Education at the elbow: The use of a Clinical Coach Framework in the Emergency Department

Amanda Naumann1, Sean Lannan1, Val Mitchell1

1Sunshine Coast Hospital and Health Service, Birtinya, Australia, 2Sunshine Coast Hospital and Health Service, Birtinya, Australia

As Emergency Departments continue to evolve and grow in line with healthcare advancements, the need to support nurses working clinically has grown accordingly.

As Nurse Educators became increasingly involved in strategic direction and leadership activities, time in point of care education became reduced. Educators were being consistently time challenged and bedside education had to compete with other organisational priorities.

The Clinical Coach (CC) Framework was initiated to provide bedside education for clinical nursing staff. An innovative program was developed, fully funding senior clinicians to provide ongoing educational support at the point of care. This position expands on the role traditionally held by facilitators and preceptors. The CC spends 80% of their time coaching staff using mentoring, teaching modelling and assessing to improve practice to benefit patient care. The remaining 20% of their time is devoted to educational administrative responsibilities such as data entry, in service planning and reviewing of induction processes. The Clinical Coach Framework requires Coaches to be accountable for and report against five common indicators: clinical induction; preceptorship; clinical development; mandatory training; and, safe practice.

This presentation describes the innovation, role activities and outcomes over a five year period.

Results demonstrate increased compliance of mandatory training, increased bedside and in-service education, improved staff induction processes and a robust method of staff progression through the various levels of Emergency Department nursing.

The Clinical Coach Framework provides a robust and educationally sound approach to providing point of care support for clinicians in the Emergency Department. The success of this framework is evidenced by its implementation in Emergency Departments across the Health Service.


Biography:

Amanda is a nurse educator for emergency services with the Sunshine Coast Hospital and Health Service. Amanda has worked in Emergency Departments in Australia and overseas, and has an interest in the development of the Advanced Practice Nurse role in ED.

 Sean is currently a nurse educator for emergency services with the Sunshine Coast Hospital and Health service. Sean has a history as a nurse working in Emergency Departments in Regional and Metropolitan Health Services and has an interest in Simulation Education.

ED nurse recognition of sepsis is critical to early administration of antibiotics in patients with sepsis to reduce mortality: A systematic review and meta-analysis

Dr Amy Johnston1, Dr Joon Park2, Professor Suhail  Doi3, Vicki  Sharman4, Justin  Clark5, Jemma  Robinson4, Professor Julia Crilly1

1Dept Emergency Medicine, Gold Coast Health and Menzies Health Institute Qld  , Southport, Australia, 2Dept Emergency Medicine, Gold Coast Health and The Prince Charles Hospital , Chermside, Australia, 3Research School of Population Health, Australian National University and College of Medicine, Qatar University, Doha, Qatar, Canberra, , Australia, 4Pharmacy Dept and Dept Emergency Medicine, Gold Coast University Hospital, Southport, Australia, 5Centre for Research in Evidence-Based Practice, Bond University , Southport, Australia

Background:  Sepsis is a time sensitive illness. Emergency department (ED) clinicians play an important role in the early recognition and management of sepsis. Part of sepsis management includes initiating broad spectrum antibiotics, ideally within the first hour of diagnosis. Despite various guidelines the evidence underpinning such recommendations remains limited. Understanding the extent to which early administration of antibiotics occurs in the ED and the impact this has on patient mortality warranted this review.

Purpose:  The goal of this review was to synthesize (pool) existing evidence regarding mortality for patients who present to the emergency department and are administered antibiotics immediately (≤1 hour) or later (>1 hour), and are diagnosed with sepsis.

Methods:  A search of databases including PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL, using the MeSH descriptors “sepsis,” “systemic inflammatory response syndrome,” “mortality,” “emergency,” and “antibiotics,” was undertaken to identify studies that reported ‘time to antibiotic administration’ and mortality in patients with sepsis. Study data were extracted using a tailored data extraction form and all studies were evaluated for methodologic quality. From an initial pool of 582 possibly relevant studies, 10 studies had quantitative data for an overall meta-analysis. Three different statistical models were used to perform the meta-analysis.

Findings:    The pooled results suggest a significant, 33%, reduction in mortality odds for immediate (≤ 1 hour) compared with later (>1 hour) antibiotic administration (OR, 0.67 [95%CI, 0.59– 0.75]) in patients with sepsis.

Implications:   Immediate antibiotic administration (≤1 hour) seemed to reduce patient mortality, helping to provide an evidence-base for ED recommendations. This timeframe requires that informed and aware nurses contribute to early, comprehensive, sepsis management within the ED. ED nurses maintain their central role as a critical components in early detection and management of patients with suspected sepsis.


Biography:

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. She is deeply committed to bringing research skills and outcomes to emergency staff and consumers. She is a widely published and cited academic and registered nurse with experience in a range of research techniques.

Disposition from the ED – a qualitative analysis of how a nurse call back system can be an effective method to improve patient experience and give valuable information for improvement.

Vanessa Gorman1, Emily Knights1,2

1Northpark Private Emergency Department, Bundoora, Australia, 2University of Melbourne, Melbourne, Australia

OBJECTIVE:

That telephone follow-up 24-72hours post discharge helps to determine a patient’s level of satisfaction with their emergency department care, provides an avenue for patient feedback and has psychological and quality benefit.

METHODS:

We report a qualitative (thematic) analysis of patient feedback about a nurse led telephone call back service over a 6 month period. Patients who attended the ED and were discharged home were contacted by phone by a nurse. Telephone call were scripted. At the end of the call patients were asked to provide feedback about the service. This feedback was analysed using thematic analysis.

RESULTS:

We identified three main themes from the feedback:

  1. Patients valued the service – people were happy to talk about their experience and the phone calls were positively received and appreciated
  2. Patients felt more involved in their care and treatment – data shows that over three-quarter of patients were impressed with the service
  3. Complaints proactively managed – patients had an avenue to provide feedback in a timely manner with reports of decreased concerns after the follow-up call was made

CONCLUSION:  The nurse follow-up call service is valued and appreciated by patients. It allows real-time feedback, which may reduce patient dissatisfaction post discharge from emergency care. Further research is required to establish the effectiveness of such an intervention.


Biography:

Emily Knights commenced her nursing career in 2003 at St Vincent’s Public Hospital, Melbourne.  Across her 15 year nursing career she has held positions such as Clinical Nurse Specialist at the Alfred Hospital’s Emergency and Trauma Centre where she completed her post-graduate diploma of Nursing Science in Emergency Care 2009.  Acting in charge nurse and critical care nurse leader. More recently the leading nurse researcher in a national study for the University of Melbourne on depression and a type 2 diabetic study at the department of General Practice within the University of Melbourne.  She spends most of her time as Associate Nurse Unit Manager of the new Northpark Private Hospital’s Emergency Department and hospital co-ordinator.

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.

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