A randomised control trial: Improving analgesic administration time for the cognitively impaired older persons

Prof. Margaret Fry1,2, Professor Lynn Chenoweth3, Professor Glenn Arendts4

1University Of Technology Sydney, Broadway, Australia; 2Northern Sydney Local Health District, St Leonards, Australia; 3University of New South Wales, Randwick, Australia; 4University of Western Australia, Perth, Australia

Introduction: Unless pain is recognised and attended to early in the patient’s journey, inadequate and inappropriate pain relief for people with cognitive impairment may result in adverse events, hospital readmissions, increased functional decline, cognitive decline, behavioural changes and co-morbid mental illness.  The aim of the study was to measure the impact of an observational pain assessment tool on analgesic administration time for cognitively impaired patients in the Emergency Department (ED).

Methods: An 18-month multi-site cluster controlled randomised trial was conducted in eight Sydney EDs. Sites (n=4) were randomised to receive the intervention. The intervention tested was the Pain Assessment in Advanced Dementia (PAINAD) tool. For the intervention sites patients, aged 65 years or older, suspected of a long bone fracture and with a confirmed cognitive impairment were screened for pain using the PAINAD. The primary outcome was time to first dose of analgesia.

Results: We enrolled 602 patients with 323 (54%) recruited from intervention and 279 (46%) non-intervention sites respectively. The medium time to analgesia was 82 minutes (IQR 45-151 minutes); intervention sites 83 (IQR 48-158 minutes) and non-intervention 82 minutes (IQR 41-147 minutes) respectively (p=.414). ED analgesia was provided to 180 (30%) patients within 60 minutes of being triaged. After adjusting for age, fracture type, arrival mode and triage category in a Cox regression model, there was no significant difference in time to analgesia between the two groups (HR 0.97, 95% CI 0.80-1.17, p 0.74).

Conclusion: While there was a small clinical trend that suggests PAINAD may improve analgesic administration time, improving practice is more complicated than the introduction of a tool. While PAINAD is a reliable and valid tool, socio-cultural, organisational and role factors may have a greater impact on ED pain management practice.


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.

Time is precious (T.I.P), a fast track pathway for palliative care patients presenting to the Emergency Department

Mrs Daniela Vasquez1, Miss Lauren Deland2

1Liverpool Hospital, Sydney, Australia, 2Liverpool Hospital, Sydney, Australia

The focus of palliative care is on quality of life through symptom management, utilising a multi-disciplinary approach, whilst providing support to the carer and family. Though not oppositional to the ED process, there are gaps in the approaches to goals of care. Additionally, palliative patients may not be viewed as emergent presentations, resulting in prolonged lengths of stay associated with delays to medical review, initiation of inappropriate investigations or treatments, and delays to initiation of therapeutic medication administration, focussed nursing assessment and appropriate care.

Demand for palliative care services are rapidly increasing, with an increase of 24% of palliative patients presenting to Liverpool ED from 2015 – 2016. Along with a boom in population associated with housing and high residential developments in the LGA, it is expected that demand for services will continue to increase. This pathway aligns with the SWSLHD strategic plan for early identification, assessment and treatment of physical, psychological, socio-cultural and spiritual needs, active support and care, and bereavement services.

The TIP pathway allows for rapid identification of patients who are presenting at end of life, escalated medical review and streamlined care with the multi-disciplinary team to coordinate care based on the patient’s wishes. In built to this pathway is an educational package for medical and nursing staff and a resource pack with a checklist to guide the patient’s journey through the ED to either the ward for ongoing palliative management according to the Care Plan for the Dying Adult Patient, or home (private residence or RACF) with community palliative care or PEACH. The aim of the pathway is to reduce unnecessary delays to patient comfort, staff confidence in managing the patient at end of life, and provision of care to the patient according to their wishes, ‘cause you never get a second chance at dying.


Daniela- i have been working in liverpool hospital for 5 years. I started my nursing in 2007 began as a enrolled nurse working in geriatrics, psycho geriatrics, surgical & cardiology. I then started my new grad program at Liverpool hospital, my 1st rotation in emergency then my 2nd rotation in haemodialysis. I found my home in the ED. I enjoy the thrill the fast paced environment and being there to comfort patients at the weakest moments.

LAUREN- I studied at UOW did my new grad year at st Vincents private 1st rotation head/ neck oncology, plastics 2nd roation gastro/ vascular. Main interest was critical care so did a year rotation of critical care at Sutherland that included 4months ICU, 4 months CCU folowed by 4 months in emergency. This is when i knew emergency is where i wanted to be. I wanted more trauma experience so i made my way to Liverpool.

We lost a father and an uncle who both went through palliative care and this opened our eyes to what was missing. We identified a big gap and we realised that we wanted to make patients comfortable so together we developed the TIP pathway.

Childhood injury in Australia – a 10-year review of the characteristics and health outcomes of injury-related hospitalisations

Prof. Kate Curtis1, A/Prof Rebecca Mitchell2, Prof Kim Foster1,3

1Sydney Nursing School, Coledale, Australia, 2Australian Institute of Health Innovation, Macquarie University, Sydney, Australia, 3North Western Mental Health & School of Nursing, Midwifery & Paramedicine, Australian Catholic University, Melbourne, Australia

Background: Injury is the leading cause of death of children aged 1 to 16 years in Australia. Despite this enormous incidence and impact, there has been no comprehensive national examination of childhood injury characteristics and health outcomes in Australia.  This information is essential to quantify the childhood injury burden, resource planning and to identify and evaluate priorities for injury prevention.

Aim: To determine the incidence, characteristics and health outcomes of injury-related hospitalisations of children in Australia

Methods: A retrospective epidemiological analysis of injury-related hospitalisations involving children aged 16 years or less in Australia during the financial years 1 July 2002 to 30 June 2012 was conducted.  Linked hospitalisation and mortality records were used to describe the characteristics of injury hospitalisations.  Binomial regression was used to examine temporal trends and Cox proportional hazard regression was used to examine factors associated with 30-day and 12-month survival post injury.  Hospital treatment costs were also estimated.

Results: There were 686,409 injury-related hospitalisations and child injury hospitalisation rates have not decreased over a ten year period. For every severely injured child, there are at least 13 children hospitalised with minor or moderate injuries.  The total hospital cost of injury hospitalisations of was $2.1 billion and falls (38.4%), most often from playground equipment (8.3%) were the most common injury mechanism. A higher proportion of injured children resided in areas of socioeconomic disadvantage.  Children had a higher risk of dying from their injuries if they; lived in regional/remote Australia, were aged ≤10 years, were more severely injured or sustained a head injury.

Conclusions: For the first time in Australia, we have a national profile of childhood injury causes, descriptions, costs and mortality. Childhood injury is costly, life changing, but preventable.  The development of a national multi-sectorial evidence informed childhood injury prevention strategy is urgently needed.


Kate Curtis has been an Emergency Nurse since 1994 and is Professor at Sydney Nursing School. She is an honorary professorial fellow at the George Institute for Global Health, a Fellow of the College of Emergency Nursing Australasia. Kate’s translational research program continues to focus on improving the way we deliver care to patients and their families

The development of the Northern Health “Paediatric Resuscitation Scribing Tool” to assist with scribing during resuscitation

Ms Pamela Perera1, Ms Adele Berry1,

1 Northern Health, Epping, Australia

Background: During resuscitation, the scribes` role is to document and provide a true and timely representation of the events in a chronological manner1. In a very challenging and stressful situation, the scribe nurse plays a key role in resuscitation. Junior staffing often results in less senior nurses being relied upon to document during a resuscitation.

Aim: In 2015, from quality performance indicators, a paediatric resuscitation scribing tool was developed to address the identified lack of detailed documentation during a paediatric arrest.

Method: The paediatric scribing tool was developed utilising Northern Health (NH) policy and procedures in accordance with the Australian Resuscitation Council (ARC) guidelines. It involved input from key stakeholders including medical and nursing workforce across quality and safety, paediatrics, critical care, emergency and education.

A pilot chart was developed which follows the A-E approach for the deteriorating patient, Basic Life Support (BLS) and Advanced Life Support (ALS) algorithms for Northern Health. A tick box approach was utilised to prompt and lead documentation for the scribe.

The chart was trialled for a period of 6 months in the Emergency Department, paediatric ward and neonatal and paediatric nursing workshop.

Conclusion: Post the 6 month trial period, changes were made according to participant’s feedback. This included extra time slots, highlighting blood sugar level and tick boxes for administration of adrenaline and amiodarone. The chart was approved for use within Northern Health in October 2016.


  1. Molan E. (2013). Scribe during emergency department resuscitation: Registered Nurse domain or up for grabs? Australasian Emergency Nursing Journal, 45-51.


Pamela Perera is the Paediatric Clinical Nurse Educator for The Northern Hospital. She has a total of 12 years of experience as a nurse, but 8 years of emergency nursing with a post graduate certificate in Critical Care.  She has held positions of a Clinical Nurse Specialist, an ANUM, and Clinical Support Nurse before becoming a Clinical Nurse Educator.

Improving clinical handover of critically ill or injured children from the Emergency Department to the Children’s Intensive Care Unit

Ms Jane Cichero1, Mr  Paul Hunstead2, Dr Puneet  Singh3, Dr Christopher  Johansson4, Ms Wendy  Stephen5, Erica  Faust6, Ms Clare  Ells7, Ms Yvonne  Janiszewski8

1Sydney Children’s Hospitals Network, Randwick, Randwick, Australia, 2Sydney Children’s Hospitals Network, Randwick, Randwick, Australia, 3Sydney Children’s Hospitals Network, Randwick, Randwick, Australia, 4Sydney Children’s Hospitals Network, Randwick, Randwick, Australia, 5Sydney Children’s Hospitals Network, Randwick, Randwick, Australia, 6Sydney Children’s Hospitals Network, Randwick, Randwick, Australia, 7Sydney Children’s Hospitals Network, Randwick, Randwick, Australia, 8Sydney Children’s Hospitals Network, Randwick, Randwick, Australia

A quality improvement project was undertaken in a paediatric tertiary referral hospital to evaluate the effectiveness of the handover process of a critically ill or injured child from the emergency department (ED) to the children’s intensive care unit (CICU). There is extensive literature regarding the significant benefit of effective Clinical Handover on patient safety 2, 3. This project aimed to evaluate effectiveness of the current handover process, identify barriers to effective handover, and implement changes to standardise the transfer process.

Surveys and focus groups were conducted to identify the barriers and levers of the clinical handover process. Using this data, a standardised patient transfer process incorporating the ISBAR principles was developed. The finalized format included a guideline and a checklist.

The process and checklist was then tested in a simulated environment by the project team. Further refinement of the guideline and tool post simulation was enabled through video review and reflection of the simulation.

The video was utilised to educate a group of clinicians from ED and CICU on the new guideline and checklist and a subsequent in situ simulation was conducted with this group. Feedback on the guideline and checklist following the simulation was collected and edits made accordingly.

An audit tool was developed to evaluate the handover process prior to and post implementation. Data to date has shown a measurable improvement in a clinical handover of children to CICU.

The opportunity to evaluate and refine the checklist in simulated settings has enabled a smooth roll out of a tool that meets the project aim of improving patient safety in the clinical handover process. The innovation of utilising the video to facilitate implementation along with re-enforcement of the use of the checklist in regular simulated scenarios has led to greater uptake and subsequently improved clinical handover and patient care.


Jane Cichero has been a Paediatric Nurse Educator since 2002. Jane holds a Graduate Certificate of Paediatrics, Paediatric Critical Care and a Graduate Diploma of Clinical Teaching. Jane has extensive experience in general paediatric nursing, paediatric intensive care and paediatric emergency nursing. Her passion for education incorporates a passion for simulation. Jane completed the Harvard Medical Simulation as a Teaching Tool Instructor Course in 2011 and has continued to develop skills and knowledge in the world of simulation. Her current role as Nurse Lead for Simulation in the Emergency Department at Sydney Children’s Hospital, Randwick enables her to promote and utilise simulation in many aspects of multidisciplinary education and quality and safety in emergency care.

‘It’s turned our world upside down’: Support needs of parents of critically injured children during ED admission

Professor Kim Foster1,2, Dr Alexandra Young3, Associate Professor Rebecca Mitchell4, Professor Kate Curtis3, Dr Connie  Van3

1Australian Catholic University, Melbourne, Australia; 2Northwestern Mental Health, Melbourne Health, Melbourne, Australia; 3Sydney Nursing School, The University of Sydney, Sydney, Australia; 4Australian Institute of Health Innovation, Macquarie University, Sydney, Australia

Introduction: Being the parent of a critically injured child involves many stressors. Parents are at risk of psychological distress and the entire family can be negatively impacted. Little is known however, about parent experiences and support needs when their child is in the Emergency Department (ED) following critical injury.

Method: This research is part of a 2 year longitudinal multi-centre mixed methods study on parent experiences and unmet needs when their child is critically injured. Forty parents of 30 critically injured children 0-12 years were recruited across 4 Australian states.  This presentation reports on qualitative findings from the initial injury period, and parent experiences of ED admission.  Forty semi-structured interview transcripts were analysed using content analysis methods, to identify parent experiences and unmet needs.

Results: On ED admission, parents were emotionally traumatized by the nature and impacts of their child’s injury event. Most events (n=16) were motor vehicle collisions and 12 parents had multiple injured family members including partners. Parents grappled with prioritising different injured family member needs at the one time. Parents were initially shocked about the injury event and focused on the child’s needs rather their own. They were challenged by the unfamiliar and confronting environment of ED and their primary concern was their child’s survival and fear of the unknown. Key parent support needs were contemporaneous and honest information about their child’s injury and required treatment; involvement in key treatment decision-making; and staff acknowledgement of the severity of the situation and emotional impact on parents. Most parents found the clinical care of their child to be timely and professional.

Conclusion: Provision of a dedicated family support coordinator in ED and focused attention to parent emotional needs at the time of injury are recommended to improve parent psychological outcomes.


Alexandra (Lexie) Young is a Postdoctoral Research Associate in the Faculty of Nursing and Midwifery at Sydney University. Her background is in sociology and social work and she has undertaken studies in the fields of family policy, education and end of life care. Lexie is currently working on the Day of Difference Foundation’s Paediatric Critical Injury Research Program which focusses on finding real world solutions to improve the care of injured children and their families.

We don’t eat our young! The Royal North Shore Hospital Second Year Transitions to Emergency Department Program

Ms Jessica Willetts1, Mr Martin Ward1

1Royal North Shore Hospital, St leonards, Australia

The creation of the innovative Second Year Transitions to Emergency Program was designed and implemented following the need to change practice around the development of our novice nurses. Our ED, had in the past, accepted first rotation TRN’s directly into the ED. Feedback from the TRN’s was that it was too early to be rotated to ED. Incidentally very few of the 38 nurses completing the TRN program over a 5 year period remained in the Emergency department with many citing professional fatigue at year three, hence the development of the Second Year Program.  This inaugural program is designed to facilitate the participant’s development of foundational knowledge and clinical skills necessary to practice safely and effectively in a Level 6 Tertiary Referral Hospital Emergency Department setting.

The objective of the program is to develop and fully support Year 2 RN’s to ready them to effectively function in the resuscitation rooms within 12 months of working in the Emergency department.

The program structure consists of a development plan to suit the needs of each participant with specific targeted training days and courses.

The key concept of the program is the invention of an ED specific Moodle page equipped with educational resources such as podcasts and ‘You Tube’ videos enabling the participants to gain a better understanding of the critical care nursing skills and how to utilise key equipment prior being exposed to the area.

Participants have been surveyed about their previous nursing experience, future intentions, current capabilities and expectations of the outcomes of the program.

The outcomes of this program are to develop and consolidate clinical emergency nursing skills within a tertiary department setting; competency in critical thinking and clinical decision making within a time pressured environment; and to commence the development of clinical leadership skills in a critical care setting.


Jess Willetts has worked at the Royal North Shore Emergency Department since 2004. Jess was appointed Clinical Nurse Specialist in 2014 and has been a Clinical nurse educator in the emergency department since 2015.  Jess has a passion for emergency nursing and a vested interest in the implementation of educational tools and simulation techniques to assist the development of nurses into proficient nursing clinicians.

‘Growing Our Own’- educational framework to assist with the recruitment, professional development and retention of emergency nurses

Mrs Danielle Waddell1, Ms Tracey Ingvorsen1, Mrs Vanessa Leonard-Roberts1, Mrs Elise Sutton1, Ms Liz Ward1, Mr Adam Watts1, Ms Stacey Williamson1

1Northern Health, Melbourne, Australia

Background: A critically high nursing EFT deficit of 21% in late 2015 in the Emergency Department (ED) at The Northern Hospital (TNH), particularly postgraduate trained emergency nurses led to a review of the current education programs in 2016.

Aim: Review of current educational programs and strategies, and development of an educational pathway to prepare and promote junior nurses to undertake postgraduate emergency nursing studies within our ED.

Method: In 2016, TNH employed additional clinical support nurses to  supervise undergraduate nurses on placement in ED. Prior to this, education was provided by the relevant university. Incorporating undergraduate nurses in our program allowed us to develop ED specific education for our junior workforce. Graduate nurse rotations were increased from 12 to 16 per year to meet interest demand, with targeted education to prepare these nurses for our grade 2 Supported Transition Emergency Practice program (STEP).  Theoretical content and clinical assessments for STEP were aligned with postgraduate course content, including encouragement to undertake the advanced pathophysiology subject at Melbourne University which forms part of the Graduate Certificate in Emergency nursing.

Conclusion: Re-alignment of our educational programs to promote the professional development of our junior nurses has proved a success. 18 months after its implementation, we have provided structured educational support to:

  • 170 undergraduate nurses
  • 20 graduate nurses (70% of graduate nurses completed an undergraduate rotation in TNH ED)
  • 34 STEP participants (53% of ED STEP completed an ED graduate rotation)
  • 25 postgraduate students (80% of postgraduate students were from STEP)

The educational alignment has allowed TNH ED to develop our novice nurses from an undergraduate level through to specialist emergency trained nurses. This in turn has decreased the EFT vacancy deficit from 21% to 3% over the last 18 months.


Danielle Waddell is currently employed as a Clinical Nurse Educator in the Emergency Department at Northern Health. Responsible for the education, co ordination, development and recruitment for all ED programs in ED / SSU

Tracey Ingvorsen is currently employed as a Clinical Support Nurse in the Emergency Department at Northern Health. Responsible for the education, support and supervision of all junior nurses and hold the undergraduate portfolio

Requisite education framework: A competency based framework for progression through the Emergency Department

Mr Sean Lannan1, Mrs Amanda  Naumann1, Mrs Val Mitchell1

1Sunshine Coast Hospital and Health Service, Birtinya, Australia

The career progression pathway for novice RNs in Emergency Departments is a process which is highly variable and dependent upon the individual and the department in which they work. It is well known that progression through the different stages of ED relies on experience, exposure to different patient conditions and situations, and the individual learning needs of the nurse in question.

Consistency and transparency often present concerns for unit managers and the educators supervising the nurse through progression. Inconsistencies in progression may occur between different nurses, especially in departments with large numbers of existing staff, or with nurses commencing their ED careers.

The Requisite Education Framework (REF) was developed by the Sunshine Coast Hospital and Health Service Practice Development Team in consultation with the relevant clinicians to provide a clear, consistent and standardised approach for tracking progression of an individual through the various areas of nursing throughout the service.

The REF can be modified to suit the specific and unique needs of the nurse through the particular areas of the Emergency Department. The REF affords an outline of the training and skills required to successfully accomplish specific roles in the ED. It requires the individual to demonstrate appropriate knowledge and competence before progressing to the subsequent area in their workplace. To advance successfully, the individual should understand career progression and professional development opportunities. These are discussed and explored during the PAD process.

For educators and managers, the results of the implementation of the REF have provided a structure to plan education, design succession planning and determine skill-mix for rostering purposes. For the individual nurse, the REF affords them the structure and clearly defines the expectations and obligations required of them for departmental progression and further career planning.


Sean is a nurse educator for emergency services with the Sunshine Coast Hospital and Health service. Sean has a history as a nurse working in Emergency Departments in Regional and Metropolitan Health Services and has an interest in Simulation Education.

Amanda is a nurse educator for emergency services with the Sunshine Coast Hospital and Health Service. Amanda has worked in Emergency Departments in Australia and overseas, and has an interest in the development of the Advanced Practice Nurse role in ED.

Innovative succession planning and leadership development in a tertiary Emergency Department: Developing the next generation of leaders through a clearly defined professional development pathway, education sessions and training days

Miss Kimberly Jackson1, Miss Cassandra Rooney1, Mrs Karen Robinson1, Mr Ben Learmont1, Mrs Dale Mason1, Mr James Hughs1

1Princess Alexandra Hospital, Woolloongabba, Australia

Over the past five years, our Queensland tertiary Emergency Department (ED) has implemented and refined a structured Professional Development Pathway (PDP) for registered nurses. Traditionally learning and development pathways in emergency nursing only include the first two years of transition to specialist practice, historically stopping after the completion of triage training.  Our PDP has demonstrated that following clinical training our nurses have been provided with the opportunity to develop further and progress into senior leadership and management positions.  Our PDP has offered professional development to support progression into area coordinator roles (i.e. Resuscitation Coordinator), leadership in education (i.e. Clinical Coach Role) as well as supported succession into departmental leadership positions (Clinical Nurse). Through this program staff have developed well rounded leadership skills and confidence in their clinical and managerial capabilities. This succession planning program has focused on developing skills in the areas of education, problem solving, motivation and support of others, delegation and other important leadership qualities.  It has provided our staff with an overview and insight into strategic direction of the healthcare organisation. This has been achieved by introducing our staff to quality improvement projects which focus on the 10 National Safety and Quality Health Services Standards, accreditation requirements, key performance indicators, budgeting considerations and human resource management responsibilities.  Since the implementation of this program our staff have developed proficient leadership skills which have made them highly sought after by the organisation and the health service. This leadership program has motivated our staff to strive for great heights within their nursing careers and has ultimately led to an increase in job satisfaction, making our department highly successful and an extremely desirable place to work, so much so that there is a long waiting list of eager nurses wanting to join our team.


Kimberly graduated from Griffith University with a Bachelor of Nursing in 2006. Kimberly works in the Princess Alexandra Hospital, commencing her career in Infectious Diseases, later transferring to the Emergency Department in 2008. Kimberly has a passion for mentoring, educating and developing her fellow colleagues; which has led her to roles in the areas of Education and Human Resource Management, and is now a Clinical Nurse Consultant within the ED. Kimberly has completed a Masters of Emergency Nursing and a Graduate Certificate in Health Professional Education.

Cassandra graduated from Griffith University with a Bachelor of Nursing in 2005. Cassandra works in the Princess Alexandra Hospital, commencing her career in a surgical ward, later transferring to the Emergency Department in early 2008. Cassandra has held many leadership and mentoring positions within the organisation including positions of Nurse Managers the areas of Human Resources and Quality Initiatives, advancing Cassandra into her current position of Clinical Nurse Consultant within the ED. Cassandra has also completed a Graduate Certificate Emergency Nursing.