professional development and local registration renewal requirements (non-UK readers). Triage is the first stage of a patient’s journey through the emergency department and is used to determine patient acuity. There is no single quantifiable metric for determining acuity, which amalgamates different factors that are more or less relevant depending on the patient’s presentation. This article explains the aim and process of triage and how nurses can ensure the process is effective and safe. The author discusses strategies nurses can use to mitigate uncertainty and to make their acuity assessments rapid, targeted and comprehensive. The author also highlights triage safety considerations, including infection prevention and control and the physical and emotional safety of patients and staff. [ABSTRACT FROM AUTHOR]

Rationale and key points: Why you should read this article: • To understand the necessary preparation required before triaging a patient • To familiarise yourself with the steps required when triaging a patient in the emergency department • To learn about the scales and algorithms used by nurses when triaging patients. Triaging patients can be a complicated process, with multiple modes of assessment taking place simultaneously, and nurses need to be confident and competent in their assessment skills. This article explains the necessary preparation for triage and outlines the steps that nurses need to take when triaging a patient in the emergency department. • Triage requires a targeted patient assessment, using both clinical judgement and triage tools to determine appropriate acuity categories. • Different scales and algorithms are used in triage, so it is essential to clearly communicate the acuity categories assigned to patients. • A structured approach to patient assessment can guide decision-making and identify issues. • Various diagnostic tests can be used to facilitate the triage process, but care needs to be taken to ensure the process is not prolonged by their use. Reflective activity: ‘How to’ articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: • How this article might improve your practice when assessing the acuity of patients in triage. • How you could use this information to educate nursing students or your colleagues on the appropriate technique and evidence base regarding the triaging of patients in the emergency department. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To be aware that women presenting to emergency departments (EDs) who are experiencing a miscarriage require sensitive nursing care including empathetic communication • To recognise that breaking bad news to patients in the ED can be challenging for nurses, partly because of insufficient training • To learn about an education programme that increased the confidence levels of nurses in breaking bad news and their comfort in managing patients’ emotions. Vaginal bleeding during pregnancy is a common patient presentation in emergency departments (EDs), and in some cases this will occur due to miscarriage. However, there are several barriers to effective and sensitive communication with patients experiencing a miscarriage. Women presenting to EDs who are experiencing a miscarriage are more likely to be psychosocially vulnerable and less satisfied with their care compared with those seeking care in the outpatient setting. There is a gap in nursing and advanced practice provider preparation regarding techniques for breaking bad news to patients in the ED setting. At one high-volume, urban ED in the US, an education programme for staff regarding best practice in breaking bad news to patients experiencing a miscarriage was developed based on an established protocol. The intention was to increase the confidence levels of nurses and other healthcare professionals in breaking bad news to these patients. After the education programme, many participants self-reported increased confidence in breaking bad news and comfort in managing patients’ emotions. The results can be used to inform education for healthcare professionals who deliver bad news in the ED and other departments. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To refresh your knowledge of the anatomy of forearm bones and the pathophysiology of bowing fractures • To increase your awareness of the diagnostic challenges and complications associated with bowing fractures • To enhance your understanding of the management of children with bowing fractures. Bowing fractures of the forearm are characterised by numerous micro-fractures on the concave surface of the affected bone(s), usually caused by a fall on an outstretched arm. Children are more susceptible to this type of injury than adults because their long bones have more elasticity. Bowing fractures of the forearm are challenging to diagnose because there are no obvious cortical defects, which can lead to inappropriate management and associated complications, including loss of movement range and loss of function. This article discusses bowing fractures of the forearm in children, including their pathophysiology, diagnosis and management. It aims to enhance emergency nurses’ awareness and knowledge of this type of injury in children and of the challenges surrounding diagnosis and management. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To recognise factors that can result in communication breakdown between staff and patients, leading to potential confrontation in the emergency department (ED) • To enhance your ability to assess and manage patients safely in ED waiting rooms • To contribute towards revalidation as part of your 35 hours of CPD (UK readers) • To contribute towards your professional development and local registration renewal requirements (non-UK readers). Increasing demand, overcrowding and insufficient resources have led to situations where patient care is delivered in emergency department (ED) waiting rooms. For nurses undertaking triage in the ED waiting room, overcrowding is challenging, particularly in terms of assessing patients in a timely fashion, monitoring patients for clinical deterioration and ordering investigations. Additionally, long waiting times and a lack of information can lead to communication breakdowns with patients and, at times, patient confrontations with ED staff. This article explores the effects of the busy environment in ED waiting rooms on patients and staff such as triage nurses and waiting room nurses. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To increase your awareness of the importance of identifying and assessing older people living with frailty • To understand the concept of frailty as a clinical syndrome • To familiarise yourself with frailty assessment tools such as the Clinical Frailty Scale, the most commonly used in the emergency department. An ageing population is leading to an increase in patients attending emergency departments (EDs) with comorbidities and age-related syndromes such as frailty. Frailty is a clinical syndrome defined as an increased vulnerability to age-related or disease-related insults in older adults due to diminishing physiological reserves. It also places increased demands on staff and hospital services. Screening for frailty early in the care pathway ensures goal-directed and timely care. This article provides an overview of frailty and its assessment in older people presenting to the ED. It discusses the most commonly used frailty assessment tool in the ED, the Clinical Frailty Scale, and identifies that the results of frailty assessment should be used to initiate appropriate individualised care in older patients. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To gain insight into caring for people at the end of life in the emergency department • To enhance your understanding of the concept of a good death • To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers) • To contribute towards your professional development and local registration renewal requirements (non-UK readers) The focus of care in the emergency department (ED) is on saving or sustaining life, but some patients admitted to the ED die in the ED. Nurses whose focus is on saving lives may therefore find themselves providing end of life care to patients and their families in a stressful and distressing environment. Providing optimal end of life care involves reflecting on what a good death looks like and how patients can be supported to have a good death. This article describes the barriers to optimal end of life care in the ED and prompts nurses to think about how they can enhance their practice when caring for dying patients and their families. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To be aware that temporary lower-limb immobilisation increases the risk of venous thromboembolism • To recognise the need to assess venous thromboembolism risk in adults with lower-limb immobilisation • To better understand which patients with lower-limb immobilisation should be offered thromboprophylaxis Temporary lower-limb immobilisation following injury is a risk factor for the development of venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism. However, patients are not always risk-assessed for VTE in clinical practice and there is a lack of consensus among healthcare professionals on whether thromboprophylaxis should be offered and to whom. This article uses the fictional case study of a patient with an ankle fracture to explore the literature and guidance on VTE risk assessment and thromboprophylaxis in adults presenting to emergency settings with lower-limb trauma requiring immobilisation. It appears that it is important to consistently risk-assess patients and offer thromboprophylaxis to those deemed at moderate or high risk of VTE, since thromboprophylaxis is safe, efficacious and cost-effective in these patient groups. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To identify the unique challenges of having to care for patients in non-clinical areas • To consider practical solutions for enhancing safety and efficiency in 'corridor care' • To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers) • To contribute towards your professional development and local registration renewal requirements (non-UK readers) Overcrowding in the emergency department (ED) is a significant issue and often leads to nursing care being delivered in areas not intended for clinical use, a practice commonly referred to as 'corridor care'. Delivering care in non-clinical areas negatively affects patient safety and poses unique professional challenges for emergency nurses while also reducing their well-being. To end – or at least reduce – corridor care, system-level interventions are needed. In the meantime, there are practical solutions that can be implemented at an individual and departmental level to mitigate some of the risks associated with it. This article discusses a pragmatic approach to patient care, and explores opportunities for nurses to mitigate risks and enhance safety and efficiency, in overcrowded EDs. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To recognise that emergency nurses have an opportunity to integrate health promotion in the care they provide • To understand the barriers to health promotion in emergency care settings • To consider how you could provide further health promotion to patients in your practice setting Background: Emergency departments (EDs) afford 'teachable moments' for health behaviour change, but staff may not see themselves as public health practitioners and it can be challenging to undertake health promotion activities in emergency care settings. Furthermore, the evidence on health promotion in these settings is limited. Aim: To investigate the views and experiences of emergency nurses and ambulance service paramedics regarding health promotion in emergency care settings. Method: A convenience sample of emergency nurses (n=3) and ambulance service paramedics (n=3) was recruited. An inductive and descriptive qualitative study design using semi-structured interviews and thematic analysis was employed. Findings: The participants understood health promotion and were willing to have conversations about it with patients. However, they cited several barriers to health promotion, including understaffing, a lack of understanding of the relevance of health promotion among staff, a lack of training and information, and the sensitivity of topics such as body weight and sexual health. Lack of time was not cited as a barrier. Conclusion: There are opportunities for developing the health promotion aspect of practice in emergency care settings, where staff and patients would benefit from a more structured, system-wide approach to health promotion. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To enhance your knowledge of the risks associated with pelvic fractures caused by high-energy trauma • To recognise the importance of conducting a primary survey adapted to patients with severe pelvic fractures • To identify the management priorities for patients who have sustained high-energy trauma to the pelvis Pelvic fractures caused by high-energy trauma such as falling from a height or road traffic collisions have a high mortality rate and patients are also at high risk of life-changing injuries. High-energy trauma to the pelvis is associated with major haemorrhage and injuries to the internal pelvic organs. Emergency nurses have a fundamental role in the initial assessment and management of patients, as well as in their ongoing care once the fracture has been stabilised and bleeding is controlled. This article describes the anatomy of the pelvis, discusses the initial assessment and management of patients who have sustained high-energy pelvic trauma, details the complications of pelvic fractures and explains patients' ongoing care in the emergency department. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To enhance your understanding of triage processes and of the primary aim of emergency triage • To explore how the principles of lean management can be applied in a healthcare setting • To read about a project successfully conducted to reduce triage time in an emergency department Emergency triage is a short-duration, high-volume process so small reductions in the time taken to triage one patient can have large repercussions on the total amount of triage time. At the emergency department of a large inner-city hospital, an efficiency and quality improvement project was undertaken to reduce the time taken to safely triage patients and optimise the use of triage nurses' time. The project involved removing processes that did not contribute to the primary aim of triage, supporting individual triage nurses to improve their performance where needed, and optimising the triage process. A 44% reduction in mean triage episode time was seen, equating to 18,000 minutes of triage nurses' time saved every month. This near doubling of triage capacity was associated with an improvement in triage accuracy. The article describes the project, which used lean management principles and statistical process control methods, and discusses its implications for emergency triage. [ABSTRACT FROM AUTHOR]

The article discusses the accidental hypothermia condition which refers to an unintentional decrease to below 35 degrees centigrade in core body temperature. Topics covered include its pathophysiology, its adverse effects on the cardiovascular, central nervous, and renal body systems among others, and the importance of preventing further heat loss and of quickly rewarming those stricken with it. Also described are investigations on such patients, and their management, and nursing care.

Why you should read this article: • To identify the clinical outcomes for patients with scalp lacerations using the hair apposition technique (HAT) in comparison to the traditional options for wound closure in the emergency department • To recognise that further research is required to support the existing evidence on the use of HAT for scalp lacerations • To be aware that emergency nurses must undertake appropriate education and clinical skills practice before implementation of HAT in their setting This literature review aimed to explore the clinical outcomes for adult and child patients with scalp lacerations using the hair apposition technique (HAT) compared with the traditional options of sutures and staples for wound closure in the emergency department (ED). Although the research is scant, in the studies examined HAT was received positively by patients, had limited complications, was cost-effective and was suitable for use in the age ranges that met the criteria for its application. Further research is required to support the existing evidence, but the use of HAT for low-risk scalp lacerations in the ED should be considered and is within the scope of all healthcare professionals who undertake appropriate practice of this clinical skill. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To recognise that children's acute pain should be assessed using validated tools appropriate for a child's age and developmental status • To enhance your knowledge of the different types of validated pain assessment tools for use with children with acute pain • To understand that children's self-reports of acute pain should be obtained whenever possible There is a lack of timely administration of an appropriate analgesic for children in acute pain in emergency departments in the UK and elsewhere. Unrelieved acute pain may result in deterioration in a child's physical and psychological condition therefore assessment is essential to enable triage nurses to offer an appropriate analgesic. This should be achieved by using a validated pain assessment tool which, where appropriate, enables the child to self-report their pain. This article describes various validated pain assessment tools for use with children with acute pain and considers how triage nurses can determine which is the most appropriate to use. Regardless of which tool is selected, it is important to offer the child an analgesic and to reassess their pain at appropriate intervals. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To recognise the challenges of undertaking clinical research in the emergency department setting • To learn about various strategies that could be used to support patient recruitment to research trials • To consider the role of nurses in recruiting patients to clinical research Research is essential for the implementation of evidence-based practice and can lead to improvements and innovations in care delivery. Although ultimately beneficial for patients and staff, the data collection involved in research often presents challenges, particularly in the emergency department (ED) setting. This article describes the challenges of undertaking a feasibility trial in a city centre ED. The target research population were adult patients who presented to the ED with an issue related to opioid misuse, for example opioid overdose, injection site wounds and/or abscess, or injury sustained during opioid intoxication. Challenges experienced during this trial included a demanding work environment, ED attendees not being suitable for recruitment into research, and suspension of the trial during the coronavirus disease 2019 (COVID-19) pandemic. The author details the strategies introduced to ensure effective patient recruitment to the trial, including nurse secondment onto the research team, offering incentives, raising awareness of the trial among ED staff and implementing flexible training. These strategies continued to be effective after a period of suspension due to the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To be aware of the differential diagnoses associated with petechial rash before initiating treatment for invasive meningococcal disease • To recognise the value of a tailored approach to the investigation, treatment and discharge of well children with petechial rash in the emergency department (ED) • To avoid over investigation and overtreatment of well children with petechial rash in the ED This article presents a discussion based on a case study of an eight-month-old boy with petechial rash who presented at the emergency department (ED). Blood tests were obtained and intravenous antibiotics were administered. The patient was admitted to the children's ward and was discharged the next day. It was suspected that the rash was caused by a non-specific viral illness. Non-blanching rashes, such as petechial rash, in well children often lead to diagnostic and treatment dilemmas in the ED. Clinicians fear missing the diagnosis of invasive meningococcal disease, which results in blood tests, cannulation and early administration of antibiotics. Non-blanching rashes have many potential causes and extensive tests and antibiotic treatment may not always be necessary and have the potential to cause harm. A tailored approach to investigate, treat and discharge well children with petechial rash from the ED is advocated. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To be aware of factors influencing a decision to activate the trauma team • To identify the importance of trauma-specific training and the support of senior staff in enhancing the confidence of less experienced colleagues • To recognise that trauma team activation may be inconsistent in trauma units Regional trauma networks enable the rapid and safe management and transfer of patients with traumatic injury between designated trauma units and one of 27 major trauma centres throughout the UK. Multispecialty trauma teams are available 24 hours a day, seven days a week, and are activated immediately upon receipt of a patient presenting with major trauma. With most serious trauma patients going direct to major trauma centres rather than a less specialised hospital-based trauma unit, it can be challenging for hospital-based trauma unit staff to gain experience and skill in this area, leading to potential inconsistencies in the process of activating the trauma team. The aim of this service evaluation was to identify factors influencing the decision to activate the trauma team in emergency department (ED) staff working within a 700-bed trauma unit. A questionnaire was sent to 107 staff and 70 completed it, a response rate of 65%. Results indicated that shortfalls in trauma-specific training, lack of clinical experience, undefined roles and responsibilities, department culture, ambulance handover, knowledge of clinical guidelines and previous experience of trauma team activation all affected the decision to activate the trauma team. Trauma-specific training and the support of senior staff could enhance confidence and appropriate trauma team activation rates. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To identify the importance of emergency nurses being able to provide appropriate care for patients who self-harm • To learn about the findings of a systematic review that examined the effects of educational interventions on emergency nurses' attitudes towards patients who self-harm • To recognise the need for improved training for emergency nurses on suicide and self-harm Negative nurse attitudes towards emergency department patients who self-harm may increase the risk of repeated self-harm and suicide. This article details a systematic review that aimed to examine the evidence on the efficacy of educational interventions to improve the attitudes of emergency nurses towards patients who self-harm. Eight articles describing six intervention studies, published between 2001 and 2018, met the criteria for inclusion. The review found that educational interventions for emergency nurses improved their attitudes to patients who self-harm, but there was a lack of consistency in the approaches used and a reliance on self-report measures. Further training for emergency nurses is needed because of their crucial role in self-harm and suicide prevention. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To enhance your knowledge and understanding of intercultural communication principles and challenges • To reflect on intercultural communication in your workplace and on how you may be able to help enhance it • To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers) • To contribute towards your professional development and local registration renewal requirements (non-UK readers) Globalisation and migration trends are reflected in emergency departments (EDs), which increasingly care for patients and employ staff from diverse cultural and/or ethnic backgrounds. EDs are busy, pressured and unpredictable environments where effective communication with patients and families is challenging at the best of times. This is compounded by language and cultural barriers experienced by patients and families whose background differs from the prevailing culture. Cultural differences and language comprehension may also be a challenge for overseas nurses recruited to the ED, who may need support from colleagues and organisations. ED nurses therefore need to be competent in intercultural communication. This involves combining optimal interpersonal skills with cultural awareness, knowledge and sensitivity. [ABSTRACT FROM AUTHOR]

The article discusses findings of a literature review on the factors that affect nurses' triage decisions in the emergency department. The study found that experienced nurses use triage algorithms to aid decision-making. Patient factors are presenting complaints, vital signs, visual presentation, verbal history or communication issues and attributes, while nurse factors are experience, intuition, training and risk. Environmental factors are physical environment, workload and staffing.

Why you should read this article: • To enhance your understanding of the role of the emergency nurse in preventing pressure ulcers • To familiarise yourself with strategies for preventing pressure ulcers in the emergency department (ED) • To learn about embedding pressure ulcer prevention into the ED workflow Patients can develop pressure ulcers within a few hours of entering an emergency department (ED). However, despite the critical role of EDs in reducing the incidence of pressure ulcers, few have protocols in place for prevention. This article describes the prevention emergency project (PEP), a quality improvement project undertaken in the ED at Karolinska University Hospital in Sweden to reduce the incidence of pressure ulcers. The article demonstrates how four simple nurse-led changes – early risk assessment, pressure-relieving equipment, intentional rounding, and using prophylactic dressings and incontinence pads – can reduce the incidence of pressure ulcers significantly when integrated into ED workflow. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To identify the importance of preparation for autonomous practitioners when breaking bad news in the emergency department (ED) • To consider further training to improve autonomous practitioners' expertise and skill in breaking bad news in the ED • To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers) • To contribute towards your professional development and local registration renewal requirements (non-UK readers) Breaking the news of potentially serious and new diagnoses to patients in the emergency department (ED) is a common but challenging aspect of the autonomous practitioner's role. It is a complex process, requiring expertise and skill. If the news is delivered appropriately there is evidence to suggest a beneficial effect on the patient's ability to cope, yet there is little formal training available and literature focused on the ED setting is limited. This article aims to guide and prepare autonomous practitioners in the ED to break bad news to patients, including during remote consultations introduced due to the coronavirus disease 2019 pandemic. It identifies the importance of preparation; different approaches to breaking bad news, namely the six-stage SPIKES framework and a case study exploring its application in practice; the range of potential patient reactions and how these can be managed, including the provision of support; and how to involve and communicate with other members of the multidisciplinary team. Suggestions for further training are outlined. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To recognise the need for the rapid triage evaluation of patients with coronavirus disease 2019 (COVID-19) who present to the emergency department (ED) • To recognise the typical characteristics of patients with COVID-19 presenting to the ED who require early continuous positive airway pressure (CPAP), based on vital signs measurements • To learn about a triage flow chart that has the potential to be used to identify patients with COVID-19 who require early CPAP Background: The coronavirus disease 2019 (COVID-19) can result in severe pneumonia, leading to acute respiratory distress syndrome, which are treated using continuous positive airway pressure (CPAP). Patients must be evaluated quickly to commence early CPAP if required. Aim: To identify patients with COVID-19 in the emergency department (ED) who require early CPAP, using vital signs measurements during triage. Method: This was a retrospective, observational, single-centre cohort study of patients with COVID-19 admitted to the ED of a university hospital in Lombardy, Italy, between 21 February 2020 and 30 April 2020. These patients were divided into two groups: those who required CPAP and those did not require CPAP. Recordings of their vital signs were retrieved from triage medical records. The vital signs values recorded in the two groups on their arrival at the ED were compared. Results: Of 601 patients, 120 (20%) required CPAP. It was identified that the typical characteristics of patients requiring early CPAP were: male (P=.013) with a median age of 68 years (P=.000), oxygen saturation of 92% (P=.000), temperature ≥38°C (P=.008), respiratory rate of 26 breaths per minute (P=.000) and had received pre-hospital oxygen therapy before arriving at the ED (P=.000). The CPAP group was divided into two subgroups: patients who had received pre-hospital oxygen therapy and those who had not. The median respiratory rate values between the two subgroups presented a statistically significant difference (P=.004). Conclusion: This study identified the characteristics of a typical patient with COVID-19 who requires early CPAP. Based on the results, the authors have devised a triage flow chart that uses selected vital signs measurements (oxygen saturation, respiratory rate and receipt of pre-hospital oxygen therapy) to identify patients requiring early CPAP. This flow chart should be trialled in a prospective study before it is used to inform clinical decision-making. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To improve your understanding of the causes and risk factors for violent or aggressive patient behaviour • To identify strategies that nurses and healthcare organisations can use to reduce violence and aggression • To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers) • To contribute towards your professional development and local registration renewal requirements (non-UK readers) Half of all reported violent incidents in healthcare settings occur in the emergency department (ED), so ED nurses are disproportionately affected by violence and aggression. Violence and aggression can cause physical injury, psychological harm, delays to patient care, eroded staff morale, increased sick leave and low staff retention. This article explores potential causes and risk factors for violent or aggressive behaviour from patients and visitors in the ED. It discusses risk assessment tools, management approaches and risk reduction strategies that can be used in the ED to tackle violence and aggression. The article also features a case study describing a successful small-scale trial of body-worn cameras at an East London ED. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To understand how zygomatic complex fractures present in the emergency department • To learn the signs and symptoms that can alert you to a potential zygomatic complex fracture • To recognise when to refer patients presenting with midface trauma to the oral and maxillofacial team Falls, assaults, road traffic accidents and sporting injuries are some of the common causes of facial bone fractures. Fractures to the zygomatic complex, or cheekbone, are one of the most common fractures to the facial skeleton. These fractures can be easily missed on assessment and examination and thus left undiagnosed. This can lead to aesthetic deformities to the facial region and, rarely, orbital compartment syndrome due to a retrobulbar haemorrhage or other ocular complications. Emergency department advanced nurse practitioners are usually the clinicians responsible for ensuring that patients with zygomatic complex fractures are screened, investigated and escalated appropriately. The aim of this article is to inform readers of the strategies and methods for diagnosing and managing patients with zygomatic complex fractures, including when these types of injuries need to be referred to the oral and maxillofacial team. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To recognise the severity of workplace violence towards emergency department (ED) nurses • To be aware of the findings of exploratory research that examined experiences of ED nurses in Indonesia of workplace violence • To identify strategies to reduce and prevent workplace violence in the ED Background: Workplace violence in hospitals is common and underreported. It has adverse effects professionally and personally for victims, and can have a negative effect on the quality of patient care. Aim: To explore Indonesian emergency department (ED) nurses' experiences of workplace violence. Method: This exploratory qualitative study used five sessions of focus group discussion. The participants were recruited from a referral hospital in a regional area of East Java province, Indonesia, using purposive sampling. Thematic analysis was used to analyse the data. Findings: A total of 13 ED nurses participated. Four themes and three sub-themes were identified: (1) Disrupting the rule; (2) Feeling unsafe; (3) Governing the case with the sub-themes mitigating violence, improving reporting flow and receiving follow-up; and (4) Keeping for myself. Conclusion: Managing workplace violence is crucial for the provision of high-quality nursing care in the ED. Hospital management's commitment to zero tolerance of violence is an important statement of support for nurses. Zero tolerance could be shown by improving safety in the ED, simplifying reporting systems and educating and training staff in responding to incidents, and de-escalation techniques. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To be aware of the association between post-traumatic stress and professional quality of life among pre-hospital emergency staff • To consider that staff with an optimal professional quality of life may provide improved care • To recognise the need for supportive interventions for pre-hospital emergency staff at risk of post-traumatic stress Background: Pre-hospital emergency staff are exposed to several occupational stressors that may have an adverse effect on their mental health and result in burnout, fatigue and symptoms of post-traumatic stress. Consequently, their professional quality of life may be adversely affected. Healthcare services may also be affected, for example, through absenteeism and loss of productivity. Aim: To determine the relationship between symptoms of post-traumatic stress and professional quality of life among pre-hospital emergency staff. Method: A cross-sectional, correlational design was adopted. Data collection tools included the PTSD (post-traumatic stress disorder) Checklist and the Professional Quality of Life Scale. Questionnaires were distributed by email to a random sample of 150 pre-hospital emergency staff from several pre-hospital emergency centres affiliated to a university of medical sciences in Iran. Results: Questionnaire responses were received from 150 pre-hospital emergency staff, a response rate of 100%. The mean score for PTSD was 33.9 (standard deviation (SD)=8.7), which indicated that respondents had moderate symptoms of post-traumatic stress. The mean score for professional quality of life was 122.5 (SD=13.4), which indicated that respondents were at a moderate level in terms of burnout and secondary traumatic stress, but a high level in terms of compassion satisfaction. There was a significant inverse relationship between symptoms of post-traumatic stress and professional quality of life (P<0.000): when symptoms of post-traumatic stress increased, respondents' professional quality of life decreased. Conclusion: Appropriate interventions are required to prevent the development of job-related PTSD and improve the professional quality of life of pre-hospital emergency staff. [ABSTRACT FROM AUTHOR]

Dementia symptoms can manifest in a variety of ways, such as anxiety, agitation and an inability to communicate unmet needs. In emergency departments (EDs), these symptoms, as well as various environmental factors, can lead to behaviour that challenges in people with dementia. Therefore, ED staff must be skilled in screening, assessing and managing this patient group effectively. This article details a literature review that was conducted to explore the evidence on managing behaviour that challenges in people with dementia in the ED and what de-escalation strategies may be useful. A literature search of eight databases was undertaken, resulting in 11 articles that were included in this literature review. Four main themes were identified: violence and aggression towards staff; manual and chemical restraint in the ED; identifying delirium and dementia; and environment and person-centred care. Strategies identified to de-escalate and reduce the risk of behaviour that challenges include: making environmental modifications to the ED; providing person-centred care; excluding or evaluating pain and unmet needs; using various tools and strategies to improve communication; and using distraction techniques. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To recognise the legal responsibility to provide equal access to care for people with learning disabilities who attend the emergency department (ED) by making reasonable adjustments • To identify approaches that can ensure people with learning disabilities who attend the ED receive equitable and timely care • To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers) • To contribute towards your professional development and local registration renewal requirements (non-UK readers) Healthcare professionals are legally obliged to make reasonable adjustments to ensure that people, including those with learning disabilities, can access appropriate and timely care. However, although people with learning disabilities are high users of general health services, staff have little understanding of learning disability with a negative effect on patient experience and outcomes. This article explores some of the challenges experienced by people with learning disabilities in the emergency department (ED). Each section focuses on a different aspect of how to adjust the delivery of healthcare to meet their needs, along with exercises to ensure those adjustments have been understood and to provide practical learning outcomes. Personal stories are also used to identify examples of when and where these adjustments could have been used to provide equal healthcare in the ED. [ABSTRACT FROM AUTHOR]

AUTH Why you should read this article: • To understand how upskilling emergency department (ED) staff could assist in addressing workload challenges • To learn the views of nurses and physicians on transferring skills from doctors to nurses, and from nurses to healthcare assistants • To recognise the barriers to expanding the nurse's role in the ED Background: Emergency departments (EDs) in New Zealand are experiencing growing demand because of rising attendances, and this is having a negative effect on patients, staff and organisations. The expansion of traditional nursing roles is one solution that has been explored internationally to ameliorate the adverse effects of increasing patient attendances. Aim: To explore the attitudes of registered nurses and physicians employed in emergency medicine towards an expanded role for registered nurses in the ED setting. Method: A mixed-methods approach was adopted, in which data were collected in two phases, using interviews and questionnaires. Semi-structured, face-to-face interviews were held with clinical and non-clinical staff employed in emergency medicine, and questionnaires were distributed to 140 physicians and nurses employed in one ED. The data were analysed to identify themes and to determine the differences between nurse and physician respondents. Findings: Ten ED staff were interviewed, including non-clinical managers (n=4), physicians (n=2) and nurses (n=4). Analysis of the interviews identified five themes: driving change; expanded nurse role; optimal environment; facilitating change; and optimising outcomes for patients. A total of 70 questionnaires were returned, with 63 from nurses and seven from physicians. Nurse respondents were more supportive than their physician colleagues of the need to expand the nursing role in the ED. Conclusion: The existing New Zealand nursing scope of practice has the capacity to develop roles, with nurses supporting this change more than physicians. If role expansion is undertaken, serious consideration needs to be given to developing clear professional boundaries to maintain patient safety and department flow. [ABSTRACT FROM AUTHOR]

AUTH Why you should read this article: • To recognise the issues that patients and family members commonly experience in the emergency department (ED) • To enhance your knowledge of the main factors that can influence patients and family members' satisfaction with ED care • To identify the improvements that could be made to care in the ED Background: Patient experience and satisfaction are often used to evaluate the quality of care provided in emergency departments (EDs). Several studies have evaluated the experiences of patients and their family members in EDs internationally, but few studies have investigated the experiences of those attending EDs in Iran. Aim: To investigate patients and family members' experiences of care in one ED in Iran. Methods: Semi-structured interviews were conducted with 17 patients and ten family members in one ED in Tehran, Iran. A qualitative content analysis approach was used to analyse the data. Findings: Three themes emerged from the data: quality of nursing care; satisfaction with medical care and waiting times; and adequate diagnostic testing and equipment. Participants reported several issues in relation to the care provided in the ED, including a lack of attention from nursing staff, long waiting times, delays in symptom management, and family members' involvement in care to compensate for high staff workload and overcrowding. Conclusion: The findings of this study demonstrate that the most important determinants of patients and family members' experiences in EDs are the quality of nursing and medical care, the length of waiting times, and adequate diagnostic testing and equipment. While it may be beneficial to involve family members in patient care, regular communication with them is essential to explain challenging situations that may affect the quality of ED care, such as low staff levels. [ABSTRACT FROM AUTHOR]

AUTH Why you should read this article: • To understand the treatment options available for children with buckle fractures • To learn how soft casting could be more effective in managing buckle fractures than the traditional method of using a rigid cast • To explore ways in which you could improve the management of buckle fractures in your area of practice Buckle fractures of the distal radius are unique to children and a frequent presentation in the emergency department (ED). In University Hospital Waterford, Ireland, the treatment of buckle fractures followed the traditional method involving a rigid cast and a follow-up hospital appointment. However, the latest literature indicates that buckle fractures are stable and heal without complication, so a minimalist approach to treatment is recommended. Therefore, the advanced nurse practitioners in the ED introduced a change in protocol at the hospital. This involved the use of a soft cast for removal at home, with verbal and written discharge information and no follow-up appointment. An audit was conducted to ensure that this new protocol was safe and effective, and the time and distance saved by patients through avoiding a return hospital visit was estimated. Treatment in a soft cast with verbal and written discharge information revealed a successful outcome for all 88 patients included in the audit. Avoiding return hospital visits resulted in significant travel time and distance savings for patients and families. [ABSTRACT FROM AUTHOR]

AUTH Why you should read this article: • To enhance your knowledge of the different types of mallet finger injury • To explore the different splints available for immobilising a closed tendinous mallet finger injury • To understand the importance of optimal patient education and patient adherence Mallet finger injuries are a common presentation in the emergency department. These injuries result from a forced flexion at the distal interphalangeal joint (DIPJ) that causes extensor tendon disruption, and possibly bone avulsion, at the base of the distal phalanx. This article describes the anatomy, mechanisms, classification and assessment of mallet finger injury. It reviews different types of splints used in the conservative management of closed tendinous mallet finger injury and discusses the latest evidence regarding immobilisation methods and treatment duration. Maintaining the DIPJ in extension during treatment is essential, so the article stresses the importance of patient adherence to treatment. [ABSTRACT FROM AUTHOR]

AUTH Why you should read this article: • To recognise why timely medicines reconciliation is important in the emergency assessment unit (EAU) • To understand the barriers to timely medicines reconciliation in the EAU • To identify potential methods of improving medicines reconciliation in the EAU Background: Medicines reconciliation is the process of creating and maintaining the most accurate list possible of all medicines a patient is taking. If medicines reconciliation cannot be completed in a timely manner in hospital emergency assessment units (EAUs), delays in treatment can occur, potentially leading to deterioration of long-term and acute conditions, patient distress and complaints. Aim: To obtain the perspectives of staff working on an EAU regarding the time patients wait for their medicines to be prescribed, including their awareness of practice and protocols. To determine the time from admission to the EAU until medicines reconciliation, and to identify if there was any time difference in medicines reconciliation according to the day of admission. Method: This was a service evaluation in which staff working in one EAU in a teaching hospital in the north east of England were asked to complete a survey in December 2017. The staff survey aimed to ascertain: whether staff were aware of any guidance relating to medicines reconciliation times; how long they thought the average waiting time was for medicines reconciliation; and if they thought there were implications for patients or staff as a result of time spent waiting for medicines reconciliation. In addition, an audit was performed analysing medicines reconciliation times for all patients admitted to the EAU during the month of December 2017. Results: A total of 30 staff members responded to the survey. While 40% (n=12) of respondents believed that the EAU had an efficient system in place for timely medicines reconciliation, 90% (n=27) believed the unit could still improve. Almost half the respondents (47%, n=14) perceived a delay in medicines reconciliation could result in exacerbation of patients' physical conditions. The clinical audit identified considerable variation in medicines reconciliation times, ranging from seven minutes to almost 24 hours. However, most medicines (82%) were reconciled within six hours. Conclusion: This service evaluation found that the median time after arrival in the EAU until completion of medicines reconciliation was two hours 48 minutes. However, almost one fifth of patients had to wait for more than six hours, and in one instance almost 24 hours. One potential solution could be increasing the involvement of hospital pharmacists or pharmacy technicians in medicines reconciliation. [ABSTRACT FROM AUTHOR]

Rhabdomyolysis is a rare and complex condition that involves injury of the skeletal muscle fibres, resulting in the release of substances such as creatine kinase and myoglobin. It is associated with acute kidney injury and mortality. This article describes the case of a 40-year-old man who presented to the emergency department after an overdose of tramadol hydrochloride. It uses critical reflection to explore traumatic and non-traumatic causes of rhabdomyolysis and reviews the literature relating to the diagnosis of rhabdomyolysis through laboratory and point-of-care testing. To ensure the timely identification of patients at risk of deterioration, emergency nurses need to be aware of the potential causes and the clinical signs and symptoms of rhabdomyolysis. [ABSTRACT FROM AUTHOR]

Background: Frequent service users, frequent attenders and high intensity users comprise a small proportion of emergency department (ED) visits but have a significant effect on cost and workload and are often ineffectively managed in healthcare settings. A new frequent service user manager (FSUM) service was set up in west Kent. This service used a case management approach to address the issue of frequent ED attendance and to support the well-being of these patients. Aim: To evaluate a pilot FSUM service designed to address the frequent use of urgent care services. Method: Service data on demographics, loneliness, anxiety, quality of life and urgent care service use were obtained for 24 frequent service users in one west Kent ED. Interviews were also undertaken with a sample of these patients (n=4) to capture their experiences of using the FSUM service. Results: The main presenting symptoms for attending the ED were pain and alcohol-related issues. After 12 months of the FSUM service, loneliness, anxiety and use of urgent care services had reduced. The participants' quality of life improved from baseline to four months, but then stabilised at 12 months. Conclusion: This evaluation demonstrated the value of taking a case management approach to address the needs of frequent service users. Healthcare services must encourage the appropriate use of urgent care services to reduce system pressures, but also to improve the well-being of patients. [ABSTRACT FROM AUTHOR]

Patients commonly present to UK emergency departments with injuries to the tips of their fingers. Mallet finger is one of the most common injuries, resulting from an injury to the extensor tendon over the dorsal surface of the distal phalanges of the hand. Timely recognition, diagnosis and management are required to prevent complications. This article provides an overview of the pathophysiology, signs, symptoms, diagnosis and management of mallet finger injuries. [ABSTRACT FROM AUTHOR]

AUTH Why you should read this article: • To be aware of the common types of prescribing errors that can occur in emergency departments (EDs) • To enhance your knowledge of the information required on prescribing forms for a medicine to be dispensed • To identify methods of reducing the rate of prescribing errors in the ED Background: Prescribing errors are a subset of medication errors that occur on the forms used to prescribe medicines for patients. On their discharge from the emergency department (ED), many patients are given a prescription form to obtain medicines from their local community pharmacist. On the identification of a prescribing error, the patient is sent back to the ED because the medicine cannot be dispensed. Aim: To identify the most common prescribing errors on prescriptions returned to one large inner-city ED in South Wales from community pharmacies. Method: Prescriptions that were returned to the ED over a six-week period from September and October 2016 were analysed to determine the types of prescribing errors that occurred and their frequency. Results: A total of 10,218 patients attended the ED over the six-week period, of which 7,731 patients were seen by a clinician and discharged home. Of these, 322 patients were discharged with a prescription, and 20 (6%) of these patients returned to the ED with a prescribing error that prevented the pharmacist from dispensing the medicines. The most common prescribing error was incorrect or missing prescriber information. Conclusion: This study identified that there was a low rate of prescribing errors in the ED, and this was comparable with the rate of prescribing errors identified in the literature. Common prescribing errors could be mitigated through the introduction of electronic prescribing in the ED. [ABSTRACT FROM AUTHOR]

AUTH Why you should read this article: • To understand the pressures involved in ensuring patient safety in the emergency department • To learn about the theory underpinning problem-based learning and team-based learning • To recognise that these teaching methods can enable learners to address patient safety challenges encountered in clinical practice Pressures from rising patient numbers and overcrowding in emergency departments (EDs) are putting patients' safety at risk. Beyond improved provision of resources, two elements are essential to patient safety in emergency care – work culture and staff training. In traditional training environments, the teacher dispenses knowledge to nursing students in a classroom setting. However, problem-based learning (PBL) and the related concept of team-based learning (TBL) aim to enhance learners' knowledge and skills in non-technical subjects, such as patient safety, as well as their ability to address challenges they encounter in clinical practice. This article explores the theories that underpin PBL and TBL and discusses how they can be used by nurse educators to motivate staff and improve patient safety in the ED. [ABSTRACT FROM AUTHOR]

Supporting and managing end of life in emergency departments (EDs) is often difficult and is becoming increasingly commonplace. Patients who present at the end of life are often triaged as low priority as their signs and symptoms are not considered life-threatening and they are often exposed to unnecessary and inappropriate tests and investigations. This results in increased stress and distress for patients and their family and carers in an environment that is not suited to this type of care. There are few specified palliative care pathways that provide the level of care required by these patients. This article describes the Time is Precious (TiP) project, the development of a palliative care decision-making framework to support and address the needs of patients who present to an ED at end of life, in a timely and appropriate manner. It also reports findings of an evaluation of TiP that show patients are identified more quickly and cared for more appropriately as nursing and medical care can be tailored to meet their needs. [ABSTRACT FROM AUTHOR]