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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]

Objective: To reduce perceived unnecessary resource use, we modified our tiered trauma response. If a patient was not physiologically compromised, surgical registrar attendance was not mandated. We investigated the effect of this change on missed injury, unplanned representation to ED, diagnostic imaging rates and staff satisfaction. Methods: A retrospective case series study assessing the 3‐month period before and after the intervention was conducted. Logistic regression analyses were used to examine the association between ordering of computerised tomography (CT) and ED length of stay (LOS), injury severity (ISS), age, surgical review and admission. A staff survey was conducted to investigate staff perceptions of the practice change. Free text data were analysed using inductive content analysis. Results: There were 105 patients in the control and 166 in the intervention group and their mean (SD) ISS was the same (ISS [SD] = 4 [±4] [P = 0.608]). A higher proportion of the control group were admitted (56.3% vs 42.2% [P = 0.032]) and they had a shorter ED LOS (274 min [202–456] vs 326 min [225–560], P = 0.044). The rate of missed injury was unchanged. A surgical review resulted in a 26‐fold increase in receipt of a whole‐body CT scan (odds ratio = 26.89, 95% confidence interval = 3.31–218.17). Just over half of survey respondents felt the change was safe (54.4%), and more surgical (90%) than ED staff (69%) reported the change as positive. Conclusion: The removal of the surgical registrar from the initial trauma standby response did not result in any adverse events, reduced admissions, pathology and imaging, but resulted in an increased ED LOS and time to surgical review. [ABSTRACT FROM AUTHOR]

Background: Women present to the emergency department (ED) with pregnancy complications including bleeding. They seek investigations, treatment and clear discharge and referral pathways. Aims: The aim was to identify trends, characteristics, ED care and discharge pathways for women who present to the ED with early pregnancy bleeding. Methods: Retrospective data (from 2011 to 2020) were extracted from a regional health district's databank. Data were processed, and deterministic linking was used to produce a final data set. Descriptive statistics were used to identify trends and characteristics. Linear and logistic regression models were used to identify factors that influence health service use, outcomes and discharge pathways. Results: Over the 10 years, there have been almost 15 000 presentations to the ED for early pregnancy bleeding, from approximately 10 000 women, 0.97% of all ED presentations. The frequency of presentations increased by 19.6% over the study period. The average age of women who presented to the ED was 29.1 years, which increased from 28.5 years (2011) to 29.3 (2020). The median length of stay was less than 4 h, and most women were treated and discharged from the ED. One‐third of presentations received neither ultrasound nor pathology, but health service costs increased by 330% from 2014 to 2020. Conclusions: Maternal age is increasing, as is the frequency of ED presentations for early pregnancy bleeding, and both factors increase demands on the ED. Findings from this study may inform strategies to improve current care models and improve quality and safety practices within the ED. [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]

Purpose: To describe the characteristics of major injury and identify determinants of long-term unplanned readmission and mortality after self-inflicted and non-self-inflicted injury to inform potential readmission screening. Method: A retrospective cohort study of 11,269 individuals aged ≥ 15 years hospitalised for a major injury during 2013–2017 in New South Wales, Australia. Unplanned readmission and mortality up to 27-month post-injury were examined. Logistic regression was used to examine predictors of unplanned readmission. Results: During the 27-month follow-up, 2700 (24.8%) individuals with non-self-inflicted and 98 (26.1%) with self-inflicted injuries had an unplanned readmission. Individuals with an anxiety-related disorder and a non-self-inflicted injury who were discharged home were three times more likely (OR: 3.27; 95%CI 2.28–4.69) or if they were discharged to a psychiatric facility were four times more likely (OR: 4.11; 95%CI 1.07–15.80) to be readmitted. Compared to individuals aged 15–24 years, individuals aged ≥ 65 years were 3 times more likely to be readmitted (OR 3.12; 95%CI 2.62–3.70). Individuals with one (OR 1.60; 95%CI 1.39–1.84) or ≥ 2 (OR 1.88; 95%CI 1.52–2.32) comorbidities, or who had a drug-related dependence (OR 1.88; 95%CI 1.52–2.31) were more likely to be readmitted. The post-discharge age-adjusted mortality rate following a self-inflicted injury (35.6%; 95%CI 29.9–41.8) was higher than for individuals with a non-self-inflicted injury (11.0%; 95%CI 10.4–11.8). Conclusions: Unplanned readmission after injury is associated with injury intent, age, and comorbid health. Screening for anxiety and drug-related dependence after major injury, accompanied by service referrals and post-discharge follow-up, has potential to prevent readmission. [ABSTRACT FROM AUTHOR]

Background: Timely definitive paediatric trauma care influences patient and parental physical and emotional outcomes. New South Wales (NSW) covers a large geographical area with all three NSW paediatric trauma centres (PTC) located in two approximated major cities, meaning it is inevitable that some injured children receive initial treatment locally and then require transfer. Little is known about the factors that then impact timely arrival of injured children to definitive care.Methods: This included children admitted between July 2015 and September 2016, <16 years with an injury severity (ISS) ≥9; or requiring intensive care admission; or deceased following injury. Children were identified through the three PTCs, NSW Trauma Registry and NSW Medical Retrieval Registry.Results: There were 593 children admitted following injury and 46% required transfer to a PTC. There was no significant difference in age, ISS, ICU admission or head injury (AIS >2) between transferred and directly transported cohorts. There were significant differences in mechanism of injury between the two groups (χ2(9) = 45.9, p < 0.001). The median (IQR) time to book a transfer from arrival at the referring facility, was 146.5 (86-238) minutes. Time from injury to arrival at the PTC more than doubled for children transferred, with significant and unwarranted variability between transporting agencies resulting in unwarranted delays to surgical intervention. For example, time spent at the referring facility by Aeromedical Retrieval Service was less than half that of the Newborn & paediatric Emergency Transport Service [53 (IQR:47-61) vs 115 (84-155) minutes (p <0.001)].Conclusion: Clinicians caring for paediatric trauma patients in facilities outside trauma centres require the capability and opportunity to identify and notify early those requiring transfer for ongoing management. The provision of a streamlined referral and transfer process for all paediatric trauma patients requiring treatment in NSW PTCs would reduce the burden on the referring facility, reduce variation amongst transport providers and improve time to definitive care. [ABSTRACT FROM AUTHOR]

Objective: Presentations to EDs for major paediatric injury are considerably lower than for adults. International studies report lower levels of critical intervention, including intubation, required in injured children. A New South Wales study demonstrated an adverse event rate of 7.6% in children with major injury. Little is known about the care and interventions received by children presenting to Australian EDs with major injury. Methods: The ED care of injured children <16 years who ultimately received definitive care at a New South Wales Paediatric Trauma Centre between July 2015 and September 2016, and had an Injury Severity Score ≥9, required intensive care admission or died were included. Results: There were 491 injured children who received treatment at 64 EDs, half (49.4%, n = 243) were treated initially in a Paediatric Trauma Centre. One third (32.8%) sustained an Injury Severity Score >12, more than half (n = 251, 51.1%) of children were classified as a triage category 1 or 2, and 38.3% received trauma team activation. Critical intervention was infrequent. Intubation was documented in 9.2% (n = 45), needle thoracostomy and activation of massive transfusion protocol in two (0.4%) and eight (1.6%) had intraosseous access established. Only a small proportion (14.7%, n = 63) had two or more observations outside the normal range. Conclusion: A small proportion of children arriving in the ED post‐major trauma have deranged clinical observations and receive critical interventions. The limited exposure in the management of trauma in paediatric patients requires measures to ensure clinicians have adequate training, skills and confidence to manage these clinical presentations in all EDs. This study provides an overview of the treatment, and clinical condition, of children presenting to ED post‐major injury. A small proportion of children arriving in ED post‐major trauma have deranged clinical observations and receive critical interventions. [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]

Catastrophic hemorrhage remains the leading cause of preventable death. Not all New South Wales (NSW) hospitals stock blood products and, as such, blood products carried by NSW Ambulance retrieval teams are often the first available to critically unwell patients. To describe the trends, characteristics and predictors of mortality prior to hospital treatment in patients receiving prehospital blood transfusion by NSW Ambulance retrieval teams attending primary missions from 2009–2018. Retrospective review of all patients who received blood products with NSW Ambulance retrieval teams between 13/8/2009 and 31/12/2018. A total of 12,468 primary taskings were reviewed, identifying 1,043 (8.4%) cases of prehospital transfusion. The proportion of missions administering blood transfusions doubled between 2009 and 2018. Road traffic incidents were the predominant etiology. Eighty per cent of patients (n = 842) reached hospital alive following transfusion. Retrieval missions had a median time of 117 minutes (IQR 74–168). An initial blood pressure <100mmHg and reduced GCS were strongly associated with prehospital mortality. The median shock index of patients prior to transfusion was 1.2, which reduced to 1.0 after transfusion. The use of prehospital blood transfusion for suspected bleeding in NSW Australia has more than doubled since 2010. Patients who received prehospital transfusion arrived at hospital with improved hemodynamic observations. [ABSTRACT FROM AUTHOR]

Background: Ambulance service blood transfusion is an area of rapid development. In New South Wales, Australia, the blood products carried by ambulance medical teams are often the first available to patients with critical bleeding. In addition to the blood products routinely carried by these teams, the Service created and implemented a method of initiating large‐volume, mixed‐product transfusions using existing blood banks: the Retrieval Transfusion Procedure (RTP). This article describes the trends and characteristics of New South Wales Ambulance RTP activations. Materials and Methods: This retrospective database review examines the patient records for all RTP activations. Key areas of investigation include logistics, product requests, population demographics, etiologies, physiology, mission timings, and transfusions. Results: Ambulance medical teams attended 27 531 missions in the reviewed period, 1573 patients received transfusion, and there were 138 RTP activations. Blood products were sourced from 40 banks and transported by police (46.7%), ambulance (27.1%), and helicopter (13.0%) to refueling stops (39.2%), prehospital scenes (24.2%) and hospitals (15.8%). The median time engaged on each mission was 189 minutes for metropolitan and 222 minutes for rural locations. Seventy‐eight patients were transfused with RTP blood products; 83.3% were traumas, of which 63.1% were motor vehicle collisions. Up to 18 units of blood products were administered before hospital arrival. There was significant (P <.001) improvement in the mean shock index of transfused patients between the first and final observations recorded. Conclusions: Ambulance service extended blood product transfusion is logistically achievable and facilitates emergency transfusions throughout the state with minimal additional infrastructure. [ABSTRACT FROM AUTHOR]

Patients who return to the Emergency Department (ED) for the same complaint are known to be at risk of adverse events. Monitoring of return visits is considered a way to measure the quality of care provided in the ED, although the most commonly used benchmark of 48 h lacks evidence. This study aimed to describe the incidence, characteristics and outcomes of patients with unplanned return visits. The study also aimed to determine the capture rate of the 48-h benchmark using an all-inclusive method of return visit identification. A retrospective cross-sectional study was conducted across three EDs in Sydney, New South Wales from July 1st, 2017 to June 30th, 2018. Visits that occurred within 28 days with the same or similar presenting complaint following discharge from the ED were classified as a return visit. Data were grouped by index and return visit. Descriptive statistics were used to summarise incidence, patient characteristics and outcomes for all presentations. Categorical data were analysed using Chi square tests. Continuous data were analysed using Mann–Whitney when data were not normally distributed and t -tests when normally distributed. Of all ED presentations (n = 164,598), 5860 (3.6%) were identified as a return visit. Return patients were younger than non-return patients, but those that required admission were older (43 vs 33 years, p = <0.01). Abdominal problems were the most common reason for return followed by urological and mental health. The median time to return was 64:51 h (IQR 20:35–226:37). Only 43% of return visits occurred within 48 h. Return visits to a different ED accounted for 13.2% of return visits. More than half of ED return visits are missed when the existing benchmark of 48 h is used. Current policy makers should consider increasing the 48-h benchmark to more accurately reflect the incidence of return visits. Further investigation into the causal factors for return visits is warranted, particularly in patients with abdominal, urological or mental health complaints. [ABSTRACT FROM AUTHOR]

Following the provision of urgent care, screening for risks known to impact patient outcomes is an extension of safe emergency nursing care, in particular for falls, pressure injury and substance use. Screening is a process that primarily aims to identify people at increased risk for specific complications. This study aimed to describe and evaluate the implementation of a consolidated electronic checklist on the screening completion rates for falls, pressure injury and substance use in a regional health district. This pre-post study used emergency data from four Emergency Departments (EDs) in southern NSW, Australia between November 2016 and February 2019. Patient characteristics, triage category, discharge diagnosis, arrival date and time, screening completion date and time and treatment location were extracted. Descriptive statistics were used to describe the characteristics of the presentations. Z test with adjusted p -values using Bonferroni Correction method was used to compare the characteristics of the presentations and the rates of screening completion. The Theoretical Domains Framework was used to identify any deficits in the implementation. There were 33,561 patients in the pre and 35,807 in the post group. There were no differences in patient characteristics between the two groups. The mean emergency department (ED) length of stay was unchanged (490.5 min pre vs 489.9 min post). The proportion of patients who had all three screens completed increased from 1.3% to 5.5% (p < 0.001). Pressure injury risk screening increased from 46.6% (pre) to 53.1% (post) (p < 0.001) as did substance use screening (1.7% vs 12.4%, p < 0.001). Screening was strongly associated to which hospital the patient was admitted, their age and ED length of stay. Of the 51 mapped intervention functions, 20 (39%) were used in the implementation. The introduction of a consolidated electronic checklist for use by emergency nurses to complete fall, pressure injury and substance use screening resulted in an overall increase in risk screening. However screening rates remained poor. Implementation that considers the capability, opportunity and motivation of those that need to alter their behaviour would likely improve the overall compliance. [ABSTRACT FROM AUTHOR]

Background: Injury is the leading cause of childhood death and disability in Australia. Prehospital emergency services in New South Wales (NSW) are provided by NSW Ambulance. The incidence, pre-hospital care provided and outcomes of children suffering major injury in NSW has not previously been described.Methods: This retrospective study was conducted between July 2015 and September 2016 and included children <16 years with an injury severity score (ISS) >9, or requiring intensive care admission, or deceased following injury and treated in NSW. Children were identified through the three NSW Paediatric Trauma Centres, the NSW Trauma Registry, NSW Medical Retrieval Registry (AirMaestro, Avinet, Australia).Results: There were 359 majorly injured children treated by NSW-based emergency service providers, the majority were male (73.3%) with a mean (SD) age of 8.0 (5.2) years. The median (IQR) injury severity score (ISS) for those transported via NSW emergency medical services was 10 (9-17), with almost half (44.1%) treated prehospital having an ISS >12. The most common documented interventions were intravenous access (44.1%) and oxygen therapy (39.6%). Intubation and chest decompression were recorded in 15.3% and 3.1% of cases respectively. The calculated median (IQR) transport charges for NSW Emergency Services was AUD $942 ($841.3-$1184.6).Conclusion: Critical interventions are performed infrequently in children with major injuries in the pre-hospital environment. The monitoring of the incidence and success rates for staff performing these interventions is not readily available from all prehospital emergency medical services operating in NSW. The capacity and processes to monitor and audit all critical interventions in the paediatric population should be resourced and clearly defined. [ABSTRACT FROM AUTHOR]

Background: Information about children treated in New South Wales (NSW), Australia following major injury has been limited to those treated at trauma centres using mortality as the main outcome measure, restricting assessment of the effectiveness of the Trauma System. This study sought to describe the detailed characteristics as well as functional and psychosocial health outcomes of all children suffering major injury in NSW.Methods: A longitudinal study was conducted between July 2015 and November 2017 and included children < 16 years requiring intensive care or an injury severity score (ISS) ≥ 9 treated in NSW or who died following injury. Children were identified through the three NSW Paediatric Trauma Centres (PTC), the NSW Trauma Registry, NSW Aeromedical Retrieval Registry (AirMaestro) and the National Coronial Information System (NCIS). Health-related quality of life (HRQoL) outcomes for children treated at the three PTCs were collected at baseline, 6 and 12 months using the Paediatric Quality of Life inventory (PedsQL 4.0) and EuroQol five-dimensional EQ-5D-Y.Results: There were 625 children, with a median (interquartile range) age of 7 (2-13) years and 71.7% were male. Around half were injured in major cities (51.2%). The median (IQR) injury severity score (ISS) was 10 (9-17). Twelve-month HRQoL measured by PedsQL remained below baseline for psychosocial health. Treatment costs increased with injury severity (p=<0.001) and polytrauma (p=<0.001). No survival benefit was demonstrated between PTC versus non-PTC definitive care. Injured females and children from rural / remote NSW were overrepresented in the deceased.Conclusion: Children treated in NSW following major injury have reduced quality of life and in particular, reduced emotional well-being at 12 months post-injury. Improved psychosocial care and outpatient follow-up is required to minimise the long-term emotional impact of injury on the child. [ABSTRACT FROM AUTHOR]

Injury remains the leading cause of death and disability for Australian children. There is known variability in the quality of care delivered to injured children in Australia. This study prioritises recommendations developed from an expert review of paediatric trauma cases, for implementation with the aim of improving health service delivery to children sustaining severe injury. A modified-Delphi study was conducted between October 2018 and February 2019. Two rounds of an online survey to rank the suitability and importance of each of the 26 recommendations was conducted. Final decisions on the priorities for change in the paediatric trauma system was determined by a consensus of ≥80% for importance and/or suitability. One hundred and one participants completed Round 1, and 60 participants completed Round 2 of the modified-Delphi. In Round 1, 13 recommendations reached ≥80% and in round 2, 11 recommendations reached ≥80%. Those ranked highest focussed on pre-hospital airway management, streamlining retrieval and transfer processes, improving hospital nursing ratios and radiology reporting. This modified-Delphi study identified the priority areas for recommended change to the NSW paediatric trauma system. Work to address these areas has the potential to provide more coordinated and timely care to children sustaining severe injury. [ABSTRACT FROM AUTHOR]

Background: There is known variability in the quality of care delivered to injured children. Identifying where care improvement can be made is critical. This study aimed to review paediatric trauma cases across the most populous Australian State to identify factors contributing to clinical incidents.Methods: Medical records from three New South Wales Paediatric Trauma Centres were reviewed for children <16 years requiring intensive care; with an injury severity score of ≥9, or who died following injury between July 2015 and September 2016. Records were peer-reviewed by nurse surveyors who identified cases that might not meet the expected standard of care or where the child died following the injury. A multidisciplinary panel conducted the peer-review using a major trauma peer-review tool. Records were reviewed independently, then discussed to establish consensus.Results: A total 535 records were reviewed and 41 cases were peer-reviewed. The median (IQR) age was 7 (2-12) years, the median ISS was 25 (IQR 16-30). The peer-review identified a combination of clinical (85%), systems (51%) and communication (12%) problems that contributed to difficulties in care delivery. In 85% of records, staff actions were identified to contribute to events; with medical task failure the most frequently identified cause (89%).Conclusion: The peer-review of paediatric trauma cases assisted in the identification of contributing factors to clinical incidents in trauma care resulting in 26 recommendations for change. The prioritisation and implementation of these recommendations, alongside a uniform State-wide trauma case review process with consistent criteria (definitions), performance indicators, monitoring and reporting would facilitate improvement in health service delivery to children sustaining severe injury. [ABSTRACT FROM AUTHOR]

To determine whether simulated multidisciplinary team training influences teamwork practices and experiences when resuscitating critically injured patients and to generate evidence for training trauma resuscitation flash teams. Trauma teams perform in stressful situations. They are 'flash' teams, mobilised quickly and comprise of different specialties and disciplines. Simulation is promoted as a training strategy. Significant gaps remain in evaluating the impact of this training on clinical practice. Further research is warranted to determine the most effective way to train trauma resuscitation flash team. Final integration phase of a mixed methods embedded experimental study. Primary quantitative results (time to critical operations, facilitators and barriers to teamwork) were merged with supplementary qualitative results (team members' experiences and perspectives) to explain the influences of simulated multidisciplinary trauma team training on teamwork and patient outcomes. Four main themes were developed: communication needs to be specific to the emergency context; collaborative decision-making influences resuscitation situations; standardisation promotes efficient trauma care; proficient leadership empowers multidisciplinary teamwork. Frontline clinicians identified real-world experiences that enable or impede team performance in trauma resuscitations. Our findings ascertain why multidisciplinary team training enhances team performance and what content should be incorporated in training programmes. [ABSTRACT FROM AUTHOR]

Aims and objectives: To explore the pain management experiences of recently discharged adult trauma patients and the discharge practices of the treating hospital. Background: Adult trauma patients are not always able to manage their pain effectively and as a result often experience intense and enduring injury pain at home. They describe their pain experience as unique and debilitating, and report feeling uninformed at hospital discharge. There is a need to understand what is fundamentally required for this population at hospital discharge, to facilitate competent pain management and promote best possible outcomes. Design: A mixed methods convergent study design. Methods: The quantitative results (incidence, intensity and impact of injury pain and the barriers to effective pain management) were merged with the qualitative results (patient experiences and beliefs) to produce greater understanding about the reasons behind the pain management practices of participants. Results: Integration of the quantitative and qualitative data produced four new themes. These themes demonstrate that recently discharged adult trauma patients do not have the knowledge or experience to understand or manage their injury pain effectively at home. Inadequate information and education by clinicians, at hospital discharge, contribute to this insufficiency. Conclusions: Clinicians need to understand the trauma patient pain experience to appreciate the importance of their discharge practices. Increased understanding and implementation of evidence‐informed discharge processes would improve current discharge practices and ultimately support and improve the trauma patient's injury pain management practices at home. Relevance to clinical practice: By understanding the patient perspective in the pain management of injuries, clinicians are better able to appreciate what hospital discharge practices and information are genuinely required by the trauma patient to manage their pain effectively at home, potentially preventing the long‐term consequences of injury pain. [ABSTRACT FROM AUTHOR]

Aims and objectives To determine potential facilitators and barriers and tailor interventions to optimise future implementation of a patient-assessment framework into emergency nursing practice. Background An evidence-informed patient-assessment framework HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) improves the quality of patient assessments performed by emergency nurses. Facilitators and barriers must be understood and tailored interventions selected to optimise implementation. Design A mixed-method convergent study design was used. Methods Thirty eight early career emergency nurses from five Australian hospitals participated in an education workshop on the HIRAID assessment framework. Simulated clinical scenarios enabled participants to experience conducting a patient assessment with and without using the framework. All participants completed surveys, interviews and focus groups to identify potential facilitators and barriers. Twenty three participants completed follow-up telephone surveys 4-6 months later. Quantitative and qualitative data were analysed separately using descriptive statistics and inductive content analysis, prior to integration. Implementation interventions were selected using the Behaviour Change Wheel. Results Nine facilitators and nine barriers were identified to potentially effect implementation of the HIRAID assessment framework. Twelve of the 23 participants (52.2%) who completed follow-up surveys reported using the framework in the clinical setting. To optimise future implementation, the education workshop needs refinement, and environmental restructuring, modelling and social support are required. Conclusion A multimodal strategy is needed to promote future successful implementation of the HIRAID assessment framework into emergency nursing practice. Relevance for clinical practice The successful implementation of the HIRAID assessment framework has the potential to improve nursing assessments of patients in emergency and other acute care settings. This study demonstrates how to systematically identify facilitators and barriers to behaviour change and select interventions to optimise implementation of evidence-informed nursing practices. [ABSTRACT FROM AUTHOR]

Background A previous report from the New South Wales (NSW) Trauma Registry identified falls and increasing age of severely injured patients as highly prevalent, but detailed injury and demographic profiles, outcomes and their predictors are poorly reported. This study describes the fall-injury profile in the older adult major trauma patient in NSW. Methods A retrospective registry based study between 2010 and 2014 on patients aged 55 years and over who sustained a moderate to critical injury from a fall, examining mortality and length of stay using regression analyses. Results There were 4263 major trauma falls between 2010 and 2014, most occurring at home (55.4%), on the same level (46.7%) and resulting in head injury (63.2%). Significant predictors for mortality following a fall were increased age, male gender, falls in residential care institutions, isolated head injuries and injury classified as critical (ISS 41–75). Conclusions The outcomes of falls in the older adult are very poor and a focused prospective study is required to identify areas for intervention and prevention. The predictors of mortality following a fall identified in this study can be used with existing research to develop tools and design care pathways for implementation in the emergency context to improve patient care and outcomes. [ABSTRACT FROM AUTHOR]

Aims To Describe injury profile and costs of older person trauma in New South Wales; quantify variations with peer group costs; and identify predictors of higher costs. Methods Nine level 1 New South Wales trauma centres provided data on major traumas (aged ≥55 years) during 2008-2009 financial year. Trauma register and financial data of each institution were linked. Treatment costs were compared with peer group Australian Refined Diagnostic Related Groups costs, on which hospital funding is based. Variables examined through multivariate analyses. Results Six thousand two hundred and eighty-nine patients were admitted for trauma. Most common injury mechanism was falls (74.8%) then road trauma (14.9%). Median patient cost was $7044 (Q1-3: $3405-13 930) and total treatment costs $76 694 252. Treatment costs were $5 813 975 above peer group average. Intensive care unit admission, age, injury severity score, length of stay and traumatic brain injury were independent predictors of increased costs. Conclusion Older person trauma attracts greater costs and length of stay. Cost increases with age and injury severity. Hospital financial information and trauma registry data provides accurate cost information that may inform future funding. [ABSTRACT FROM AUTHOR]

Objective. This research examines the existing funding model for in-hospital trauma patient episodes in New South Wales (NSW), Australia and identifies factors that cause above-average treatment costs. Accurate information on the treatment costs of injury is needed to guide health-funding strategy and prevent inadvertent underfunding of specialist trauma centres, which treat a high trauma casemix. Methods. Admitted trauma patient data provided by 12 trauma centres were linked with financial data for 2008-09. Actual costs incurred by each hospital were compared with state-wide Australian Refined Diagnostic Related Groups (AR-DRG) average costs. Patient episodes where actual cost was higher than AR-DRG cost allocation were examined. Results. There were 16 693 patients at a total cost of AU$178.7 million. The total costs incurred by trauma centres were $14.7 million above the NSW peer-group average cost estimates. There were 10 AR-DRG where the total cost variance was greater than $500 000. The AR-DRG with the largest proportion of patients were the upper limb injury categories, many of whom had multiple body regions injured and/or a traumatic brain injury (P < 0.001). Conclusions. AR-DRG classifications do not adequately describe the trauma patient episode and are not commensurate with the expense of trauma treatment. A revision of AR-DRG used for trauma is needed. [ABSTRACT FROM AUTHOR]

Abstract: Background: Accurate economic data are fundamental for improving current funding models and ultimately in promoting the efficient delivery of services. The financial burden of a high trauma casemix to designated trauma centres in Australia has not been previously determined, and there is some evidence that the episode funding model used in Australia results in the underfunding of trauma. Aim: To describe the costs of acute trauma admissions in trauma centres, identify predictors of higher treatment costs and cost variance in New South Wales (NSW), Australia. Materials and methods: Data linkage of admitted trauma patient and financial data provided by 12 Level 1 NSW trauma centres for the 08/09 financial year was performed. Demographic, injury details and injury scores were obtained from trauma registries. Individual patient general ledger costs (actual trauma patient costs), Australian Refined Diagnostic Related Groups (AR-DRG) and state-wide average costs (which form the basis of funding) were obtained. The actual costs incurred by the hospital were then compared with the state-wide AR-DRG average costs. Multivariable multiple linear regression was used for identifying predictors of costs. Results: There were 17,522 patients, the average per patient cost was $10,603 and the median was $4628 (interquartile range: $2179–10,148). The actual costs incurred by trauma centres were on average $134 per bed day above AR-DRG costs-determined costs. Falls, road trauma and violence were the highest causes of total cost. Motor cyclists and pedestrians had higher median costs than motor vehicle occupants. As a result of greater numbers, patients with minor injury had comparable total costs with those generated by patients with severe injury. However the median cost of severely injured patients was nearly four times greater. The count of body regions injured, sex, length of stay, serious traumatic brain injury and admission to the Intensive Care Unit were significantly associated with increased costs (p <0.001). Conclusion: This multicentre trauma costing study demonstrated the feasibility of trauma registry and financial data linkage. Discrepancies between the observed costs of care in these 12 trauma centres and the NSW average AR-DRG costs suggest that trauma care is currently underfunded in NSW. [Copyright &y& Elsevier]

Background: In NSW Australia, a formal trauma system including the use of helicopter emergency medical services (HEMS) has existed for over 20 years. Despite providing many advantages in NSW, HEMS patients are frequently over-triaged; leading to financial implications for major trauma centres that receive HEMS patients. The aim of this study was to investigate the financial implications of HEMS over-triage from the perspective of major trauma centres in NSW. Methods: The study sample included all trauma patients transported via HEMS to 12 major trauma centres in NSW during the period: 1 July 2008 to 30 June 2009. Clinical data were gathered from individual hospital trauma registries and merged with financial information obtained from casemix units at respective hospitals. HEMS over-triage was estimated based on the local definition of minor to moderate trauma (ISS⩽12) and hospital length of stay of less than 24 hrs. The actual treatment costs were determined and compared to state-wide peer group averages to obtain estimates of potential funding discrepancies. Results: A total of 707 patients transported by HEMS were identified, including 72% pre-hospital (PH; n=507) and 28% inter-hospital (IH; n=200) transports. Over-triage was estimated at 51% for PH patients and 29% for IH patients. Compared to PH patients, IH patients were more costly to treat on average (IH: $42,604; PH: $25,162), however PH patients were more costly overall ($12,329,618 [PH]; $8,265,152 [IH]). When comparing actual treatment costs to peer group averages we found potential funding discrepancies ranging between 4% and 32% across patient groups. Using a sensitivity analysis, the potential funding discrepancy increased with increasing levels of over-triage. Conclusions: HEMS patients are frequently over-triaged in NSW, leading to funding implications for major trauma centres. In general, HEMS patient treatment costs are higher than the peer group average and the potential funding discrepancy varies by injury severity and the type of transport performed. Although severely injured HEMS patients are more costly to treat, HEMS patients with minor injuries make up the majority of HEMS transports and have larger relative potential funding discrepancies. Future episode funding models need to account for the variability of trauma patients and the proportion of patients transported via HEMS. [ABSTRACT FROM AUTHOR]

Aims To describe the costs of acute trauma admissions for children aged ≤15 years in trauma centres; to identify predictors of higher treatment costs and quantify differences in actual and state-wide average cost in New South Wales (NSW), Australia. Method Admitted trauma patient data provided by 12 trauma centres was linked with financial data for 2008-2009. Demographic, injury details and injury severity scores (ISS) were obtained from trauma registries. Individual patient costs, Australian Refined Diagnostic Related Groups (AR-DRG) and state-wide average costs were obtained. Actual costs incurred by each hospital were compared with state-wide AR-DRG average costs. Multivariate multiple linear regression identified predictors of cost. Results There were 3493 patients with a total cost of AUD$20.2 million. Falls (AUD$6.7 million) and road trauma (AUD$4.4 million) had the highest total expenditure. The reduction in cost between ISS < 9 compared to ISS 9-12 and ISS > 12 was significant ( P < 0.0001). The median cost of injury increased with every additional body region injured ( P < 0.0001). For each additional day spent in hospital, there was an increased cost of AUD$1898 and patients admitted to an intensive care unit (ICU) cost AUD$7358 more than patients not admitted to ICU. The total costs incurred by trauma centres were AUD$1.4 million above the NSW peer group average cost estimates. Conclusions The high financial cost of paediatric patient treatment highlights the need to ensure prevention remains a priority in Australia. Hospitals tasked with providing trauma care should be appropriately funded and future funding models should consider trauma severity. [ABSTRACT FROM AUTHOR]

Abstract: Paediatric trauma centres seek to optimise the care of injured children. Trends in state-wide paediatric care and outcomes have not been examined in detail in Australia. This study examines temporal trends in paediatric trauma outcomes and factors influencing survival and length of stay. A retrospective review was conducted using data from the NSW Trauma Registry during 2003–2008 for children aged 15 years and younger who were severely injured (injury severity score>15). To examine trauma outcomes descriptive statistics and multivariable logistic and linear regression were conducted. There were 1138 children severely injured. Two-thirds were male. Road trauma and falls were the most common injury mechanisms and over one-third of incidents occurred in the home. Forty-eight percent of violence-related injuries were experienced by infants aged less than 1 year. For the majority of children definitive care was provided at a paediatric trauma centre, but less than one-third of children were taken directly to a paediatric trauma centre post-injury. Children who received definitive treatment at a paediatric trauma centre had between 3 and 6 times higher odds of having a survival advantage than if treated at an adult trauma centre. The number of severe injury presentations to the 14 major trauma centres in NSW remains constant. It is possible that injury prevention measures are having a limited effect on severe injury in NSW. This research provides stimulus for change in the provision and co-ordination in the delivery of trauma care for injured children. [Copyright &y& Elsevier]

The article discusses the results of a study that examined the trends in mechanism and outcome of major traumatic injury and mortality in adults following the implementation of the trauma monitoring program in New South Wales (NSW). A decreasing trend in severe trauma presentations is noted in the age group of 16 to 34 years while an increasing trend is presented among older people. It concludes that deaths from major trauma declined in NSW since 2003.

Predominantly, males have a higher risk of injury mortality and morbidity than females. However, less is known about gender differences for injury and trauma outcome at a regional level. The aim of this study was to examine the epidemiologic profile and trauma outcomes of males and females at a level 1 trauma center to inform local injury prevention efforts. A retrospective review was conducted of injuries identified from the trauma registry of the New South Wales St George Public Hospital during January 1, 2004, to December 31, 2008. There were 6763 major trauma presentations, and 65.1% of these were of males. Males had a higher proportion of trauma presentations in each age group, except for those younger than 15 years, 45 to 54 years, and older than 65 years. Almost all presentations were as a result of unintentional injuries. However, 8% of males were victims of assault compared with 2% of females. Males were more likely to be injured while working and during leisure or sports activities and at sporting, farming, home, trade, and industrial locations than females. Males were more likely to be more severely injured than females and generally had a longer hospital length of stay. There was no significant difference in the rate of mortality between the genders. There are distinct differences between the sexes regarding the mechanism and severity of injury and trauma outcomes. Local injury prevention initiatives should be targeted to address gender differences. Future social research should examine the interplay of the construction of masculinities with male injury. [ABSTRACT FROM AUTHOR]

Objectives: To compare the proportion of patients exposed to a radiation dose in excess of 20 mSv, and to document missed injuries before and after the introduction of a panscan protocol for blunt trauma. Methods: Data were collected retrospectively from our trauma database for 6 months before and after implementation of the protocol. All radiological studies performed during the initial patient assessment were identified. Radiation doses for each patient were calculated. Subgroup analyses were age ≤30 and >30 years, injury severity score (ISS) <16 and ≥16, and patient disposition as discharged from ED or admitted. Results: There were 656 patients before and 624 after the introduction of the protocol. The proportion of patients exposed to a radiation dose >20 mSv increased by 8% (95% confidence interval [CI] 4-12), which equated to one extra person being exposed to >20 mSv for every 13 patients treated after the introduction of the protocol. The odds of receiving a radiation dose >20 mSv after the introduction of the protocol compared with the odds before were increased across all subgroups (≤30 years: odds ratio [OR] 2.7, 95% CI 1.3-5.8, P = 0.008; >30 years: OR 2.2, 95% CI 1.5-3.4, P < 0.001; ISS < 16: OR 2.4, 95% CI 1.5-3.9, P < 0.001; ISS ≥ 16: OR 2.0, 95% CI 1.0-3.7, P = 0.04; discharged home: OR 2.1, 95% CI 0.7-6.0, P = 0.17; admitted: OR 2.2, 95% CI 1.5-3.3, P < 0.001). There were six missed injuries before and four after. Conclusions: Introduction of a panscan protocol increased the proportion of trauma patients receiving a radiation dose >20 mSv. This increased risk occurred regardless of age or injury severity. [ABSTRACT FROM AUTHOR]

Injury among older persons is well recognized as a growing problem. We reviewed our level-1 trauma center trauma registry finding that the most frequent presentations among people aged older than 65 years were due to falls and motor vehicle crashes. We surveyed participants at two of our older person injury awareness seminars to identify risk factors. Participants at our out-reach programme have several injury risk factors including polypharmacy for which our programme content has been tailored. We discuss this in relation to the older person injury-prevention literature. Because implementing our out-reach seminars, older person trauma presentations to our trauma center have decreased slightly. [ABSTRACT FROM AUTHOR]

Aim: To examine fall-related hospitalised morbidity in New South Wales (NSW) and to describe the pattern of fall-related major trauma presentations at a Level 1 Trauma Centre in NSW for younger and older fallers. Methods: Fall-related injuries were identified in the NSW Admitted Patients Data Collection during 1 July 1999–30 June 2008 and the trauma registry of the NSW St George Public Hospital during 1 January 2006–6 December 2008. Results: There were 434 138 hospitalisations and 862 fall-related trauma presentations. Older fallers had a higher incidence of hospitalisation, being more likely to fall on the same level during general activities at home, injuring their hip or thigh. Older fallers were also more likely to have an Injury Severity Score > 9, undergo physiotherapy and stay in hospital for >1 day than younger fallers. Conclusion: Falls, particularly for older individuals, are an important cause of serious injury, representing a considerable burden in terms of hospitalised morbidity. [ABSTRACT FROM AUTHOR]

Aim: Whether treatment at paediatric trauma centres (PTCs) provides a survival advantage for injured children over treatment at adult trauma centres (ATCs) remains inconclusive. This study examines the association between trauma centre type and in-hospital mortality for severely injured paediatric trauma patients in New South Wales, Australia.Methods: A retrospective examination of paediatric patient characteristics (aged ≤15 years), treatment and injury outcome was conducted using data from the New South Wales Trauma Registry for 2009-2014. Logistic regression was used to examine the association of in-hospital mortality and type of trauma centre.Results: There were 1230 children who were severely injured (i.e. Injury Severity Score; ISS > 12) and 81.0% received definitive care at a PTC. Two-thirds were male, 37.8% were aged 11-15 years and falls represented 32.0% of the injuries. Almost half (48.9%) the injured children had an ISS between 16 and 24, 31.9% between 25 and 39 and 3.8% an ISS between 40 and 75. The mean and median hospital length of stay was 17.5 and 5 days, respectively. Fifty percent of children that received definitive care at a PTC were admitted to an ICU compared to 23.9% at a Level 1 ATC. There were 119 (9.7%) in-hospital deaths. Children aged ≤15 years who were treated at a Level 1 ATC had 6.1 times higher odds of not surviving their injuries than if treated at a PTC.Conclusion: Children who received definitive care at a PTC had a survival advantage compared to those treated at a Level 1 ATC. Prospectively examining the processes of care for severely injured children may assist in identification of quality and system changes required to ensure optimal trauma care within the health-care system. [ABSTRACT FROM AUTHOR]

Introduction: Injury is a leading cause of death and disability among children and young people. Recovery may be negatively affected by unwarranted clinical variation such as representation to an emergency department (ED), readmission to a hospital, and mortality. The aim of this study was to examine unwarranted clinical variation across providers of care of children and young people who were hospitalised for injury in New South Wales (NSW).Materials and Methods: Retrospective population-based cohort study using linked ED, hospital, and mortality data of all children and young people aged ≤25 years who were injured and hospitalised during 1 January 2010-30 June 2014 in NSW. Unwarranted clinical variation across providers was examined using three indicators. That is, for each hospital that treated ≥100 cases per year, risk standardised ratios were calculated with 95% and 99.8% confidence limits using the number of observed and expected events of (1) representations to ED within 72 h, (2) unplanned readmissions to hospital within 28 days, and (3) all-cause mortality within 30 days.Results: There were 189,990 injury-related hospitalisations of children and young people. Of these, 4.4% represented to an ED, 8.7% were readmitted to hospital, and 0.2% died. Of the 45 public hospitals that treated ≥100 cases per year, higher than expected rates of ED representations, hospital readmissions, and mortality were observed in eleven, six, and two hospitals, respectively.Conclusion: The rates of ED representations, hospital readmissions, and mortality among children and young people hospitalised for injury in NSW were similar to the rates reported in other countries. However, unwarranted clinical variation across public hospitals was observed for all three indicators. These findings suggest that by improving routine follow-up support services post-discharge for children and young people and their families, it may be possible to reduce unwarranted clinical variation and improve health outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Background and context: Helicopter Emergency Medical Services (HEMS) are highly resource-intensive facilities that are well established as part of trauma systems in many high-income countries. We evaluated the cost-effectiveness of a physician-staffed HEMS intervention in combination with treatment at a major trauma centre versus ground ambulance or indirect transport (via a referral hospital) in New South Wales (NSW), Australia. Methods: Cost and effectiveness estimates were derived from a cohort of trauma patients arriving at St George Hospital in NSW, Australia during an 11-year period. Adjusted estimates of in-hospital mortality were derived using logistic regression and adjusted hospital costs were estimated through a general linear model incorporating a gamma distribution and log link. These estimates along with other assumptions were incorporated into a Markov model with an annual cycle length to estimate a cost per life saved and a cost per life-year saved at one year and over a patient''s lifetime respectively in three patient groups (all patients; patients with serious injury [Injury Severity Score>12]; patients with traumatic brain injury [TBI]). Results: Results showed HEMS to be more costly but more effective at reducing in-hospital mortality leading to a cost per life saved of $1,566,379, $533,781 and $519,787 in all patients, patients with serious injury and patients with TBI respectively. When modelled over a patient''s lifetime, the improved mortality associated with HEMS led to a cost per life year saved of $96,524, $50,035 and $49,159 in the three patient groups respectively. Sensitivity analyses revealed a higher probability of HEMS being cost-effective in patients with serious injury and TBI. Conclusion: Our investigation confirms a HEMS intervention is associated with improved mortality in trauma patients, especially in patients with serious injury and TBI. The improved benefit of HEMS in patients with serious injury and TBI leads to improved estimated cost-effectiveness. [Copyright &y& Elsevier]

Abstract: Injuries represent a significant health burden in Australia. In New South Wales (NSW), no routine follow-up of post-injury health outcomes is conducted. This article describes the development of a protocol and the conduct of a pilot study to collect information on trauma outcomes at 3 months post-injury at two trauma centres. A modified Victorian model of trauma outcomes monitoring was adopted, with potential participants required to ‘opt in’ to the collection. Fifty-three percent of individuals contacted consented to opt in, with 75% of these completing an interview. The data items collected were able to provide an indicator of the impact of trauma on individuals. This study has highlighted that there are important methodological issues to be addressed in terms of recruitment in establishing long-term trauma outcomes data collections that are representative of the trauma population. Ultimately, information from a long-term trauma outcomes collection could be linked to data collections to conduct research across the injury continuum. [Copyright &y& Elsevier]