Results of a protocol for a nurse led analgesia intervention in an urban Emergency Department – Pain-Protocol Initiating Nurses (P-PIN) – a retrospective review

Mrs Natasha Jennings1, Ms Claire Hatherley1, Ms Rachel Cross1,2, Dr Grainne Lowe1,3, Dr Gerard O’Reilly1,4, Dr Biswadev Mitra1,4, Dr Paul Jennings5

1Emergency and Trauma Centre, The Alfred Hospital, Commercial Road, Melbourne VIC 3004; 2La Trobe University, Alfred Clinical School  Melbourne VIC 3004; 3Deakin University, Burwood, VIC 3125; 4National Trauma Reserach Institute, The Alfred Hospital, Prahran, VIC 3181; 5Department of Community Emergency Health and Paramedic Practice, Monash University

Background. Nurse led analgesia programs have been found to be safe and effective in reducing time to analgesia and improve the quality of pain assessment and treatment. A pre-implementation study demonstrated poor compliance with the national target of patients receiving analgesia within 30 minutes (26.6%: 95% CI: 19.1-35.1), prolonged times for first doses of analgesia (median time 60.5 (IQR 30-87) mins and poor documentation of pain scores (PS; 52.3%). Pain protocol initiating nurses (P-PIN) in the emergency department (ED) of a busy urban hospital was introduced in December 2016 to standardise the approach to nurse led analgesia, reduce time to analgesia, improve pain score documentation and improve efficiency of pain control. The aim of this study was to evaluate safety and effectiveness of this protocol.

Methods. A retrospective explicit review of the medical records of all patients receiving P-PIN analgesia was conducted at one-month intervals. Data extracted included patient demographics, compliance with the national standard of analgesia within 30minutes, time to first dose of analgesia, pain score documentation and protocol violations.

Results. There were 48 patients that received nurse led analgesia during the first 3 months of the protocol intervention. Compliance with the national target of patients receiving analgesia within 30 minutes was 91%. The median time to first dose of analgesia was 16 (IQR 10.5-26) mins. There were no adverse errors reported and documentation of PS was 100%. There was one protocol violation for nurse led analgesia being given to a patient with chest pain, which is an exclusion criterion.

Discussion. Pain protocols have been shown to improve the incidence, accuracy and documentation of pain assessment and treatment efficiency. Translation of these findings into clinical nursing practice helps to reduce the gap in translational of research to clinical practice.  A thorough implementation strategy and education program with close evaluation focusing on patient safety has been used to optimise outcomes for patients presenting with pain to the ED.


Biography:

Tash is an emergency nurse practitioner with a focus on advancing nursing practice.

Claire is a Clinical Nurse Educator at the Alfred Emergency & Trauma Centre. She has completed her Masters of Nursing (Emergency Care) with a specific focus on emergency management and treatment of pain.

‘Oh the places you will go – and what will you find when you get there?’ An account of nurses overcoming barriers in a refugee crisis to provide nursing care

Ms Helen Zahos1

1Dept Emergency Medicine Gold Coast Health, Southport, Australia

The year 2015 saw a mass exodus of Refugees fleeing Syria and surrounding countries; considered by many to be the largest humanitarian crisis since World War 2. Many had fled from destroyed homes, at gunpoint, with just the clothes on their backs and often their child in their arms.

As a remote and disaster area emergency nurse, with experience in refugee and asylum seeker health services on Christmas Island and Nauru, I needed to use my nursing knowledge and skills in the crisis. I spent six weeks on the Greek island of Lesvos. Some days saw arrivals of up to 5000 Refugees crossing in rubber boats. Injuries varied, but I was present for the boat accident of 28th October where 300 people were involved in one accident, and in that one night 11 children and 27 adults drowned. I then spent 6 weeks on the border of FYROM and Greece, including the first border closures and the refugee clashes with the police and army. Our health service faced unparalleled social, political and economic barriers in a tiny geographical region bombarded by need. But the team I worked with managed! Our focus during the crisis was not on the thousands of people in front of us, but rather that one person that each of us could help. Have you ever covered a person shivering cold with a warm blanket? Or held a stranger in your arms that is grieving for their child? Helped another human being, without discrimination, and without expecting anything in return? This for me is what nursing represents, and that feeling extends to my ability to apply my skills and knowledge and assist in the refugee crisis, making a difference one person at a time.

Ask yourself, as an emergency nurse, ‘What have I done about this?’


Biography:

Helen is a bilingual emergency nurse at Gold Coast University Hospital. She had experience working in disaster responses such as the Philippines post typhoon Hyan  2013 and in Nepal after the Earthquake of 2015. She has worked in refugee and asylum seeker health on Christmas Island and Nauru. Nominated as Australian of the year 2017 (Qld), she is a passionate advocate for nurses making a difference to people in need.

Refugees on the Aegean, and beyond: An emergency nursing perspective on humanitarian aid work and primary care

Mr Michael Henley1

1Hunter New England Health: Tamworth Base Hospital, Tamworth, Australia, 2College of Emergency Nursing Australasia, Sydney, Australia

In recent years, the plight of people fleeing war and persecution internationally has escalated. In 2016, the United Nations High Commission for Refugees released statistics showing that there are now more people displaced, seeking asylum, or listed as a refugee, than ever before – including in the years following World War II. People escaping from such situations have very unique challenges in their healthcare needs, and delivering effective medical and nursing care to these populations often requires ambitious and unorthodox solutions.

In the August of 2016, I travelled to Greece to volunteer time working in Medical Clinics at Refugee Camps sheltering people fleeing from conflict in Syria, Iraq and Afghanistan. There, I had the opportunity to work with multiple Non-Government Organisations to deliver care to a diverse variety of ethnic groups with various chronic and acute conditions; ranging from acute illness and injury occurring inside the camps, to the lasting mental trauma from experiences they have fled from, to pregnancies, and chronic conditions no longer manageable in a tent. All in all, the experience was both challenging and rewarding, emotional and enlightening.

This presentation will outline the setting, nature, and challenges of delivering healthcare in the Humanitarian Aid setting, far removed from the familiarity of the Emergency Department. It will then explore the Authors’ personal experience of working in Greece in the above settings in 2016. At the time of writing, plans are underway to return to Greece in Mid-2017, and also assist at a newly established field hospital in Northern Iraq, serving up to 270,000 people displaced by conflict. This too will be outlined. Brief case studies and examples showing a cross-section of this unique population’s healthcare needs will also be discussed.


Biography:

Michael is a Fourth year postgraduate Nurse, currently working in the Emergency Department of Tamworth Base Hospital in North Western New South Wales. From the outset he has embraced Emergency Nursing, with all the challenges and rewards it brings. Michael has a keen passion for  furthering the speciality of Emergency Nursing and recently became a Committee Member of the CENA NSW branch. A multivariate experience such as working as a Senior Duty RN in a small district hospital (as a Graduate Nurse!), ride-along opportunities taken with the RFDS, and annual leave spent volunteering in Medical clinics in Refugee camps overseas, have all left Michael with an appreciation for the way Emergency nursing care can be delivered in less than typical circumstances.

The Perfect Storm: South Australian Emergency Department clinician’s experience of an extreme weather event

Dr Karen Hammad1, Ms Megan Wake2, Ms Carla Zampatti2, Ms Sally Neumann3

1Flinders University, Adelaide , Australia, 2Royal Adelaide Hospital Emergency Department, Adelaide, Australia, 3Mount Gambier Hospital Emergency Department, Mount Gambier, Australia

Background: On the 28th of September 2016 South Australians experienced an unprecedented extreme weather event forcing the South Australian Commissioner of Police to declare a major incident. The event lasted for nearly a week and resulted in widespread power outages, flooding and structural damage. South Australian Emergency Department (ED) staff who worked during the event were unable to care for patients as they usually would. This experience presented an opportunity to understand how ED clinicians were affected by the event and provides insight into how prepared ED clinicians are for future events.

Method: The purpose of this research was twofold, aimed at generating an understanding of how ED clinicians were impacted by the event and how prepared ED clinicians feel for future events. Ethical approval was provided by Flinders University Social and Behavioural Research Ethics Committee.  An online survey was distributed to nurses and doctors through the College of Emergency Nursing Australasia (CENA) and the Australasian College of Emergency Medicine (ACEM).  56 nurses and doctors who worked in a South Australian ED between 28th September and 3rd October 2016 responded to the survey.  A descriptive analysis of the survey responses was undertaken.

Results: For the majority of respondents in this research, the extreme weather event significantly impacted their ED and clinicians changed their practice as a result. There were common themes throughout the state. The results of the study also demonstrates inconsistencies in current disaster training with the most common type of disaster training being hospital in-service lectures and the majority of respondents reporting that they hadn’t participated in disaster training since 2014.

Conclusion: This presentation will report on the findings of the research focusing on how EDs and clinical practice were impacted. Further recommendations about preparing clinicians using educational resources will also be discussed.


Biography:

Karen is a CENA Fellow, she is currently employed as a Lecturer in the College of Nursing and Health Sciences at Flinders University where she runs the post graduate emergency nursing program and a Masters degree in Disaster Health Care. Karen is also an emergency nurse with more than 20 years experience.

Moments of disaster response in the Emergency Department

Dr Karen Hammad1

1Flinders University, Adelaide , Australia

Introduction: In the end we will not remember the years we spent in nursing. We will only remember the moments (Donahue 1996). We experience our lives as a series of memorable moments, some good and some bad. Undoubtedly, the experience of participating in disaster response, is likely to stand out as a memorable moment in a nurses’ career. This presentation will describe five distinct moments of nursing in the emergency department (ED) during a disaster response. Our existing understanding of emergency nurses’ participation in disaster response comes largely from narrative accounts of single events. This study is unique because it explores the experience of nursing in the ED during a disaster across different geographical regions and disaster types.

Method: A Hermeneutic Phenomenological approach informed by van Manen underpins the research process. Thirteen nurses from different countries around the world participated in interviews about their experience of working in the ED during a disaster. Interviews were conducted face to face or via Skype. Thematic analysis and a guided existential reflection resulted in two different perspectives of the experience of working as a nurse in the ED during a disaster response. This presentation will report on one of these aspects.

Results: The moments of notification, waiting, patient arrival, caring for patients and reflection described by nurses who participated in this research provide insight into the experience of nursing in the ED during a disaster response. Consideration of these individual moments will lead to recommendations for future preparedness of emergency nurses.

Conclusion: This presentation focuses on one aspect of the findings of a PhD study and provides an in-depth insight into the experience of nursing in the ED during a disaster response which can help generate awareness and inform future disaster preparedness of emergency nurses.


Biography:

Karen is a CENA Fellow, she is currently employed as a Lecturer in the College of Nursing and Health Sciences at Flinders University where she runs the post graduate emergency nursing program and a Masters degree in Disaster Health Care. Karen is also an emergency nurse with more than 20 years experience.

Eye tracking technology; education through innovation

Mrs Louise Veitch1, Mr Anil Thaduri1, Mr Matt Luther1, Mrs Jodie Burke1, Dr Eamon Merick1,2, Dr Janie Busby Grant2

1Calvary Public Hospital Bruce, Nicholls, Australia, 2University of Canberra, Canberra, Australia

While eye tracking technology has been used to evaluate nursing and medical care amongst a variety of clinical specialties in simulated environments, until now there have not been any studies conducted using this technology in real time, with real patients, in an environment such as the Emergency Department. This study will help to identify and compare the approach, execution and clinical findings of the initial primary assessment of patients in the critical care setting of Calvary Hospital Emergency Department. The eye tracking devices will be worn by four groups of participants; novice and experienced Registered Nurses and novice and experienced Medical Officers for comparison of eye tracking and visual field analysis on various emergency presentations.

The research design is aimed to track the visual assessment skills of medical and nursing professionals caring for the critically ill patient. This technology tracks and records the data in real time whilst nurses and medical officers perform the primary assessment by identifying clinical features of the patient. By obtaining real time and recordable eye tracking data, the approach, eye tracking, cognitive cue processing and interpretation of symptoms from assessment findings can be analysed. The findings will then help identify the disparities between the novice and experienced groups to improve clinical practice by further education, and targeted skill enhancement. The study may also reveal the elements of primary assessment that can be learned, compared to skills that are acquired through ongoing professional exposure and experience.


Biography:

Louise and Anil are Registered Nurses in the Emergency Department at Calvary Hospital in Canberra.

Both Anil and Louise are currently studying for the Masters Degree in Emergency Nursing, through the University of Tasmania.

Anil has previously worked as a Surgical and ICU Nurse, and Louise has had experience in Medical, Surgical and Mental Health Nursing, prior to commencing in the Emergency Department.

Go hard in the waiting room: Early methoxyflurane

Mrs Allison Jordan1, Mr Matt Luther1

1Calvary Public Hospital Bruce, Dunlop, Australia

Pain remains a primary impetus for people presenting to an Emergency Department (ED), yet literature suggests pain is frequently poorly managed in the ED setting.

Approximately 40% of Calvary Public Hospital Bruce’s ED presentations are related to minor trauma such as lacerations, falls, pushbike and sporting injuries. A clinician who recognises these injuries as non-life threatening may trivialise and subjectively assess the pain and administer suboptimal analgesia resulting in the patient experiencing pain while waiting to be seen. This can sometimes be for an extended period.

At the Calvary ED, the Advanced Practice and Triage Nurses utilise an ‘Initial Pain Management Procedure’ in which they may nurse initiate a single dose of medication(s) historically reserved for an acute area of an ED. These medications include methoxyflurane, fentanyl, morphine or oxycodone, as well as common and synergistic analgesia options such as paracetamol and ibuprofen.

Methoxyflurane is a volatile and self-administered inhalation analgesic indicated for short term use to aid in managing acute or procedural pain. Methoxyflurane is commonly utilised by Ambulance Services due to its ease of administration, fast action and effectiveness in relieving intense pain. These characteristics resemble the requirements for use in the ED as methoxyflurane provides an excellent non-invasive and patient controlled option to meet rapid pain relief requirements and expectations prior to synergistic analgesic agents.

Within the ED waiting room, the option of nurse administered methoxyflurane to a patient in the ED waiting area enables a rapid intervention and response to a patient reporting mild to severe pain, and has minimal impact on the subsequent treatment options available to manage more complex or longer term pain.

Methoxyflurane is accessible via a locked cupboard located at the triage desk. A Standard Operating Procedure for administering it has been developed and approved by the appropriate clinical and patient safety committees.

I am pleased to share the story of our introduction of methoxyflurane as an additional analgesic option for minor trauma within Emergency Department waiting room, and happy to report the anecdotal benefits of reduced patient discomfort and ensuing improved patient amenity.


Biography:

Allison graduated in 2001 and commenced a New Graduate Program at Calvary Hospital. Once completing her new graduate year Allison moved to Victoria and worked at Werribee Hospital. The moving to Sydney to work at St George Hospital. This is where Allison found her love in life Emergency Nursing. In 2010 Allison successfully completed Masters of Nursing (Nurse Practitioner) and successfully applied for a Nurse Practitioner position at Calvary Public Hospital. Allison leads a team of 6 strong APN’s and leads the APN education program and teaches the APN training sessions. Allison has mentored many APN’s and Senior ED Nurses. Allison has a passion for adequate pain relief in the waiting room and for optimising paediatric pain relief in the ED.

Abracadabra! Unveiling the invisible work of emergency nurse practitioners

Mr Matt Lutze1,2,3, Professor  Margaret Fry2,5, Ms  Glenda  Mullen4, Dr Jane  O’Connell2, Ms  Danielle  Coates4

1St George Hospital, Emergency Department, Kogarah, Australia, 2University of Technology Sydney, Faculty of Health, Ultimo, Australia, 3University of Sydney, Sydney Nursing School , Camperdown , Australia, 4Sydney Children’s Hospital Network, Emergency Department, Randwick, Australia, 5Director Research and Practice Development Nursing and Midwifery Directorate NSLHD  , St Leonards, Australia

Objectives: This study sought to quantify and qualify the collaborative and secondary consulting clinical practice patterns of emergency nurse practitioners (ENPs). Within the literature there is extensive evidence of the direct clinical management provided by ENPs. However, ENP secondary activities incorporating consultation, advice and clinical support are not well described.

Design/Methods: This was a three-month prospective multicentre study design which explored ENP secondary consultations using an electronic medical record template. The template was designed to capture direct (patient contact) and indirect (staff advice / consultation) activities.

Results: ED presentations across the four sites were 54,970. ENPs were involved in the care of 2628 (5%) patients. Of the 2628 patients ENPs managed 2017 (77%) patients as the primary provider (primary consultations) and 611 (23%) as secondary consultations (direct and indirect contact).

Secondary consultations conducted by ENPs were on average 11.1 minutes (median 7.0 minutes). Of the secondary consultations 60% (n=367) required direct patient contact. Secondary consultations were commonly initiated by nurses (n=191; 31%) or emergency registrars (n=136; 22%). The majority (n=424; 69%) of secondary consultations involved patients with either musculoskeletal (n=238; 39%) and wounds and burns (n=186; 30%). ENPs requested 155 (21%) investigations and prescribing was performed on 144 (24%) occasions. Procedural support (n=303, 50%) was predominantly for wound management (n=141; 47%) or plaster/splints/crutches (n=113; 37%). When an ENP provided a secondary consultation, re-presentation rates were lower (1% compared to 6.5%).

Conclusion/Recommendations: The study highlights the invisible and valuable work of secondary consultations by ENPs.  Approximately 25% of patients who received care from an ENP did so as a secondary consult. The study identified that all ED clinical staff utilised ENPs for expertise in patient management. The ENP secondary consultation template was quick and easy to use and could be adapted for other nurse practitioner specialties or other care providers.


Biography:

Matt has been a nurse for almost 20 years and a nurse practitioner for more than 10. He has worked in the UK and Australia across ED, primary care, prehospital and critical care areas. Whilst Matt loves pretending he is a researcher, his attention to beer and its secondary benefits tend to enhance the quality of his discussions, usually about ultramarathon running or more important things like his kids and family… Oh the places you’ll go 🙂

Meditation-based wellness and compassion training in the Emergency Department: The Canterbury Hospital experience

Mr Glen Wiseman1, Mr Nickolas Yu2

1Canterbury Hospital Emergency Department, Campsie, Australia, 2Sydney Local Health District Nursing & Midwifery Executive, Camperdown, Australia

Research has found that compassion is a key element of patient and family-centred care. Elements of compassion include understanding, appraisal, empathy, motivation and responding. A number of studies have found that meditation training can increase compassion A meditation-based mental and emotional fitness training program called ‘Sankalpa’ was designed and has been conducted on a weekly basis since late 2015 among Emergency Department nurses at Sydney’s Canterbury Hospital.

Quantitative (psychometric, pre/post-test) and qualitative findings reflecting impacts associated with this program will be presented, along with a description of the program itself.


Biography:

Glen Wiseman has over 15 years emergency nursing experience. He has a passion for education and improving service delivery and has found a perfect fit working as the clinical nurse educator and clinical nurse consultant. With encouragement from colleagues Glen has gained experience in meditation facilitation and supporting staff in developing strategies to deliver compassionate care.

Improving care for people with Parkinson’s disease presenting to an Emergency Department: Implementing a care bundle

Prof. Margaret Fry1,3, Mrs Marion Harris2

1University of Technology Sydney, Broadway, Australia, 2Hornsby Hospital NSLHD, Hornsby , Australia, 3Northern Sydney Local Health District, Royal North Shore Hospital, Australia

Introduction:  Hospital presentations to the Emergency Department (ED) can be traumatic for people with Parkinson’s disease (PD) due to the complexity of clinical management and medication regimens and the potential side effects. As a result care can be compromised if not coordinated well, medication regimens are not maintained and or inappropriate prescribing of PD medicines.

Method:  This was a study evaluating the implementation of a care in one Sydney ED. The evaluation involved a pre-post medication record audit, patient interviews and nurse surveys. The care bundle included a: clinical pathway, education program and a learning package, electronic medical record prompt, patient sticker for the medical record, multidisciplinary involvement and clinician electronic alerts, and ED based PD medications.

Results: The pre-post medication audit identified a 13% improvement in the correct prescription of PD medications, although this was not statistically significant (X2 2.101df 2 p=.147).  There was a 21% improvement in timely PD administration in the pre-post audit which was statistically significant (X2 4.024 df 2 p=.041). Twenty-nine patient telephone interviews were conducted with the majority male (n=22, 76%), average age 78years, living in their own home (n=11 38%), with a PD disease duration 7.1years. ED nursing knowledge survey response rate was 51% (n=30).  The majority (n= 25; 84%) of respondents were female with a median of 9.3 years nursing experience and 5 years ED experience. Post care bundle implementation identified improvement in pharmacy alerts (100%) and reviews (76%), medication documentation (94%) and PD sticker usage (74%).

Conclusion: Implementation of the ED care bundle has led to early identification of patients with PD, improved medication regimens, increased nursing knowledge, multidisciplinary engagement, improved documentation, and consistency in pathway adherence, improved patient satisfaction, and access to PD information.


Biography:

Professor Fry is Director of Research and Practice Development for Northern Sydney Local Health District and holds a Professorial Chair position with the University of Technology Sydney. Professor Fry has a strong emergency care background, has held CNC positions and is an authorised Nurse Practitioner (NSW). Professor Fry has extensive senior nursing experience and a proven research track with 118 peer reviewed publications and over $2.2million in grant, research tenders and or scholarship funding.

123415