How to successfully implement transitional research findings into practice in a busy emergency department

Adrienne Ling1
1Royal North Shore Hospital

Back ground:
Approximately 17,000 Australians sustain a fractured neck of femur every year, A 2010 study in Australian Emergency Departments1:
• Only 7% of hip fracture patients received a nerve block in the ED
• Morphine was administered to nearly 60% of patients
• Median time to analgesia of any form was 75 minutes
• Less than 50% of patients had documented pain scores

Other studies have demonstrated that:
• Regional nerve block techniques (RNBs) are more effective than IVI analgesia for managing #NOF pain.
• A Fascia Iliaca Block (FIB) is a type of RNB and patients who have FIBs require significantly less opiate analgesia, potentially reducing risk of delirium.
• FIBs can be safely and effectively performed by registered nurses
• Nurse-initiated FIB early in the patient journey

The focus of this Translational Research project was to implement this proven approach to pain management as a routine procedure. This meant identifying and overcoming various barriers and obstacles

Secondary gains:
Ready-to-use FIB equipment packs were designed. A pre and post FIB checklist on the EMR (FirstNet) system was designed to make documentation streamlined. Charting pain, using the tools Visual Analogue Scale (VAS) and Pain Assessment in Advanced Dementia (PAINAD) for non-verbal and cognitively-impaired patients facilitated the recording of pain scores. Falls patients without #NOF have benefited from the knowledge of PAINAD as an alternative pain scoring tool

Further learning’s:
The eight hour original mixed theory workshops taught by medical staff, is now taught by nurses. Negotiated with anaesthetics re degree of sterility from full sterile gowns to a pair of sterile gloves. Anaesthetising the skin pre insertion of FIB needle abolished. Ropivacaine was low dose 0.2% now changed to full dosage 0.75%.

Conclusion:
The FIB assessors have credentialed 32 nurses across two hospitals, no adverse events recorded. The FIB program was deemed successful as a research implementation project.


Biography:
Adrienne is currently working at Royal North Shore Hospital (RNSH) Emergency Department (ED) as the Clinical Nurse Educator and Clinical Nurse Specialist with 8 years’ emergency nursing experience. Adrienne commenced her nursing carer 16 years ago as an Enrolled Nurse (EN) at St Vincent’s Hospital Sydney while completing her Bachelor of Nursing. Academically she has obtained at her Graduate Certificate in Critical Care and this year has commenced a Masters of Advanced Nursing – majoring in education at the University of Technology Sydney. She is commitment to staff education, development and promotion of evidenced base practice.

Implementation of Guidelines for Sepsis Management in Emergency Departments: A systematic Review

Ms Yasmin Sungkar1,2, Professor Julie Considine2, Associate Professor Anastasia  Hutchinson2
1Northern Health, Epping Melbourne, Australia, 2Deakin University, Burwood Melbourne, Australia

Introduction: Timely, evidence-based emergency care for patients with sepsis  decreases intensive care unit admissions and mortality. Despite international and local campaigns promoting evidence-based criteria for sepsis recognition and guidelines for sepsis management, delays in the care of patients with sepsis is still an important issue in emergency departments (EDs). The primary aim of this systematic review was to examine the effect of implementation of guidelines for the ED management of sepsis had on time to antibiotic administration. Secondary aims were to examine changes in evidence-based sepsis care and patient outcomes.
Method: A systematic literature review of English language publications published in academic databases was performed from 1st January 2002 and 31st May 2016 using search terms related to sepsis, emergency care, guidelines and evidence-based practice. A Population, Intervention, Comparator, Outcome (PICO) assessment was carried out to define the types of studies included in this review. Screening and filtering of search results was reported as per the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines.
Results: Nineteen studies were included for analysis: all used longitudinal repeated measures cohort study designs. The studies were of low to moderate methodological quality. Of the 19 studies included, time to antibiotic administration decreased in 18 (95%) studies  and increased in one (5%) study  following guideline implementation. Five studies  reported improvements in compliance with specific elements of sepsis guidelines, and nine studies reported an increase in lactate sampling .  Reductions in inpatient mortality ranging from 1% to 24% were reported in 12 studies with two studies reporting increased mortality after guideline implementation.
Conclusion: Implementation of sepsis management guidelines in EDs improves the timeliness of processes of care and may improve patient outcomes.


Biography:
Yasmin Sungkar is a Critical Care Registered Nurse currently working in the Emergency Department of The Northern Hospital in Epping Victoria. For the last 5 years, Yasmin has also been involved in a quality improvement project called Step on Sepsis. Step on Sepsis is a Northern Health initiative which aims to improve the early recognition and prompt treatment of patients with or at risk of sepsis. Yasmin has also recently completed her Honors thesis on sepsis guideline implementation in EDs.

Medication safety program for patients with known allergy to antibiotics: use of an electronic medication prescription system in Emergency Department (ED) in Hong Kong

Ms. Angela WONG1, Dr. Larry LEE1, Dr. Kin-Ming POON1, Mr. Heyman TANG1, Ms. Wai-Ling CHAN1
1Department of Accident and Emergency, Tin Shui Wai Hospital, New Territories West Cluster, Hospital Authority, , Hong Kong SAR

Introduction: Prescription or administration of antibiotics to a patient with known allergy to antibiotics of the same class is a medication error which could lead to permanent harm or even death. In 2017, there were two related medication incidents reported in EDs of New Territories West Cluster (NTWC), Hong Kong. The leading reason is staffs’ unawareness of possible cross-sensitivity of antibiotics of the same class and the prescription order from ED doctors are sometimes in terms of written or verbal orders and hence drug allergy could not be checked electronically.

Objectives:

  • To reduce the incidence of known drug allergy related medication error in ED
  • To promote culture of medication safety

Methods: ED of Tin Shui Wai Hospital (TSWH) of NTWC – A newly established ED in NTWC of Hong Kong has implemented an electronic medication prescription system – ‘Admission Medication Order Entry (AMOE)’ since its commencement of service in March 2017. For hospitals under Hospital Authority in Hong Kong, patient’s medical history is recorded electronically in ‘Clinical Management System (CMS)’, including updated allergy history. AMOE system is linked with CMS and thus can provide mandatory system allergy checking upon drug prescription through CMS. AMOE system first applied on drug prescriptions of non-urgent, semi-urgent and urgent patients in ED, except resuscitation cases. Its use was extended to all antibiotics’ prescriptions of all patients, including resuscitation cases, from November 2017 onwards. The rate of related medication incidents of EDs of NTWC was reviewed periodically.

Result: There was nil related medication incident reported in ED of TSWH since the implementation of AMOE system. Culture of medication safety was promoted through daily coaching and internal training.

Conclusion: The use of AMOE system in ED can reduce the rate of medication incidents efficiently. Further enhancement on the system will be carried out to make it more fit in the future clinical management system.


Biography:
Ms. Angela Wong is an Emergency Specialty Nurse and works as an Advanced Practice Nurse in Accident and Emergency Department (AED) of Tin Shui Wai Hospital (TSWH) of New Territories West Cluster (NTWC) in Hong Kong. She graduated from the School of Nursing of the Hong Kong Polytechnic University in 2006. She also completed the Master of Science in Cardiology awarded by the Chinese University of Hong Kong in 2013. She worked in AED of Tuen Mun Hospital (TMH) of NTWC from 2006 – 2017. She participated in the commission of the opening of service of AED of TSWH – a newly established AED in NTWC of Hong Kong since 2017. She is the Training and Development (T&D) Coordinator in the department. She helps to deal with T&D related issues and implement relevant enhancement work e.g. coordinating department nurse training days, promoting Continuous Quality Improvement (CQI) programs, carrying out audits etc. She is also the vice-chairperson of Medication Safety Subcommittee in the department and helps to promote the culture of medication safety.

The use of personal, quick-reference lanyard cards to reduce transition shock in New Graduate emergency nurses.

Ms Sophie Williams1
1Calvary Health Care Bruce, Evatt, Australia

Background: The commencement of professional practice is daunting for newly registered nurses, who often experience ‘transition shock’ – the culture shock of transitioning into the clinical reality of nursing. Critical care settings have comparably higher rates of transition shock, which is hypothesized to be due to the added fears of time-critical situations in a fast-paced environment. In the authors’ workplace, staff are recruited at regular intervals to undertake the departments’ Emergency Nursing Program. Due to operational demand, new/graduate nurses are frequently allocated to Acute bedspaces, where new patients are received for initial assessment and work up.
Development: Inconsistencies were observed in the patient assessment/workup by new or graduate staff and were believed to be related to the two main factors of a) restricted Nurse Educator support outside of business hours; and b) the graduates’ mimicry of the habits of their assigned mentor only. In response, a ‘quick-reference’ guide was suggested for initial patient assessment/workup, targeting ‘ATS2-Urgent’ patients, who require assessment and intervention within ten minutes. In these instances, new nurses may find themselves unsure of the immediate requirements or a logical, prioritised sequence in which they should be attended. The quick-reference guide was produced in the format of personal lanyard cards, one each for the most common ATS 2-style presentations such as Chest Pain or Shortness of Breath. The card captures the essential nursing interventions for each type of presentation, referencing departmental policies and best-practice guidelines, and is presented in a dot-pointed step-by-step order to guide initial patient assessment and workup.
Findings: The use of quick-reference lanyard cards were found to be successful in reducing the transition shock in new/transitioning nursing staff through reducing anxiety and providing guidance for consistent initial patient workup and assessment.


Biography:
Sophie is a Registered Nurse in the Emergency Department at Calvary Hospital in Canberra, currently working in a variety of roles including Advanced Practice, Resuscitation, Triage and as the hospitals after-hours Clinical Assist Nurse. Sophie has strong interests in advanced practice and education, having completed postgraduate qualifications in Clinical Education and Emergency Nursing from the Australian Catholic University and the University of Sydney.

CQI program- Enhancement of patient safety by Standardization of central medication trolley in resuscitation room in the Accident and Emergency Department (AED) of Pok Oi Hospital (POH)

Ms Wai Yuet Leung1
1Hospital Authority Of Hong Kong, Yuen Long NT, Hong Kong

Introduction

Accident and Emergency Departments (AED) are designed to provide urgent, high quality, continuously accessible and unscheduled care for a wide range of acute injuries and diseases. AED extended its scope of services to provide higher quality of care and benchmark with international standards. However, the increased in the attendance and service demand, medical and nursing manpower shortage and great turnover rate of staffs which leaded to unfamiliar with the medication names and usage of medicine. To enhance the patient safety POH AED standardization of central medication trolley in resuscitation room to reduce the medication incidents.

Objective:

  • To standardize the medication labels by using the same format of naming provided by pharmacy
  • To maintain safe medication storage and adequate drug stock level;
  • To enhance the patient safety by accurately and timely administration of prescribed drugs.

Method:

  • By collaboration with the Medication Safety Subcommittee in POH AED and POH pharmacy, the following measures were implemented:
  • Use the labels provided by pharmacy to standardize the naming to avoid typo errors in the medication trolley in resuscitation room
  • Assign a designated nursing staff to check and monitor the stock level and storage safety of the drugs with restrictive access control;
  • Use same design medication trolleys in the three resuscitation rooms
  • Cross check by pharmacist

Results:

  • Three medication trolleys are standardized to use the same design and labeling of medication in resuscitation rooms,
  • A designated nurse will check the expiry dates and stock everyday to ensure the effective monitoring of medication stock level, improve workflow, eliminate wastage of time and expired drugs;
  • Pharmacists will cross check for unscheduled time to enhance safety.
  • Reduce medication incidents by 60% through the standardization.

Conclusion: Standardization of central medication trolley in resuscitation room in the Accident and Emergency Department (AED) reduced the medication incidents in AED and worth to promote to other AEDs in Hong


Biography:
An AED nurse work in NTWC AEDs in Hong Kong, care AED patients in both A&E and emergency medicine wards over 10 years

 

Escalation of care for clinical deterioration in the ED

Mrs Vanessa Leonard-Roberts1,2, Professor Julie Considine2,3,4, Professor Judy Currey2,4
1Northern Health , Epping, Australia, 2Deakin University, Burwood, Australia, 3Eastern Health , Box Hill, Australia, 4Deakin Centre for Quality and Patient Research, Geelong, Australia

Recognising and responding to clinical deterioration is a national patient safety priority. Safety systems such as Medical Emergency Teams (METs) have been developed to ensure a prompt response to clinical deterioration and a reduction in the number of associated adverse events.

This study formed part of a larger study exploring the response of ED Nursing Shift Leaders to episodes of escalation of care for patient clinical deterioration. The aim of this study was to describe the characteristics of episodes of escalation of care for clinical deterioration that were observed during that study. Data were analysed using Statistical Package for Social Sciences (SPSS) Version 23.0. Descriptive statistics were used to summarise the study findings.

The study was conducted in an urban district ED in Melbourne, Australia. The ED had three levels of clinical deterioration, PreMET, MET and cardiac arrest, each with specific escalation of care criteria. 10 RNs participated in the study. There were 65 breaches of PreMET, MET and cardiac arrest criteria in 37 patients. Study data were collected between October and December 2015 across a variety of shifts.

Analysis of the escalations of care for clinical deterioration revealed three findings. First, of the escalations of care that came from within the ED 72.4% (n=21) were from registered nurses with postgraduate qualifications in emergency nursing. Only 6.9% (n=2) escalations came from graduate (novice) nurses. Second, escalation of care originated from all areas of the ED and not just the resuscitation area. Finally, nurse concern was a common cause for MET escalation. There were 36 MET criteria breaches, 28 PreMET criteria breaches and 1 cardiac arrest breach. The most common reason for PreMET escalation in adults was heart rate abnormality and the most common reason for MET escalation was for nurse concern followed by tachypnoea.

In conclusion, managing escalation of care for patient clinical deterioration has a direct impact on patient safety. This study provided an opportunity to increase understanding of the characteristics of escalation of care for clinical deterioration. An increased understanding of escalation of care for clinical deterioration is crucial to reduce associated adverse events and improve patient outcomes.


Biography:
Vanessa Leonard-Roberts was born in Africa and spent most of her early career in the health industry working as an executive. In 2008 she moved to Australia where she completed a Bachelor of Nursing followed by a Master of Nursing Practice in 2017.

Occupational Violence and Aggression in the Emergency Department

Mrs Sharon Klim1, Doctor Ainslie Senz1, Ms. Elisa Ilarda1, Professor Anne Maree Kelly1
1Western Health, St Albans, Australia

Background:  Violence in Emergency Departments (ED) is a significant problem world-wide.  Emergency settings are considered high risk areas with the number of incidents of staff exposure to violence ranging from 60 to 90% (Taylor and Rew, 2010). Despite some research being carried out in Emergency Departments few studies have evaluated the effectiveness of violence management and prevention strategies (Lau, Magarey and Cutcheon, 2005). Most research has focused on the rates of violence and the impact on staff.  There has been a significant gap in research studies so far, to provide a framework and practical interventions for guiding evidence based practice (Taylor and Rew, 2010).
Aim:  To review the outcome of implementation of the Bröset Violence Checklist (BVC); an evidence based violence risk assessment tool to the ED.
Methodology:  A two part study:

  1. A before-and-after survey; to assess changes to staff knowledge, attitudes, perceptions and confidence with respect to risk assessment for aggression/ violence.
  2. A before-and-after point prevalence data collection period; to compare risk assessment rating distribution between unstructured clinical assessment and the BVC.

Results: 76 Pre-implementation and 83 Post-implementation surveys completed.  In both surveys >70% of staff reported being subjected to verbal or physical aggression/violence and no change in confidence to prevent violence. However, there were statistically significant changes in the screening of patients for violence/ aggression risk, and improved confidence in staff ability to assess risk of violence and to identify risk factors. For the point prevalence component, in the pre-implementation cohort, 30% of patients underwent risk assessment (74/250). This increased to 82% after implementation (p<0.001). There was no difference in the distribution of assessed risk (low, moderate, high) after implementation with approximately 1% being assessed as high risk.
Conclusion: Occupational violence is common in ED. Prevention, including risk assessment, is a key strategy for mitigation. Using an assessment tool improves staff confidence in assessing risk, and provides a strategy for early identification and intervention. Reducing violence in all healthcare settings improves staff and patient safety and experience for all patients and visitors.


Biography:
Sharon Klim is a research coordinator for the Joseph Epstein Centre for Emergency Medicine Research at Western Health. Sharon is also a Clinical Nurse Specialist in the Emergency Department at Footscray Hospital where her research knowledge and experience is often sought with assisting staff with quality improvement projects and other innovative ideas.  Sharon’s area of clinical expertise is clinical handover and leadership.

IV cannula use on disposition of Emergency Department patients

Miss Rebekah Bernoth1
1John Flynn Hospital, Tugun, Australia

Peripheral intravenous cannulas are inserted in emergency departments at a high volume. There are various uses for these cannulas, including pathology collection, pain relief, medication administration and intravenous fluid therapy while in the Emergency Department (ED). When a patient is transferred to the ward from the ED the IV cannula is left intact though it may not be utilised as part of care on the ward. The issue examined in this research study is whether this practice increases the risk for infection or trauma to the site of insertion and whether the cannula should be removed at the end of the emergency stay before being discharged to the ward. Our objective is to safely manage our patients treatment and do this by reducing the risk of infection.

Methodology: We have studied 240 random peripheral intravenous cannula insertions from one private ED over a 12 month period. This retrospective qualitative research collected data regarding the insertion at the ED, the use of the cannula in ED, the usage of the cannula on the ward post discharge from ED, infection at site and the removal time of the cannula.
Results: The findings in this data is that over 50% of patients who are sent to the ward with a cannula inserted did not have their cannula used for any treatment and therapy of any sort. Over 60% of the cannulas that were not used on the ward remained insitu for 48 or more hours.
Implications: The results of this study leads to the further discussion on whether IV cannulas should be removed at the end of the ED stay in order to reduce the potential for infection as well as removing the task of the ward nurses flushing the cannula, redressing the site and documentation according to the hospital policy on management of the IV cannula.

 


Biography:
Rebekah Bernoth is a clinical nurse at John Flynn Hospital Emergency Department. Rebekah has been a nurse for 17 years and in that time practised in a wide scope of nursing including medical, surgical, pain management and speaking at overseas conferences before spending many years in Intensive Care and now in an Emergency Department. She is an academic tutor at Southern Cross University, facilitates TAFE and university students in hospital settings. Rebekah has spent most of her years post graduating from Bachelor of Nursing furthering her education and is currently in the middle of her second Masters in Emergency Nursing. She enjoys the study and keeping up with the every changing nursing practises and new therapies with the drive to not stop studying and learning. She is an advocate for the innovation of best-evidence practise to promote better outcomes for patients and staff satisfaction. Rebekah has had a passion for nursing since a young age of 6yrs and never considered another career. Rebekah believes in the quote “When you’re a nurse you know that every day you will touch a life or a life will touch yours”, proving to be true with many experiences and challenges over her nursing career.

A weekend in-service program led by clinicians in the Emergency Department

Mrs Hui (Grace) Xu1, Dr  Pauline Calleja2
1Queensland Health, Meadowbrook, Australia, 2Griffith University, Nathan, Australia

Background: In-service training is an indispensable strategy for maintaining and increasing emergency nurses’ competency to deliver safe patient care (1, 2). In-service training is traditionally run by a nurse education team. Often other senior nursing members (i.e. nurse practitioner or clinical nurse consultant) have limited involvement in staff nurse educational activities due to multiple reasons. Limited research addresses in-service training and senior nursing clinician’s roles in contributing to ongoing staff educational activities in emergency departments (ED).  This project was undertaken to develop a new model of in-service training program for emergency nurses.
Methods: This innovated model of education activities commenced in 2017 in a busy urban public teaching hospital ED in Queensland Australia. There was no in-service delivered during weekends in the ED prior to this project. The department has a large portion of junior nurses with less than 3 years ED experience. The in-service sessions were undertaken on both Saturday and Sunday every weekend during afternoon handover time (1430-1500) commencing in January 2017. The weekend in-services were organised and delivered by experienced clinicians’ including nurse practitioners, clinical nurse consultants, clinical nurses and senior staff nurses. The in-service topics focused on clinically relevant contents. Monthly in-service fliers were delivered to all nursing staff via email and on education whiteboards in the department at the beginning of each month.
Results: 127 sessions and 63.5 hours in-service delivered to staff nurses in the ED between January 2017 and April 2018. This is an ongoing educational activity and continues in the department. Staff nurses who attended the sessions provided positive verbal feedback and requested the ins-service program to continue.
Conclusion: This weekend in-service educational model provided an additional learning opportunity for a cohort of inexperienced emergency nurses focusing on clinically relevant learning. Further research for this model is planned.


Biography:
Grace (Hui) Xu is a Nurse Practitioner, academic, nurse researcher and staff wellness advocator in a teaching hospital emergency department (ED) within Queensland Health. She provides emergency care to adults and children who present the ED within the Ambi-Care model of care service. She also works as an academic staff member at Griffith University School of Nursing and Midwifery. Grace started to develop her research capacities in 2017 with the support of some experienced ED researchers. Her passion in promoting staff wellness and staff education drives her interest in becoming a key driver and stakeholder of the Staff Wellness Committee in her ED.

Building an engaging team: an experience for the newly formed nursing team in Accident & Emergency (A&E) Department in Tin Shui Wai Hospital (TSWH) in Hong Kong.

Mr Heyman Tang1, Ms Angela WONG1, Ms Wai Ling Chan1, Ms Wan Man Lam1, Ms  Chiu Ying Chan1, Ms Mei Mei Chan1, Ms  Elaine Wong1, Ms Ka Po Ng1
1Accident & Emergency Department, Tin Shui Wai Hospital, Hospital Authority, , Hong Kong

TSWH commenced 8 hour A&E service on 15 March 2017.  It serves around 300,000 populations in TSW district. A new nursing team has been forming and going through different stages with different challenges.

Objectives:

  • To execute staff engagement activities
  • To maintain staff retention

Methods: Deming Cycle (PDSA)
Plan: Staff- mix analysis (in A&E experience) : novice (<1 year: 10%), junior (1-3 years: 24%), senior (> 3 years: 66%, in which 4-10 years: 19% and > 10 yrs 47 %). Daily attendance (12 hrs): 233 in average, max: 293. Around 30 cases of admission (17%) daily: Escort cases: nurses: 543 (0-9 cases daily); Staff came from different departments with different background.  Overwhelming figures lead to stress.
Do: Developed programs to engage staff e.g. coaching system, preceptor-ship program; Pilot training program (every nurse as speaker so as to achieve “they teach & they learn”)
Study: Assessed the effectiveness and injected new initiatives for the pilot and trials.
Act :

  • Engaged all nurses to divide 6 teams to manage 30 Subcommittees / task force groups e.g. infection control, Fall prevention & drug safety etc.  Encouraged to implement improvement projects to increase sense of belonging and self-actualization.
  • Regular meetings to review manpower to cater high attendance and high Inter-hospital Transport (IFT) cases.
  • Encouraged to participate staff engagement programs in community e.g. CPR training to secondary school students and health care staff in Mainland China and Community CPR Marathon so as to enhance staff’s self-esteem and self-actualization.
  • Further data collection by observation, interview and staff coaching survey.

Results: 55% (nurses) expressed stressful i.e. rating 1-5 (high stress level 1 to 10 low stress level).  However, 77% expressed “very happy” at work i.e. rating 8-9 (unhappy 1 to 10 very happy) and 18% rated 10.  95% of staff expressed they were “fully engaged”.  No staff resignation since service commencement.
Conclusion: A good leader is essential to build an engaging team.  Steve Jobs stated that “The only way to do great work is to love what you do”.  In turns, the only way to build great team is to love your team.


Biography:
Ms. Angela Wong is an Emergency Specialty Nurse and works as an Advanced Practice Nurse in Accident and Emergency Department (AED) of Tin Shui Wai Hospital (TSWH) of New Territories West Cluster (NTWC) in Hong Kong. She graduated from the School of Nursing of the Hong Kong Polytechnic University in 2006. She also completed the Master of Science in Cardiology awarded by the Chinese University of Hong Kong in 2013. She worked in AED of Tuen Mun Hospital (TMH) of NTWC from 2006 – 2017. She participated in the commission of the opening of service of AED of TSWH – a newly established AED in NTWC of Hong Kong since 2017. She is the Training and Development (T&D) Coordinator in the department. She helps to deal with T&D related issues and implement relevant enhancement work e.g. coordinating department nurse training days, promoting Continuous Quality Improvement (CQI) programs, carrying out audits etc. She is also the vice-chairperson of Medication Safety Subcommittee in the department and helps to promote the culture of medication safety.

 

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