A 5-year cross-specialty collaboration to reduce the pressure on hospital emergency beds in the Emergency Medicine Ward (EMW) of a regional emergency department in Hong Kong

Mr Edward Hong1, Dr Jeffrey Fung1, Dr SM Lam2, Ms Kat Wong2
1Department of Accident and Emergency, Tuen Mun Hospital, Hospital Authority, Hong Kong, 2Department of Child and Adolescent Psychiatry, Castle Peak Hospital, Hospital Authority, Hong Kong

Introduction: EMW of emergency department (ED) in Hong Kong provides a platform for multi-disciplinary and cross-specialty collaboration in managing selected acute conditions. The pressure on those emergency hospital beds is markedly increased during winter surge period in Tuen Mun Hospital. Child and adolescent (C&A) psychiatric patients admitted into EMW have a longer length of hospital stay due to limited in-patient consultation sessions. Nurse management need to explore the solutions to tackle this issue without any additional resources.

  1. Shortening waiting time for in-patient C&A psychiatric consultation in EMW
  2. Enhancing bed utilization in EMW so as to reserve more beds for emergency admission
  3. Reducing burden on the short-supplied interview room facilities at EMW

Methodology: Through workflow reengineering by nursing and medical management both in EMW and C&A Psychiatry (CAP), a series of kaizen programs have implemented from 2012 to 2017.

  1. To increase in-patient consultation quotas by means of extra sessions after long holidays/long weekends.
  2. To decrease C&A psychiatric patients’ length of stay in EMW by bed overflow management between EMW and CAP.
  3. To minimize in-patient consultation demands from ED and EMW by early discharge of those stable C&A psychiatric patients with adequate social support and arranging early out-patient follow up by CAP.

Results: Under no additional resources situation, extra in-patient C&A psychiatric consultation sessions are added on 42% of the first working days that followed public holidays/long weekends from 2012 to 2017 to shorten the waiting time effectively. With the bed overflow arrangement during the winter surge periods from 2015 to 2017, 10 bed-days per month are successfully reserved for improving the overcrowding situation in EMW.

Conclusion: For the past 5 years, nurse management has taken up an effective role in this cross-specialty re-engineering collaborative program to reduce the pressure on hospital emergency beds.

Mr. Edward Hong received his nursing bachelor’s degree and his master’s degree in “Management in Health and Social Care” both in Oxford Brookes University.
He has worked for Hospital Authority in Hong Kong for over 30 years and he is responsible for the efficient administration of all activities relating to Emergency Medicine Ward in Tuen Mun Hospital and he has been appointed as Ward Manager since 2012. He is also being appointed as an Honorary Tutor in the School of Nursing in the University of Hong Kong since 2014.


Dr Natasha Jennings1, Ms Claire Hatherley1, Ms Rachel Cross1, Dr Grainne Lowe1, Dr Gerard O’Reilly1, Dr Dev Mitra1, Dr Paul Jennings2
1The Alfred, Prahran, Australia, 2Ambulance Victoria, Geelong, Australia

BACKGROUND. Nurse led analgesia programs are safe and effective in reducing time to analgesia and improving 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 the 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 for 12 months post intervention. 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. Preliminary data at 3, 6 and 9 months demonstrated significant reduction of time to analgesia and improved documentation of pain scores. The final results will be available for presentation at Research week.
DISCUSSION. Pain protocols improve the frequency, accuracy and documentation of pain assessment and treatment efficiency. Translational research is key to implementation of these findings into direct clinical nursing practice, reducing the gap between research and patient outcomes.  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.

Tash and Claire are emergency nurses that  have implemented and championed nurse initiated protocols at the Alfred Emergency and Trauma Centre.

Departmental Delphi assessment of audit and research priorities

Miss Anna  Carison1
1The Royal Children’s Hospital, Melbourne, Parkville, Australia

Objective: Quality improvement initiatives and research projects in the ED can be time and resource consuming, making it important for staff to prioritise these activities for maximum buy-in and implementation into practice. Ideally this is assessed across craft groups.
Methods: 2 stage Delphi survey of senior emergency medical, nursing and allied health staff at a tertiary level dedicated paediatric ED (Royal Children’s Hospital, Vic, annual census of 90,000 children, 150 nurses and >50 medical staff). Stage 1 was a survey of audit and research topics, and stage 2 was a Likert priority ranking of the most frequently listed topics. These topics will be ranked according to feasibility and impact using a modified Hanlon process.
Results: Of 95 senior ED staff, an estimated 85 were available during the study period and 71 (83%) responded to part 1 and at the time of abstract submission, 33 (39%) have responded to part 2. The survey yielded 17 audit topics and 14 research questions. The top priority audit topics were 1. Length of stay of patients with mental health issues and reasons for delayed review / discharge, 2. Impact of the rapid assessment team on ED flow, 3. Response time to specialist referrals; research topics were 1. Intravenous management of asthma, 2.  Fluid management in sepsis 3. Management and treatment challenges of children and adolescents with autism spectrum disorder.
Conclusion: A departmental Delphi process has provided audit and research priorities that are of departmental importance rather than based on individual interests. This process of identification of audit and research topics may also increase staff interest and participation and may improve the translation of findings into practice.

Anna has worked in the Emergency Department at the Royal Children’s Hospital for 10 years and was endorsed as a Nurse Practitioner in 2014. She has been involved in several quality improvement initiatives in her clinical area and is particularly interested in exploring the audit and research priorities of ED staff, with the aim to increase staff interest, participation and hopefully translation of findings into practice.


Human Factor Training for high fidelity teams within the Emergency Department

Miss Tanya Boghikian1
1Western Health, Footscray, Australia

Non-clinical human factor skills are currently assumed to be naturally acquired with experience through professional maturation. Training is focused on the clinical components of patient care, however no formal training currently exists for emergency department staff to equip clinicians with the non-clinical skills that allow for cohesive teamwork in a high stress environment. Adverse individual interactions within the team have been proven to profoundly affect patient outcomes. Evidence suggests that poor professional exchanges – conflict, power struggles, poor communication and deficient leadership – lead to harmful outcomes. Couple these components with a high stress and time poor emergency department the risk increases considerably. Human factor skills training, encompasses teaching core communication, leadership and followship role clarity, repetitive simulation with collaborative team training, as well as familiarity with practice environment and orientation to equipment.

My vision is to create a formal human factors training program for nursing staff in the emergency department. Having conducted needs assessment surveys amongst staff, key non-clinical skills that were not formally taught were identified. We have already commenced components of this training program in the form of in-situ simulation with key human factor objectives accompanying clinical objectives, communication training such as graded assertiveness, role clarity within the resuscitation team, activities to embed orientation to equipment and environment and individual practice reflection through regular shift debriefing.

Tanya has been a registered nurse for 8 years. Having had broad-based training across the acute specialties she has settled on a career in emergency nursing. Fascinated by the diverse patient population within emergency departments and the high fidelity environment in which the teams treat this patient cohort, she became interested in the human factor elements behind the clinical skill and how we can improve as a team ultimately to improve patient care. In her spare time, having completed a-month long hiking trip across Spain last year, Tanya enjoys training for further long distance hiking ventures to come.

A Nurse Practitioner Candidate’s Management of a Complex Forearm Wound – A Learning Experience

Ms Catherine Roberts1, Ms  Natasha  Jennings1, Mr John Thompson1,2
1Alfred Health , Melbourne, Australia, 2La Trobe University , Bundoora, Australia

After a long stint in health care management , Katie chose to return to the ‘front line’ and completed her MANP in 2014.  For the last 16 months Katie has worked as a Nurse Practitioner Candidate in the Alfred Emergency and Trauma Centre.

Patients with open wounds and injuries are a frequent presentation to Australian emergency departments. More often than not, these injuries are managed in the fast track areas of emergency departments or minor injury units. Such injuries can be managed by Nurse Practitioners, and in many cases the patient can be discharged home. A percentage of these patients, following assessment by a nurse practitioner, have more complex wound needs and may require appropriate specialist referral and admission.

This case study explores the management of a complex forearm wound, and the holistic care provided by the nurse practitioner candidate. The nurse practitioner candidate learnings included advanced knowledge of anatomical and functional limb assessment of upper limb injuries. Importantly, the case highlights not only the provision of timely , quality care but the transition from emergency nurse to emergency nurse practitioner candidate.

Katie has had greater than 25 years emergency nursing experience in a number of public and private hospitals both interstate and in Victoria.

Better simulation by design: A best-practice in simulation framework for use in ED nurse education

Elicia Kunst1, Professor Amanda Henderson2, Dr Amy Johnston3
1Southern Cross University, Bilinga, Australia, 2Princess Alexander Hospital , Brisbane, Australia, 3The University of Queensland, Brisbane, Australia

Simulation education has been widely incorporated in nursing education, in Australia and internationally. Simulation is valued because it allows the development of skills and knowledge in a safe, supported environment, with minimal risk to consumers or learners. Simulation is also valued professionally because of its reliability in meeting learning outcomes. It can deliver highly reproducible clinical experiences, as well as providing access to uncommonly encountered experiences, like critical events. When structured as a dynamic learner-centred activity, simulation can trigger reflective practice. Such outcomes of simulation are not automatic. Simulations need to be carefully constructed, including scaffolding using appropriate pedagogy, and developing authentic and realistic scenarios.  The use of a quality framework and a consistent approach to high-quality debriefing at the conclusion of the simulation experience can improve learning outcomes and ensure that ED clinical staff are exposed to evidence-based high-quality learning experiences.

However, it can be challenging and time-consuming to develop effective learning experiences in the busy ED clinical environment. Preparation is an important aspect of the development and implementation of high-quality and high-impact simulation, and to ensure consistency in nurse education. To improve this process, a comprehensive best practice framework, based upon international and Australian quality simulation guidelines (1,2,3), has been developed and evaluated by nurse educators.

This presentation will explain and highlight the key components of a framework for quality in simulation design and implementation, which can be used to scaffold the development of new scenarios, or evaluate and improve the quality of existing simulation activities in ED nurse education.

  1. Arthur, C., Levett-Jones, T. & Kable, A. (2013) ‘Quality indicators for the design and implementation of simulation experiences: A Delphi study’, Nurse Education Today 33, 1357–1361.
  2. INACSL Standards Committee (2016). INACSL standards of best practice. Clinical Simulation in Nursing, 12(S), S21-S25.
  3. Kelly, M. A., et al (2016). OSCE best practice guidelines—applicability for nursing simulations. Advances in Simulation, 1(1), 10.

Elicia Kunst is a nursing lecturer and emergency department nurse, who is currently undertaking a PhD investigating the use of simulation in nurse education


Ms Inaam Safatly1, Dr Hugh  Singleton1, Ms Kelly  Decker1, Ms Cristina Roman1, Dr Adam Bystrzycki1, Professor Biswadev Mitra1
1Emergency and Trauma Centre, The Alfred, Melbourne, Australia

Introduction:  In clinical practice warfarin is a challenging medication to manage due to its narrow therapeutic index and potential for many significant medication interactions.  Numerous international healthcare systems have developed appropriate guidelines to improve the safe use of warfarin.  However, despite these guidelines adverse events to warfarin are common.
Aim:  To evaluate the efficacy of an educational program focused at improving emergency clinician compliance with the Thrombosis and Haemostasis Society of Australia and New Zealand (THANZ) evidence-based guidelines for management of patients that presented to the Emergency Department (ED) with supratherapeutic INR levels. Supratherapeutic INRs, especially those exceeding 4.5, are associated with increased risk of haemorrhage.
Methods:  A pre and post intervention cohort study was conducted. The intervention involved the development and delivery of an educational program in accordance with the current THANZ guidelines. Retrospective data from 1 July 2014 to 30 June 2015 and prospective data 1 Jan 2016 to 31 Dec 2016 were collected on ED patients currently anticoagulated with warfarin. This study was conducted in a large tertiary care hospital in Melbourne, Australia where subjects included all consecutive patients in the study periods that presented to the ED with an initial INR result of >4.5 on warfarin only. Subjects managed by an admitted team or anticoagulated with direct oral anticoagulants were excluded. Data collection included baseline demographics, medical history, INR results, bleeding risk assessment, the presence of active bleeding, and administration of fresh frozen plasma, prothrombinex and vitamin K.
Results: Data on 158 patients with an INR >4.5 were collected. Of these, data on 46 patients were excluded. Overall management in 31 (27.7%) patients did not follow recommended guidelines. There was no difference detected between pre and post groups with 17 (28.3%) compliant with guidelines pre-intervention and 14(26.9%) post intervention; p=0.87.
Conclusion:  Emergency department management of patients on warfarin with supratherapeutic INR’s requires continual quality improvement. Frequency of emergency clinician compliance with the current evidence-based guidelines was moderate and did not improve significantly with targeted education. This highlights the complexities of warfarin management and the need for multi-disciplinary engagement of patients presenting with supratherapeutic INRs.

Inaam Safatly is a registered nurse currently working in the Emergency and Trauma Centre of The Alfred Hospital.  As a novice researcher, Inaam saw the opportunity of undertaking a department quality project with numerous senior multidisciplinary staff as a learning opportunity.

Reducing medication administration errors: What’s out there for emergency department nurses?

Mrs Tracey Millichamp1, Dr Amy N.B. Johnston2,3
1PhD Candidate, School of Nursing, Midwifery and Social Work, University of Queensland, 2Department of Emergency Medicine, Princess Alexandria Hospital   , Wooloongabba, Australia, 3School of Nursing, Midwifery and Social Work The University of Queensland, Wooloongabba, Australia, 4Clinical Nurse Consultant, Redland Emergency Department, Metro South Health, Australia

Medications, as a frequently used treatment modality, are associated with a higher incidence of adverse events than other interventions and they remain one of the most common causes of accidental harm to health consumers.¹ It is estimated that 5-10% of all medications administered to a patient in an acute setting will include some form of medication administration error.²  Some evidence suggests this rate is particularly high during unplanned hospital admissions, such as emergency department (ED) presentations, perhaps associated with concomitant factors including increased use of high-risk medications, patient acuity and the high rate of patient turnover.¹˒² This scoping review explores medication safety initiatives in emergency settings and their applicability to reducing medication administration errors in the ED nursing environment.  It examines and synthesises current research, maps key concepts and identifies gaps in the literature. Five databases, CINAHL, MEDLINE, ERIC, PUBMED and EMBASE, were interrogated using search terms such as medication administration, medication error and medication safety. The outputs were combined, duplicates removed, titles and then abstracts scanned independently by two authors for relevance. Data extraction and synthesis is presented in a tabulated form including a quality assessment of each study. Generally there is a paucity of studies related to effective ED interventions and the level of evidence is medium to poor. The authors will present the results, a synthesis of the data and review the utility of the studies for ED nursing care delivery.

  1. Australian Commission on Safety and Quality in Healthcare (2013) Literature review: Medication safety in Australia, ACSQH, Sydney.
  2. Roughead, E Semple, S & Rosefield, E (2016) The extent of medication errors and adverse drug reactions throughout the patient journey in acute care in Australia. International Journal of Evidenced Based Healthcare, 14(3): 113-122.

Tracey is a Clinical Nurse Consultant at Redland Hospital emergency department in Queensland.

Who Stole The Sharps Bin? Reducing waste from the Emergency Department: A recycling process for contaminated and non-contaminated waste

Ms Cherylynn Mcgurgan1, Ms Susan  Harding, Ms  Elizabeth Bradbury
1Royal Melbourne Hospital City Campus, Moonee Ponds, Australia

The Royal Melbourne Hospital Emergency Department (RMH ED) is an acute tertiary trauma centre which manages around 78,000 presentations per year.  Emergency Departments are busy, noisy, fast paced environments with many tasks, procedures and lifesaving events being performed by teams simultaneously.

The Royal Melbourne Hospital ED’s project aim is progressively working towards environmentally sustainable practices.  Early 2018 the Nursing and Midwifery Board of Australia (NMBA) adopted the International Council of Nurses Code of Ethics. This code encourages nurses to address environmental issues as they play a pivotal role in reducing waste in our clinical environment which impacts on health and wellbeing.

Two years ago the Central Sterile Store Department (CSSD) ceased to re-sterilise a number of everyday items. This resulted in individual departments implementing single use instruments and drape packs. Initially all single use instruments were disposed of in the infectious waste sharps bin but it was soon realised that this had a negative impact on cost and was not a sustainable, financial process.

A small team of environmentally conscious staff formed the Emergency Department Green Team with the aim of implementing sustainable changes to combat the enormous waste created when we changed to single patient use items.  Initially staff participated in a `Survey Monkey’ which identified their limited to no existent knowledge on waste segregation and its impact on the environment. The RMH ED currently participates in a number of waste reduction strategies which include

–              The Little Blue towel program

–              Disposable metal  Instrument recycling

–              The introduction of disposable / 100% recyclable curtains

–              Changeover from polystyrene to recyclable paper cups

–              Co-mingle bins

–              Promotion of paper bedsheets in fast track areas

This poster aims to articulate the importance of providing quality patient care with an environmental friendly focus on sustainable practices.

Clinical Nurse Specialist and Equipment Nurse in the Emergency Department of the Royal Melbourne Hospital .

Who let the dogs in?

Mrs Elizabeth Bradbury1, Ms Susan Harding1, Ms Cherylynn McGurgan1
1Melbourne Health, Parkville, Australia

The Royal Melbourne Hospital (RMH) is a state-wide trauma service seeing around 78,000 presentations annually. The Emergency Department (ED) management team recognises staff as our greatest asset and chose to invest in `Caring for the Carers’ by developing a wellbeing program which aligned strongly with our organisational vision to be `First In Care’ and an employer of choice.

2018 marked our commitment to improve staff wellbeing by continuing to promote Compassion Fatigue Workshops, introducing Peer Support and Preceptorship Programs and our innovative Dog Program.

In January 2018 our Dog Program, was trialled for 4 months at two days per week in our non-clinical space. The overwhelmingly positive response resulted in Monday – Friday implementation.

The RMH ED has had international and national interest through Facebook and Channel 9 news coverage.  The most pleasing feedback however has come from our own staff when surveyed. Questions included:

Do you think that staff morale has improved since the introduction of the Dog Program: Yes: 87%

Have you noticed a reduction in personal stress since the introduction of the Dog Program: Yes: 64%

Do you believe the Dog Program has improved interpersonal relationships within the ED? Yes: 79%

  • “It’s one of the best staff wellbeing strategies to be introduced. You could be having the shift from hell and coming upstairs to the dogs just takes so much stress away!”
  • “Love! Can and has made a bad day great!”
  • “Great initiative! The dog program has definitely made our workplace a lot more enjoyable and puts a smile on our face.”


RMH ED acknowledges that our Wellbeing programs, including our Dog Program do not eliminate the volume, acuity and stress related to Emergency nursing. However we believe that our innovative approach has enriched our workplace culture and improved staff retention.

Liz Bradbury has over 30 years of emergency nursing experience. After completing her Post Graduate Emergency Nursing Certificate and a Diploma in Business, has progressed through CNS and ANUM roles and is currently the Clinical Nurse Manager in the Emergency Department at the Royal Melbourne Hospital. Liz has dedicated years building teams and supportive environments to enhance the professional growth and development of her staff. Liz has long advocated for a greater focus on wellbeing for Emergency Department nursing staff  to support mental health, address the impact of occupational violence and aggression (OVA) and  identify enablers for longevity in the emergency nursing role. Liz has been involved in promoting and supporting departmental wellbeing tools to minimize impact of emergency trauma, Occupational Violence and Aggression (OVA) and aims for RMH ED to be recognised as an Employer of Choice