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.

Post resuscitation management of cardiac arrest patients in the critical care environment: A retrospective audit of compliance with evidence based guidelines

Mrs Annabel Milonas1, Professor Julie Considine2,3, Associate Professor Anatascia Hutchinson2, Dr John Green1, Dr David Charlesworth3, Ms Andrea Doric3

1Northern Health, Epping, Australia, 2Deakin University, Geelong, Australia, 3Eastern Health, Box Hill, Australia

Background: There is a clear relationship between evidence-based post resuscitation care and survival and functional status at hospital discharge. It is clear that resuscitation should not stop after return of spontaneous circulation from a cardiac arrest. The Australian Resuscitation Council recommends protocol driven care to enhance chance of survival for cardiac arrest survivors. Emergency healthcare providers’ are obliged to ensure protocol driven post resuscitation care is timely and evidence based.

Objectives: The aim of this study was to examine adherence to best practice guidelines in the first 24 hours post resuscitation in ED and to the ICU having suffered an out of hospital  cardiac arrest and survived initial resuscitation.

Method: A retrospective audit of medical records of survivors of cardiac arrest was conducted at two health services in Melbourne, Australia. Criteria audited were: primary cardiac arrest characteristics, oxygenation & ventilation management, cardiovascular care, neurological care and patient outcomes.

Findings: Four major findings were: i) Use of FIO2 of 1.0 and hyperoxia was common during the first 24 hours of post resuscitation management, ii) Variability in cardiac care, with timely 12 lead ECG and majority of patients achieving systolic BP greater than 100mmHg, but delays in transfer to cardiac catheterization laboratory, iii) Neurological care was suboptimal with a high incidence of hyperglycaemia and failure to provide therapeutic hypothermia in almost 50% of patients, iv) There was association between in-hospital mortality and specific elements of post-resuscitation care during the first 24 hours of hospital admission.

Conclusion: Evidence-based context-specific guidelines for post resuscitation care that span the whole patient journey are needed. Reliance on national guidelines does not necessarily translate to evidence based care at a local level, so strategies to ensure effective implementation of research evidence are urgently required.

ACKNOWLEDGEMENTS: This study was funded by a Northern Health Research Grant


Biography:

Annabel is Education Coordinator for the Surgical and Cardiac Clinical Service Unit at Austin Health. Her experience includes an extensive career in emergency nursing education both in the clinical and academic arenas as well as Deterioration and Resuscitation Program Coordinator for Austin Health and Northern Health respectively. Her qualifications include a Masters of Education and is currently studying her second Masters in Terrorism and Security Studies, as well as a specialty in emergency nursing. Her responsibilities include workforce professional development and implementation and development of nursing programs for all level of learners in acute and critical care nursing. She has led organizational implementation of National Health standards  including establishing and maintaining systems for recognizing and responding to deteriorating patients across all sectors of the organization: acute care, sub-acute care and community based care.

A large part of her current role is professional leadership.She is an ARC ALS 2 Director and instructor who travels to other health services and interstate to deliver ALS education. She is currently chair of the Victorian expert group of deterioration and resuscitation coordinators that enables focused expertise and bench-marking in matters of clinical deterioration and resuscitation. She reviews for the Australasian Emergency Nursing Journal.

Improving the early identification and management of sepsis: Successful implementation of an evidence-based screening and treatment pathway at Eastern Health

Miss Meredith Symons1, Mrs Andrea  Doric1, Mr Chris Jackson1, Mr Dan Neale1, Dr Hussein Alabodi1

1Box Hill Hospital, Eastern Health, Melbourne, Australia

Introduction: Sepsis is a medical emergency. Research shows that early recognition of sepsis and timely administration of antibiotics can improve patient outcomes and reduce mortality. Performance monitoring identified sepsis as a high prevalence condition contributing to episodes of clinical deterioration in our organisation.

Study Objectives: Enhance sepsis recognition

  • Ensure timely appropriate sepsis management
  • Reduce mortality, morbidity and length of stay from sepsis

Methods: In July 2015, the Improving Sepsis Recognition and Management program was implemented at Eastern Health,  including:

  • A sepsis screening tool
  • An evidence-based sepsis pathway
  • Alignment of antibiotic prescribing guidelines to evidence
  • A sepsis pathology order set
  • Education sessions for clinical staff

Following on from the initial rollout, locally led gains were further enhanced in the ED through participation in the Emergency Care Clinical Network (ECCN) 2016 evidence-based quality improvement sepsis project which included:

  • Raising staff awareness through education, lanyards, posters and regular feedback of audit data
  • Collaboration with pharmacy, antibiotic stewardship, clinical deterioration committee
  • Celebrating World Sepsis Day
  • Holding a Sepsis Screening Challenge

Results: Results pre- and post-ECCN project were significant with key outcomes as follows:

  • Sepsis identified at triage or first nursing contact – increased from 11% to 21%
  • Intravenous antibiotics given within one hour of ED presentation – increased from 11% to 42%
  • Intravenous fluids commenced within one hour of ED presentation – increased from 44% to 63%
  • Serum lactate measured – increased from 78% to 89%
  • Hospital length of stay decreased from 9.5 to 6.0 days for patients presenting to ED with sepsis

Conclusion: The introduction of the sepsis pathway has enhanced clinician capability, improved resilience and is contributing to better patient outcomes. Importantly, providing data showing improvements helps to engage staff to change their practice.


Biography:

Meredith is an Emergency Clinical Nurse Specialist at Box HIll Hospital with a particular interest in quality improvement and safety in the ED.  She has previously presented an initiative to prevent blood transfusion errors at ICEN 2014.  Meredith is currently completing a Masters of Advanced Nursing Practice with the goal of attaining endorsement as an Emergency Nurse Practitioner.

A theory-informed toolkit for implementing a patient-assessment framework into emergency nursing practice

Dr Belinda Munroe1,2, Professor Kate Curtis1,2, Associate Professor Thomas Buckley2, Kate  Ruperto1, Orinda Jones1, Tracey Couttie1, Dr Lou Atkins3

1Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, Australia, 2Sydney Nursing School, University of Sydney, Camperdown, Australia, 3Centre for Behaviour Change, University College, London, UK

Background: The emergency nursing assessment framework ‘HIRAID’ (History, Identify Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) improves patient assessment and communication skills of emergency nurses.¹ A range of facilitators and barriers were identified to potentially impact on the uptake and use of HIRAID.²

Aim: Design interventions to address facilitators and barriers, and optimise implementation of HIRAID in emergency nursing practice.

Methods: Implementation interventions were selected to target facilitators and barriers using the Behaviour Change Wheel.³ Resources were devised to enable delivery of interventions.

Results: A multimodal toolkit was devised to deliver behaviour change techniques selected, including feedback, demonstration, instruction, credible sources and prompts. The toolkit consists of educational and training resources for nurses and educators, an e-learning module, a preceptor program and simulation training exercises. A video was created to persuade nurses to use HIRAID in their practice, modelling executive support and demonstrating how to use the framework in practice. Electronic documentation templates, posters and reference cards were also designed to prompt use of HIRAID in the clinical environment.

Conclusion: This theory-informed toolkit has the potential to optimise implementation of HIRAID in emergency nursing practice. Further evaluation is needed to evaluate the impact of the HIRAID assessment framework and implementation strategy on clinical practice.

  1. Munroe B, Curtis K, Murphy M, Strachan L, Considine J, Hardy J, et al. A structured framework improves clinical patient assessment and nontechnical skills of early career emergency nurses: A pre-post study using full immersion simulation. J Clin Nurs. 2016;25(15-16):2262-74.
  2. Munroe B, Curtis K, Buckley T, Lewis M, Atkins L. Optimising implementation of a patient-assessment framework for emergency nurses: A mixed-method study. Journal of Clinical Nursing. Under review.
  3. Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science. 2011;6:42.

Biography:

Belinda works a Clinical Nurse Consultant for the Emergency Departments across the Illawarra Shoalhaven. She completed her PhD in 2016, which included validating the first emergency nursing assessment tool internationally. Belinda also holds a peer nominated board position with the College of Emergency Nursing Australasia NSW, and is a Clinical Senior Lecturer at Sydney Nursing School.

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