The Melbourne Mobile Stroke Unit providing pre-hospital stroke care

Background:
Stroke patients benefit from early intervention. The Melbourne Mobile Stroke Unit (MSU) is the first pre-hospital stroke service in Australia. The MSU has an integrated on-board CT scanner and carries both acute stroke and ambulance personnel. The MSU aims to improve pre-hospital stroke triage, reduce the time to stroke treatment and provide improved access to comprehensive stroke centres through immediate on-site access to specialised staff and multimodal CT imaging.

Methods:
Data, including time metrics, were prospectively collected on all MSU dispatches, and compared to national standards.

Results:
The MSU launched on 20th November 2017 and operates within a 20km radius of The Royal Melbourne Hospital, Australia, delivering patients to 8 primary and comprehensive stroke centres across the city. In the first 6 months of operation, the MSU was dispatched to 604 code stroke calls. 264 (44%) cases were attended, while 340 (56%) were cancelled pre-MSU arrival after an initial paramedic assessment. Of attended calls, 132 patients (50%) received a non-contrast CT scan and 68 (26%) received a Circle of Willis CT angiogram. The MSU delivered pre-hospital thrombolysis to 27 patients (39% of ischaemic stroke<4.5 hours); median scene-to-CT time 21 min, scene-to-needle 42 mins and onset-to-needle 108 mins were substantially faster than the Australian average of 27 min, 72 mins and 156 mins respectively. Additional MSU treatment included anticoagulation reversal (4 patients), blood pressure reduction (10 patients), seizure management (1 patient) and clinical trial enrolment for both haemorrhagic and ischaemic stroke (8 patients). The MSU has reduced inter-hospital transfers by diagnosing large vessel occlusions and neurosurgery candidates in the pre-hospital setting on 27 occasions (19% all stroke patients), bypassing initial hospitals for specialist centres.

Conclusion:
The Melbourne MSU is achieving thrombolysis workflow consistent with comprehensive stroke centres. It has reduced onset-to-needle times and allowed additional patients to receive thrombolysis. Pre-hospital triage has removed transport delays from inter-hospital transfers.


Skye is a Nurse Practitioner and the Nursing Coordinator of the Melbourne Mobile Stroke Unit at The Royal Melbourne Hospital, Victoria. She has an extensive background in critical care nursing, holds a Master’s degree in nursing, and has completed 2 International stroke nursing courses, she is also the first Board Certified Advanced Neurovascular Practitioner in Australia. Skye is the co-chair of the Acute Stroke Nurses Education Network (ASNEN), an organisation dedicated to improving the delivery of evidence-based stroke care, education and networking opportunities for Australian stroke nurses. Her passion is improving hyperacute stroke care, stroke research and stroke education

Can a fridge magnet bleed? – adventures in mass casualty incident/novel health based exercises

A Very Bad Thing (VBT) has happened. Staff in the Emergency Department (and elsewhere in the hospital) are expected to respond and manage the VBT as they were trained and as detailed in their plans. Except these days it is difficult to find the time to train staff and anyway the plans can be disconnected from the reality of the ED environment.
A fundamental tenet of all emergency management arrangements is the requirement to exercise plans, procedures and/or personnel to ensure that organisations and individuals are capable of responding to significant incidents.

Over the past 12 years Don Garlick has been responsible for developing and delivering exercises to test the response of staff and processes at a large regional hospital in Victoria. This presentation will explore the successes, pitfalls and failures of actual emergency management exercises, providing delegates with practical insights into:

  • Developing ‘normal business’ fire training to incorporate low frequency-high consequence emergencies
  • Delivering five hospital based large Mass Casualty Incident exercises
  • Using performance indicators to monitor performance across time and fuel improvements
  • The rewards of collaborating with emergency services and emergency management agencies at a local and regional level
  • Finding opportunities to provide hospital staff with unique health based exercises such as decontamination and VMAT deployment

Don Garlick is the Manager: Emergency Management for Ballarat Health Services. In this role Don is responsible for the planning, training, response and recovery arrangements for BHS; a large regional, multi-campus service with over 4000 employees and over 500 patient/residential beds. Don is part of the Victorian state-wide health based emergency management exercise and training faculty, represents CENA on the FEMO program, and is involved in local, regional and state-wide emergency management committees.
Don holds a Masters in Emergency Management (Distinction), Advanced Diplomas of Public Safety & Business Management, Graduate Diploma of Critical Care and Cert IV’s in Fire Technology, Training & Assessment, Work Health & Safety, Frontline Management and a Cert II in Firefighting Operations.
He continues to work part time as an ANUM at the Ballarat Base Hospital Emergency Department.
In his spare time, he is a 30-year veteran CFA volunteer firefighter in a busy urban brigade and because he was a bit bored, recently joined the Royal Australian Army Nursing Corp as a Reserve Nursing Officer.

#Goodvibes: Improving staff moral in the Emergency Department

Andrea Lazo1, Amelia Rich1, Amanda Riley1
1
Emergencey Department, Box Hill Hospital

#Goodvibes: Recognition of the little things, can mean big things for staff morale in the Emergency Department. The unique combination of conflicting priorities such as patient acuity, KPI’s and department expectations has been documented to leave staff feeling burnt out, exhausted and sometimes undervalued. This is where #GoodVibes comes in to make a change. This has occurred through acknowledging the actions, dedications and the little things we do for one another.

Clerical, nursing, medical, PSA’s, security, volunteers and ISS cleaning services have all been brought together through recognising each other’s efforts through regular peer “shout outs” to thank each other for their help and support. Since conception in 2016, there has been over 700 documented shout outs.

As a unified team, we all want the same goals and that is to provide the best quality health care and well-being to our patients. With recognition for our accomplishments from our peers, we are able to come together and create a collaborative and positive team. Our team work is reflected in our patient’s outcome, and our greatest desire to become the best health professionals we can be.

This straightforward, inexpensive model of peer support has been evidenced to be adapted to other areas of nursing. #GoodVibes has the potential to increase a positive work place culture in emergency departments across Australia.

Shout out to those that make your work place great. Shout out to your colleagues who you appreciate. Shout out to those who work tirelessly. Shout out to make someone smile.

A thematic analysis of good vibes communicates that actions most appreciated involve unique skill sets. These include escalation of deteriorating patient, deescalating aggression, willingness to assist with any activity and the show of friendship and support in any situation.

A small thanks can have a big impact.

Low investment, high returns, high staff retention rate.

#GVP


#GoodVibes is an initiative pioneered by Amelia Rich, Andrea Lazo and Amanda Riley since 2016 that has united staff in the Box Hill Emergency Department. This has occurred through acknowledging the actions, dedications and the little things staff do for one another. This leads to an increase in staff morale.

The authors of this presentation are Critical Care Registered Nurses who are highly dedicated to not only promoting a positive environment for patients and families, but also staff.
The idea for the project started on an ACEN cruise to Fiji where daily announcements were made and people on board could send a message to someone they knew. It had such a positive effect and everyone cheered when the announcements were heard. This led to the question – could they implement the idea in an emergency department? So they did, and here we are today.

Documented episodes of security presence in the clinical notes: a comparison with security records

Mrs Jill Duncan1, Mr Scott  Trudgett1, Dr Nathan Brown1,5, Mr James Hughes1,4, Dr David  Rosengren1,5, Dr Julia Crilly2,3
1Royal Brisbane and Womens Hosptal, Herston , Australia, 2Gold Coast Health, Qld , Australia, Southport, Gold Coast, Australia, 3Griffith University, Southport, Gold Coast, Australia, 4Queensland University of Technology, Kelvin Grove, Brisbane, Australia, 5University of Queensland, St Lucia, Brisbane, Australia

Background: Emergency departments (ED) are high risk settings for workplace violence (WPV). Almost half of the episodes of WPV in the ED are perpetrated by patients under the influence of substance misuse. A culture of underreporting of WPV exists in the ED. WPV has a significant impact, affecting staff, patients and visitors to healthcare settings. Communication of this risk is essential for the management of these patients and safety of all who enter the healthcare facility.
Aim: The aim of this study was to compare the documented presence of security in the clinical notes to security records to identify if reporting differences exist.
Methods: This retrospective observational study involved the analysis of ED data, security data and medical record data for alcohol-related patient presentations made to a level six tertiary referral ED in Queensland, Australia between April 2016 and August 2017. The documented security presence was compared between security records and ED records.
Results: Of the 680 alcohol-related ED presentations reviewed, there was considerable difference in reporting of security presence: 10.2 % reported in the security data, 3.4% reported in the clinical notes.
Conclusion: The limited documentation of WPV in the clinical notes has potential ramifications for members of the multi-disciplinary team in terms of risk management of these patients. Findings demonstrate a need to continue with organisationally supported strategies to minimise WPV and improve safety for staff and visitors to healthcare facilities.


Biography:
Jill is an experienced Registered Nurse who has worked across many specialities at many different levels. The last eight years of her career she has worked in the Emergency and Trauma Centre at the Royal Brisbane and Women’s Hospital. She is currently working in a Clinical Nurse Researcher position, exploring the impact of alcohol related presentations on the emergency department as part of a multisite study.

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

Adrienne Ling1
1Royal North Shore Hospital

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

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

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

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

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

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


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

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

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

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


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

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

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

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

Objectives:

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

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

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

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


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

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

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

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


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

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

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

Introduction

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

Objective:

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

Method:

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

Results:

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

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


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

 

Escalation of care for clinical deterioration in the ED

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

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

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

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

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

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


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

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