Developing skills and a collaborative culture in paediatric critical care

Jane Cichero1, Catherine  Sumsky,2, Kylie  Furness3, Lisa  Sealey4, Nerralie Shaw5

1Sydney Children’s Hospitals Network, Randwick, Randwick, Australia, 2Sydney Children’s Hospitals Network, Randwick, Randwick , Australia, 3Sydney Children’s Hospitals Network, Randwick, Randwick, Australia, 4Sydney Children’s Hospitals Network, Randwick, Randwick, Australia, 5Sydney Children’s Hospitals Network, Randwick, Randwick, Australia

Introduction

At the beginning of the millennium two critical care areas at Sydney Children’s Hospital were working in isolation. Registered Nurses (RN) in the Emergency Department (ED) were often involved in the rapid resuscitation of patients. These resuscitations required skills that were difficult for the ED nurse to acquire. Conversely, RN’s from the Children’s Intensive Care Unit (CICU) would provide support for the resuscitations in an environment they were unfamiliar with.  It was conceived that creating a culture of collaboration between two nursing teams would enhance skill development in paediatric critical care.

Background

The Nurse Educators from both areas developed and piloted the ED – ICU rotation program in 2005. Specific learning objectives were developed to align with the National Standards for Critical Care Nurse Education.

Outcomes

More than ten years on, the ED-ICU rotation program is ingrained in the roster and a number of collaborative innovations in education and quality and safety have resulted. Innovations that include combined simulation team training, ED representation on the ICU Access Nurse Study day, shared education for advanced skills development and collaborative quality projects such as the recently endorsed ED-CICU Handover Checklist and accompanying policy document in 2016.

Discussion

This paper outlines the benefits of a nursing rotation for staff between a paediatric emergency department and a paediatric intensive care unit and the subsequent impact on skill development and staff retention.  The resulting progression of skill acquisition and development of a collaborative culture between units will also be outlined along with the vision for future combined Paediatric Critical Care post graduate learning.


Biography:

Jane Cichero has been a Paediatric Nurse Educator since 2002. Jane holds a Graduate Certificate of Paediatrics, Paediatric Critical Care and a Graduate Diploma of Clinical Teaching. Jane has extensive experience in general paediatric nursing, paediatric intensive care and paediatric emergency nursing. Her passion for education incorporates a passion for simulation. Jane completed the Harvard Medical Simulation as a Teaching Tool Instructor Course in 2011. Jane currently works in the Emergency Department at Sydney Children’s Hospital, Randwick as Nurse Educator and the Nurse Lead for Simulation.

CPE: Are you ready for the new super bug hitting your ED?

Jo-Anne McShane1, Dr Andrew  Maclean1,2, Leanne  Houston4, Helen Marquand4, Madeleine Smith1, A/Prof Mary O’Reilly2,3

1Emergency Department, Box Hill Hospital, Eastern Health, Box Hill , Australia, 2Eastern Health Clinical School, Monash University Faculty of Medicine, Nursing and Health Sciences, Box Hill, Australia, 3Department of Infectious Diseases, Eastern Health, Box Hill, Australia, 4Infection Prevention and Control, Eastern Health, Box Hill, Australia

Aim

This study aimed was to determine if patients who were at risk of Carbapenemase-producing Enterobacteriaceae (CPE) were isolated and screened correctly in the Emergency Department.

Background

Carbapenemase-producing Enterobacteriaceae (CPE)  is the latest ‘superbug’ on the scene of multi-resistant organisms (MRO’s)  is already endemic in America, India and China. The key factor in reducing the spread of CPE in Australia is the surveillance, screening and management of those at risk.  Emergency Department admissions account for a significant number of potentially CPE colonised patients and provide an opportunity for screening and implementation of transmission based precautions to prevent transmission within the hospital setting.  In response to recommendations regarding CPE screening and pre-emptive isolation in the DHHS (Victoria) guideline on Carbapenemase- resistant Enterobacteriaceae (2015), questions about an overnight stay in a hospital overseas within the last  year were added to the ED triage process. Patients  who said yes were classified as a CPE risk 2 and isolation and screening was required during their Emergency visit.

Methods

A retrospective e-audit from March 2016 to March 2017 (using Symphony, the electronic Emergency Department Information System) with a filter capturing a CPE risk factor of 2 was data matched with the Infection Prevention and Control (IPAC) units spread sheets and Pathology’s CPE database. Data collected:  presenting complaint, discharge status, CPE risk, data source, specimen collection and isolation of patients. Data was entered into Excel and analysed using IBM SPSS v22 .

Results

Throughout the audit process it was discovered there was significant issues affecting the ability to isolate and screen at risk CPE patients including communication, resources, knowledge deficits and technology issues.

Conclusion

Pre-emptive isolation and screening of patients with CPE risk factors in the Emergency Department is an important initiative in identifying  and containing  CPE within the health service.

Funding

Medtronic Infection Control Scholarship


Biography:

Jo-Anne is an enthusiastic Emergency Nurse with 20 yrs experience in Australian and overseas Emergency Departments. Jo-Anne is currently a research nurse at Box Hill Emergency Department and is particularly enthusiatic about Infection Prevention and Control practise and research.

Building a culture of simulation in a paediatric Emergency Department

Jane Cichero1, Dr Nichola  Concannon2, Dr Linda Durojaiye3

1Sydney Children’s Hospitals Network, Randwick, Randwick, Australia, 2Sydney Children’s Hospitals Network, Randwick, Randwick, Australia, 3Sydney Children’s Hospitals Network, Randwick, Randwick, Australia

Simulated learning environments (SLE’s) have become integral to many education programs in healthcare today. Since 2014 the Sydney Children’s Hospital Emergency Department (ED) has supported nursing and medical simulation lead positions to facilitate the development of a simulation education program to support learning in the ED and inform practice.

Our comprehensive ED Simulation program includes multidisciplinary in-situ scenarios and one day team training courses, triage, advanced nursing practice and clerical scenarios,  clinical skills teaching, faculty training and mentoring, and senior ED staff communication and challenging conversation scenarios.

Latent errors and knowledge gaps revealed during sessions are recorded and tabled at the ED Quality and Safety Committee. In addition, any significant clinical incidents inform the development of new systems or tools which are tested and rehearsed in SLE’s.

Evaluations utilise a 5 point likert scale with free text option have been extremely positive across all aspects, the majority indicating scores in the two highest bands.

Defined quality data has been measured and patient safety initiatives have been developed.

Faculty training and a mentoring model has widened the pool of skilled simulation educators resulting in a sustainable workforce to support a culture of simulation in ED.

The ED simulation program has provided a positive impact on the culture and safety in our ED. The SLE’s are consistently used to inform practice, develop and check clinical tools and systems and improve care for patients and families in the ED. Ongoing feedback through the quality cycle continues, further improving and refining these tools/systems.

After two years there is a perceived difference in staff attitude to simulation, with regular requests for inclusion in future SLE events, a testament to the value staff now place on this type of learning, demonstrating that faculty have been successful in creating a safe learning environment for all.


Biography:

Jane Cichero has been a Paediatric Nurse Educator since 2002. Jane holds a Graduate Certificate of Paediatrics, Paediatric Critical Care and a Graduate Diploma of Clinical Teaching. Jane has extensive experience in general paediatric nursing, paediatric intensive care and paediatric emergency nursing. Her passion for education incorporates a passion for simulation. Jane completed the Harvard Medical Simulation as a Teaching Tool Instructor Course in 2011 and has continued to develop skills and knowledge in the world of simulation . Her current role as Nurse Lead for Simulation in the Emergency Department at Sydney Children’s Hospital, Randwick enables her to promote and utilise simulation in many aspects of multidisciplinary education and quality and safety in emergency care.

Back to basics

Aileen Pooley1

1Calvary Health Care Bruce, Canberra, Canberra, Australia

As emergency nurses, we can get caught up in the theatrics of the advanced care we endeavour to provide. This often results in core or basic elements of care not being met.

Gone is the age of one evening off per week (from patient care) for courting and cleaning purposes, hospital corners and rounding with each doctor, though there will always remain a physician who expects this from nursing.

With increasing pressures to perform more complex, time consuming duties, while maintaining a higher skill set, we risk deviating from the basic day to day tasks that remain core to the function of a nurse and the needs of our patients.

On professional reflection, our department noted an increase in near misses and potentially unsafe practise. We also recognised that the most immediate way to address these matters was not to introduce greater complexity but to in fact go ‘back to basic’ to consistently provide high quality care for our patients, their families and the wider community.

An initiative began re-educating and re-focusing on the importance of basic care for our patients. We have created a proactive team to promote passion of emergency nursing, re-dedicated to the importance of basic nursing care within our department without impacting on advanced practise continuing to support our higher acuity patients. This approach facilitates a decrease in medication errors and gaps in our handover process. A key component of this approach being focused on looking and talking to our patients rather than becoming task orientated.

By re-focusing our whole team, we have seen a fall in near misses, improved staff morale and an increase in patient satisfaction. Adapting Lieutenant General David Morrison’s stance “the standard you walk past is the standard you accept”, everyone is driving towards a common goal of patient centred care on all levels.


Biography:

Aileen is a registered nurse in the Emergency Department at Calvary Hospital in Canberra. Aileen successfully graduated from the University of Canberra where she completed a Bachelor of Nursing Degree.  Aileen has completed a post graduate certificate and is working towards her diploma in Emergency nursing and currently undertaking a child and family health care diploma.

Aileen is competent in the roles of triage, medical emergency team and working towards her advanced practice nursing.  Aileen is passionate about improving patient outcomes and staff education to improve the health and safety of all patients.

An ED avoidance strategy outside the walls of a busy ED; emergency health care delivery for a planned mass gathering

Tonya Donnelly1, Dr Amy Johnston2, Nerolie Bost1, Dr Michael Aitken1, Cary Strong3, Jo Timms1, Kate Gilmore1, Professor Julia Crilly2

1Dept Emergency Medicine, Gold Coast Health , Southport, Australia, 2Dept Emergency Medicine Gold Coast Health And Menzies Health Institute Qld  , Southport, Australia, 3Gold Coast LASN, Queensland Ambulance Service, Ormeau, Australia

You’re off to great places, but why do you go? So you’ve set up a tent – but what does it show?

Background: Emergency department (ED) crowding and ambulance transportation rates are known to be increasing annually. The implementation of ED avoidance strategies during events such as mass-gatherings can be an important. One such strategy, the ‘Schoolies week’ health tent has been in operation for 10+ years. Evidence in support of its use for ED avoidance has been primarily anecdotal.

Methods: This was a retrospective observational study.  The study sample included all 16-18 years old patient presentations made to the ED over a three week period (pre, during, post Qld Schoolies week) and to a temporary medical tent (during Qld Schoolies week) in 2014. Patient information from the ED and ambulance service databases were linked. Descriptive and inferential statistics were used for analysis.

Results: A total of 1,028 patient presentations were made by the 16-18 year age group to the ED and/or health tent over the three week study period ( (120 pre, 684 during, 224 post Qld Schoolies week). During the schoolies week, a total of 420 presentations were made to the health tent with an average of 60 per night. The majority (n=394) were seen and discharged from the tent while some (n=26) required further ED care.

Conclusions: The results suggest that a temporary facility for one week during the Schoolies mass-gathering event was a useful ED avoidance strategy for young adult school leavers. Pressure on the hospital EDs and ambulance services was relieved, and access by local residents maintained, because the on-site tent diverted young people away from the local EDs. Given the increase in ED crowding and pressures on ambulance services, such care models may be worth considering for mass gathering events in other locations.


Biography:

Tonya Donnelly is a highly experienced award-winning ED CNC, who has held the disaster/mass gathering portfolio at Gold Coast Health Service for ~10 years. She is committed to developing and implementing evidence-based ED avoidance strategies that really reduce patient load and enhance care delivery in local EDs. She is passionate about the establishment of hospital avoidance programs particularly around mass gatherings.

Amy Johnston is a conjoint research fellow in Emergency Care, based between Gold Coast Health and Menzies Health Institute Queensland/School of Nursing and Midwifery Griffith University, seconded from a senior lecturer position at Griffith University. She is deeply committed to bringing research skills and outcomes to emergency staff. She is a widely published and cited academic and registered nurse with experience in a range of research techniques. Her love of clinical research is heartfelt and (hopefully) infectious. She is involved in HDR student supervision and onsite development of ED staff research skills.

Achoo achoo: Have you got the flu? How well do triage nurses identify potential influenza patients?

Jo-anne Mcshane1, Dr Andrew Maclean1,2, Leanne Houston4, Helen  Marquand4, Madeleine Smith1, A/Prof Mary O’Reilly2,3

1Emergency Department, Box Hill Hospital, Eastern Health, Box Hill, Australia, 2Eastern Health Clinical School, Monash University Faculty of Medicine, Nursing and Health Sciences, Box Hill, Australia, 3Department of Infectious Diseases, Eastern Health, Box Hill, Australia, 4Infection Prevention and Control, Eastern Health, Box Hill, Australia

Aim

The aim of the study was to see if triage and primary care Emergency Department (ED) nurses identified potentially infectious influenza patients in the Emergency Department and if correct isolation practices were being implemented.

Background

The identification and management of patients with potentially infectious diseases is a challenging aspect of triage. The triage clinician has minutes to decide what may be potentially wrong with a patient and what immediate actions are needed. In addition, post triage often patients spend a significant amount of time in the waiting room of ED’s , potentially infecting other patients and staff.

Methods

A retrospective e-audit (using Symphony, the electronic Emergency Department Information System) with filters set to capture patients with influenza like illness (ILI) and an e-audit of influenza  Polymerase Chain Reaction (PCR) ordered from Box Hill ED was undertaken from July- September 2016, during peak influenza season. Data collected:  presenting complaint, observations, time to isolation and if Transmission Based Precautions (TBP) were implemented during their ED visit. Data was entered into Excel and analysed using IBM SPSS v22.

Results

Detailed data analysis will be presented including follow-up action taken to address the gaps between current performance and best practice.

Conclusion

Triage and primary care nurses in the ED have an opportunity to improve their practise of identifying potential infectious patients by understanding the case definitions for ILI, applying surgical masks at triage, and isolating the patient until results of PCR testing are available. Identifying these patients early will help prevent transmission to other, sick vulnerable patients and staff both in ED and the inpatient setting.

Funding

The lead author is a recipient of an Medtronic Infection Control Scholarship


Biography:

Jo-Anne is an enthusiastic Emergency Nurse with 20 yrs experience in Australian and overseas Emergency Departments. Jo-Anne is currently a research nurse at Box Hill Emergency Department and is particularly enthusiatic about Infection Prevention and Control practice and research.

‘Growing our own’- educational framework to assist with the recruitment, professional development and retention of emergency nurses

Danielle Waddell1, Tracey Ingvorsen1, Vanessa Leonard-Roberts1, Elise Sutton1, Elizabeth Ward1, Adam Watts1, Stacey Williamson1

1Northern Health, Melbourne, Australia

Background:A critically high nursing EFT deficit of 21% in late 2015 in the Emergency Department (ED) at The Northern Hospital (TNH), particularly postgraduate trained emergency nurses led to a review of the current education programs in 2016.

Aim:Review of current educational programs and strategies, and development of an educational pathway to prepare and promote junior nurses to undertake postgraduate emergency nursing studies within our ED.

Method:In 2016, TNH employed additional clinical support nurses to  supervise undergraduate nurses on placement in ED. Prior to this, education was provided by the relevant university. Incorporating undergraduate nurses in our program allowed us to develop ED specific education for our junior workforce. Graduate nurse rotations were increased from 12 to 16 per year to meet interest demand, with targeted education to prepare these nurses for our grade 2 Supported Transition Emergency Practice program (STEP).  Theoretical content and clinical assessments for STEP were aligned with postgraduate course content, including encouragement to undertake the advanced pathophysiology subject at Melbourne University which forms part of the Graduate Certificate in Emergency nursing.

Conclusion:Re-alignment of our educational programs to promote the professional development of our junior nurses has proved a success. 18 months after its implementation, we have provided structured educational support to:

  • 170 undergraduate nurses
  • 20 graduate nurses (70% of graduate nurses completed an undergraduate rotation in TNH ED)
  • 34 STEP participants (53% of ED STEP completed an ED graduate rotation)
  • 25 postgraduate students (80% of postgraduate students were from STEP)

The educational alignment has allowed TNH ED to develop our novice nurses from an undergraduate level through to specialist emergency trained nurses. This in turn has decreased the EFT vacancy deficit from 21% to 3% over the last 18 months.


Biography:

Danielle Waddell:

Currently employed as Clinical Nurse Educator in the Emergency Department at Northern Health. Responsible for the education, co ordination, development and recruitment for all educational programs in the ED /SSU.

Tracey Ingvorsen:

Currently employed as a Clinical Support Nurse in the Emergency Department at Northern Health. Responsible for the education, support and supervision of all junior nurses and holds the undergraduate portfolio.

“Opening Night” – the experience of creating and leading a new team, and the experience of commissioning a new Emergency Department

Vanessa Gorman1

1Northpark Private Emergency Department, Bundoora, Australia

OBJECTIVE:

Evaluate the experience of commissioning a new Emergency Department, and strategies for building a new emergency team from the nurse manager perspective.

METHODS:

Review the requirements needed for commissioning of a new emergency department from the nurse unit managers perspective.

Retrospectively evaluate the core values and needs for building a successful team.

Understand and evaluate the strategies and phases of the recruitment process when building a new emergency nursing team.

Review of recommendations from governing bodies such as College of Emergency Nursing and Australian College of Emergency Medicine.

RESULTS:

In November 2016 the Emergency Department was successfully opened in one of Australia’s biggest growth corridors to help meet the needs of the local community.  There was successful recruitment of a highly skilled emergency nursing team that also met the needs of the community and organisation. A strong foundation was set for the new emergency nursing team to be successful and inspired with a focus towards ongoing professional development and the provision of excellent quality emergency care.

CONCLUSIONS:

During the planning phases for the commissioning of a new Emergency Department it is important to understand the needs of the community when building a highly skilled, motivated and dedicated emergency nursing team. Understanding the requirements and aspects of building a successful team is core during the recruitment phase to ensure you have the ‘right people for the right job’.


Biography:

Vanessa Gorman commenced her emergency nursing career in 1996 at Austin Hospital, Melbourne. Across her 20 year career in emergency nursing she has held positions such as Associate Unit Manager, Nurse Unit Manager, Project Manager, Senior Policy Advisor – Department of Health, Bed Access Coordinator, Nursing Educator and State Trauma Manager. Vanessa holds an enduring passion for trauma nursing and is an accredited international trauma coder and actively works with the State Trauma Registry in Victoria. Vanessa holds post-graduate qualifications in Emergency Nursing and is currently completing a Masters in Health Services Management through Monash University. Vanessa is an appointed member to the International Advisory Council for the Emergency Nursing Association (USA), which aims to make improvements within emergency nursing globally.  Vanessa is dedicated to improving nursing work conditions with a particular interest in fatigue management. In 2015 she was co-lead in a Worksafe Victoria project with a focus on fatigue management for Emergency Nurses.

“I am a pathway champion” – a retrospective look at the influences of a sepsis pathway

Dale Reading1

1Calvary Health Care Bruce, Giralang , Australia

Sepsis and septic shock continues to be a major healthcare problem worldwide.

Australia’s Society of Critical Care Medicine’s Surviving Sepsis campaign highlighted that the early identification and appropriate management of sepsis improves patient outcomes. This recognition has bought about an increased focus on the definition of sepsis, with the third international consensus definition for sepsis and septic shock (Sepsis 3) being released in 2016. The definition of sepsis evolves in light of considerable advances in the understanding of sepsis’ pathobiology, management and epidemiology. The recommendations from Sepsis 3 were that sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. The quick Sequential (sepsis-related) Organ Failure Assessment (qSOFA) scoring system was developed from the work of the international consensus group on sepsis, as a bedside screening tool for clinicians to identify patients who may have a prolonged Intensive Care Unit stay or mortally due to sepsis. This tool identifies at risk patients who need timely targeted care to reduce associated morbidity and mortality.

Within our ED we modified existing sepsis pathways to incorporate the qSOFA tool to improve the recognition of patients with sepsis, enabling rapid intervention. As with all change, the pathway has had a mixed reaction from clinicians on the floor. During the implementation of the pathway, the primary concern was that the pathway was not capturing the right patients. Despite this concern, there has been an improvement in how we treat sepsis patients in the department.

qSOFA was one of the many contributing factors, alongside an increased department wide focus on sepsis and a clear treatment progression as laid out in the pathway. Due to the many factors involved, I would argue such improvements cannot be attributed to qSOFA alone. Other aspects of the pathway such as the empowerment of nursing staff to be able to recognise and initiate the sepsis pathway may have had a greater impact than qSOFA alone. This is not to suggest that qSOFA is not a valuable tool, yet qSOFA is a set of cues or prompts to suggest sepsis, the true detection of sepsis remains at the bedside, by a clinician.


Biography:

Dale Reading is a registered nurse at the emergency department working at Calvary Public Hospital Bruce. Dale graduated from the University of Canberra with a Bachelor of Nursing and continued postgraduate studies in emergency nursing at the University of Tasmania. Dale has been involved in a number of quality improvement projects to improve clinical practice and is currently focused on nurse’s assessment of patient in the ED.

Designing and conducting simulation. Tricks and tips

“Designing and conducting simulation – tricks and tips. It’s not all about the bells and whistle’s, low fidelity or high fidelity….it’s all learning”

Aim: The aim of this workshop is provide some tools , advice and practice for developing and implementing simulation in emergency departments to support the acquisition and rehearsal of skills and knowledge in paediatrics.

Background: The value of clinical simulation has become highly regarded in healthcare education and has been reported to enhance critical thinking, problem solving, clinical judgement and rapid response skills. In addition, evidence suggests that simulation greatly improves communication amongst staff, positively impacting on patient outcomes.

Overview of workshop: The purpose of the workshop is to provide an immersive experience for paediatric clinicians and educators in delivering department based simulation. Using simulation, the participants will be able to follow through a scenario the management and stabilisation of an acutely unwell child. Participants learning will be facilitated through participation and role modelling, and will cover the following components: how to direct, troubleshoot and debrief simulation. The scenario and workshop is applicable to those clinicians involved in the delivery of paediatric education in any setting, particularly those outside the tertiary centres.

Facilitators: Jane Cichero & Nadine Alcorn

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