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Aims: This paper aims to identify the frequency and nature of evidence-practice gaps in the initial neuro-protective nursing care of patients with moderate or severe traumatic brain injury provided by Thai trauma nurses., Background: Little is known about how Thai trauma nurses use evidence-based practice when providing initial neuro-protective nursing care to patients with moderate or severe traumatic brain injury., Design: A mixed methods design was used to conduct this study., Methods: Data were collected from January to March 2017 using observations and audits of the clinical care of 22 patients by 35 nurses during the first 4 h of admission to trauma ward. The study site was a regional hospital in Southern Thailand., Results: The major evidence-practice gaps identified were related to oxygen and carbon dioxide monitoring and targets, mean arterial pressure and systolic blood pressure targets and management of increased intracranial pressure through patient positioning and pain and agitation management., Conclusion: There were evidence-practice gaps in initial neuro-protective nursing care provided by Thai trauma nurses that need to be addressed to improve the safety and quality of care for Thai patients with moderate or severe traumatic brain injury., (© 2020 John Wiley & Sons Australia, Ltd.)

Background: Clinical leadership is fundamental to patient safety. The Emergency Department (ED) nurse-in-charge is a key leadership role; however, few studies have explored the management of clinical deterioration from the ED nurse-in-charge perspective. The aim of this study was to explore ED nurses-in-charge' perceptions of their role in responding to episodes of escalation of care for clinical deterioration of ED patients., Methods: A prospective exploratory descriptive design was used to address the study aims. The study was conducted in an urban ED in Melbourne, Australia. Senior emergency nurses who fulfilled the role of being in charge of the ED were invited to participate. In-depth semi-structured interviews were conducted between December 2015 and March 2016. Interview transcripts were analysed using thematic analysis., Results: Two major themes, each with two subthemes were identified. The first major theme of Clinical Risk Management comprised sub-themes of Clinical Skills and Confidence. The second major theme of Resource Management comprised sub-themes of Human Resource Management and Logistical Resource Management., Conclusions: Strong collaboration, logistical and clinical risk management roles were perceived as fundamental to the nurse-in-charge's capacity to respond to escalations of care for clinical deterioration within in a complex team environment such as the ED., (Copyright © 2020 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.)

Aims and Objectives: To explore the factors emergency nurses use to inform their decisions regarding frequency and nature of vital sign assessment., Background: Research related to clinical deterioration and vital sign assessment in the emergency department is in its infancy. Studies to date have explored the frequency of vital sign assessment in the emergency department; however, there are no published studies that have examined factors that emergency nurses use to inform their decisions regarding frequency and nature of ongoing vital sign assessment., Design: A prospective exploratory design was used. Data were collected using a survey consisting of eight patient vignettes., Methods: The study was conducted in one emergency department in metropolitan Melbourne. Participants were emergency nurses permanently employed at the study site., Results: A 96% response rate was achieved (n = 47/49). The most common frequency of patient reassessment nominated by participants was 15 or 30 minutely, with an equal number of participants choosing these frequency intervals. Abnormality in initial vital sign parameters was the most common factor identified for choosing either a 15- or 30-minute assessment interval. Frequency of assessment decisions was influenced by years of emergency nursing experience in one vignette and level of postgraduate qualification in three vignettes. Heart rate, respiratory rate and blood pressure were all nominated by over 80% of participants as vital signs that participants considered important for reassessment. The frequency and nature of vital signs selected varied according to vignette content. There were significant negative correlations between assessment of conscious state and years of nursing experience and assessment of respiratory rate and years of emergency nursing experience. Level of postgraduate qualification did not influence selection of parameters for reassessment., Conclusion: Emergency nurses are tailoring vital sign assessment to patients' clinical status, and nurses are integrating known vital sign data into vital sign decision-making., Relevance to Clinical Practice: Accurate assessment and interpretation of vital sign data is fundamental to patient safety. Emergency nurses are responsible for the initial and ongoing assessment of undiagnosed or undifferentiated patients. Prior to medical assessment, emergency nurses are solely responsible for patient assessment, escalation of care and implementation of interventions within nursing scope of practice., (© 2016 John Wiley & Sons Ltd.)

Background: Team-based learning (TBL) is a highly structured educational strategy that improves student engagement, promotes deeper learning and builds professional skills but has had limited use in nursing education., Aims: To examine participant experiences of TBL using one-off teams in a hospital setting., Method: A prospective exploratory design was used in an urban district hospital in Melbourne, Australia. The sample was 49 registered nurses. The intervention was a TBL-based education program focused on assessment and management of adult patients with isolated distal limb injuries. Data were collected using two instruments that evaluated participant experiences of the narrated slide presentation and participant experiences of learning of using TBL. Quantitative data were analysed using descriptive statistics and thematic analysis was used to analyse the qualitative data., Results: The results revealed two key themes: "quality of learning" and "positive team experience". The presentation was accessed twice or more by 51% of participants. Participants perceived a high quality of learning: 95.5% stated that their learning expectations were met or exceeded. Three quarters of participants (77.5%) commented about the contribution of their team members., Conclusion: Participants in this study thought TBL provided them a positive learning experience, as individuals and as teams. Education methodologies that focus on professional attributes and behaviours in addition to clinical skill are well suited to emergency nursing whereby nurses have to be theoretically prepared for practice and work well in teams., Relevance to Clinical Practice: TBL has a natural synergy with the requirements of advanced nursing practice and offers a positive learning experience that enhances clinical outcomes., (Copyright © 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.)

Recognising and responding to clinical deterioration is a safety priority. The aim of this study was to determine the frequency, nature, and response of emergency department Nursing Shift Leaders to episodes of escalation of care for patient clinical deterioration. A prospective exploratory descriptive design was used. Participants were recruited from the senior nurses at the study site that fulfilled the role of being in charge of the ED. Study data were collected between 29 October and 17 December 2015 across various shifts using an observation tool developed specifically for this study. This study had three major findings. First, escalation of care for clinically deteriorating patients to the Nursing Shift Leader occurs frequently. There were 37 observed escalations of care, equating to 1.02 episodes per hour. Second, Nursing Shift Leaders rely on clinical emergency nursing skills to recognise, prioritise and respond to escalation of care for clinically deteriorating patients. Finally, the Nursing Shift Leaders' role in responding to escalation of care for clinical deterioration is multifaceted. The Nursing Shift Leaders' role in responding to escalation of care for clinical deterioration is complex and includes navigation of a multifaceted team environment and logistical challenges unique to the time pressured, unpredictable ED milieu. [ABSTRACT FROM AUTHOR]

Aims and objectives To explore the characteristics of and interactions between clinicians, patients and family members during management of the deteriorating adult patient in the emergency department. Background Previous research into family presence during resuscitation has identified many positive outcomes when families are included. However, over the last three decades the epidemiology of acute clinical deterioration has changed, with a decrease in in-hospital cardiac arrests and an increase in acute clinical deterioration. Despite the decrease in cardiac arrests, research related to family presence continues to focus on care during resuscitation rather than care during acute deterioration. Design Descriptive exploratory study using nonparticipatory observation. Methods Five clinical deterioration episodes were observed within a 50-bed, urban, Australian emergency department. Field notes were taken using a semistructured tool to allow for thematic analysis. Results Presence, roles and engagement describe the interactions between clinicians, family members and patients while family are present during a patient's episode of deterioration. Presence was classified as no presence, physical presence and therapeutic presence. Clinicians and family members moved through primary, secondary and tertiary roles during patients' deterioration episode. Engagement was observed to be superficial or deep. There was a complex interplay between presence, roles and engagement with each influencing which form the other could take. Conclusions Current practices of managing family during episodes of acute deterioration are complex and multifaceted. There is fluid interplay between presence, roles and engagement during a patient's episode of deterioration. Relevance to clinical practice This study will contribute to best practice, provide a strong foundation for clinician education and present opportunities for future research. [ABSTRACT FROM AUTHOR]

Background Understanding of clinical deterioration of emergency department patients is rapidly evolving. The aim of this study was to investigate the frequency and nature of vital sign collection and clinical deterioration in emergency care. Methods A descriptive exploratory approach was used. Data were collected from the records of 200 randomly selected adults with presenting complaints of abdominal pain, shortness of breath, chest pain and febrile illness from 1 January to 31 December 2014 at a 22 bed emergency department in Melbourne, Australia. Results When controlled for length of stay, heart rate was the most frequently assessed vital sign per hour (median = 0.9) whilst Glasgow Coma Score was the least frequently assessed vital sign per hour (median = 0.5). Clinical deterioration (one or more vital signs fulfilling hospital medical emergency team activation criteria during emergency department care) occurred in 14.5% of patients. Of the 5466 vital sign measures, 19.6% were abnormal, 1.9% indicated clinical deterioration. Conclusions Clinical deterioration occurred in one in seven patients, and one in five vital signs documented were outside of accepted normal ranges. Thus, emergency department physiological status has implications for patient safety and nursing practice, in particular clinical handover for patients requiring hospital admission. [ABSTRACT FROM AUTHOR]

Summary Background The nature of acute clinical deterioration has changed over the last three decades with a decrease in in-hospital cardiac arrests and an increase in acute clinical deterioration. Despite this change, research related to family presence continues to focus on care during resuscitation rather than during acute deterioration. Aim To explore healthcare clinician attitudes, beliefs and perceptions of current practices surrounding family presence during episodes of acute deterioration in adult Emergency Department patients. Methods Clinicians ( n = 156) from a single study site in Melbourne, Australia completed a 17-item survey. Results Participants disagreed that family members would interrupt (59.0%) or interfere (61.5%) with patient care if present during episodes of patient deterioration. Most (77.6%) participants stated that they included family during episodes of patient deterioration. Females, nurses and Australians/New Zealanders had a more positive attitude towards including family during episodes of patient deterioration when compared to males, doctors and clinicians of other ethnicities. Nurses with post-graduate qualifications and those with more years of experience had a more positive attitude towards including family during episodes of patient deterioration than nurses without post-graduation qualification and with less years of experience. Conclusions Clinicians had predominantly positive attitudes towards including family during episodes of patient deterioration and perceived it to be a common day-to-day practice. Gender, profession, country of birth, education level and years of experience all impacted on clinician attitudes, beliefs and perceptions of family presence during acute deterioration. [ABSTRACT FROM AUTHOR]

Aims To examine the relationship between physiological status at the emergency department-ward interface and emergency calls (medical emergency team or cardiac arrest team activation) during the first 72 hours of hospital admission. Background Ward adverse events are related to abnormal physiology in emergency department however the relationship between physiology at the emergency department-ward interface and ward adverse events is unknown. Design Descriptive and exploratory design. Methods The study involved 1980 patients at three hospitals in Melbourne Australia: i) 660 randomly selected adults admitted via the emergency department to medical or surgical wards during 2012 and who had an emergency call; and ii) 1320 adults without emergency calls matched for gender, triage category, usual residence, admitting unit and age. Results/findings The median age was 78 years and 48·8% were males. The median time to the first emergency call was 18·8 hours and ≥1 abnormal parameters were documented in 34·9% of patients during the last hour of ED care and 47·1% of patients during first hour of ward care. Emergency calls were significantly more common in patients with heart rate and conscious state abnormalities during the last hour of emergency care and abnormal oxygen saturation, heart rate or respiratory rate during the first hour of ward care. Medical emergency team afferent limb failure occurred in 55·3% patients with medical emergency team activation criteria during first hour of ward care. Conclusion The use of physiological status at the emergency department-ward interface to guide care planning and reasons for and outcomes of medical emergency team afferent limb failure are important areas for future research. [ABSTRACT FROM AUTHOR]

Aims and objectives. To explore nurses' documentation of physiological observations in acute care; emergency department, medical and surgical units. Background. In Australia, physiological observations include respiratory rate, oxygen saturation, heart rate, blood pressure, temperature and level of consciousness. There is a clear relationship between abnormal physiological observations and adverse events. Nurses have highest level of responsibility for accurate measurement, interpretation and documentation of physiological observations. Design. A descriptive exploratory design was used and the study data were collected using a prospective point prevalence approach between 25 July 2012-22 August 2012. Methods. The study was conducted in the emergency department, two 30-bed medical units and one 30-bed surgical unit of a 578 bed public health service in Melbourne, Australia. All adult patients aged >18 years present during data collection periods were eligible for inclusion. Patients in the emergency department resuscitation area were excluded. Patient characteristics and physiological observations for the preceding 24 hours in ward patients or eight hours in emergency department patients were collected. Results. One hundred and seventy-eight patients were included; 38 emergency department patients, 84 medical patients and 56 surgical patients. The median age was 72-5 years and 43-8% were males. The most frequently documented physiological observations were respiratory rate, oxygen saturation, heart rate and systolic blood pressure. The least frequently recorded physiological observations were temperature and conscious state. One or more abnormal physiological parameters was documented in 79-8% (n = 142) patients; evidence of reporting abnormalities was documented in 19-7% of patients (n = 28/142). When controlled for length of stay, physiological observations were more frequently documented in the emergency department. Conclusions. There was variability in the number of parameters documented and frequency of physiological observations documented by nurses. Relevance to clinical practice. Physiological abnormalities that do not necessarily fulfil rapid response team activation criteria are common in acute care patients and provide nurses with an opportunity for early recognition of deteriorating patients. [ABSTRACT FROM AUTHOR]

Summary Background Despite emerging evidence regarding clinical deterioration in emergency department (ED) patients, the widespread uptake of rapid response systems (RRS) in EDs has been limited. Aims To evaluate the effect of an ED RRS on reporting of clinical deterioration and determine if there were differences between patients who did, and did not, deteriorate during ED care. Methods A retrospective cross sectional design was used to conduct this single site study in Melbourne, Australia. Stratified random sampling identified 50 patients with shortness of breath, chest pain or abdominal pain per each year studied (2009–2012) giving a total of 600 patients. The intervention was an ED RRS implemented in stages. Results The frequency of clinical deterioration was 14.8% (318 episodes/89 patients). Unreported deterioration decreased each year (86.7%; 68.8%; 55.3%; 54.0%, p = 0.141). Patients who deteriorated during ED care had a longer median ED length of stay (2.8 h; p < 0.001), were 31.9% more likely to need hospital admission ( p < 0.001) and 4.9% more likely to die in hospital ( p = 0.044). Conclusions A staged ED specific RRS decreased the frequency of unreported clinical deterioration. Controlled multi-site studies of ED specific RRSs are needed to examine the effect of formal ED RRSs on patient outcomes. [ABSTRACT FROM AUTHOR]

Summary Despite many studies of family presence during resuscitation, no validated tool exploring the attitudes and beliefs of healthcare staff towards family presence has been published. The aim of this paper is to describe the development of a tool to accurately measure the attitudes and beliefs of emergency department staff towards family presence in the deteriorating adult patient, present the results of validity and reliability testing, and present the final validated tool. Twenty-nine items were developed, informed by themes from the literature and unvalidated published tools related to family presence during resuscitation. The tool was piloted on a sample of 68 emergency nursing and medical staff. Content validity and face validity were established using feedback from participants. Reliability was established by unidimensionality, exploratory factor analysis and internal consistency. Sixteen items were deleted from the original tool due to low item-to-total correlations and low communalities. Exploratory factor analysis of the remaining items revealed four factors with acceptable correlation coefficients and appropriate explanation of variance. Cronbach's alpha for each factor was >0.7 indicating a high degree of internal consistency. The four factors were labelled and arranged in a logical order to form the final tool, the Emergency Department Family Presence Survey. [ABSTRACT FROM AUTHOR]

Summary: Background: Triage nurse initiated X-rays (NIXRs) are safe and effective, however, little is known about the ability of other RNs, particularly those without postgraduate qualifications in emergency nursing, to order NIXRs. The aim of this study was to evaluate an innovative NIXR education programme for emergency nurses. Method: The education programme was multi-faceted, delivered using Team-Based Learning (TBL) and augmented by a decision support checklist. Using a prospective exploratory design, 276 NIXR requests from June to December 2011 were audited. Three groups were compared: (i) RNs with and without postgraduate qualifications irrespective of how they were educated in NIXR, (ii) RNs with and without postgraduate qualifications who undertook the NIXR education programme, and (iii) RNs who did and did not undertake the NIXR programme irrespective of postgraduate qualifications. Results: There were 130 NIXRs by 28 RNs with postgraduate qualifications and 146 NIXRs by 12 RNs without postgraduate qualifications. Analysis of all RNs showed RNs without postgraduate qualifications had higher incidence of appropriate NIXRs (83.6% vs 66.2%, p =0.003) however when controlled for the NIXR education programme, statistical significance was lost (83.6% vs 67.5%, p =0.017). RNs who undertook the NIXR education programme had superior documentation of patient assessment findings and higher incidence of appropriate X-ray requests than RNs who did not undertake the NIXR education programme (80.4% vs 65.2%, p =0.042). Conclusions: With appropriate educational preparation, RNs without postgraduate qualifications in emergency nursing can safely engage in NIXR. Structured education using TBL and a decision support checklist produces superior assessment and X-ray requests when compared to ad hoc education and role modelling. [Copyright &y& Elsevier]