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Background: There is a gap in the literature comparing communication during handover between military and NHS emergency care settings. Objectives: This study aimed to explore differences in handover communication in the NHS and the military, and to understand how paramedics manage the transition between settings. Design: This was a qualitative study for which 13 paramedics were interviewed. It focused on handover communication in NHS emergency care settings and Camp Bastion Hospital, Afghanistan. Methods: Interviews were conducted with regular and reservist paramedics serving in the Royal Air Force who had undertaken a deployment with the Medical Emergency Response Team. Semi-structured interviews were recorded, transcribed, coded and subjected to a thematic analysis. Results: Three principal themes were identified: differences between handover communication; standardisation; and the challenge of transition. Conclusion: Participants were most concerned about standardisation. Transition theory and resilience may account for the difficulties encountered when transitioning between different care settings.

Patient and family liaison practitioners are a relatively recent addition to UK helicopter emergency medical services to support patients with their recovery. A service evaluation was completed that mapped the current provision of patient and family liaison practitioner roles in helicopter emergency medical services in the United Kingdom.An online survey was distributed to key stakeholders involved with UK helicopter emergency medical service patient and family liaison practitioner roles. Quantitative survey results were described, and open-ended questions were analyzed using content analysis.Twenty UK helicopter emergency medical services responded to the survey. Nine of these services employ patient and family liaison practitioners with 4 additional helicopter emergency medical services planning to initiate the role. There is variation in the employment models used between the services. The patient and family liaison practitioner role provides important benefits to patients and their families, clinicians, and the helicopter emergency medical service.Nine UK helicopter emergency medical services employ patient and family liaison practitioners. This role benefits patients, their families, helicopter emergency medical service clinicians, and helicopter emergency medical service charities. Further research is required to understand how the role works in practice and to understand how to maximize the benefits to stakeholders.

ObjectiveTo systematically review research on acute hospital care for frail or older adults experiencing moderate to major trauma.SettingElectronic databases (Medline, Embase, ASSIA, CINAHL Plus, SCOPUS, PsycINFO, EconLit, The Cochrane Library) were searched using index and key words, and reference lists and related articles hand-searched.Included articlesPeer-reviewed articles of any study design, published in English, 1999–2020 inclusive, referring to models of care for frail and/or older people in the acute hospital phase of care following traumatic injury defined as either moderate or major (mean or median Injury Severity Score ≥9). Excluded articles reported no empirical findings, were abstracts or literature reviews, or referred to frailty screening alone.MethodsScreening abstracts and full text, and completing data extractions and quality assessments using QualSyst was a blinded parallel process. A narrative synthesis, grouped by intervention type, was undertaken.Outcome measuresAny outcomes reported for patients, staff or care system.Results17 603 references were identified and 518 read in full; 22 were included—frailty and major trauma (n=0), frailty and moderate trauma (n=1), older people and major trauma (n=8), moderate or major trauma (n=7) 0r moderate trauma (n=6) . Studies were observational, heterogeneous in intervention and with variable methodological quality.Specific attention given to the care of older and/or frail people with moderate to major trauma in the North American context resulted in improvements to in-hospital processes and clinical outcomes, but highlights a relative paucity of evidence, particularly in relation to the first 48 hours post-injury.ConclusionsThis systematic review supports the need for, and further research into an intervention to address the care of frail and/or older patients with major trauma, and for the careful definition of age and frailty in relation to moderate or major trauma.International Prospective Register of Systematic Reviews (PROSPERO)CRD42016032895.

There is a growing body of literature on handover communication between prehospital and hospital receiving teams in civilian emergency care settings but little is known about how this differs from handover in the UK military medical services. This literature review shows that civilian handover is a complex process conducted in less-than-ideal circumstances, and it is affected by human behaviour and patient factors. There is a debate around standardisation including the use of the Mechanism, Injury or Illness, Signs, Treatment (MIST) mnemonic. There is limited understanding of how this mnemonic was used by the UK military, how it was developed to deal with specific patient characteristics or in the context of military operations in Afghanistan within which it evolved. Advancements in clinical practice made during conflict are ancillary to military objectives and should be supported by an evidence base before being transferred to civilian health care.

Background The burden of frailty on older people is identifiable by its adverse effect on mortality, morbidity and long term functional and health outcomes. In patients suffering from a traumatic injury there is increasing evidence that it is frailty rather than age that impacts greatest on these outcomes and that early identification can guide frailty specific care. The aim of this study was to evaluate the feasibility of nurse-led assessment of frailty in older trauma patients in the ED in patients admitted to major trauma centres. Methods Patients age 65 years and over attending the Emergency Departments (ED) of five Major Trauma Centres following traumatic injury were enrolled between June 2019 and March 2020. Patients were assessed for frailty whilst in the ED using three different screening tools (Clinical Frailty Scale [CFS], Program of Research to Integrate Services for the Maintenance of Autonomy 7 [PRIMSA7], and the Trauma Specific Frailty Index [TSFI]) to compare feasibility and accuracy. Accuracy was determined by agreement with geriatrician assessment of frailty. The primary outcome was identification of frailty in the ED using three different assessment tools. Results We included 372 patients whose median age was 80, 53.8% of whom were female. The most common mechanism of injury was fall from less than 2 m followed by falls greater than 2 m. Completion rates for the tools were variable, 31.9% for TSFI, compared to 93% with PRISMA7 and 98.9% with the CFS. There was substantial agreement when using CFS between nurse defined frailty and geriatrician defined frailty. Agreement was moderate using PRISMA7 and slight using TSFI. Conclusions This prospective study has demonstrated that screening for frailty in older major trauma patients within the Emergency Department is feasible and accurate using CFS. Trial registration ISRCTN, ISRCTN10671514. Registered 22 October 2019

Background Helicopter Emergency Medical Services (HEMS) allow critical care personnel to attend incidents alongside transporting patients to hospital. The study site is a UK based emergency department and major trauma centre, accepting flights from a wide geographical area. Aims To characterise the impact of HEMS on a major trauma centre clinical resources and the impact of the UK regional trauma network launch on HEMS asset provision. Methods Flight case-mix data were obtained from Emergency Department (ED) records (non-trauma patients) and from the Trauma Audit and Research Network database (trauma patients). Statistical analysis was in Excel. Results 432 flights landed at the site between August 2018 and July 2019. 178 flights originated from the incident scene (145 trauma, 26 non-trauma), 107 from other hospitals, and 5 to other hospitals. Hospitalisation was reduced to a median of 6 days. Conclusions Primary HEMS trauma patients utilised significant clinical resources but had shorter hospitalisations than those without HEMS intervention. The regional trauma network improved HEMS tasking and utilised critical car cars to provide advanced pre-hospital care locally. Further work should compare HEMS versus ground ambulance to determine the impact of HEMS on patient outcomes and cost implications to both HEMS operators and receiving hospital.

IntroductionThe burden of frailty on older people is easily recognisable by increasing mortality and morbidity, longer hospital stays and adverse discharge locations. In the UK, frailty screening has recently become part of the best practice commissioning tariff within National Health Service England, yet there is no evidence or consensus as to who should carry out this assessment or within which time frame. As major trauma is an increasing burden for older people, there is a need to focus clinician’s attention on early identification of frailty in the emergency department (ED) in patients with major trauma as a way to underpin frailty specific major trauma pathways, to optimise recovery and improve patient experience. Throughout the patient with major trauma pathway, nurses are perhaps best placed to conduct timely clinical assessments working with the patient, family and multidisciplinary team to influence ongoing care. This study aims to determine the feasibility of nurse-led assessment of frailty in patients aged 65 years or more admitted to major trauma centres (MTCs).Methods and analysisThis is a prospective observational study conducted across five UK MTCs, enrolling 370 participants over 9 months. The primary aim is to determine the feasibility of nurse-led frailty assessment in MTC EDs in patients aged 65 years or more following traumatic injury. The prevalence of frailty and the best assessment tool for use in the ED will be determined. Other outcome measures include quality of life and frailty assessment 6 months after injury, mortality and discharge outcomes.Ethics and disseminationThe study was given ethical approval by the Social Care Research Ethics Committee (REC no 19/IEC08/0006). Findings will be published in scientific journals and presented to national and international conferences.Trial registration numberISRCTN10671514.

Introduction:Mental health is a growing global concern with a significant rise in patients calling emergency services to respond to their needs. Paramedics in the UK are increasingly being asked to respond to this increase in demand. Aim:This study explores how paramedics perform in practice when managing patients experiencing mental health issues. Methods:Qualitative observation over 240h and interviews involving 21 paramedics and 20 patients with mental illness. Results:Using Goffman’s seminal textPresentation of Selfto frame the analysis the findings of this study reveal that paramedics '“perform” on two stages: front stage and back stage. Their coping mechanisms, in the metaphorical sense, include props such as uniform and scripts filled with humour, stereotyping and nostalgia to aid in their management of this specialist patient group. Conclusions:Paramedics feel frustrated and unsupported when dealing with patients experiencing mental health issues. This study identifies the coping mechanisms paramedics use to manage this patient group but questions the longevity of these mechanisms and therefore recommends additional support for paramedics with further supportive education around mental health.

© 2019 Foundation for the Sociology of Health & Illness Over the last quarter century, non-medical prescribing in the UK has grown significantly; eight non-medical professional groups now have authority to prescribe a wide range of medicines, suggesting it could be a potent driver of pharmaceuticalisation. In this article, we present data from a case study of physiotherapists’ prescribing practices. UK physiotherapists have had legal rights to prescribe medicines since 2005, but relatively little is known about the contribution they make to expanding patient access to medicines. We approached our study through a lens of governmentality to capture the mentalities and micro-practices governing physiotherapist non-medical prescribing. Ethnographic methods were used to gather data from an outpatient orthopaedic service in an NHS Trust in England employing physiotherapist prescribers. From the data, we identified a grid of intelligibility – an organising framework formulated by powerful discourses and technologies of government through which physiotherapist prescribing was acted into being. A primary effect of this grid was the constitution of new physiotherapist subjectivities, mostly as non-prescribers of medicines contrary to policy intentions, underpinned by a familiar and enduring template of medical professionalism.

BackgroundPolicy has been focused on reducing unnecessary emergency department attendances by providing more responsive urgent care services and guiding patients to ‘the right place’. The variety of services has created a complex urgent care landscape for people to access and navigate.ObjectivesTo describe how the public, providers and policy-makers define and make sense of urgent care; to explain how sense-making influences patients’ strategies and choices; to analyse patient ‘work’ in understanding, navigating and choosing urgent care; to explain urgent care utilisation; and to identify potentially modifiable factors in decision-making.DesignMixed-methods sequential design.SettingFour counties in southern England coterminous with a NHS 111 provider area.MethodsA literature review of policy and research combined with citizens’ panels and serial qualitative interviews. Four citizens’ panels were conducted with the public, health-care professionals, commissioners and managers (n = 41). Three populations were sampled for interview: people aged ≥ 75 years, people aged 18–26 years and East European people. In total, 134 interviews were conducted. Analyses were integrated to develop a conceptual model of urgent care help-seeking.FindingsThe literature review identified some consensus between policy and provider perspectives regarding the physiological factors that feature in conceptualisations of urgent care. However, the terms ‘urgent’ and ‘emergency’ lack specificity or consistency in meaning. Boundaries between urgent and emergency care are ill-defined. We constructed a typology that distinguishes three types of work that take place at both the individual and social network levels in relation to urgent care sense-making and help-seeking.Illness workinvolves interpretation and decision-making about the meaning, severity and management of physical symptoms and psychological states, and the assessment and management of possible risks. Help-seeking was guided bymoral work: the legitimation and sanctioning done by service users.Navigation workconcerned choosing and accessing services and relied on prior knowledge of what was available, accessible and acceptable. From these empirical data, we developed a model of urgent care sense-making and help-seeking behaviour that emphasises that work informs the interaction between what we think and feel about illness and the need to seek care (sense-making) and action – the decisions we take and how we use urgent care (help-seeking).LimitationsThe sample population of our three groups may not have adequately reflected a diverse range of views and experiences. The study enabled us to capture people’s views and self-reported service use rather than their actual behaviour.ConclusionsMuch of the policy surrounding urgent and emergency care is predicated on the notion that ‘urgent’ sits neatly between emergency and routine; however, service users in particular struggle to distinguish urgent from emergency or routine care. Rather than focusing on individual sense-making, future work should attend to social and temporal contexts that have an impact on help-seeking (e.g. why people find it more difficult to manage pain at night), and how different social networks shape service use.Future workA whole-systems approach considering integration across a wider network of partners is key to understanding the complex relationships between demand for and access to urgent care.Study registrationThis study is registered as UKCRN 32207.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Multiscale Designer, developed by Altair, has been studied for its suitability for fatigue life prediction of advanced composite aircraft structures made of polymer matrix composites. The extensive experimental data provided by the Air Force Research Laboratory have been utilized to characterize the linear, non-linear, monotonic, and cyclic loading properties of micro-constituents comprising the polymer matrix composite system. The characterized properties have been then utilized to predict fatigue life and residual strength and stiffness of the aerospace grade polymer matrix composites.

Aims/Objectives/BackgroundFrailty screening for major trauma patients has recently become part of the best practice commissioning tariff within NHS England, yet there is no consensus as to who should carry out this assessment or which tool best identifies frailty in the Emergency Department (ED). As the trauma population ages there is a need for accurate early identification of frailty in the ED to underpin frailty specific major trauma pathways. The primary aim of this study was to determine the feasibility and accuracy of ED nurse-led frailty assessment in patients ≥ 65 years admitted to Major Trauma Centres (MTCs).Methods/DesignA prospective observational study was conducted across five UK MTCs, enrolling 370 participants over nine months. Eligible patients were aged 65 or more requiring trauma team activation. Frailty was assessed in the ED using three different tools: Trauma Specific Frailty Index (TSFI); Clinical Frailty Scale (CFS); PRISMA-7. ED nurse frailty assessment was correlated with Geriatrician assessment within 72 hours of admission using Spearman’s correlation coefficient and kappa statistic for measuring the interrater agreement.Results/ConclusionsComplete frailty assessments were calculated for CFS in 99.4% of patients, PRISMA7 in 95.9% and TSFI in 37.58%. Rates of frailty differed between tools: CFS 32%, PRISMA7 57% and TSFI 92% whilst Geriatrician determined frailty was 37%. In all tools frail patients were older (ps 0.639,pED nurses can accurately assess older major trauma patients for frailty using the Clinical Frailty Scale. These findings support assessment of frailty in the ED in order to identify patients who would benefit from early frailty specific care.

Summary This manuscript presents an accelerated time domain homogenization methodology for prediction of material and structural failure under fatigue loading. The methodology is based on mathematical homogenization theory applied to the time domain. The method addresses the computational challenge associated with the scale disparity between the characteristic fatigue load period and the overall fatigue life. Cycle sensitive continuum damage mechanics modeling is used to describe the progressive damage accumulation under fatigue loading. The original initial boundary value problem is decomposed into coupled fast and slow time scale problems. A quasilinear approximation to the fast time scale problem is introduced to efficiently evaluate the response under a fatigue load cycle. The effect of the new time integrator on the thermodynamic consistency of the resulting system of discrete equations is demonstrated for a general class of continuum damage mechanics models. The proposed method is numerically verified based on a scalar damage model and a spatially multiscale damage model used for predicting fatigue life of composite materials. The proposed accelerated time integrator is shown to have reasonable accuracy and is orders of magnitude more computationally efficient when compared with previously proposed time homogenization methods. Copyright © 2015 John Wiley & Sons, Ltd.

Introduction Following the introduction of the regional trauma system in 2012 the role of the trauma nurse coordinator (TNC) has been rolled out. This study aims to determine the demographic and practice profile of nurses performing the TNC role in England. Methods An electronic survey of TNCs across the 18 trauma networks in England was conducted. Results Fifty-three TNCs responded (62%) to the survey. Seventeen different role titles identified. The majority of TNCs had an emergency or trauma/orthopaedics clinical background. The largest proportion of time spent was clinical (38%). Least amount of time was spent in the education (7%), and research (3%). Nearly a quarter of respondents (23%) had some form of formal research training, nearly half (47%) were assisting others in research. Over half (55%) of respondents felt that they did not have adequate human resources to conduct their role. Discussion This research has provided baseline information about nurses in the role of TNC, their role titles and domains of the role 18 months after the formal introduction of trauma networks in England. There are some marked similarities and differences in the time spent in the different domains of the role between these findings and those published internationally.

Introduction: there is lack of evidence about ankle sprain patients presenting to emergency department (ED) in the UK. The study aim was to determine prevalence, demographic and clinical characteristics of patients attending to one ED. Knowing those characteristics may help setting prevention strategies and inform effective clinical practice.Methods: a retrospective review of records from patients’ database system was conducted between May and November 2015 (inclusive).Results: 909 new patients with ankle sprain were recorded during the study period. Patients had a median age of 27 years (IQR 20). Men aged between 14 and 37 years had higher percentage of injuries compared to women of a similar age. Overall prevalence of injury was equally distributed between men and women. Most patients were sent to radiography department for ankle/foot X-ray (89%). Over half of patients (58%) were sent home with no follow-up treatment. A subsample (n = 106) from the original sample (n = 909) showed a variety of causes of injury such as tripping (29%), non-specific injury (26.4%), sports (26%), walking (12.2%) and other accidental causes (6%). Football was the most prevalent sport (13%).Conclusions: prevention strategies, appropriate assessment tools and tailored rehabilitation programs are warranted to reduce number of patients and potential chronic symptoms.

In 1911, a BMJ editorial expressed concern over what was viewed as “ an increasing tendency for nursing associations to employ nurses who are not only allowed but apparently in many places encouraged to prescribe and administer drugs, to treat minor injuries and generally act as minor medical practitioners”. In the view of the editor “in her proper place a nurse is invaluable both to the patient and to the doctor but that the training and qualifications of a nurse do not fit her and were never intended to fit her to discharge the functions of an independent practitioner”.1 There are some who would still concur with this view, but just as no one conceived of a male nurse in 1911 (they are now 17% of the workforce), the evolution of emergency medicine, combined with social, political and economic forces in healthcare, have provided a fertile environment for innovation and role development. The ED holds great appeal for nurses who are prepared to challenge and step outside of traditional boundaries in the interests of patients although this has often been met with uncertainty and resistance. The nurse’s official role in the emergency department of the late 1960s was mainly to undress patients and record a set of vital signs for the doctor whose role it was to assess, diagnose and treat the patient. From 1967, there has been an increasing recognition and acknowledgement of the contribution of emergency nurses to the specialty in the UK. Short falls in indigenous medical staffing led to casualty departments being staffed by overseas doctors who, although clinically able, were often unfamiliar with local culture, colloquialisms and patterns of frequent attenders. In these situations, experienced nurses often elicited and deciphered complex medical histories for the doctor. Thus, in a very subtle way they held …

Introduction: Emergency care services are looking for new models of care delivery to deal with changing patient demographics and increased pressures. It has been suggested that advanced non-medical practitioners might be valuable for delivering such new models of care. However, it is not clear what the impact of the deployment of advanced non-medical practitioners in emergency care is. This scoping study addresses the following research question: What is known from the literature about the different types of impact of the deployment of advanced (autonomous) non-medical practitioners in emergency care?Methods and analysis: A scoping study will be undertaken to examine and map the impact of the deployment of advanced non-medical practitioners in emergency care. The scoping study follows the methodology proposed by Arksey and O'Malley. Searches will be carried out on databases of peer-reviewed literature and other sources to systematically identify and characterise the literature. Papers will be screened using a 2-stage process to identify the most relevant literature. Papers will be screened by title and abstract, followed by full-text review. Data abstraction and synthesis will be performed using a narrative thematic analysis.Ethics and dissemination: We will communicate the findings to Health Education England, NHS Improvement and the Royal College of Emergency Medicine through existing links provided by members of the project team. We anticipate that the findings will also be of interest to other similar organisations internationally. By identifying gaps in the research literature, we anticipate that the study will generate recommendations for informing future high-quality research studies about the impact of advanced non-medical practitioners in emergency care as well as in other settings. The research findings will be submitted for publication to relevant peer-reviewed journals as well as professional magazines. The scoping study uses only previously published material, and does not require ethical review.

Background: Clinical handover plays a vital role in patient care and has been investigated in hospital settings, but less attention has been paid to the interface between prehospital and hospital settings. This paper reviews the published research on these handovers. Methods: A computerised literature search was conducted for papers published between 2000 and 2013 using combinations of terms: ‘handover’, ‘handoff’, ‘prehospital’, ‘ambulance’, ‘paramedic’ and ‘emergency’ and citation searching. Papers were assessed and included if determined to be at least moderate quality with a primary focus on prehospital to hospital handover. Findings: 401 studies were identified, of which 21 met our inclusion criteria. These revealed concerns about communication and information transfer, and themes concerning context, environment and interprofessional relationships. It is clear that handover exchanges are complicated by chaotic and noisy environments, lack of time and resources. Poor communication is linked to behaviours such as not listening, mistrust and misunderstandings between staff. While standardisation is offered as a solution, notably in terms of the use of mnemonics (alphabetical memory aids), evidence for benefit appears inconclusive. Conclusions: This review raises concerns about handovers at the interface between prehospital and hospital settings. The quality of existing research in this area is relatively poor and further high-quality research is required to understand this important part of emergency care. We need to understand the complexity of handover better to grasp the challenges of context and interprofessional relationships before we reach for tools and techniques to standardise part of the handover process.

Since major trauma networks were introduced, medical and non-medical staff have been required to undergo trauma training. The recommended training programme is the advanced trauma life support course, but its cost and the difficulties involved in securing study leave can make it unfeasible as a training option. This article discusses the trauma intermediate life support programme, an innovative, one-day programme for staff to acquire knowledge and skills in trauma management. The programme, which focuses on damage-control resuscitation, involves low- and medium-fidelity simulation in trauma or resuscitation rooms. It has been quantitatively reviewed by 50 candidates, who all stated that it has helped them to improve their practice.

Just as we are witnessing the re-emergence of Star Wars, it seems the 'turf wars' that have dogged AE care are back. Since its inception as a specialty, AE nurses have been accused of being 'Jacks (and Jill's, to be politically correct) of all trades and masters of none'. The inference being that all we do is 'mind' patients until they receive definitive care. Clearly this is not the case. As AE nurses have demonstrated over the years, our skills are in the recognition and management of acute illness or injury, regardless of the patient's age, physical or psychological condition. Rather than being a 'master of none' we are masters of immediate care.

Introduction The assessment and treatment of children with major injury is fraught with difficulty – differences in anatomy and physiology mean that children that have suffered trauma can be over or under assessed. In recent years, there has been an increase in the use of biochemical markers, such as haematocrit, to assist the clinician in determining severity of injury. This paper examines the evidence surrounding lactate as a marker in paediatric trauma. Method A literature search was completed on Medline, CINAHL, Ovid and Science. 63 papers were initially identified – 41 papers were rejected after reading the abstracts. Of the 22 remaining papers – 6 had a paediatric focus, 16 were adult – of these 12 were rejected as not primary studies. Ten papers were fully critically reviewed – of these only one article related to paediatric patients and trauma. Results The literature shows that an elevated lactate in a trauma patient is strongly correlated to severity of injury, length of stay and morbidity and mortality. However, one elevated lactate may be misleading and lactate clearance – that is the time when lactate levels return to normal, is just as important in the assessment of the severely injured. However, from this literature review it is clear that there is very little evidence for the relationship between lactate levels and trauma in children and that more studies are required.

This manuscript presents a multiscale modeling methodology for failure analysis of composites subjected to cyclic loading conditions. Computational homogenization theory with multiple spatial and temporal scales is employed to devise the proposed methodology. Multiple spatial scales address the disparity between the length scale of material heterogeneities and the overall structure, whereas multiple temporal scales with almost periodic fields address the disparity between the load period and overall life under cyclic loading. The computational complexity of the multiscale modeling approach is reduced by employing a meso-mechanical model based on eigendeformation based homogenization with symmetric coefficients in the space domain, and an adaptive time stepping strategy based on a quadratic multistep method with error control in the time domain. The proposed methodology is employed to simulate the response of graphite fiber-reinforced epoxy composites. Model parameters are calibrated using a suite of experiments conducted on unidirectionally reinforced specimens subjected to monotonic and cyclic loading. The calibrated model is employed to predict damage progression in quasi-isotropic specimens. The capabilities of the model are validated using acoustic emission testing.

dougherty l., sque m. & crouch r. (2012) Decision-making processes used by nurses during intravenous drug preparation and administration. Journal of Advanced Nursing68(6), 1302–1311. Abstract Aim. The aim of this study was to explore the decision-making processes that nurses use during intravenous drug administration and how this influences risk taking and errors. Background. Intravenous drug errors have been estimated to be a third of all drug errors. Previous drug error research has focused on observation of nurses and errors they make but has not attempted to understand the decision-making processes used during the preparation and administration of intravenous drugs. Method. A three-phased ethnographic study was carried out in a specialist cancer hospital in 2007 using focus groups, observation and interviews. This article is concerned with the observation and interview phase. Observation took place on two wards, each over a week. Twenty nurses were observed preparing and administering intravenous drugs; then interviewed about their procedure. Data analysis was carried out using a five stage approach. Findings. Major themes identified include: interruptions; identification and knowing the patient; routinized behaviour, prevention of errors. These represent the findings of the observation and interviews with the nurses. One key finding was the lack of checking of patient identity prior to IV drug administration, which appeared to be based on nurses feeling they knew the patient well enough, although this was in contrast to how they checked even familiar drugs. This article will focus on identification and knowing the patient. Conclusion. Implications for practice included: exploring new and effective methods of education based on behavioural theories; involving staff in updating policies and procedures; formal assessment of staff during intravenous preparation and administration.

The adverse pulmonary effects of asbestos are well accepted in scientific circles. However, the extrapulmonary consequences of asbestos exposure are not as clearly defined. In this review the potential for asbestos to produce diseases of the peritoneum, immune, gastrointestinal (GIT), and reproductive systems are explored as evidenced in published, peer-reviewed literature. Several hundred epidemiological, in vivo, and in vitro publications analyzing the extrapulmonary effects of asbestos were used as sources to arrive at the conclusions and to establish areas needing further study. In order to be considered, each study had to monitor extrapulmonary outcomes following exposure to asbestos. The literature supports a strong association between asbestos exposure and peritoneal neoplasms. Correlations between asbestos exposure and immune-related disease are less conclusive; nevertheless, it was concluded from the combined autoimmune studies that there is a possibility for a higher-than-expected risk of systemic autoimmune disease among asbestos-exposed populations. In general, the GIT effects of asbestos exposure appear to be minimal, with the most likely outcome being development of stomach cancer. However, IARC recently concluded the evidence to support asbestos-induced stomach cancer to be “limited.” The strongest evidence for reproductive disease due to asbestos is in regard to ovarian cancer. Unfortunately, effects on fertility and the developing fetus are under-studied. The possibility of other asbestos-induced health effects does exist. These include brain-related tumors, blood disorders due to the mutagenic and hemolytic properties of asbestos, and peritoneal fibrosis. It is clear from the literature that the adverse properties of asbestos are not confined to the pulmonary system.

Children with same-sex attracted parents develop well in terms of their health and wellbeing. There are many recognised factors that have an impact on child health, in general, including individual, family and wider social mediators. The aim of this study is to determine the impact of family structure and socio-demographic characteristics on child health and wellbeing in Australian same-sex parent families.A cross-sectional survey of self-identified same-sex attracted parents from across Australia was used to collect information on child health and wellbeing between May and December 2012. Mixed-effects multiple linear regression models were used to identify associations between family structure/socio-demographic characteristics and child wellbeing. Child health outcomes were measured using the Child Health Questionnaire and the Strengths and Difficulties Questionnaire.In same-sex parent families, biological relationships, parental gender and parental education were not significantly associated with health and wellbeing. Parental income, rurality and stable parental relationships were associated with health and wellbeing, and living in a single-parent household was associated with poorer wellbeing.Stable dual parent families offer good outcomes for children with same-sex attracted parents. Family processes are most important. This study does not support the assertion that children require both male and female parents, nor that biological relationships are essential to health and wellbeing. This study provides scientific data from a cross-sectional Australian-based study to describe and understand health determinants for children in family contexts that comprise same-sex parent and all family contexts. It recommends equitable, stigma-free family support.

Traditionally, healthcare professionals have been expected to acquire technical skills while minimal attention has been paid to the non-technical skills (NTS) they require to work in complex health environments, such as resuscitation rooms. This article explains the importance of NTS in improving patient outcomes and why a model of dynamic nurse leadership is useful in resuscitative care.

OBJECTIVE: Getting staffing levels wrong in hospitals is linked to excess mortality and poor patient experiences but establishing the safe nurse staffing levels in the emergency department (ED) is challenging because patient demand is so variable. This paper reports a review conducted for the National Institute for Health and Care Excellence (NICE) which sought to identify the research evidence to inform UK nursing workforce planning.DESIGN: We searched 10 electronic databases and relevant websites for English language studies published from 1994. Studies included reported a direct measure of nurse staffing relative to an activity measure (eg, attendances, patient throughput) or an estimate of nurse staffing requirements. Randomised or non-randomised trials, prospective or retrospective observational, cross-sectional or correlational studies, interrupted time-series, and controlled before and after studies were considered.RESULTS: We identified 16,132 items via databases and 2193 items through manual and other searching. After title/abstract screening (by one reviewer, checked by a second) 55 studies underwent full assessment by the review team. 18 studies met the inclusion criteria for the NICE review, however 3 simulation studies that reported simulated rather than measured outcomes are not reported here.CONCLUSIONS: The evidence is weak but indicates that levels of nurse staffing in the ED are associated with patients leaving without being seen, ED care time and patient satisfaction. Lower staffing is associated with worse outcomes. There remain significant gaps and in particular a lack of evidence on the impact of staffing on direct patient outcomes and adequate economic analyses to inform decisions about nurse staffing. Given that an association between nurse staffing levels and patient outcomes on inpatient wards has been demonstrated, this gap in the evidence about nurse staffing in EDs needs to be addressed.

Introduction: with the introduction of regional trauma networks in England, ambulance clinicians have been required to make triage decisions relating to severity of injury, and appropriate destination for the patient, which may require ‘bypassing’ the nearest Emergency Department. A ‘Trauma Unit Bypass Tool’ is utilised in this process. The Major Trauma Triage tool smartphone application (App) is a digital representation of a tool, available for clinicians to use on their smartphone. Prior to disseminating the application, validity and performance against the existing paper-based tool was explored.Methods: a case-based study using clinical scenarios was conducted. Scenarios, with appropriate triage decisions, were agreed by an expert panel. Ambulance clinicians were assigned to either the paper-based tool or smartphone app group and asked to make a triage decision using the available information. The positive predictive value (PPV) of each tool was calculated.Results: the PPV of the paper tool was 0.76 and 0.86 for the smartphone app. User comments were mainly positive for both tools with no negative comments relating to the smartphone app.Conclusion: the smartphone app version of the Trauma Unit Bypass Tool performs at least as well as the paper version and can be utilised safely by pre-hospital clinicians in supporting triage decisions relating to potential major trauma

Summary Background The emergency department is a dynamic environment with a high throughput of patients. The clinical stability of patients varies considerably. In order to provide optimal care for patients a responsive staffing pattern is required. There is a need for a valid and reliable, prospective, emergency department patient classification system to set adequate nurse staffing levels in the UK. Aims and objectives To conduct a systematic review of the literature and determine the validity, reliability, strengths and weaknesses of emergency department patient classification systems. Methods The following electronic databases were searched for years 1985–2004: MEDLINE; CINAHL; COCHRANE Library databases DARE, CDSR, CCTR, BioMedNet Reviews, National Research Register (NRR). Manual searches were also conducted and relevant references retrieved from those listed in key papers, reports, theses and dissertations. Studies were also retrieved by contacting researchers in the field. Results Twelve patient classification systems met all the inclusion criteria. Only three systems reported evidence of good validity and reliability: the ED Patient Needs Matrix developed in the US, the Conner’s Tool (a modified version of the ED Patient Needs Matrix) developed in Australia and the Jones Dependency Tool developed in the UK. Conclusion There are very few patient classification systems developed for use in the ED setting that have demonstrated good validity and reliability. The Jones Dependency Tool is a simple, easy to use prospective, patient classification system that has demonstrated good validity and reliability in the UK.

The current political healthcare economy is blurring traditional professional bound aries, and national agendas are requiring nurses to take on more roles and tasks previously undertaken by doctors. The emergency nurse practitioner’s expanding scope of practice has moved beyond managing the care of patients with minor injuries, to include those with ‘minor’ illnesses and indeed beyond that to the management and care of those with increasingly complex, acute and chronic conditions. The process of conjugation between the two disciplines has been driven by the demands and pressures on the health economy. Given the unprecedented and increasing overlap in practice between the domains of medicine and nursing, it is time to re-examine differences between them and clarify the issues which divide them. There is a need to benchmark infrastructure and standardize the education and development of nurses undertaking advanced practice roles. There is also a need for continued debate on the future of the health care workforce, informed by research, to facilitate correct and cost effective decision making.

The incidence of sexually transmitted infections in England and Wales is rising. Data from the Public Health Laboratory Service (PHLS 2001) show that cases of gonorrhoea rose by 27% between 1999 and 2000, and the diagnoses of chlamydia increased by 18%. Recent statistics from Genitourinary Medicine (GUM) clinics in England show a rise in infectious syphilis of 43% in men and 36% in women (PHLS 2003). In 2001, the government released its first national strategy for sexual health (Department of Health 2001). One of the main aims of this is to reduce the prevalence of undiagnosed HIV and sexually transmitted infections (STIs). Patients with STIs may present to the emergency department (ED) for treatment and advice either because specialist services such as GUM clinics do not routinely offer a 24-h service or they may not recognise that their problem is related to a sexually transmitted infection. It is fundamental that ED staff are able to recognise common symptoms of STIs, and know when to intervene with treatment and when to refer to specialists. The prevalence of patients attending the emergency departments with STIs may be masked. Patients may complain of symptoms which lead to incorrect diagnoses (for example, a patient with dysuria may be discharged home with the diagnosis of ‘‘urinary tract infection’’) which presents significant