Search

Emergency nurses are the first clinicians to see patients in the ED; their practice is fundamental to patient safety. To reduce clinical variation and increase the safety and quality of emergency nursing care, we developed a standardised consensus-based emergency nurse career pathway for use across Australian rural, regional, and metropolitan New South Wales (NSW) emergency departments. An analysis of career pathways from six health services, the College for Emergency Nursing Australasia, and NSW Ministry of Health was conducted. Using a consensus process, a 15-member expert panel developed the pathway and determined the education needs for pathway progression over six face-to-face meetings from May to August 2023. An eight-step pathway outlining nurse progression through models of care related to different ED clinical areas with a minimum 172 h protected face-to-face and 8 h online education is required to progress from novice to expert. Progression corresponds with increasing levels of complexity, decision making and clinical skills, aligned with Benner's novice to expert theory. A standardised career pathway with minimum 180 h would enable a consistent approach to emergency nursing training and enable nurses to work to their full scope of practice. This will facilitate transferability of emergency nursing skills across jurisdictions. [ABSTRACT FROM AUTHOR]

Background: Implementing evidence that changes practice in emergency departments (EDs) is notoriously difficult due to well-established barriers including high levels of uncertainty arising from undifferentiated nature of ED patients, resource shortages, workload unpredictability, high staff turnover, and a constantly changing environment. We developed and implemented a behaviour-change informed strategy to mitigate these barriers for a clinical trial to implement the evidence-based emergency nursing framework HIRAID® (History including Infection risk, Red flags, Assessment, Interventions, Diagnostics, communication, and reassessment) to reduce clinical variation, and increase safety and quality of emergency nursing care. Aim: To evaluate the behaviour-change-informed HIRAID® implementation strategy on reach, effectiveness, adoption, quality (dose, fidelity) and maintenance (sustainability). Methods: An effectiveness-implementation hybrid design including a step–wedge cluster randomised control trial (SW-cRCT) was used to implement HIRAID® with 1300 + emergency nurses across 29 Australian rural, regional, and metropolitan EDs. Evaluation of our behaviour-change informed strategy was informed by the RE-AIM Scoring Instrument and measured using data from (i) a post HIRAID® implementation emergency nurse survey, (ii) HIRAID® Instructor surveys, and (iii) twelve-week and 6-month documentation audits. Quantitative data were analysed using descriptive statistics to determine the level of each component of RE-AIM achieved. Qualitative data were analysed using content analysis and used to understand the 'how' and 'why' of quantitative results. Results: HIRAID® was implemented in all 29 EDs, with 145 nurses undertaking instructor training and 1123 (82%) completing all four components of provider training at 12 weeks post-implementation. Modifications to the behaviour-change informed strategy were minimal. The strategy was largely used as intended with 100% dose and very high fidelity. We achieved extremely high individual sustainability (95% use of HIRAID® documentation templates) at 6 months and 100% setting sustainability at 3 years. Conclusion: The behaviour-change informed strategy for the emergency nursing framework HIRAID® in rural, regional, and metropolitan Australia was highly successful with extremely high reach and adoption, dose, fidelity, individual and setting sustainability across substantially variable clinical contexts. Trial registration: ANZCTR, ACTRN12621001456842. Registered 25 October 2021. [ABSTRACT FROM AUTHOR]

Acute gastroenteritis is a major cause of morbidity and mortality in children. The aim of this study was to explore assessment and management of children aged between 6 and 48 months presenting to the emergency department (ED) with acute gastroenteritis. This retrospective cohort study included 340 children aged 6–48 months. Data were collected by medical record audit for children presenting between 1 January and 31 December 2019. General assessments were appropriate, specific dehydration assessment, blood pressure measurement and fluid balance chart documentation could be improved. Management of children with severe or no/mild dehydration was largely compliant with current recommendations: there was variability in management of children with moderate dehydration. There were no significant differences between Australian Aboriginal and non-Aboriginal children in terms of dehydration severity and pathology abnormalities, however there were differences in management strategies. ED management of children with gastroenteritis was largely consistent with, or superior to, evidence-based recommendations. There was variability in the management of children with moderate dehydration and Australian Aboriginal children but it is unclear whether this is suboptimal or patient specific care. This study has highlighted areas for further research in this unique context. [ABSTRACT FROM AUTHOR]

To determine the impact implementation of Emergency Department Clinical Emergency Response System (EDCERS) on inpatient deterioration events and identify contributing causal factors. EDCERS was implemented in an Australian regional hospital, integrating a single parameter track and trigger criteria for escalation of care, and emergency, specialty and critical care clinician response to patient deterioration. In this controlled pre-post study, electronic medical records of patients who experienced a deterioration event (rapid response call, cardiac arrest or unplanned intensive care admission) on the ward within 72 h of admission from the emergency department (ED) were reviewed. Causal factors contributing to the deteriorating event were assessed using a validated human factors framework. Implementation of EDCERS reduced the number of inpatient deterioration events within 72 h of emergency admission with failure or delayed response to ED patient deterioration as a causal factor. There was no change in the overall rate of inpatient deterioration events. This study supports wider implementation of rapid response systems in the ED to improve management of deteriorating patients. Tailored implementation strategies should be used to achieve successful and sustainable uptake of ED rapid response systems and improve outcomes in deteriorating patients. [ABSTRACT FROM AUTHOR]

Aims and Objectives: To determine if the use of an emergency nursing framework improves the accuracy of clinical documentation. Background: Accurate clinical documentation is a nursing professional responsibility essential for high‐quality and safe patient care. The use of the emergency nursing framework "HIRAID" (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) improves emergency nursing care by reducing treatment delays and improving escalation of clinical deterioration. The effect of HIRAID on the accuracy of nursing documentation is unknown. Design: A quasi‐experimental pre‐post study was conducted and the report was guided by the strengthening the reporting of observational studies in epidemiology (STROBE) checklist. Methods: HIRAID was implemented in four regional/rural Australian emergency departments (ED) using a range of behaviour change strategies. The blinded electronic healthcare records of 120 patients with a presenting problem of shortness of breath, abdominal pain or fever were reviewed. Quantity measures of completeness and qualitative measures of completeness and linguistic correctness of documentation adapted from the D‐Catch tool were used to assess accuracy. Differences between pre‐post groups were analysed using Wilcoxon rank‐sum and two‐sample t‐tests for continuous variables. Pearson's Chi‐square and Fisher exact tests were used for the categorical data. Results: The number of records containing the essential assessment components of emergency care increased significantly from pre‐ to post‐implementation of HIRAID. This overall improvement was demonstrated in both paediatric and adult populations and for all presentation types. Both the quantitative and qualitative measures of documentation on patient history and physical assessment findings improved significantly. Conclusion: Use of HIRAID improves the accuracy of clinical documentation of the patient history and physical assessment in both adult and paediatric populations. Relevance to Clinical Practice: The emergency nursing framework "HIRAID" is recommended for use in clinical practice to increase the documentation accuracy performed by emergency nurses. [ABSTRACT FROM AUTHOR]

Undetected clinical deterioration is a major cause of high mortality events in Emergency Department (ED) patients. Yet, there is no known model to guide the recognition and response to clinical deterioration in the ED, integrating internal and external resources. An integrative review was firstly conducted to identify the critical components of recognising and responding to clinical deterioration in the ED. Components identified from the review were analysed by clinical experts and informed the development of an ED Clinical Emergency Response System (EDCERS). Twenty four eligible studies were included in the review. Eight core components were identified: 1) vital sign monitoring; 2) track and trigger system; 3) communication plan; 4) response time; 5) emergency nurse response; 6) emergency physician response; 7) critical care team response; and 8) specialty team response. These components informed the development of the EDCERS protocol, integrating responses from staff internal and external to the ED. EDCERS was based on the best available evidence and considered the cultural context of care. Future research is needed to determine the useability and impact of EDCERS on patient and health outcomes. [ABSTRACT FROM AUTHOR]

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. 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. 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. 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. [ABSTRACT FROM AUTHOR]

The aim of this study was to examine emergency nurses' activity levels and associations between hourly activity levels within-shifts. Fifty emergency nurses (45 females, 5 males) wore ActiGraph accelerometers and completed work diaries for up to 4 weeks. A sub-group (n = 42) also wore activPALs. Multilevel analyses examined temporal associations between hourly periods. In any hourly period, increased time spent in moderate- to vigorous-intensity physical activity (MVPA) was associated with less time spent in MVPA in the following hourly period. In any afternoon hourly period, increased time spent in MVPA was associated with more time spent in light-intensity physical activity in the following hourly period. No other associations were significant. Emergency nurses maintain activity levels within-shifts, except when more time spent in MVPA was associated with less time spent in MVPA in the following hour; a potential recovery strategy. Future research should determine how emergency nurses maintain their activity levels within-shifts. Practitioner Summary: Emergency nursing is physically demanding; however, it is unknown how active they are during hourly periods within-shifts. Emergency nurses' activity levels were maintained within hourly periods of a shift. Except for an increase in MVPA in 1 h was associated with a decrease in MVPA in the following hour. Abbreviations: CPR: cardiopulmonary resusitation; LPA: light-intensity physical activity; MPA: moderate-intenisty physical activity; MVPA: moderate- to vigorous-intensity physical activity; SED: sedentary [ABSTRACT FROM AUTHOR]

Emergency nurses work consecutive, rotating shift patterns. However, how their occupational physical activity levels are associated between these shifts is unknown. This study aimed to examine the associations between emergency nurses' time spent in different activity levels across one shift and the following day's shift. Fifty emergency nurses (45 female, five male) wore an ActiGraph accelerometer and completed work and sleep diaries across four weeks in 2018. A sub-sample (n = 42) also wore an activPAL inclinometer. Time spent sedentary, physically active, and in postural positions was determined. Multi-level analyses examined associations between one shift and the following day's shift. Additional time spent sedentary and in light-intensity physical activity during the first shift was associated with more time spent being physically active in the following day's shift for all rotations except back-to-back night shifts. However, additional time spent engaged in moderate- to vigorous-intensity physical activity during the first shift was associated with less time spent physically active in the following day's shift for afternoon-morning and morning-afternoon rotations. These findings demonstrate that shift sequences may impact emergency nurses' physical activity across shifts. Future research should identify the strategies emergency nurses use to maintain activity levels between shifts. [ABSTRACT FROM AUTHOR]

Aims and objectives: To examine the relationship between resuscitation status and (i) patient characteristics; (ii) transfer characteristics; and (iii) patient outcomes following an emergency inter‐hospital transfer from a subacute to an acute care hospital. Background: Patients who experience emergency inter‐hospital transfers from subacute to acute care hospitals have high rates of acute care readmission (81%) and in‐hospital mortality (15%). Design: This prospective, exploratory cohort study was a subanalysis of data from a larger case–time–control study in five Health Services in Victoria, Australia. There were 603 transfers in 557 patients between August 2015 and October 2016. The study was conducted in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology guidelines. Methods: Data were extracted by medical record audit. Three resuscitation categories (full resuscitation; limitation of medical treatment (LOMT) orders; or not‐for‐cardiopulmonary resuscitation (CPR) orders) were compared using chi‐square or Kruskal–Wallis tests. Stratified multivariable proportional hazard Cox regression models were used to account for health service clustering effect. Findings.: Resuscitation status was 63.5% full resuscitation; 23.1% LOMT order; and 13.4% not‐for‐CPR. Compared to patients for full resuscitation, patients with not‐for‐CPR or LOMT orders were more likely to have rapid response team calls during acute care readmission or to die during hospitalisation. Patients who were not‐for‐CPR were less likely to be readmitted to acute care and more likely to return to subacute care. Conclusions: Two‐thirds of patients in subacute care who experienced an emergency inter‐hospital transfer were for full resuscitation. Although the proportion of patients with LOMT and not‐for‐CPR orders increased after transfer, there were deficiencies in the documentation of resuscitation status and planning for clinical deterioration for subacute care patients. Relevance to Clinical Practice: As many subacute care patients experience clinical deterioration, patient preferences for care need to be discussed and documented early in the subacute care admission. [ABSTRACT FROM AUTHOR]

Objective: To determine the relationships between: (i) total ED length of stay (EDLOS) and in‐hospital mortality, ward clinical deterioration; and (ii) between time of bed request, ward transfer and in‐hospital mortality, with a particular focus on patients transferred just prior to a 4 h EDLOS. Methods: Retrospective cohort study using data from three acute care hospitals in Melbourne, Australia. Adult patients admitted from the ED to a non‐monitored ward within 8 h. Patients were sub‐grouped by EDLOS; EDLOS 3.5–4 h compared to 0–3.5 h and 4–8 h. In‐hospital mortality, number of medical emergency team (MET)/cardiac arrest team (CAT) events. Results: A total of 24 746 patients were included: 4396 patients with EDLOS <210 min; 4090 patients with EDLOS of 210–240 min; and 16 260 patients with EDLOS >240 min. Mortality overall was 2.2% (n = 545), highest mortality was seen with EDLOS >4 h (2.4%, n = 399) and lowest in patients with EDLOS 3.5–4 h (1.5%, n = 63, OR 0.67 [95% CI: 0.47–0.93, P = 0.02]). Time from bed request to transfer of >240 min was associated with increased odds of death at hospital discharge (adjusted OR 1.39 [95% CI: 1.08–1.78]). There was no difference in rate of MET calls within 24 h between groups (3.5–4 h = 64 [1.5%], <3.5 h = 60 [1.5%], 4–8 h = 235 [1.4%]). Conclusions: Both shorter time in ED and shorter time between bed request and ward transfer were independently associated with improved outcomes. Whole of hospital measures to reduce length of stay in the ED should focus on shorter ward transfer times after bed request. [ABSTRACT FROM AUTHOR]

Abstract Background Australian and international data show that transfer from inpatient rehabilitation to acute care hospitals occurs in one in ten patients. Early unplanned transfers from subacute to acute care hospitals raises questions about the safety of patient transitions between health sectors. Objectives To explore the characteristics of early and late emergency interhospital transfers from subacute to acute care. The investigators defined early transfers as occurring within 1 day and late transfers occurring after 1 day after subacute care admission. Design This prospective, exploratory cohort study is a subanalysis of data from a larger case-time-control study. Setting Twenty-two wards of eight subacute care hospitals in five major health services in Victoria, Australia. All subacute care hospitals were geographically separate from their health services' acute care hospitals. Participants All patients with an emergency transfer from inpatient rehabilitation or geriatric evaluation and management wards to an acute care hospital within the same health service were included. Patients receiving palliative care were excluded. Methods Data were collected between 22 August 2015 and 30 October 2016 by record audit. To compare patient and admission characteristics between early and late transfers Cochran-Mantel-Haenszel test (CMH) or logistic regression were used to account for health service clustering effect. Results There were 602 transfers: 54 early (48 patients) and 548 late transfers (505 patients). There was no difference in median age (79.5 vs 80, p = 0.680) or Charlson Comorbidity index (both groups = 3, p = 0.933). Early transfer patients had lower functional independence measure scores on subacute care admission (median 45 vs 66, p < 0.001). Prior to transfer, fewer early transfers had a limitation of medical treatment order in place during their subacute care admission (25.9% vs 48.7%, p < 0.001). The majority of both early and late transfers resulted in acute care hospital readmission (85.1% vs 77.7%, p = 0.204). For patients admitted to acute care, there was no difference in median acute care length of stay (6.5 vs 8 days, p = 0.367). Early transfer patients had fewer in-hospital deaths than late transfer patients (3.8% vs 16.1%, p = 0.004). Conclusions The high rates of acute care readmission in both groups suggest that transfer was warranted. Early transfer patients had lower in-patient mortality so emergency interhospital transfers, while resource intensive, appear to have a safety benefit. Early transfer patients were less likely than late transfer patients to have limitation of medical treatment orders, so the influence of resuscitation status and patient goals of care on transfer decisions warrants further investigation. [ABSTRACT FROM AUTHOR]

Aim: To examine nursing handover of vital signs during patient care transition from the emergency department (ED) to inpatient wards. Background: Communication failures are a leading cause of patient harm making communication through clinical handover an international healthcare priority. The transition of care from ED to ward settings is informed by nursing handover. Vital sign abnormalities in the ED are associated with clinical deterioration following hospital admission. Understanding the role and perceived value of vital sign content in clinical handover is important for patient safety. Methods: An integrative design was used. A search of electronic databases was undertaken using MEDLINE, CINAHL, EMBASE, Cochrane, Web of Science and SCOPUS. Identified records were screened to elicit further studies for inclusion. A comprehensive peer‐review screening process was performed. Studies were included that described the surrounding issues of handover, vital signs, ED, transition of care and ward. Results: Five studies were included in the final review, one specific to nursing and four specific to emergency medicine. Vital signs were perceived to be an important inclusion in clinical handover, and the communication of vital signs in handover was perceived to be indicators for patient safety and risk factors for future clinical deterioration. The ED environment had an influence on effective communication within handover. Conclusions: Vital signs were an important inclusion for clinical handover. Deficiencies in vital sign content were perceived to be risk factors for patient adverse events following hospital admission. The quality of vital sign information in clinical handover may be important for accurate decision‐making. Relevance to clinical practice: Vital signs are an important component of clinical handover and are perceived to be indicators for patient safety and risk of future adverse events. [ABSTRACT FROM AUTHOR]

Timely, evidence-based emergency care for sepsis saves lives. The primary aim of this systematic review was to examine the effect of implementation of guidelines for the ED management of sepsis on time to antibiotic administration. Secondary aims were to examine changes in evidence-based sepsis care and patient outcomes. In August 2018, we performed a systematic literature review of English language publications from 1st January 2002 and 31st July 2018 indexed in a number of academic databases using search terms related to sepsis, emergency care, guidelines and evidence-based practice. Twenty-four studies were included for analysis: all used longitudinal repeated-measures cohort study designs. The studies were of low-to-moderate methodological quality. Of the 24 studies included, 22 (92%) reported decreases in antibiotic administration times and two (8%) reported an increase in antibiotic administration time. All eight studies measuring compliance to completing all components of the sepsis guidelines, as well as all 12 studies measuring lactate sampling reported improvements in antibiotic administration times. Reductions in inpatient mortality ranging from 0.8% to 30.4% were reported in 12 studies and two studies reported increases. Implementation of local sepsis management guidelines in EDs improves the timeliness of processes of care and may improve patient outcomes. [ABSTRACT FROM AUTHOR]

Objective: To characterise older people who frequently use emergency departments (EDs) and compare patient outcomes with older non-frequent ED attenders.Design: Retrospective comparative cohort study. Logistic regression modelling of patient characteristics and health service usage, comparing older frequent ED attenders (≥4 ED attendances in 12 months) to non-frequent ED attenders.Setting: Three Australian public hospital EDs, with a total of 143 327 emergency attendances in the 12 months.Participants: People aged ≥65 years attending the ED in financial year 2013/2014.Main Outcome Measures: The primary outcome was frequent ED use; secondary outcomes were ED length of stay, discharge destination from ED, hospital length of stay, re-presentation within 48 h, hospital readmission within 30 days and in-hospital mortality.Results: Five percent of older people were frequent attenders (n = 1046/21 073), accounting for 16.9% (n = 5469/32 282) of all attendances by older people. Frequent ED attenders were more likely to be male, aged 75-84 years, arrive by ambulance and have a diagnosis relating to chronic illness. Frequent attenders stayed 0.4 h longer in ED (P < 0.001), were more likely to be admitted to hospital (69.2% vs 67.2%; P = 0.004), and had a 1 day longer hospital stay (P < 0.001). In-hospital mortality for older frequent ED attenders was double that of non-frequent attenders (7.0% vs 3.2%, P < 0.001) over 12 months.Conclusions: Older frequent ED attenders had more chronic disease and care needs requiring hospital admission than non-frequent attenders. A new approach to care planning and coordination is recommended, to optimise the patient journey and improve outcomes. [ABSTRACT FROM AUTHOR]

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]

Background Older adults are high users of emergency department services and their care requirements can present challenges for emergency nurses. Although clinical outcomes for older patients improve when they are cared for by nurses with specialist training, emergency nurses’ knowledge and self-assessment of care for older patients is poorly understood. Aim To assess emergency nurses’ knowledge and self-rating of practice when caring for older patients. Methods A cross-sectional self-report survey of emergency nurses (n = 101) in Melbourne, Australia. Results Mean scores were 12.7 (SD 2.66) for the 25-item knowledge of older persons questionnaire, and 9.04 (SD 1.80) for the 15-item gerontic health related questions. Scores were unaffected by years of experience as a registered nurse or emergency nurse. More than 80% of nurses rated themselves as ‘very good’ or ‘good’ in assessing pain (94.9%), identifying delirium (87.8%), and identifying dementia (82.8%). Areas with a ‘poor’ ratings were identifying depression (46.5%), assessing polypharmacy (46.5%) and assessing nutrition (37.8%). Conclusions There was variation in knowledge and self-rating of practice related to care of older patients. The relationship between knowledge and self-ratings of practice in relation to actual emergency nursing care of older people and patient outcomes warrants further exploration. [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]

Aim To develop a framework for emergency nursing transition to specialty practice programmes. Background Transition to Specialty Practice programmes were introduced to fill workforce shortages and facilitate the transition of nurses to specialty nursing practice. These programmes are recognized as an essential preparation for emergency nurses. Emergency nursing Transition to Specialty Practice programmes have developed in an ad hoc manner and as a result, programme characteristics vary. Variability in programme characteristics may result in inconsistent preparation of emergency nurses. Design Donabedian's Structure-Process-Outcome model was used to integrate results of an Australian study of emergency nursing Transition to Specialty Practice programmes with key education, nursing practice and safety and quality standards to develop the Transition to Specialty Practice (Emergency Nursing) Framework. Methods An explanatory sequential design was used. Data were collected from 118 emergency departments over 10 months in 2013 using surveys. Thirteen interviews were also conducted. Comparisons were made using Mann-Whitney U, Kruskal-Wallis and Chi-square tests. Qualitative data were analysed using content analysis. Results Transition to Specialty Practice programmes were offered in 80 (72·1%) emergency departments surveyed, to improve safe delivery of patient care. Better professional development outcomes were achieved in emergency departments which employed participants in small groups ( Median = 4 participants) and offered programmes of 6 months duration. Written assessments were significantly associated with articulation to postgraduate study (Chi-square Fisher's exact P = <0·001). Conclusion The Transition to Specialty Practice (Emergency Nursing) Framework has been developed based on best available evidence to enable a standardized approach to the preparation of novice emergency nurses. [ABSTRACT FROM AUTHOR]

Background: Theoretical frameworks and models based on behaviour change theories are increasingly used in the development of implementation interventions. Development of an implementation intervention is often based on the available evidence base and practical issues, i.e. feasibility and acceptability. The aim of this study was to describe the development of an implementation intervention for the T3 Trial (Triage, Treatment and Transfer of patients with stroke in emergency departments (EDs)) using theory to recommend behaviour change techniques (BCTs) and drawing on the research evidence base and practical issues of feasibility and acceptability.Methods: A stepped method for developing complex interventions based on theory, evidence and practical issues was adapted using the following steps: (1) Who needs to do what, differently? (2) Using a theoretical framework, which barriers and enablers need to be addressed? (3) Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? A researcher panel was convened to review the list of BCTs recommended for use and to identify the most feasible and acceptable techniques to adopt.Results: Seventy-six barriers were reported by hospital staff who attended the workshops (step 1: thirteen TDF domains likely to influence the implementation of the T3 Trial clinical intervention were identified by the researchers; step 2: the researcher panellists then selected one third of the BCTs recommended for use as appropriate for the clinical context of the ED and, using the enabler workshop data, devised enabling strategies for each of the selected BCTs; and step 3: the final implementation intervention consisted of 27 BCTs).Conclusions: The TDF was successfully applied in all steps of developing an implementation intervention for the T3 Trial clinical intervention. The use of researcher panel opinion was an essential part of the BCT selection process to incorporate both research evidence and expert judgment. It is recommended that this stepped approach (theory, evidence and practical issues of feasibility and acceptability) is used to develop highly reportable implementation interventions. The classifying of BCTs using recognised implementation intervention components will facilitate generalisability and sharing across different conditions and clinical settings. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background Early acute coronary syndrome (ACS) care occurs in the emergency department (ED). Death and disability from ACS are reduced with access to evidence-based ACS care. In this study, we aimed to explore if gender influenced access to ACS care. Methods A retrospective descriptive study was conducted for 288 (50% women, n = 144) randomly selected adults with ACS admitted via the ED to three tertiary public hospitals in Victoria, Australia from 1.1.2013 to 30.6.2015. Results Compared with men, women were older (79 vs 75.5 years; p = 0.009) less often allocated triage category 2 (58.3 vs 71.5%; p = 0.026) and waited longer for their first electrocardiograph (18.5 vs 15 min; p = 0.001). Fewer women were admitted to coronary care units (52.4 vs 65.3%; p = 0.023), but were more often admitted to general medicine units (39.6 vs 22.9%; p = 0.003) than men. The median length of stay was 4 days for both genders, but women were admitted for significantly more bed days than men (IQR 3–7 vs 2–5; p = 0.005). Conclusions There were a number of gender differences in ED care for ACS and women were at greater risk of variation from evidence-based guidelines. Further research is needed to understand why gender differences exist in ED ACS care. [ABSTRACT FROM AUTHOR]

Background: Multiple barriers may inhibit the adoption of clinical interventions and impede successful implementation. Use of standardised methods to prioritise barriers to target when selecting implementation interventions is an understudied area of implementation research. The aim of this study was to describe a method to identify and prioritise barriers to the implementation of clinical practice elements which were used to inform the development of the T3 trial implementation intervention (Triage, Treatment [thrombolysis administration; monitoring and management of temperature, blood glucose levels, and swallowing difficulties] and Transfer of stroke patients from Emergency Departments [ED]).Methods: A survey was developed based on a literature review and data from a complementary trial to identify the commonly reported barriers for the nine T3 clinical care elements. This was administered via a web-based questionnaire to a purposive sample of Australian multidisciplinary clinicians and managers in acute stroke care. The questionnaire addressed barriers to each of the nine T3 trial clinical care elements. Participants produced two ranked lists: on their perception of: firstly, how influential each barrier was in preventing clinicians from performing the clinical care element (influence attribute); and secondly how difficult the barrier was to overcome (difficulty attribute). The rankings for both influence and difficulty were combined to classify the barriers according to three categories ('least desirable', desirable' or 'most desirable' to target) to assist interpretation.Results: All invited participants completed the survey; (n = 17; 35% medical, 35% nursing, 18% speech pathology, 12% bed managers). The barriers classified as most desirable to target and overcome were a 'lack of protocols for the management of fever' and 'not enough blood glucose monitoring machines'.Conclusions: A structured decision-support procedure has been illustrated and successfully applied to identify and prioritise barriers to target within an implementation intervention. This approach may prove to be a useful in other studies and as an adjunct to undertaking barrier assessments within individual sites when planning implementation interventions. [ABSTRACT FROM AUTHOR]

Generating knowledge through quality research is fundamental to the advancement of professional practice in emergency nursing and care. There are multiple paradigms, designs and methods available to researchers to respond to challenges in clinical practice. Systematic reviews, randomised control trials and other forms of experimental research are deemed the gold standard of evidence, but there are comparatively few such trials in emergency care. In some instances it is not possible or appropriate to undertake experimental research. When exploring new or emerging problems where there is limited evidence available, non-experimental methods are required and appropriate. This paper provides the theoretical foundations and an exemplar of the use of case study and case-based research to explore a new and emerging problem in the context of emergency care. It examines pre-hospital clinical judgement and decision-making of mental illness by paramedics. Using an exemplar the paper explores the theoretical foundations and conceptual frameworks of case study, it explains how cases are defined and the role researcher in this form of inquiry, it details important principles and the procedures for data gathering and analysis, and it demonstrates techniques to enhance trustworthiness and credibility of the research. Moreover, it provides theoretically and practical insights into using case study in emergency care. [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]

Summary Background The impact of limitation of medical treatment orders (LOMT) on patient outcomes following transfer from sub-acute care to the Emergency Department remains unclear. Methods Retrospective medical record review of 431 adult in-patients who required ambulance transfer following clinical deterioration during a sub-acute care admission during 2010. Results Common reasons for transfer were respiratory (18.9%) or neurological (19.0%) conditions; 35.7% (154/431) were transferred within one week of sub-acute care admission. LOMT orders were in place for 37.8% ( n = 163) patients who were older ( p < 0.001), with more comorbidities ( p < 0.005), specifically cardiac, renal and pulmonary disease than patients without LOMT. Patients with LOMT orders had more physiological abnormalities before transfer; tachypnoea (43.7% vs 28.6%), hypoxaemia (63.5% vs 48.4%) and severe hypoxaemia (27.6% vs 14.5%). There were no differences in rates of admission, cardiac arrest, Medical Emergency Team activation or ICU admission. For admitted patients, those with LOMT orders had significantly ( p ≤ 0.005) higher mortality: in-hospital (21.9% vs 11.3%); 30 days (23.9% vs 12.3%) and 60 days (28.2% vs 13.4%). Conclusions Patients with LOMT had higher levels of comorbidity and were more acutely ill during their sub-acute care admission. Once transferred those with a LOMT had similar rates of cardiac arrest, MET activation and unplanned ICU admission, but higher mortality. [ABSTRACT FROM AUTHOR]

Summary Background Rapid Response Team (RRT) calls can often occur within 24 h of hospital admission to a general ward. We seek to determine whether it is possible to identify these patients before there is a significant clinical deterioration. Methods Retrospective case–controlled study comparing patient characteristics, vital signs, and hospital outcomes in patients triggering RRT activation within 24 h of ED admission (cases) with matched ED admissions not receiving a RRT call (controls). Results Over 12 months, there were 154 early RRT calls. Compared with controls, cases had a higher heart rate (HR) at triage (92 vs. 84 beats/min; p = 0.008); after 3 h in the ED (91 vs. 80 beats/min; p = 0.0007); and at ED discharge (91 vs. 81 beats/min; p = 0.0005). Respiratory rate (RR) was also higher at triage (21.2 vs. 19.2 breaths/min; p = 0.001). On multiple variable analysis, RR at triage and HR before ward transfer predicted early RRT activation: OR 1.07 [95% CI 1.02–1.12] for each 1 breath/min increase in RR; and 1.02 [95% CI 1.002–1.030] for each beat/minute increase in HR, respectively. Study patients required transfer to the intensive care in approximately 20% of cases and also had a greater mortality: (21% vs. 6%; OR 4.65 [95% CI 1.86–11.65]; p = 0.0003) compared with controls. Conclusions Patients that trigger RRT calls within 24 h of admission have a fourfold increase in risk of in-hospital mortality. Such patients may be identified by greater tachycardia and tachypnoea in the ED. [ABSTRACT FROM AUTHOR]

Summary Background Emergency nurses have a key role in managing the large numbers of patients that attend Australian emergency departments (EDs) annually, and require adequate educational preparation to deliver safe and quality patient care. This paper provides a detailed profile of nursing resources in Australian EDs, including ED locations, annual patient attendances, nurse staffing including level of education, and educational resources. Methods Data were collected via online surveys of emergency Nurse Unit Managers and Nurse Educators and the MyHospitals website. Data were analysed by hospital peer group and state or territory. Comparisons were made using the Kruskal–Wallis Test and Spearman Rank Order Correlation. Results In 2011–2012, there were a median of 36,274 patient attendances to each of the 118 EDs sampled (IQR 28,279–46,288). Most of the nurses working in EDs were Registered Nurses (95.2%). Organisations provided educational resources including Clinical Nurse Educators (80.6%), learning packages (86%) and facilitation of postgraduate study (98%), but resources, both human and educational varied substantially between states and territories. One-third of emergency nurses held a relevant postgraduate qualification (30%). Conclusion There are important variations in the emergency nursing resources available between Australian states and territories. The high percentage of RNs in Australian EDs is a positive finding, however strategies to increase the percentage of nurses with relevant postgraduate qualifications are required. [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]

Aims and objectives. To test the feasibility of an evidence-based care bundle in a Thai emergency department. The specific objective of this study was to examine the impact of the implementation of the care bundle on the initial emergency nursing management of patients with severe traumatic brain injury. Background. A care bundle approach is one strategy used to improve the consistency, quality and safety of emergency care for different patients groups, however, has not been tested in patients with severe traumatic brain injury. Design. A pretest/post-test design was used. The study intervention was an evidence-based care bundle for initial emergency nursing management of patients with severe traumatic brain injury. Methods. Nonparticipant observations were conducted between October 2012-June 2013 at an emergency department of a 640 bed regional hospital in Southern Thailand. The initial emergency nursing care was observed in 45 patients with severe traumatic brain injury: 20 patients in the pretest period and 25 patients in the post-test period. Results. There were significant improvements in clinical care of patients with severe traumatic brain injury after implementation of the care bundle: (1) use of end-tidal carbon dioxide monitoring, (2) frequency of respiratory rate assessment, (3) frequency of pulse rate and blood pressure assessment, and (4) patient positioning. Conclusion. This study demonstrated that implementation of an evidence-based care bundle improved specific elements of emergency nurses' clinical management of patients with severe traumatic brain injury. Relevance to clinical practice. The study suggests that a care bundle approach can be used as a strategy to improve emergency nursing care of patients with severe traumatic brain injury. [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]

The purpose of this retrospective, cross-sectional study was to determine the prevalence of advance care planning (ACP) among older people presenting to an Emergency Department ( ED) from the community or a residential aged care facility. The study sample comprised 300 older people (aged 65+ years) presenting to three Victorian EDs in 2011. A total of 150 patients transferred from residential aged care to ED were randomly selected and then matched to 150 people who lived in the community and attended the ED by age, gender, reason for ED attendance and triage category on arrival. Overall prevalence of ACP was 13.3% ( n = 40/300); over one-quarter (26.6%, n = 40/150) of those presenting to the ED from residential aged care had a documented Advance Care Plan, compared to none (0%, n = 0/150) of the people from the community. There were no significant differences in the median ED length of stay, number of investigations and interventions undertaken in ED, time seen by a doctor or rate of hospital admission for those with an Advance Care Plan compared to those without. Those with a comorbidity of cerebrovascular disease or dementia and those assessed with impaired brain function were more likely to have a documented Advance Care Plan on arrival at ED. Length of hospital stay was shorter for those with an Advance Care Plan [median ( IQR) = 3 days (2-6) vs. 6 days (2-10), P = 0.027] and readmission lower (0% vs. 13.7%). In conclusion, older people from the community transferred to ED were unlikely to have a documented Advance Care Plan. Those from residential aged care who were cognitively impaired more frequently had an Advance Care Plan. In the ED, decisions of care did not appear to be influenced by the presence or absence of Advance Care Plans, but length of hospital admission was shorter for those with an Advance Care Plan. [ABSTRACT FROM AUTHOR]

Objectives To derive and validate a mortality prediction model from information available at ED triage. Methods Multivariable logistic regression of variables from administrative datasets to predict inpatient mortality of patients admitted through an ED. Accuracy of the model was assessed using the receiver operating characteristic area under the curve ( ROC-AUC) and calibration using the Hosmer- Lemeshow goodness of fit test. The model was derived, internally validated and externally validated. Derivation and internal validation were in a tertiary referral hospital and external validation was in an urban community hospital. Results The ROC-AUC for the derivation set was 0.859 (95% CI 0.856-0.865), for the internal validation set was 0.848 (95% CI 0.840-0.856) and for the external validation set was 0.837 (95% CI 0.823-0.851). Calibration assessed by the Hosmer- Lemeshow goodness of fit test was good. Conclusions The model successfully predicts inpatient mortality from information available at the point of triage in the ED. [ABSTRACT FROM AUTHOR]

Aims To identify the impact of in-reach services providing specialist nursing care on outcomes for older people presenting to the emergency department from residential aged care. Methods Retrospective cohort study compared clinical outcomes of 2278 presentations from 2009 with 2051 presentations from 2011 before and after the implementation of in-reach services. Results Median emergency department length of stay decreased by 24 minutes (7.0 vs 6.6 hours, P < 0.001) and admission rates decreased by 23% (68 vs 45%, P < 0.001). The proportion of people with repeat emergency department visits within six months decreased by 12% (27 vs 15%). The proportion of admitted patients who were discharged with an end of life palliative care plan increased by 13% (8 vs 21%, P = 0.007). Conclusions There was a significant reduction in the median length of stay, fewer hospital admissions and fewer repeat visits for people from residential aged care following implementation of in-reach services. [ABSTRACT FROM AUTHOR]

Summary Background Thai emergency nurses play a vital role in caring for patients with severe TBI, and are an important part of the healthcare team throughout the resuscitation phase. They are also responsible for continuous physiological monitoring, and detecting deterioration associated with increased intracranial pressure and preventing secondary brain injury. However, there is known variation in Thai nurses’ knowledge and care practices for patients with severe TBI. In addition, there are no specific evidence-based practice guidelines available for emergency nursing management of patients with severe TBI. Aim The aim of this paper is to describe the development of an evidence-based care bundle for initial emergency nursing management of patients with severe TBI for use in a Thai ED context. Results An evidence-based care bundle focused on seven major elements: (1) establish a secure airway along with c-spine protection, (2) maintain adequacy of oxygenation and ventilation, (3) maintain circulation and fluid balance, (4) assessment of GCS, and pupil size and reactivity, (5) maintain cerebral venous outflow, (6) management of pain, agitation, and irritability, and (7) administer for urgent CT scan. Conclusions A care bundle is one method of promoting consistent, evidence-based emergency nursing care of patients with severe TBI, decreasing unnecessary variations in nursing care and reducing the risk of secondary brain injury from suboptimal care. Implementation of this evidence-based care bundle developed specifically for the Thai emergency nursing context has the potential to improve the care of the patients with severe TBI. [ABSTRACT FROM AUTHOR]

Summary Background Medication safety is of increasing importance and understanding the nature and frequency of medication errors in the Emergency Department (ED) will assist in tailoring interventions which will make patient care safer. The challenge with the literature to date is the wide variability in the frequency of errors reported and the reliance on incident reporting practices of busy ED staff. Methods A prospective, exploratory descriptive design using point prevalence surveys was used to establish the frequency of observed medication errors in the ED. In addition, data related to contextual factors such as ED patients, staffing and workload were also collected during the point prevalence surveys to enable the analysis of relationships between the frequency and nature of specific error types and patient and ED characteristics at the time of data collection. Results A total of 172 patients were included in the study: 125 of whom patients had a medication chart. The prevalence of medication errors in the ED studied was 41.2% for failure to apply patient ID bands, 12.2% for failure to document allergy status and 38.4% for errors of omission. The proportion of older patients in the ED did not affect the frequency of medication errors. There was a relationship between high numbers of ATS 1, 2 and 3 patients (indicating high levels of clinical urgency) and increased rates of failure to document allergy status. Medication errors were affected by ED occupancy, when cubicles in the ED were over 50% occupied, medication errors occurred more frequently. ED staffing affects the frequency of medication errors, there was an increase in failure to apply ID bands and errors of omission when there were unfilled nursing deficits and lower levels of senior medical staff were associated with increased errors of omission. Conclusions Medication errors related to patient identification, allergy status and medication omissions occur more frequently in the ED when the ED is busy, has sicker patients and when the staffing is not at the minimum required staffing levels. [ABSTRACT FROM AUTHOR]

Summary: Background: The use of rapid response systems such as Medical Emergency Team (MET) improves recognition and response to clinical deterioration in in-patient settings. However, few published studies have investigated use of rapid response systems in Australian emergency departments (ED). Aim: To examine the frequency, nature and outcomes of clinical deterioration in ED patients and compare the utility of hospital MET calling criteria with ED specific Clinical Instability Criteria (CIC) for recognition of deteriorating patients. The outcomes of interest were the prevalence of deterioration in ED patients, the utility of MET versus ED CIC, and the outcomes (MET activation, in-hospital mortality at 30 days) of patients who experienced deterioration during ED care. Method: An exploratory descriptive design was used. Vital sign data were prospectively collected from 200 patients receiving ED care in the general treatment areas of regional, publicly funded health service in Victoria, Australia, during May 2012. Outcome data were collected by follow up medical record audit. Results: Of the 200 ED patients recruited, 2% fulfilled the study site MET criteria and 7.5% fulfilled ED CIC. The median age of patients fulfilling MET criteria was 85 years compared with a median age of 74 years for patients fulfilling the ED CIC criteria. Of the 136 ED patients admitted to in-patient wards, 5.9% required MET activation during admission and 3.7% of these MET activations occurred within 24h of emergency admission. Five percent of patients died in-hospital within 30 days of ED attendance. Conclusions: ED specific criteria for activation of a rapid response system identifies more ED patients at risk of clinical deterioration. The results of this study highlight a need for EDs to implement and evaluate systems to increase recognition of deteriorating patients designed specifically for the emergency care context. [Copyright &y& Elsevier]

Summary: Background: In Thailand, the rate of TBI-related hospitalisation is increasing, however, little is known about the evidence-based management of severe TBI in the developing world. The aim of this study was to explore Thai emergency nurses’ management of patients with severe TBI. Methods: An exploratory descriptive mixed method design was used to conduct this two stage study: survey methods were used to examine emergency nurses’ knowledge regarding management of patients with severe TBI (Stage 1) and observational methods were used to examine emergency nurses’ clinical management of patients with severe TBI (Stage 2). The study setting was the emergency department (ED) at a regional hospital in Southern Thailand. Results: 34 nurses participated in Stage 1 (response rate 91.9%) and the number of correct responses ranged from 33.3% to 95.2%. In Stage 2, a total of 160 points of measurement were observed in 20 patients with severe TBI over 40h. In this study there were five major areas identified for the improvement of care of patients with severe TBI: (i) end-tidal carbon dioxide (ETCO2) monitoring and targets; (ii) use of analgesia and sedation; (iii) patient positioning; (iv) frequency of nursing assessment; and (v) dose of Mannitol diuretic. Conclusions: There is variation in Thai nurses’ knowledge and care practices for patients with severe TBI. To increase consistency of evidence-based TBI care in the Thai context, a knowledge translation intervention that is ecologically valid, appropriate to the Thai healthcare context and acceptable to the multidisciplinary care team is needed. [Copyright &y& Elsevier]

This research aimed to describe the number and type of residents admitted to emergency depart-ments (EDs) over 2 years; and to explore nurses' perceptions of the reasons why residential aged care facility (RACF) residents are referred to EDs. The research objective was addressed in a retrospective exploratory study using data on admissions to EDs from RACFs (N = 3,094) at the participating organisation over a 2-year period, and interview data on seven RACF and four ED nurses' perceptions of the issues involved. Most residents presenting at EDs required urgent medical attention. Major themes identified by RACF and ED nurses included issues related to staff competency, availability of general practitioners, lack of equipment in RACFs, residents and family members requesting referrals, communication difficulties, and poor attitudes towards RACF staff. There is a need to use strategies to detect residents whose conditions are deteriorating and treat them promptly in RACFs. [ABSTRACT FROM AUTHOR]

Summary: Background: Much of the literature about emergency nurses willingness to work during disasters has been from a non-Australian perspective. Despite the many recent disasters, little is known of Australian nurse's willingness to participate in disaster response. This paper presents findings from a study that explored nurses willingness to attend work during a disaster and the factors that influenced this decision. Methods: Data were collected consecutively using a combination of focus group and interview methods. Participants in this study, registered nurses from emergency departments, were recruited through convenience sampling from four hospitals in Australia. Participant narrative was electronically recorded, transcribed and thematically analysed. Results: The participants for both the focus groups and interviews compromised a mix of ages, genders and years of experience as emergency nurses from across four jurisdictions within Australia. Three major themes that influenced willingness emerged with a number of subthemes. Theme one reflected the uncertainty of the situation such as the type of disaster. The second theme surrounded the preparedness of the workplace, emergency nurse and colleagues, and the third theme considered personal and professional choice based on home and work circumstances and responsibilities. Conclusions: The decision to attend work or not during a disaster, includes a number of complex personal, work-related and professional factors that can change, depending on the type of disaster, preparedness of the work environment and the emergency nurses’ personal responsibilities at that time [Copyright &y& Elsevier]

Objective: To describe the reported impact of Pandemic (H1N1) 2009 on EDs, so as to inform future pandemic policy, planning and response management. Methods: This study comprised an issue and theme analysis of publicly accessible literature, data from jurisdictional health departments, and data obtained from two electronic surveys of ED directors and ED staff. The issues identified formed the basis of policy analysis and evaluation. Results: Pandemic (H1N1) 2009 had a significant impact on EDs with presentation for patients with 'influenza-like illness' up to three times that of the same time in previous years. Staff reported a range of issues, including poor awareness of pandemic plans, patient and family aggression, chaotic information flow to themselves and the public, heightened stress related to increased workloads and lower levels of staffing due to illness, family care duties and redeployment of staff to flu clinics. Staff identified considerable discomfort associated with prolonged times wearing personal protective equipment. Staff believed that the care of non-flu patients was compromised during the pandemic as a result of overwork, distraction from core business and the difficulties associated with accommodating infectious patients in an environment that was not conducive. Conclusions: This paper describes the breadth of the impact of pandemics on ED operations. It identifies a need to address a range of industrial, management and procedural issues. In particular, there is a need for a single authoritative source of information, the re-engineering of EDs to accommodate infectious patients and organizational changes to enable rapid deployment of alternative sources of care. [ABSTRACT FROM AUTHOR]

Considine J, Lucas E, Martin R, Stergiou HE, Kropman M, Chiu H. International Journal of Nursing Practice 2012; 18: 60-67 Rapid intervention and treatment zone: Redesigning nursing services to meet increasing emergency department demand The impact of emergency nursing roles in demand management systems is poorly understood. The aim of this study was to evaluate emergency nurses' role in a specific emergency department (ED) demand management system: rapid intervention and treatment zone (RITZ). A descriptive exploratory approach was used. Data were collected from audit of 193 randomly selected patient records and 12 h of clinical practice observation. The median age of participants was 31 years, 51.8% were males and 99.5% were discharged home. Nurse qualifications or seniority had no significant effect on waiting time or length of stay (LOS). There were disparities between documented and observed nursing practice. Thedesignation and qualifications of RITZ nurses made little difference to waiting times and ED LOS. Specific documentation and communication systems for areas of the ED that manage large numbers of low complexity patients warrant further research. [ABSTRACT FROM AUTHOR]

Objective: The present study aimed to compare ED waiting times (for medical assessment and treatment), treatment times and length of stay (LOS) for patients managed by an emergency nurse practitioner candidate (ENPC) with patients managed via traditional ED care. Methods: A case–control design was used. Patients were selected using the three most common ED discharge diagnoses for ENPC managed patients: hand/wrist wounds, hand/wrist fractures and removal of plaster of Paris. The ENPC group ( n = 102) consisted of patients managed by the ENPC who had ED discharge diagnoses as mentioned above. The control group ( n = 623) consisted of patients with the same ED discharge diagnoses who were managed via traditional ED care. Results: There were no significant differences in median waiting times, treatment times and ED LOS between ENPC managed patients and patients managed via traditional ED processes. There appeared to be some variability between diagnostic subgroups in terms of treatment times and ED LOS. Conclusion: Patient flow outcomes for ENPC managed patients are comparable with those of patients managed via usual ED processes. [ABSTRACT FROM AUTHOR]

Background: The implementation of evidence-based protocols for stroke management in the emergency department (ED) for the appropriate triage, administration of tissue plasminogen activator to eligible patients, management of fever, hyperglycaemia and swallowing, and prompt transfer to a stroke unit were evaluated in an Australian cluster-randomised trial (T3 trial) conducted at 26 emergency departments. There was no reduction in 90-day death or dependency nor improved processes of ED care. We conducted an a priori planned process influential factors that impacted upon protocol uptake.Methods: Qualitative face-to-face interviews were conducted with purposively selected ED and stroke clinicians from two high- and two low-performing intervention sites about their views on factors that influenced protocol uptake. All Trial State Co-ordinators (n = 3) who supported the implementation at the 13 intervention sites were also interviewed. Data were analysed thematically using normalisation process theory as a sensitising framework to understand key findings, and compared and contrasted between interviewee groups.Results: Twenty-five ED and stroke clinicians, and three Trial State Co-ordinators were interviewed. Three major themes represented key influences on evidence uptake: (i) Readiness to change: reflected strategies to mobilise and engage clinical teams to foster cognitive participation and collective action; (ii) Fidelity to the protocols: reflected that beliefs about the evidence underpinning the protocols impeded the development of a shared understanding about the applicability of the protocols in the ED context (coherence); and (iii) Boundaries of care: reflected that appraisal (reflexive monitoring) by ED and stroke teams about their respective boundaries of clinical practice impeded uptake of the protocols.Conclusions: Despite initial high 'buy-in' from clinicians, a theoretically informed and comprehensive implementation strategy was unable to overcome system and clinician level barriers. Initiatives to drive change and integrate protocols rested largely with senior nurses who had to overcome contextual factors that fell outside their control, including low medical engagement, beliefs about the supporting evidence and perceptions of professional boundaries. To maximise uptake of evidence and adherence to intervention fidelity in complex clinical settings such as ED cost-effective strategies are needed to overcome these barriers.Trial Registration: Australian New Zealand Clinical Trials Registry ( ACTRN12614000939695 ). [ABSTRACT FROM AUTHOR]

Background: Clinical guidelines recommend that assessment and management of patients with stroke commences early including in emergency departments (ED). To inform the development of an implementation intervention targeted in ED, we conducted a systematic review of qualitative and quantitative studies to identify relevant barriers and enablers to six key clinical behaviours in acute stroke care: appropriate triage, thrombolysis administration, monitoring and management of temperature, blood glucose levels, and of swallowing difficulties and transfer of stroke patients in ED.Methods: Studies of any design, conducted in ED, where barriers or enablers based on primary data were identified for one or more of these six clinical behaviours. Major biomedical databases (CINAHL, OVID SP EMBASE, OVID SP MEDLINE) were searched using comprehensive search strategies. The barriers and enablers were categorised using the theoretical domains framework (TDF). The behaviour change technique (BCT) that best aligned to the strategy each enabler represented was selected for each of the reported enablers using a standard taxonomy.Results: Five qualitative studies and four surveys out of the 44 studies identified met the selection criteria. The majority of barriers reported corresponded with the TDF domains of "environmental, context and resources" (such as stressful working conditions or lack of resources) and "knowledge" (such as lack of guideline awareness or familiarity). The majority of enablers corresponded with the domains of "knowledge" (such as education for physicians on the calculated risk of haemorrhage following intravenous thrombolysis [tPA]) and "skills" (such as providing opportunity to treat stroke cases of varying complexity). The total number of BCTs assigned was 18. The BCTs most frequently assigned to the reported enablers were "focus on past success" and "information about health consequences."Conclusions: Barriers and enablers for the delivery of key evidence-based protocols in an emergency setting have been identified and interpreted within a relevant theoretical framework. This new knowledge has since been used to select specific BCTs to implement evidence-based care in an ED setting. It is recommended that findings from similar future reviews adopt a similar theoretical approach. In particular, the use of existing matrices to assist the selection of relevant BCTs. [ABSTRACT FROM AUTHOR]

Background: Internationally recognised evidence-based guidelines recommend appropriate triage of patients with stroke in emergency departments (EDs), administration of tissue plasminogen activator (tPA), and proactive management of fever, hyperglycaemia and swallowing before prompt transfer to a stroke unit to maximise outcomes. We aim to evaluate the effectiveness in EDs of a theory-informed, nurse-initiated, intervention to improve multidisciplinary triage, treatment and transfer (T3) of patients with acute stroke to improve 90-day death and dependency. Organisational and contextual factors associated with intervention uptake also will be evaluated.Methods: This prospective, multicentre, parallel group, cluster randomised trial with blinded outcome assessment will be conducted in EDs of hospitals with stroke units in three Australian states and one territory. EDs will be randomised 1:1 within strata defined by state and tPA volume to receive either the T3 intervention or no additional support (control EDs). Our T3 intervention comprises an evidence-based care bundle targeting: (1) triage: routine assignment of patients with suspected stroke to Australian Triage Scale category 1 or 2; (2) treatment: screening for tPA eligibility and administration of tPA where applicable; instigation of protocols for management of fever, hyperglycaemia and swallowing; and (3) transfer: prompt admission to the stroke unit. We will use implementation science behaviour change methods informed by the Theoretical Domains Framework [1, 2] consisting of (i) workshops to determine barriers and local solutions; (ii) mixed interactive and didactic education; (iii) local clinical opinion leaders; and (iv) reminders in the form of email, telephone and site visits. Our primary outcome measure is 90 days post-admission death or dependency (modified Rankin Scale >2). Secondary outcomes are health status (SF-36), functional dependency (Barthel Index), quality of life (EQ-5D); and quality of care outcomes, namely, monitoring and management practices for thrombolysis, fever, hyperglycaemia, swallowing and prompt transfer. Outcomes will be assessed at the patient level. A separate process evaluation will examine contextual factors to successful intervention uptake. At the time of publication, EDs have been randomised and the intervention is being implemented.Discussion: This theoretically informed intervention is aimed at addressing important gaps in care to maximise 90-day health outcomes for patients with stroke.Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN12614000939695 . Registered 2 September 2014. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to quantify the health economic treatment costs of clinical deterioration of patients within 72 h of admission via the emergency department.Methods: This study was conducted between March 2018 and February 2019 in two hospitals in regional New South Wales, Australia. All patients admitted via the emergency department were screened for clinical deterioration (defined as initiation of a medical emergency team call, cardiac arrest or unplanned admission to Intensive Care Unit) within 72 h through the site clinical deterioration databases. Patient characteristics, including pre-existing conditions, diagnosis and administrative data were collected.Results: 1600 patients clinically deteriorated within 72 h of hospital admission. Linked treatment cost data were available for 929 (58%) of these patients across 352 Australian Refined Diagnosis Related Groups. The average (standard deviation) treatment costs for patients who deteriorated within 72 h was $26,778 ($34,007) compared to $7727 ($12,547). The average hospital length of stay of the deterioration group was nearly 8 days longer than patients without deterioration. When controlling for length of stay and Australian Refined Diagnosis Related Group codes, the incremental cost per episode of deterioration was $14,134.Conclusion: Clinical deterioration within 72 h of admission is associated with increased treatment costs irrespective of diagnosis, hospital length of stay and age. Implementation of interventions known to prevent patient deterioration require evaluation. [ABSTRACT FROM AUTHOR]