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Objective: To explore clinicians' use and perceptions of interdisciplinary communication pathways for escalating care within the pre-medical emergency team (pre-MET) tier of rapid response systems. Method: A sequential mixed-methods study was conducted using observations and interviews. Participants were clinicians (nurses, allied health, doctors) caring for orthopaedic and general medicine patients at one hospital. Descriptive and thematic analyses were conducted. Results: Escalation practices were observed for 13 of 27 pre-MET events. Leading communication methods for escalating pre-MET events were alphanumeric pagers (61.5%) and in-person discussions (30.8%). Seven escalated pre-MET events led to bedside pre-MET reviews by doctors. Clinician interviews (n = 29) culminated in two themes: challenges in escalation of care, and navigating information gaps. Clinicians reported deficiencies in communication methods for escalating care that hindered interdisciplinary communication and clinical decision-making pertaining to pre-MET deterioration. Conclusion: Policy-defined escalation pathways were inconsistently utilised for pre-MET deterioration. Available communication methods for escalating pre-MET events inadequately fulfilled clinicians' needs. Variable perceptions of escalation pathways illuminated a lack of of a shared mental model about clinicians' roles and responsibilities. To optimise timely and appropriate management of patient deterioration, communication infrastructure and interdisciplinary collaboration must be enhanced. What is known about the topic? To promote earlier recognition of, and response to, deteriorating ward patients, Australian rapid response systems include a pre-medical emergency team (pre-MET) tier. Escalation pathways within the pre-MET tier are poorly understood. What does this paper add? Policy-defined escalation pathways were inconsistently utilised. Clinicians identified deficiencies in communication methods (e.g. alphanumeric pagers) for escalating pre-MET deterioration. Perceptions of escalation pathways illuminated a lack of of a shared mental model about clinicians' roles and responsibilities. What are the implications for practitioners? To optimise the management of pre-MET deterioration, ward-based communication infrastructure and interdisciplinary collaboration must be enhanced. [ABSTRACT FROM AUTHOR]

Objective. We aim to examine the activities undertaken by medical and surgical ward nurses at a major health service in Victoria, Australia, to inform nursing and midwifery strategic workforce planning. Methods. This descriptive, exploratory study was conducted on 17 wards from three acute care hospitals in one of Victoria’s largest health services. The Work Observation Method by Activity Timing tool was used to enable participants to document the time spent in each of 10 nursing activity domains. Results. Data from 70 respondents across all shifts showed nurses spent one-third of their time in direct care. Registered nurses spent a lower proportion of time than enrolled nurses in direct care and medications overall. Compared with enrolled nurses, registered nurses spent less time in direct care on morning shifts and documentation on afternoon shifts, and more time on ward-related activities on afternoon shifts. Conclusions. Medical and surgical enrolled nurses and registered nurses spent comparable proportions of time engaged in specific activities. Further research is required to understand the influences on the time devoted to direct care and how time spent in direct care intersects with other activities, and the relationship with patient outcomes and quality of care indicators. [ABSTRACT FROM AUTHOR]

Aim: To understand how the COVID‐19 pandemic impacted nurse educators' and novice nurses' experience with the perioperative transition to specialty practice program. Design: A qualitative descriptive study. Methods: Semi‐structured interviews were conducted with five perioperative nurse educators and five perioperative transition to specialty practice program participants from a major metropolitan health service in Melbourne. Data were collected between April and July 2021. Interviews were audio‐recorded and transcribed verbatim, and data were analysed using reflexive thematic analysis. Results: Five themes were identified. The value of the perioperative transition to specialty practice program in supporting novice nurses was recognized in the theme 'Nurturing our novices'. Widespread changes to clinical practice were demonstrated in the theme 'Every day is different', including changes to elective surgery, redeployment of staff and the transmission risk of COVID‐19. 'The perils and joys of online learning' revealed both challenges and benefits of transitioning theoretical education from face‐to‐face to online delivery. 'Roller coaster of emotions' represented the heightened emotions participants experienced due to the COVID‐19 pandemic. 'Looking back to move forward' encompassed participants' reflections on the year, considering the challenges, adaptive strategies and the future of perioperative nursing education. Conclusion: The perioperative transition to specialty practice program was significantly impacted by the COVID‐19 pandemic. Participants needed to adapt to rapid and frequent changes, which contributed to feelings of emotional distress, affected consolidation of clinical learning and reduced engagement with theoretical education. Impact Perioperative nurses should acknowledge that opportunities for learning were decreased for transition to specialty practice program participants during the pandemic. Ongoing support and education should be provided, to nurture the future generation of perioperative nurses. [ABSTRACT FROM AUTHOR]

Aims and objectives: To explore: i) the frequency and nature of patient participation in nursing handover and ii) patients' and nurses' perceived strategies to enhance patient involvement in nursing handover. Background: Patient participation in nursing handover is important for patient‐centred care, shared decision‐making, patient safety and a positive healthcare experience Design: A multi‐site prospective study using a mixed methods design. Methods: Between September and December 2019, nursing handovers were observed on ten randomly selected wards, followed by semi‐structured interviews with patients (n = 33), and nurses (n = 20) from the observed handovers. Data were analysed using descriptive statistics for structured observations and thematic analysis of interviews, and triangulated to develop a greater understanding of patient participation in nursing handover. This study is reported using the Good Reporting of Mixed Methods Study guidelines. Results: The median patient age was 77 years and 47% (n = 55) patients were female. Of the 117 handovers, 76.9% (n = 90) were conducted in the patient's presence. Patients were active participants in 33.3% (n = 30) and passive participants in 46.7% (n = 42) of handovers; in 20% of handovers (n = 18), the patient had no input at all. Active participation was more likely in women (vs. men), surgical patients (vs. medical patients) and when nurses displayed engagement behaviours (eye contact, opportunity to ask questions, explanations). Three major themes were identified from the interviews: 'Being Involved', 'Layers of Influence' and 'Information Exchange'. Conclusions: The main finding was that patient participation in handover was low and strongly influenced by a complex interplay of factors including patient and nurse preferences and perceptions. Relevance to Clinical Practice: Handover is an essential tool in the provision of safe patient care. Patients were able to actively participate in nursing handover when they understood the purpose and timing of handover and had rapport with nurses. [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]

Abstract: Aims and objectives: To establish the frequency of clinical deterioration in the early postoperative period in patients who have undergone general or orthopaedic surgery. Background: Worldwide, clinical deterioration is a significant problem in acute care settings. Early recognition and response to clinical deterioration is one of the ten National Safety and Quality Health Service Standards in Australia. However, there is limited understanding of the frequency of clinical deterioration in surgical patients. Methods: A point prevalence study was conducted from September–October 2014. The records of 100 consecutive in patients admitted for orthopaedic (n = 48) or general surgery (n = 52) to a health service in Melbourne, Australia, were audited. The frequency of clinical deterioration episodes was summarised using descriptive statistics. Results: Baseline characteristics of the two patient groups were equivalent except that orthopaedic patients were older than the general surgery patients (median age 71 [IQR 19] years vs. 62 [IQR 17] years). There were 17 medical emergency team calls and 23 calls for urgent clinical review in 28 patients. The main indications for emergency calls were hypotension (26%), fever (19%), hypoxia (15%), tachycardia (13%) and altered blood glucose level (11%). The majority of episodes were managed on the ward, and there were one ICU transfer and no cardiac arrest calls. Conclusion: One in four patients experienced early postoperative clinical deterioration. Hypotension was the most common trigger for escalation of care highlighting a need to optimise fluid and haemodynamic management of postoperative patients. Relevance to clinical practice: Haemodynamic instability leading to the activation of rapid response systems is very common in the immediate postoperative period. There is the need for locally tailored interventions to optimise fluid management and decrease incidence of further complications. [ABSTRACT FROM AUTHOR]

Objectives. The aim of the present study was to describe and compare organisational guidance documents related to recognising and responding to clinical deterioration across five health services in Victoria, Australia. Methods. Guidance documents were obtained from five health services, comprising 13 acute care hospitals, eight subacute care hospitals and approximately 5500 beds. Analysis was guided by a specific policy analysis framework and a priori themes. Results. In all, 22 guidance documents and five graphic observation and response charts were reviewed. Variation was observed in terminology, content and recommendations between the health services. Most health services' definitions of physiological observations fulfilled national standards in terms of minimum parameters and frequency of assessment. All health services had three-tier rapid response systems (RRS) in place at both acute and subacute care sites, consisting of activation criteria and an expected response. RRS activation criteria varied between sites, with all sites requiring modifications to RRS activation criteria to be made by medical staff. All sites had processes for patient and family escalation of care. Conclusions. Current guidance documents related to the frequency of observations and escalation of care omit the vital role of nurses in these processes. Inconsistencies between health services may lead to confusion in a mobile workforce and may reduce system dependability. [ABSTRACT FROM AUTHOR]

Aims and objectives: To obtain an understanding of how Hospital in the Home (HITH) nurses recognise and respond to clinical deterioration in patients receiving care at home or in their usual place of residence. Background: Recognising and responding to clinical deterioration is an international safety priority and a key nursing responsibility. Despite an increase in care delivery in home environments, how HITH nurses recognise and respond to clinical deterioration is not yet fully understood. Design: A prospective, descriptive exploratory design was used. A survey containing questions related to participant characteristics and 10 patient scenarios was used to collect data from 47 nurses employed in the HITH units of three major health services in Melbourne, Australia. The 10 scenarios reflected typical HITH patients and included medical history and clinical assessment findings (respiratory rate, oxygen saturation, heart rate, blood pressure, temperature, conscious state and pain score). Results: The three major findings from this study were that: (i) nurse and patient characteristics influenced HITH nurses’ assessment decisions; (ii) the cues used by HITH nurses to recognise clinical deterioration varied according to the clinical context; and (iii) although HITH nurses work in an autonomous role, they engage in collaborative practice when responding to clinical deterioration. Conclusion: Hospital in the Home nurses play a fundamental role in patient assessment, and the context in which they recognise and respond to deterioration is markedly different to that of hospital nurses. Relevance to clinical practice: The assessment, measurement and interpretation of clinical data are a nursing responsibility that is crucial to early recognition and response to clinical deterioration. The capacity of HITH services to care for increasing numbers of patients in their home environment, and to promptly recognise and respond to clinical deterioration should it occur, is fundamental to safety within the healthcare system. Hospital in the Home nurses are integral to a sustainable healthcare system that is responsive to dynamic changes in public health policies, and meets the healthcare needs of the community. [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]

Aims and objectives To examine and describe the relationship between physiological status and violent and aggressive behaviours in hospital patients. Background The majority of adverse events are preceded by physiological abnormalities; whether physiological deterioration is a predictor of violent or aggressive behaviours remains unknown. Design Prospective case-control study. Methods Prospective audit of 999 patients from two major health services in Melbourne, Australia. There were 333 cases who required an emergency response for aggressive or violent behaviour (Code Grey) in the emergency department, medical or surgical units, or inpatient mental health unit between January-June 2015. Two control patients who did not have a Code Grey were randomly selected from the same unit and same day that the Code Grey occurred for the case patient. Results Patient locations were 54·4% medical or surgical units, 23·7% emergency department and 21·9% mental health units. Code Grey patients had less documentation of physiological assessment and were more likely to have respiratory rate, heart rate and conscious state abnormalities in the 12 hours preceding Code Grey. After adjusting for confounders, the risk of Code Grey was highest for patients with confusion. Conclusion Patients experiencing behavioural disturbance had lower standards of patient assessment, greater incidence of physiological abnormalities and more inpatient deaths. Early recognition of, and response to, patient and physiological predictors of Code Grey should be a strategy to prevent behavioural escalation to the point of Code Grey. Relevance to clinical practice Strategies are needed to improve physiological assessment of patients with behavioural disturbance while ensuring staff safety. There are patient and physiological factors associated with increased risk of Code Grey that may be used to prevent behavioural escalation to the point of an emergency response. [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]

Patient safety research focussing on recognizing and responding to clinical deterioration is gaining momentum in generalist health, but has received little attention in mental health settings. The focus on early identification and prompt intervention for clinical deterioration enshrined in patient safety research is equally relevant to mental health, especially in triage and crisis care contexts, yet the knowledge gap in this area is substantial. The present study was a controlled cohort study ( n = 817) that aimed to identify patient and service characteristics associated with clinical deterioration of mental state indicated by unplanned admission to an inpatient psychiatric unit following assessment by telephone-based mental health triage. The main objective of the research was to produce knowledge to improve understandings of mental deterioration that can be used to inform early detection, intervention, and prevention strategies at the point of triage. The results of the study found that the clinical profile of admitted patients was one of complexity and severity. Admitted patients were more likely to have had complex psychiatric histories with multiple psychiatric admissions, severe psychotic symptoms, a history of treatment non-adherence, and poorer social functioning than non-admitted patients. [ABSTRACT FROM AUTHOR]

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

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

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]

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]

The article focuses on a study conducted by researcher Julie L. Preston related to online education programs to train nurses in recording and interpreting atrial electrograms (AEG). It states that the ability of nurses to interpret AEGs improved after participating in education programs. It mentions that AEGs are very important for the appropriate treatment of cardiac arrhythmias in patients who undergo cardiac surgeries. A need for further research on patient outcomes is highlighted.

Summary Background Formal processes for recognising and responding to deteriorating emergency department (ED) patients are variable despite features of the ED context that may increase the risk of unrecognised or unreported clinical deterioration. The aim of this study was to determine the frequency and nature of unreported clinical deterioration in emergency care. Methods A prospective, exploratory descriptive design was used. Data were collected during nine point prevalence surveys (PPS) from 1 May to 30 June 2009 at an urban district hospital in Melbourne Australia. Patients present in ED cubicles during the PPS ( n = 186) were included in the study. Results Unreported clinical deterioration occurred in 12.9% of patients ( n = 24/186). Unreported clinical deterioration was more common when: (i) patients aged ≥65 years comprised >50% of patients within the ED; (ii) occupancy of the resuscitation, monitored or general adult cubicles was >50%; and (iii) the proportion of patients requiring treatment within 30 min (Australasian Triage Category 1, 2 or 3) was ≤50% of the total ED population. Conclusions Unreported clinical deterioration is an important quality indicator of emergency care. The effect of the collective ED patient group on the frequency and nature of adverse events for individual ED patients is poorly understood and warrants further investigation. [ABSTRACT FROM AUTHOR]

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

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]

The study aims to identify the reasons for, and outcomes from, unplanned transfers from subacute care to acute care. A retrospective patient record review of patients requiring unplanned transfer from subacute to an acute care emergency department ( ED) from 1 July 2008 to 30 June 2009 was undertaken. Data collected included patient demographics, clinical characteristics in preceding transfer, and on ED arrival and outcome data. There were 136 patients included in the study with a median age of 81 years. The most common reasons for transfer were respiratory problems and altered conscious state. In the 24 h preceding transfer, 92.6% of patients had ≥ 1 physiological abnormality and 10.3% of patients had no physiological parameters documented. On ED arrival, 75% of patients had physiological abnormalities. Hospital admission occurred in 75% of patients and the inpatient mortality rate was 14.7%. Factors associated with inpatient mortality were tachypnoea and severe hypoxaemia in 24 h preceding transfer and tachypnoea, hypoxaemia, hypoxaemia, severe hypoxaemia and hypothermia on ED arrival. Patients requiring unplanned transfer had higher inpatient mortality than older hospital users. Reasons for unplanned transfer reflect known predictors of in-hospital adverse events so predictive use of physiological data and patient characteristics might optimize patient safety. [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]

This study examined the emergency nurse practitioner candidate (ENPC) scope of practice in a Victorian emergency department (ED). The emergency nurse practitioner (ENP) role is relatively new in Victoria and the scope of the ENP(C) practice is yet to be defined. International research literature regarding the ENP role has focused on outcomes such as patient satisfaction, waiting times and/or ED length of stay, accuracy and adequacy of documentation, use of radiography, and patient education, health promotion and communication issues. A prospective exploratory design was used to conduct this cohort study. There were 476 ENPC-managed patients between 14 July 2004 and 31 March 2005 with an average age of 29 years. The majority (77.2%) of ENPC-managed patients were discharged from the ED. The majority of the ENPC time was devoted to clinical practice (55%) and development of clinical practice guidelines (25%). Of patients managed by the ENPC, 49.6% required medications, 51% required diagnostic imaging and 8.6% required pathology testing during their ED stay. The most common discharge referrals were made to local medical officers (73.5%) and the most common referrals made for patients requiring admission were made to the plastic surgery (37.3%) and orthopaedic (35.5%) units. Extensions to the current scope of emergency nursing practice are pivotal to effective management of specific patient groups by ENP. The ENP model of care is an important strategy for the management of increased service demands in Victoria; however, little is known about the scope of the ENPC practice and many outcomes of the ENP care are yet to be defined. Further research to better understand the relationships between ENP outcomes is required if the contribution that ENPs make to emergency care is to be accurately quantified. [ABSTRACT FROM AUTHOR]

Abstract The Emergency Department at Dandenong Hospital has recently developed an evidence-based clinical guideline for the emergency department management of hip fractures. This paper will comment on the role of clinical guidelines in the emergency department, discuss the process of the development of evidence-based guidelines for the care of hip fractures and present the evidence found during the development process. Evidence-based recommendations for practice are made regarding pulse oximetry and supplemental oxygen, preoperative use of skin traction, thromboembolism prophylaxis, pain management including the use of nerve blocks, pressure area care, the use of indwelling urinary catheters and time to surgical repair. [ABSTRACT FROM AUTHOR]

Objective: To investigate the psychosocial effects of the COVID-19 pandemic on nurses and midwives working in acute care settings, specifically psychological distress, self-reported concerns, and perceived impact on their work and personal lives. Background: Little is known about the psychosocial impact of the pandemic on nurses and midwives in Australia, a country with a substantially lower number of COVID-19 cases and deaths than many others. Few studies investigating the prevalence of psychological distress among nurses during the pandemic have been conducted in more than one setting, especially in the Australian context. Study design and methods: Cross-sectional survey design (STROBE checklist). Nurses and midwives (n=1,611) at four metropolitan tertiary health services in Melbourne, Australia completed an anonymous online survey between 15 May and 31 August 2020, which assessed symptoms of depression, anxiety and stress (DASS-21); concerns related to COVID-19; and other effects of COVID-19. Space was provided for free-text comments. Results: Approximately one fifth of respondents reported moderate to extremely severe symptoms of depression, anxiety and stress. Fewer years of clinical experience were significantly associated with higher levels of psychological distress. More than half of the respondents were extremely/very concerned about passing COVID-19 on to family members and about their family's health, and almost half were concerned about caring for a patient who had confirmed or suspected COVID-19. Respondents reported that certain precautionary measures such as personal protective equipment (PPE) interfered with their ability to provide optimal patient care. Positive aspects of the pandemic were also reported including a sense of togetherness and cooperation among staff. Conclusion: The COVID-19 pandemic has had a considerable impact on the psychological wellbeing and work and personal lives of nurses and midwives working in acute care settings in Melbourne, Australia, particularly those with less clinical experience. Implications for nursing and health services research, policy and practice: Nurses and midwives, particularly those with less clinical experience, would benefit from additional, targeted wellbeing and support initiatives. For those with less experience, initiatives could include being partnered with more experienced colleagues and educators who can provide practical and emotional support and monitor their stress levels. What is already known about the topic? * Nurses and midwives have experienced more psychological distress than other healthcare workers during the COVID-19 pandemic. * Most studies about the psychosocial impact of the COVID-19 pandemic on nurses and midwives have been conducted in a single health service. * Few studies have concurrently investigated the experiences of nurses and midwives from different health services during the COVID-19 pandemic especially in the Australian context. What this paper adds * Despite the relatively low number of COVID-19 cases and deaths in Australia, the COVID-19 pandemic has had a considerable impact on the psychological wellbeing and work and personal lives of Australian nurses and midwives. * About one in five of the nurses and midwives surveyed reported moderate to extremely severe symptoms of depression, anxiety and stress during the first wave of the pandemic. * Nurses and midwives with fewer years of clinical experience experienced higher levels of psychological distress than those with more experience. [ABSTRACT FROM AUTHOR]

Emergency interhospital transfers from inpatient subacute care to acute care occur in 8% to 17.4% of admitted patients and are associated with high rates of acute care readmission and in-hospital mortality. Serious adverse events in subacute care (rapid response team or cardiac arrest team calls) and increased nursing surveillance are the strongest known predictors of emergency interhospital transfer from subacute to acute care hospitals. However, the epidemiology of clinical deterioration across sectors of care, and specifically in subacute care is not well understood. To explore the trajectory of clinical deterioration in patients who did and did not have an emergency interhospital transfer from subacute to acute care; and develop an internally validated predictive model to identify the role of vital sign abnormalities in predicting these emergency interhospital transfers. This prospective, exploratory cohort study is a subanalysis of data derived from a larger case-time-control study. 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. All patients with an emergency transfer from inpatient rehabilitation or geriatric evaluation and management unit to an acute care hospital within the same health service were included. Patients receiving palliative care were excluded. Study data were collected between 22 August 2015 and 30 October 2016 by medical record audit. The Cochran-Mantel-Haenszel test and bivariate logistic regression analysis were used to compare cases with controls and to account for health service clustering effect. Data were collected on 603 transfers (557 patients) and 1160 controls. Adjusted for health service, ≥2 vital sign abnormalities in subacute care (adjusted odds ratio=8.81, 95% confidence intervals:6.36-12.19, p<0.001) and serious adverse events during the first acute care admission (adjusted odds ratio=1.28, 95% confidence intervals:1.08-1.99, p=0.015) were the clinical factors associated with increased risk of emergency interhospital transfer. An internally validated predictive model showed that vital sign abnormalities can fairly predict emergency interhospital transfers from subacute to acute care hospitals. Serious adverse events in acute care should be a key consideration in decisions about the location of subacute care delivery. During subacute care, 15.7% of cases had vital signs fulfilling organisational rapid response team activation criteria, yet missed rapid response team activations were common suggesting that further consideration of the criteria and strategies to optimise recognition and response to clinical deterioration in subacute care are needed. [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]

Aim(s): To explore vital sign assessment (both complete and incomplete sets of vital signs), and escalation of care per policy and nursing interventions in response to clinical deterioration., Design: This cohort study is a secondary analysis of data from the Prioritising Responses of Nurses To deteriorating patient Observations cluster randomised controlled trial of a facilitation intervention on nurses' vital sign measurement and escalation of care for deteriorating patients., Methods: The study was conducted in 36 wards at four metropolitan hospitals in Victoria, Australia. Medical records of all included patients from the study wards during three randomly selected 24-h periods within the same week were audited at three time points: pre-intervention (June 2016), and at 6 (December 2016) and 12 months (June 1017) post-intervention. Descriptive statistics were used to summarise the study data, and relationships between variables were examined using chi-square test., Results: A total of 10,383 audits were conducted. At least one vital sign measurement was documented every 8 h in 91.6% of audits, and a complete set of vital signs was documented every 8 h in 83.1% of audits. There were pre-Medical Emergency Team, Medical Emergency Team or Cardiac Arrest Team triggers in 25.8% of audits. When triggers were present, a rapid response system call occurred in 26.8% of audits. There were 1350 documented nursing interventions in audits with pre-Medical Emergency Team (n = 2403) or Medical Emergency Team triggers (n = 273). One or more nursing interventions were documented in 29.5% of audits with pre-Medical Emergency Team triggers and 63.7% of audits with Medical Emergency Team triggers., Conclusion: When rapid response system triggers were documented, there were gaps in escalation of care per policy; however, nurses undertook a range of interventions within their scope of practice in response to clinical deterioration., Relevance to Clinical Practice: Medical and surgical ward nurses in acute care wards frequently engage in vital sign assessment. Interventions by medical and nurgical nurses may occur prior to, or in parallel with calling the rapid response system. Nursing interventions are a key but under-recognised element of the organisational response to deteriorating patients., Implications for the Profession And/or Patient Care: Nurses engage in a range of nursing interventions to manage deteriorating patients, (aside from rapid response system activation) that are not well understood, nor well described in the literature to date., Impact: This study addresses the gap in the literature regarding nurses' management of deteriorating patients within their scope of practice (aside from RRS activation) in real world settings. When rapid response system triggers were documented, there were gaps in escalation of care per policy; however, nurses undertook a range of interventions within their scope of practice in response to clinical deterioration. The results of this research are relevant to nurses working on medical and surgical wards., Reporting Method: The trial was reported according to the Consolidated Standards of Reporting Trials extension for Cluster Trials recommendations, and this paper is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology Statement., Patient or Public Contribution: No Patient or Public Contribution., (© 2023 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Concerns regarding the physical and mental health impacts of frontline healthcare roles during the COVID-19 pandemic have been well documented, but the impacts on family functioning remain unclear. This study provides a unique contribution to the literature by considering the impacts of the COVID-19 pandemic on frontline healthcare workers and their families. Thirty-nine frontline healthcare workers from Victoria, Australia, who were parents to at least one child under 18 were interviewed. Data were analysed using reflexive thematic analysis. Five superordinate and 14 subordinate themes were identified. Themes included more family time during lockdowns, but at a cost; changes in family responsibilities and routines; managing increased demands; healthcare workers hypervigilance and fear of bringing COVID-19 home to their family members; ways in which families worked to "get through it". While efforts have been made by many healthcare organisations to support their workers during this challenging time, the changes in family functioning observed by participants suggest that more could be done for this vulnerable cohort, particularly with respect to family support.

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

Background: 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., Methods: 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., Results: 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., Conclusion: 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., (Copyright © 2020 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.)

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., (© 2019 John Wiley & Sons Ltd.)

Objective: To describe characteristics and outcomes of emergency interhospital transfers from subacute to acute hospital care and develop an internally validated predictive model to identify features associated with high risk of emergency interhospital transfer., Design: Prospective case-time-control study., Setting: Acute and subacute healthcare facilities from five health services in Victoria, Australia., Participants: Cases were patients with an emergency interhospital transfer from subacute to acute hospital care. For every case, two inpatients from the same subacute care ward on the same day of emergency transfer were randomly selected as controls. Admission episode was the unit of measurement and data were collected prospectively., Main Outcome Measures: Patient and admission characteristics, transfer characteristics and outcomes (cases), serious adverse events and mortality., Results: Data were collected for 603 transfers in 557 patients and 1160 control patients. Cases were significantly more likely to be male, born in a non-English speaking country, have lower functional independence, more frequent vital sign assessments and experience a serious adverse event during first acute care or subacute care admissions. When adjusted for health service, cases had significantly higher inpatient mortality, were more likely to have unplanned intensive care unit admissions and rapid response team calls during their entire hospital admission., Conclusions: Patients who require an emergency interhospital transfer from subacute to acute hospital care have hospital admission rates and in-hospital mortality. Clinical instability during the first acute care admission (serious adverse events or increased surveillance) may prompt reassessment of patient suitability for movement to a separate subacute care hospital., (© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective The aim of the present study was to gain an understanding of the factors associated with unplanned hospital readmission within 28 days of acute care discharge from a major Australian health service. Methods A retrospective study of 20575 acute care discharges from 1 August to 31 December 2015 was conducted using administrative databases. Patient, index admission and readmission characteristics were evaluated for their association with unplanned readmission in ≤28 days. Results The unplanned readmission rate was 7.4% (n=1528) and 11.1% of readmitted patients were returned within 1 day. The factors associated with increased risk of unplanned readmission in ≤28 days for all patients were age ≥65 years (odds ratio (OR) 1.3), emergency index admission (OR 1.6), Charlson comorbidity index >1 (OR 1.1-1.9), the presence of chronic disease (OR 1.4) or complications (OR 1.8) during the index admission, index admission length of stay (LOS) >2 days (OR 1.4-1.8), hospital admission(s) (OR 1.7-10.86) or emergency department (ED) attendance(s) (OR 1.8-5.2) in the 6 months preceding the index admission and health service site (OR 1.2-1.6). However, the factors associated with increased risk of unplanned readmission ≤28 days changed with each patient group (adult medical, adult surgical, obstetric and paediatric). Conclusions There were specific patient and index admission characteristics associated with increased risk of unplanned readmission in ≤28 days; however, these characteristics varied between patient groups, highlighting the need for tailored interventions. What is known about the topic? Unplanned hospital readmissions within 28 days of hospital discharge are considered an indicator of quality and safety of health care. What does this paper add? The factors associated with increased risk of unplanned readmission in ≤28 days varied between patient groups, so a 'one size fits all approach' to reducing unplanned readmissions may not be effective. Older adult medical patients had the highest rate of unplanned readmissions and those with Charlson comorbidity index ≥4, an index admission LOS >2 days, left against advice and hospital admission(s) or ED attendance(s) in the 6 months preceding index admission and discharge from larger sites within the health service were at highest risk of unplanned readmission. What are the implications for practitioners? One in seven discharges resulted in an unplanned readmission in ≤28 days and one in 10 unplanned readmissions occurred within 1 day of discharge. Although some patient and hospital characteristics were associated with increased risk of unplanned readmission in ≤28 days, statistical modelling shows there are other factors affecting the risk of readmission that remain unknown and need further investigation. Future work related to preventing unplanned readmissions in ≤28 days should consider inclusion of health professional, system and social factors in risk assessments.

Background: 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., Methods: 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., Results: 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., Conclusions: 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., (Copyright © 2018 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.)

Background: The study aim was to explore the systems for recognising and responding to clinical deterioration in adult and paediatric Victorian emergency department (ED) patients after their initial triage assessment., Methods: A survey of Victorian EDs was conducted. Senior ED nursing staff was asked about ED characteristics, vital sign documentation, systems for recognising and responding to deteriorating ED patients, quality assurance and governance of ED rapid response systems (RRSs)., Results: Sixteen EDs participated (17 metropolitan and 13 regional or rural) giving a response rate of 53.3% (16/30). The organisational definition of a deteriorating patient applied to the ED at 50% of sites (n=8). Vital sign documentation was paper-based (43.6%), electronic (37.6%) or a combination (18.8%) of both. The majority of EDs (87.5%, n=14) had an ED RRS; 50% had one tier, single trigger RRS and 31.3% of EDs had a two tier, single trigger RRS. At 68.8% of sites the ED RRS activation criteria were the same as ward MET (medical emergency team) activation criteria. The most common method of escalation of care for deteriorating ED patients were face-to-face communication (87.5%) and overhead announcements within the ED (68.8%). The ED rapid response team (RRT) was composed of ED specific staff in 50.5% of sites, and staff external to the ED at 12.5% of sites. Two thirds of sites (68.7%) collected data about clinical deterioration in ED patients., Conclusions: Most EDs had an RRS but there was variability in activation criteria and members of the responding team both between EDs, and between ED and the ward RRSs., (Copyright © 2018 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.)

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 (T 3 ) 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 T 3 intervention or no additional support (control EDs). Our T 3 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.

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 (2.8h; 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., (Copyright © 2015 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: The aim of the present study was to examine the timing and outcomes of patients requiring an unplanned transfer from subacute to acute care., Methods: Subacute care in-patients requiring unplanned transfer to an acute care facility within four Victorian health services from 1 January to 31 December 2010 were included in the study. Data were collected using retrospective audit. The primary outcome was transfer within 24 h of subacute care admission., Results: In all, 431 patients (median age 81 years) had unplanned transfers; of these, 37.8% had a limitation of medical treatment (LOMT) order. The median subacute care length of stay was 43 h: 29.0% of patients were transferred within 24 h and 83.5% were transferred within 72 h of subacute care admission. Predictors of transfer within 24 h were comorbidity weighting (odds ratio (OR) 1.1, P = 0.02) and LOMT order (OR 2.1, P < 0.01). Hospital admission occurred in 87.2% of patients and 15.4% died in hospital. Predictors of in-hospital mortality were comorbidity weighting (OR 1.2, P < 0.01) and the number of physiological abnormalities in the 24 h preceding transfer (OR 1.3, P < 0.01)., Conclusions: There is a high rate of unplanned transfers to acute care within 24h of admission to subacute care. Unplanned transfers are associated with high hospital admission and in-hospital mortality rates.

Background: Triage nurse initiated X-rays (NIXRs) are safe and effective, however, little is known about the ability of other RNs, particularly those without postgraduate qualifications in emergency nursing, to order NIXRs. The aim of this study was to evaluate an innovative NIXR education programme for emergency nurses., Method: The education programme was multi-faceted, delivered using Team-Based Learning (TBL) and augmented by a decision support checklist. Using a prospective exploratory design, 276 NIXR requests from June to December 2011 were audited. Three groups were compared: (i) RNs with and without postgraduate qualifications irrespective of how they were educated in NIXR, (ii) RNs with and without postgraduate qualifications who undertook the NIXR education programme, and (iii) RNs who did and did not undertake the NIXR programme irrespective of postgraduate qualifications., Results: There were 130 NIXRs by 28 RNs with postgraduate qualifications and 146 NIXRs by 12 RNs without postgraduate qualifications. Analysis of all RNs showed RNs without postgraduate qualifications had higher incidence of appropriate NIXRs (83.6% vs 66.2%, p=0.003) however when controlled for the NIXR education programme, statistical significance was lost (83.6% vs 67.5%, p=0.017). RNs who undertook the NIXR education programme had superior documentation of patient assessment findings and higher incidence of appropriate X-ray requests than RNs who did not undertake the NIXR education programme (80.4% vs 65.2%, p=0.042)., Conclusions: With appropriate educational preparation, RNs without postgraduate qualifications in emergency nursing can safely engage in NIXR. Structured education using TBL and a decision support checklist produces superior assessment and X-ray requests when compared to ad hoc education and role modelling., (Copyright © 2012 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: There are many Emergency Department (ED) demand management systems that include advanced practice emergency nursing roles. The aim of this study is to examine and compare three advanced emergency nursing practice roles: ED Fast Track, Clinical Initiatives Nurse (CIN) and Rapid Intervention and Treatment Zone (RITZ)., Method: A descriptive exploratory approach was used to conduct this study at an urban district hospital in Melbourne, Australia. The study participants were patients managed in each of the three systems with advanced practice emergency nursing roles: Fast Track, CIN and RITZ., Results: There were a total of 551 patients: 195 Fast Track patients, 163 CIN managed patients and 193 RITZ patients. CIN managed patients were older (p<0.001), with higher levels of clinical urgency (p<0.001), and higher hospital admission rates (p<0.001). CIN managed patients had shorter waiting time for nursing care (p=0.001) and lower incidence of medical assessment within the time associated with their triage category (p<0.0001). ED LOS for discharged patients was significantly longer for CIN managed patients (p<0.001). CIN managed patients had a significantly higher incidence of electrocardiography (p<0.001), blood glucose measurement (p<0.001), intravenous cannulation (p<0.001), pathology testing (p<0.001), and analgesia administration (p<0.001) when compared to Fast Track and RITZ patients., Conclusions: Advanced practice roles in emergency nursing can have different applications in the ED context. Clarity about role intent and scope of practice is important and should inform educational preparation and teams within which these roles operate., (Copyright © 2012 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: There is scant published evidence that explains how ICU nurses' manage low-flow oxygen therapy; and, hence little is known about how low-flow oxygen therapy is delivered on a daily basis., Aim: The aims of this study were first to observe how ICU nurses' manage low-flow oxygen therapy and then to compare observed nursing practice on the management of oxygen therapy with patients' documented measures of oxygen saturation (SpO2) and respiratory rate (RR)., Method: From May to July 2009, eight 2h observation periods were conducted in one ICU of a metropolitan hospital in Melbourne, Victoria. Data were collected at using a structured observation tool, field notes and chart review. Quantitative data were analysed using descriptive and frequency statistics, and textual data were reviewed using a content analysis procedure., Results: Over the 16 h of observed nursing practice, there were 96 points of measurement involving 16 patients and 16 ICU nurses. The management of low-flow oxygen therapy varied between nurses and data revealed that nurses did not always promote effective oxygenation. Documented SpO2 was 98.0% (SD 2.8%) and observed SpO2 was 96.3% (SD 1.8%). Documented RR was 19.6 breaths/min (SD 3.5) and observed RR was 21.0 breaths/min (SD 16.8). Episodes of hypoxaemia and tachypnoea occurred while patients were receiving oxygen and nurses did not always respond appropriately., Conclusion: ICU nurses' management of low-flow oxygen therapy was suboptimal and documentation of oxygenation and respiratory rate was inaccurate. Further exploration of how ICU nurses manage low-flow oxygen therapy is a necessary prelude to the conduct of interventional studies and the development of better guidance to support low-flow oxygen therapy in the ICU., (Copyright © 2011 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: The RESCUE study examined the prevalence of patients at risk of a medical emergency in acute care settings by assessing the prevalence of cases where patients fulfil the hospital-specific criteria for MET activation. This article will detail the study methodology including the ethics applications and approvals process, organisational preparation, research staff training, tools for data collection, as well as barriers encountered during the conduct of the study., Design and Setting: A point prevalence design conducted at 10 hospitals, comprising of private and public, secondary and tertiary referral, ICU equipped, metropolitan and regional settings., Patients: All inpatients were eligible except intensive care and psychiatric patients., Measurement and Main Results: On a single day consenting inpatients in each hospital had a single set of vital signs obtained, their observation chart reviewed and followed up for MET activations, unplanned ICU admissions, cardiac arrests and 30 and 60 day mortality. Of 2199 eligible patients, 1688 (76.76%) were assessed, 175 (7.95%) refused consent and 336 (15.28%) were unavailable. Access to patients was refused in some wards despite ethics approval. Data collection required 2 student nurses approximately 14 min per patient assessment., Conclusion: In conducting a large multi-site point prevalence study, critical organisational processes were shown to influence the access to patients. This study demonstrated the impact of variation in Human Research Ethics Committee interpretations of protocols on consenting processes and the importance of communication and leadership at ward level to promote access to patients., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: The aim of this study was to examine reported incidents affecting Emergency Department (ED) episodes of care., Methods: A retrospective audit of ED patients was carried out in an urban district hospital in Melbourne, Australia from 1 January 2008 to 31 December 2008. The main outcome measure was presence or absence of reported patient-related incident(s) during ED care., Results: There were 984 patient-related incidents (n=984) during 2008.The most common incidents were related to patient behaviour (66.4%), patient management (10.1%) and medications (6.5%). Patients whose ED care involved reported incident(s) were older, had higher triage categories, longer length of ED stay and were more likely to need hospital admission or leave at their own risk. Eighteen per cent of reported incidents occurred in patients aged 65&emsp14;years and over. Incidents affecting older patients were more likely to be related to breach of skin integrity, patient management, diagnosis and patient identification, and less likely to involve patient behaviour., Conclusions: Reported incident(s) occurred in 0.47% of ED episodes of care. Differences in personal and clinical characteristics of patients whose ED care involved reported incident(s) highlights the need for better understanding of incidents occurring in the ED in order to improve systems for high-risk patients.

Despite their important role in chemical, biological and radiological (CBR) incident response, little is known about emergency nurses' perceptions of these events. The study aim was to explore emergency nurses' perceptions of CBR incidents and factors that may influence their capacity to respond. Sixty-four nurses from a metropolitan Emergency Department took part. The majority were willing to participate in CBR incidents and there was a positive association between willingness to participate and postgraduate qualification in emergency nursing. Willingness decreased, however, with unknown chemical and biological agents. One third of participants reported limitations to using personal protective equipment. Few participants had experience with CBR incidents although 70.3 per cent of participants had undergone CBR training. There were significant differences in perceptions of choice to participate and adequacy of training between chemical, biological and radiological incidents. The study results suggest that emergency nurses are keen to meet the challenge of CBR incident response.

Aims: This study aimed to examine the effect of an educational intervention on discharge advice given to parents leaving the emergency department with a febrile child., Background: Childhood fever is a common reason to seek emergency care. Many children are discharged from the emergency department with fever as a significant component of their illness; therefore, it is vital that emergency department medical and nursing staff provide accurate and reliable information about childhood fever management., Design: A pre/post-test design was used. The outcome measure was parental advice regarding paediatric fever management and the intervention for the study was an educational intervention for emergency department nursing staff that consisted of two tutorials. Data were collected using structured telephone interviews., Results: Data were collected from 22 families during the pretest period and 18 families during the post-test period. The number of parents leaving the emergency department with no advice decreased by 48% (p = 0.002). Reports of written advice increased by 69.7% (p < 0.001) and there was a 38.4% increase in reports of verbal advice (p = 0.014). Parents leaving the emergency department with both written and verbal advice increased from 0 to 55.6% (p < 0.001). Reports of advice by nursing staff increased by 52% (p < 0.001) and there were significant increases in specific instructions related to oral fluid administration (22.7 vs. 77.8, p = 0.001) and use of antipyretic medications (27.2 vs. 77.8, p = 0.001)., Conclusion: Evidence-based education of emergency nurses improved both the amount and quality of discharge advice for parents of febrile children., Relevance to Clinical Practice: Parents and health care professionals alike need to better understand the physiological benefits of fever and the potential harmful effects of aggressive and often unwarranted treatment of fever.

Aim: This study examined the effect of an education intervention on emergency nurses' decisions related to oxygen administration., Method: A controlled pre-test/post-test quasi-experimental design was used. The intervention was a written self directed learning package. Outcome measures were (i) factual knowledge measured using parallel form multiple choice questions (MCQs) and (ii) clinical decisions measured using parallel form MCQs, parallel form patient scenarios and clinical practice observation., Results: Eighty-eight nurses from 4 Melbourne EDs participated in the study (control group: n=37 and experimental group: n=51). Subgroups of nurses from the experimental group also participated in the patient scenarios (n=20) and clinical practice observation (n=10). Emergency nurses' knowledge increased as a function of education. Both patient scenario data and clinical practice observation showed decreased selection of nasal cannulae, increased selection of air entrainment masks and a trend towards selection of higher oxygen flow rates following education., Conclusions: Evaluation of educational interventions in nursing should focus on identifying strategies that enhance learning in a clinical environment, are valid in terms of the clinical context and culture in which they are being used and most importantly, produce sustained improvements in actual clinical practice.

Introduction: This study examined the effect of an educational intervention of factual knowledge on emergency nurses' knowledge and clinical decisions related to paediatric fever., Method: A prospective pre-test/post-test design was used. Emergency nurses' factual knowledge was measured by parallel multiple choice questions and the intervention for the study was an educational intervention consisting of two tutorials. Pre-test data were collected in early June 2005 and post-test data were collected during August 2005., Results: Thirty-one emergency nurses completed the pre and post-test multiple choice questions. Emergency nurses' knowledge increased following the tutorials. Pre-test score was positively correlated with knowledge acquisition. Self-reports of independent decisions related to fever management were influenced by experience, hours of employment, level of appointment, postgraduate qualifications and pre-test score., Discussion: High levels of variability in knowledge and knowledge acquisition suggest a review of undergraduate and postgraduate curricula is warranted. Although this study identified associations between independent fever management decisions and participant characteristics, further research is pivotal to better understanding these relationships.