Understanding Practice: the factors that influence management of mild traumatic brain injury in the emergency department – a qualitative study using the Theoretical Domains Framework

Emma J Tavender, Marije Bosch, Russell L Gruen, et al

Aim/Abstract: Mild traumatic brain injury is a frequent cause of presentation to emergency departments. Despite the availability of clinical practice guidelines in this area, there is variation in practice. One of the aims of the Neurotrauma Evidence Translation program is to develop and evaluate a targeted, theory- and evidence-informed intervention to improve the management of mild traumatic brain injury in Australian emergency departments. This study is the first step in the intervention development process and uses the Theoretical Domains Framework to explore the factors perceived to influence the uptake of four key evidence-based recommended practices for managing mild traumatic brain injury.

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Improving the care of people with traumatic brain injury through the Neurotrauma Evidence Translation (NET) program: protocol for a program of research

Sally E Green, Marije Bosch, Joanne E McKenzie et al

Aim/Abstract: The Neurotrauma Evidence Translation (NET) program was funded in 2009 to increase the uptake of research evidence in the clinical care of patients who have sustained traumatic brain injury. This paper reports the rationale and plan for this five-year knowledge translation research program. The overarching aims of the program are threefold: to improve outcomes for people with traumatic brain injury; to create a network of neurotrauma clinicians and researchers with expertise in knowledge translation and evidence-based practice; and to contribute knowledge to the field of knowledge translation research. The program comprises a series of interlinked projects spanning varying clinical environments and disciplines relevant to neurotrauma, anchored within four themes representing core knowledge translation activities: reviewing research evidence; understanding practice; developing and testing interventions for practice change; and building capacity for knowledge translation in neurotrauma. The program uses a range of different methods and study designs, including: an evidence fellowship program; conduct of and training in systematic reviews; mixed method study designs to describe and understand factors that influence current practices (e.g., semi-structured interviews and surveys); theory-based methods to develop targeted interventions aiming to change practice; a cluster randomised trial to test the effectiveness of a targeted theory informed intervention; stakeholder involvement activities; and knowledge translation events such as consensus conferences

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The Psychology of Influence

Peter Anthony

Influence begins with every breath you take, and every conversation you make. This is particularly crucial in emergency and critical care environments where every communication moment is crucial. Mindful communication not only gives you more influence, but increases your compassion too – not just for your patients but for yourself. You will learn from the latest research how to create more influence through more mindfulness. The key topics we will discuss in emergency nursing environments will be:

  • Mindful influence moment by moment
  • What Mindset to master to encourage two way communication
  • Keys to conversational influence



Peter Anthony is a Director at Thriive where he helps health professionals develop their influencing skills to achieve patient outcomes. He was formerly Associate Director of Executive Education at Australian Catholic University.He has a Masters in Communication and has run workshops on influence and positive coaching in 12 countries over 16 years. His book ‘Influence People’ describes a six step approach to having a collaborative conversation that leaves both people better off. Peter has developed a specialty in helping nurses achieve patient outcomes by using practical approaches from the positive psychology toolkit.
In Peter’s plenary session – The Psychology of Influence – He will highlight the latest learnings from positive psychology for emergency nurses with a focus on how to deal with stress and influence patients.

Rapid rule out of acute coronary syndrome (ACS)

Erin O’Callaghan1, Marianne Griffen1

1 Emergency Clinical Care Network, Melbourne VIC

Assessment of risk is part of the chest pain assessment process within Emergency Departments. In 2016, the National Heart Foundation and Cardiac Society released guidelines advising that selected patients requiring rule out of Acute Coronary Syndrome in the Emergency Department can have a shorter assessment process. This project aimed to provide Emergency Departments across Victoria with guidance about how to combine clinical risk stratification, ECG and troponin testing; along with structure on how to guide patient management in a clear clinical pathway documentation process.

Background: The Emergency Care Clinical Network actively engages with emergency clinicians in creating and building sustainable improvements and innovation in the delivery of emergency care in Victoria. A key focus is to enhance the use of evidence-based care to reduce variation in clinical practise and improve patient care. Within this project: patients were considered eligible for the rapid rule out pathway if they had no high risk features, a modified TIMI score of 0 or 1, depending on the troponin assay used and a normal or unchanged ECG. Implementation of rapid rule out Acute Coronary Syndrome pathway for eligible patients would be in parallel with ‘standard’ practice for other patients.

Results: In 2016, a similar project was conducted; the median change in length of stay for the rapid rule out group over nine months was 96 minutes. The median change in length of stay was 58 minutes. This year the project aims to build on those, with results due November 2017.

Findings: The rapid rule out pathway reduced the average length of stay for patients in the Emergency Department using evidence based practice to guide clinicians. Extended benefits included clear discharge planning and patient education which improved patient centred care.

Summary: Implementation of the rapid rule out pathway in the Emergency Department enhances patient care by reducing variation in clinical practice based on evidence resulting in reduced length of stay and improved patient centred care.


 Erin O’Callaghan is an Emergency Clinical Nurse Specialist and Associate Nurse Unit Manager. She works at a large tertiary Emergency Department (ED) and concurrently a smaller private ED in Melbourne. Erin also holds the position of  a Teaching Associate with Monash University.  Erin has a Master of Nursing (emergency). As part of this, Erin completed a research thesis titled ‘Compassion Fatigue in Emergency Nurses’ in 2015.  Erin has experience in homeless youth outreach and mental health case management. 
Erin is currently on secondment to Safer Care Victoria the Victorian Department of Health and Human Services, working within the Emergency Clinical Care Network (part of Safer Care Victoria). As a Senior Project Officer/ Nursing advisor. Erin’s role is to implement sustainable and innovative evidence based projects that reduce variation in clinical practice and improve quality of care across Victorian Emergency Departments.

Injury management skills (binders, splints, HFNP, eFast, xray)

Join us to hear about the science behind these and other interventions, and get hands on experience in this interactive workshop

Interventions that will be covered are some of those that can be lifesaving in all types of emergency environments: rural, regional, pre-hospital, during transport and in the major trauma centre

We will discuss the purpose of each of the following and learn to use correctly

  • pelvic binder (purpose and correct placement)
  • the CT6 traction splint
  • eFAST
  • chest and pelvis xrays
  • Quikclot
  • highflow nasal cannulae
  • soft (foam) and philadelphia collars

Facilitators: Alex Tzannes, Rochelle Cummins

Rochelle has worked in ED for almost 10 years, 8 of which have been at SGH. For the past 5 years she has worked in the ED educator roles and currently is acting in the CNC role. She works closely with the Trauma service at SGH and have a passion for providing high quality patient care to all patient’s in the ED.

The trends and characteristics of older people presenting with mental health or drug and alcohol conditions to four emergency departments

Prof. Margaret Fry1,2, Mr Steven Kay2, Dr Rosalind Elliott1,2

1University Of Technology Sydney, Broadway, Australia, 2Northern Sydney Local Health District, St Leonards, Australia

Introduction: The incidence of older people with mental health and/or drug and alcohol conditions is on the rise.  It has been estimated that older people with mental health and/or drug and alcohol conditions will double by 2020.  Emergency Departments (ED) need to be alert to the needs of this cohort. Therefore, the aim of this study was to explore trends and characteristics of older people with mental health and/or drug and alcohol conditions presenting to ED.

Methods: A 12 month retrospective medical record audit was conducted of presentations by older people (aged 65 years and over) with mental health and/or drug and alcohol conditions. The study was conducted in four Sydney EDs; one university tertiary referral hospital and three district Hospitals.

Results: There were 40,093 presentations during the study period; 2.3% (n=900) were related to mental health or drug and alcohol related conditions. The majority were female (n=471, 52.3%) with a mean age of 79 years and more than half arrived by ambulance. Diagnoses related to cognitive impairment (n=234, 26%), affective disorders (n=233, 26.0%), chronic mental health conditions (n=91, 10.1%) and aggression (n=86, 9.6%). Alcohol related (n=120, 13.3%) conditions or medication overdose (n=81, 9.0%) were more common than suicide related presentations (n=55, 6.1%). There was no documentation of completed suicide. Sixty-three per cent were admitted as an inpatient, with a seen by time of 36 minutes (mean) and a length of stay of 6 hours 21 minutes (mean).

Conclusion: Given our ageing population, early recognition and appropriate assessment will assist in better outcomes and management, reduce disease burden and improve overall quality of life for older people of this patient group.


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. Her program of research has led to significant state and national practice change. She was awarded Australasian emergency nurse of the year in 2005 and St George Hospital nurse of the year in 2001 and was a finalist in 2014 Nursing Excellence Awards for ‘Innovation in Research”. Professor Fry has also been awarded NSW Heath Care awards for innovative research making a difference for practice.

Implementation, evaluation and refinement of an intervention to improve blunt chest injury management

Prof. Kate Curtis1,2,6, Dr Connie Van1, A/Prof Stephen Asha2,5, Dr Mary Lam3, Dr Annalise Unsworth2, Dr Louise Atkin5, Dr Madison Reynolds6

1Sydney Nursing School, Sydney, Australia, 2St George Clinical School, Faculty of Medicine, University of New South Wales, High Street, , Kensington, Australia, 3Faculty of Health Psychology, Health Information Management, Genetic/Bioinformatics. University of Technology, Sydney, Australia, 4Centre for Behaviour Change, University College London, London, England, 5Emergency Department, St George Hospital, Kogarah, Australia, 6Trauma Service, St George Hospital, Kogarah, Australia

Failure to treat even one rib fracture early with sufficient analgesia, physiotherapy and respiratory support can lead to pneumonia, respiratory failure and/or death. Introduction of an early notification protocol for isolated blunt chest injured patients (ChIP) in our major trauma centre initiated consistent, multidisciplinary, tailored patient care that reduced the odds of patients developing pneumonia by 56%. The overall uptake of the protocol however was poor (68%) and factors which hindered or helped activation unknown.


– To determine factors influencing protocol uptake

– Identify evidence informed interventions to improve protocol use

– Re-implement and evaluate protocol compliance

Methods: Two methods were used in this mixed methods study conducted from 2012-2016.

1) Review of 603 linked trauma registry and medical records to identify any patient characteristics influencing protocol activation, and

2) Survey of 99 hospital staff to identify implementation barriers and facilitators. The survey was mapped to the Theoretical Domains Framework (TDF), known to impact clinician behaviour change.

Quantitative data were analysed using descriptive statistics, qualitative data coded in NVivo10.  Interventions to change target behaviours were sourced from the Behaviour Change Technique Taxonomy in consultation with stakeholders.

Principle findings: Eligible patients who did not receive ChIP were not different in demographic or clinical characteristics to those that did. Fifteen facilitators and 10 barriers were identified by staff. Seven interventions were selected to address target behaviours including modelling, training, persuasion and social influence. A multifaceted relaunch strategy, including video, targeted the motivation of activators and responders and the empowerment of nursing staff. In the 4 months post relaunch, uptake improved to 91% (p=.001).

Conclusions: Behaviour change theory may be used to improve clinical protocol implementation in the ED context. Newly implemented clinical protocols should incorporate clinician behaviour change assessment, strategy and interventions.


Kate has been an emergency and trauma nurse clinician since 1994 and is Professor of Trauma and Emergency Nursing at the University of Sydney, where she leads the Paediatric Critical Injury Research Program. She is an honorary Professorial Fellow at the George Institute for Global Health and in 2011 was awarded the Frank McDermott Award for research completed and published in the last 10 years judged to have led to the greatest improvements in care of severely injured patients in Australia and NZ. Kate’s translational research program continues to focus on improving the way we deliver care to patients and their families and she is the world’s most published author in the field of Trauma and Emergency Nursing. Kate is also on the Editorial Board of the Australasian Journal of Emergency Nursing and a Fellow of the College of Emergency Nursing Australasia.

CREDIT: Cannulation Rates in the Emergency Department Intervention Trial. Improving patient care through the reduction of unnecessary cannula insertion in the Emergency Department

Ms Tracey Hawkins1, Dr Jaimi Greenslade1,2, Ms Maria Donohue3, Mr Matt Jensen, Dr  Julian  Williams1, Prof  Louise  Cullen1,2

1Queensland Health, Herston, Australia, 2University of Queensland, Brisbane, Australia, 3Griffith University, Nathan, Australia

Aim: Peripheral intravenous cannula (PIVC) are commonly placed in the emergency department (ED) and are often unused. Reducing unused cannula is important because inserting PIVC takes time, costs money and places the patient at risk for pain and infection. The aim of this study was examine whether a multi-modal education program could reduce PIVC placement in the ED.

Methods and Results: A prospective historical-case controlled study and cost analysis was conducted in a single tertiary ED in Brisbane, Australia. Patients were excluded if they were triage category one, had a PIVC inserted by ambulance services or transferred from another hospital.  Over a three month period, a multi-modal intervention including information sessions, posters, educational material, and change champions was implemented. PIVC placement and utilisation within 24 hours were evaluated for all eligible patients. A total of 4,173 participants were included in the analysis. PIVC were placed in 42.14% of patient pre-intervention and 32.38% post-intervention, a reduction of 9.76% (95% CI: -12.72 to -6.80%). PIVC usage within 24 hours of admission was 70.51% pre-intervention and 83.41% post-intervention, an increase of 12.86% (95% CI: 8.71-17.01%). Sixty-six patients were observed in the ED for cost analysis. The mean time per PIVC insertion was 15.2 ± 9.6 minutes. PIVC insertion cost including staff time and consumables per participant was $22.80.  Based on an observed 7.1% reduction the intervention resulted in a saving of $4,718 over the study period. If applied to all Australian EDs, an annual saving of $13.7 million could result.

Conclusion: The intervention reduced PIVC placement in the ED and increased use of those placed.  This program benefits patients and health services alike, with potential for large cost savings. This initiative has been selected as part of the “Choosing Wisely” campaign to continue the translation and implementation of the CREDIT program


Tracey Hawkins is a Registered Emergency Nurse who has been with the Emergency Research Group since its inception in 2008. She is a passionate clinician and research nurse, working in a dual role position combining her clinical role with her interest in clinically relevant research.  Tracey leads the departmental research nurse team providing the public face for patient recruitment, managing the behind-the-scenes responsibilities such as data collation and sample management.

Tracey started her nursing career in 1992 at the Central Queensland University Rockhampton and, after several years in infectious diseases and high dependency units at the Royal Brisbane and Women’s Hospital she headed to the UK where she worked as an emergency nurse for four years. On her return, she worked in rural and remote hospitals across Queensland.  Returning to the Department of Emergency Medicine at RBWH in 2001 and completing post graduate studies. She resides in Moreton Bay with her husband and two children.

Implementing clinical practice change in the Emergency Department for sepsis and fractured neck of femur; the good, the bad and the ugly of trying to change clinicians practice

Ms Julie Gawthorne1

1St Vincents Hospital, Sydney, Australia

Aim: Implementing clinical practice changes in Emergency Departments (ED’s) can be challenging. This paper aims to discuss how one ED implemented changes to improve the management of sepsis and fracture neck of femurs (NOF’s). It will discuss the fundamental drivers that lead to sustainable clinical improvements and improved patient outcomes

Background: The mortality rate for severe sepsis is 25%. Fractured NOF is the leading cause of morbidity and mortality in elderly patients.

Despite evidence, it is acknowledged that translating evidence into clinical practice is slow and the gap between what we know and what we do remains. Clinical practice guidelines take up to three years to  implemente and require time, skill, and resources.

Implementation: The ED joined Clinical Excellence Commission (CEC) ‘sepsis kills’ program that aimed to improve sepsis recognition and reduce time to antibiotics for septic patients .

The fracture NOF project aimed to developed evidence based pain management guidelines that included nurse initiated FIB’s .

Multidisciplinary working parties focused on delivering patient centred care through developing evidenced based guidelines, education packages, auditing tools and implementation plans.

Results: Sepsis recognition improved from 67% to 90% Time to antibiotics decreased from 103 to 43 minutes. Patients receiving antibiotic within 60 minutes increased from 28% to 80% These improvements have been maintained for over three years.

FIBs insertion increased from 2% to 80%. Up to 50% of all FIB’s were inserted by nursing staff. Delirium rates decreased from 44% to 33%. Hospital length of stay decreased from 13 to 10 days.

Conclusion: Despite evidence, changing clinical practice in the ED is challenging. Engaging clinicians, time constraints, clinical priorities, and limited resources all contribute significantly on the ability of ED’s to successfully implement change. The ED has shown that strong clinical lead leadership focusing on patient centred care ultimately improves patient outcomes.


Julie is the Clinical Nurse Consultant in Emergency at St Vincent’s Hospital, Sydney.  She started her emergency nursing career at St Vincent’s Hospital in 1995. Since then Julie has worked in London and a number of Sydney ED’s before returning to St Vincent’s as the CNC in 2004.

She has also worked in Tanzania and Sudan with Medicines San Frontier

Julie has a Master’s in Nursing in Critical Care, is a Clinical Fellow at the Australian Catholic University, and is a member of the St Vincent’s Hospital Nursing Leadership Team.