The feasibility of illicit drug monitoring in an Emergency Department setting: Data from a 12 month pilot study

Sam Alfred1, Peter Stockham2, Emma Partridge3

1Emergency Physician & Clinical Toxicologist. Royal Adelaide Hospital (RAH), 2Principal Forensic Scientist, Toxicology. Forensic Science South Australia (FSSA), 3Forensic Scientist, Toxicology. Forensic Science South Australia (FSSA)

Quality data regarding patterns of illicit drug use in the community is available from a range of sources; however the accuracy of hospital level data is limited by the necessarily subjective attribution of a causative agent by treating clinicians.

We report on a process capable of accurately profiling illicit drug use, and deliverable in the Emergency Department setting.

Ethics approval was obtained with a waiver of consent. Patients who presented to the RAH Emergency Department with unusual or severe toxicity as consequence of drug use and a clinical requirement for intravenous access were enrolled. Laboratory logistics caped samples at 2 per week. The clinical data set targeted the setting of drug use, clinical toxidrome and outcome, and was designed to facilitate collection by clinical staff.

Six mL of blood from subjects was placed in a study fridge prior to transfer to FSSA. Sample treatment and extraction methodologies included protein precipitation, liquid-liquid extraction and solid phase extraction. Analysis techniques and instrumentation included enzyme linked immunosorbent assay (ELISA), gas chromatography with flame ionisation detector (GC-FID), liquid chromatography with diode array detector (LC-DAD), quadrupole time of flight mass spectrometer (LC-QTOF-MS) or triple quadrupole detector (LC-QQQ).

84 patients were enrolled (54 male, 30 female) with a mean age of 31yrs. Poly drug use was the norm with an average of 3.2 agents detected per patient, the most frequent of which were methamphetamine (38/84), amphetamine (33/84), benzodiazepines (31/84), ethanol (23/84, mean 0.152 g/dL),  GHB (20/84), opiates (20/84), cocaine (13/84), and MDMA (13/84). 7 patients (0.8%) were clinically intoxicated without an identifiable agent on assay. We detected very few cannabinoid receptor agonists and no fentanyl derivatives, and are developing improved assays with a broader library to enhance detection. The majority of patients (42%) were managed and discharged from the Emergency Department or its Short Stay Ward, and Intensive Care was required in 19%. There were no deaths.

Our pilot study demonstrates that it is possible to accurately profile illicit drug use associated with hospital presentation, and has provided the basis for a successful research grant that will support expanded enrolments across 4 major hospitals in Adelaide.


Biography:

Associate Professor Sam Alfred graduated from Adelaide University in 1996 before moving to Sydney and undertaking training in Emergency Medicine at Westmead Hospital. His early post fellowship years involved work in Emergency Medicine at St George Hospital, and retrieval medicine with the Sydney Aeromedical Retrieval Service. A move back to Adelaide in 2005 allowed the pursuit of both of these practices in a single location through MediFlight and the Emergency Department of the Royal Adelaide Hospital.  A mounting interest in the field of Toxicology saw him subsequently complete a fellowship in Clinical Toxicology via the New South Wales Poison Centre, and he currently holds appointments in Emergency Medicine and Clinical Toxicology at the Royal Adelaide Hospital, and is a Medical Retrieval Consultant with the MedSTAR retrieval service. He is an Associate Professor in Acute Care Medicine at the University of Adelaide.

The time is now: Care of the older person in emergency, providing an education resource for emergency clinicians

Erin Cranitch1,2, Ellen Burkett1,2, Tamara Ward1, Laura Hines1

1Clinical Excellence Queensland, 2Metro South Health

Background:

Australian Emergency Departments (EDs) are experiencing significant growth in older person presentations.  Older persons, defined as people sixty-five years and older, are more likely to present with complex histories, co-morbidities and pharmacological considerations.  Older people present with symptoms and deceptively different vital signs from their younger counterparts, that may correlate with serious pathology.  Often referred to as ‘atypical or non-specific’ these symptoms also confound diagnosis and timely treatment in ED.  There is an opportunity to educate ED Nurses about these differences.  A survey of national health department sites and a grey literature search, was unable to identify any other departments with a specific older person  module within current training packages for ED nurses.

Objectives:

The project aim was to develop a statewide education module on the unique care needs of older persons in the ED with content able to be utilised across the spectrum of novice to highly experienced senior nurses. This education will be a catalyst for improvement of clinical outcomes for this growing cohort.

Methods:

A working group of Emergency and Gerontologic nursing, medical and allied health experts was formed to inform the development of content and learning activities with geriatric specific domains.  The domains encompass care of the older person in Emergency, common older person presentations and pharmacologic and psychosocial considerations of the older person.  The content also addressed important adult medico-legal issues relevant to the older person cohort in ED.

Results:

The module is being rolled out across Queensland EDs to coincide with a statewide Frail Older Persons program. Quality indicators will be measured via self-report of clinician knowledge and satisfaction of care provided to this vulnerable cohort.  The module will be incorporated into the statewide Emergency Transition Support Program during its next review and is available for nation-wide health departments via the Queensland Frail Older Persons website.  The content is suitable to be leveraged for other groups including medical officers and allied health clinicians.


Biography:

Erin is an Emergency (ED) Nurse Practitioner (NP) and a Clinical Lead at the Healthcare Improvement Unit, Clinical Excellence Queensland.  With more than eleven years in ED including adult and paediatric tertiary centres and a founding member of two ED outreach teams for Residential Care Facility patients Erin has a special interest in vulnerable groups across the age continuum.  Erin has completed the Masters of Nursing Science, NP, Masters of Emergency Nursing and the International Paediatric Postgraduate Certificate.  Erin has the International Diploma of Humanitarian Assistance (IDHA) and is member of the IDHA 37 Alumni, New York. Erin is a health delegate on the Australian Medical Assistance Team and a sessional academic at Queensland University of Technology.

Cannulation Rates in the Emergency Department Intervention Trial (CREDIT) – regional site implementation

Mrs Karen Smith1, Ms Sunayana Moriarty1, Prof Louise Cullen2, Ms Tracey Hawkins2, A/Prof Jaimi Greenslade2

1Queensland Health, Mackay Base Hospital, Mackay, Australia, 2Queensland Health, RBWH, Brisbane, Australia

Aim: It has been estimated that up to 10% of peripheral intravenous cannula (PIVC) inserted within the Emergency Department (ED) are not used. An education campaign, termed CREDIT, was designed to reduce the number of cannula inserted. This would have many potential benefits, including time for insertion, cost, risk of pain and infection for patients. The aim of this study is to evaluate CREDIT within a regional facility.

Methods and Results: A pre-post test study will be conducted in a single Regional ED in Mackay, Australia. The exclusion criteria consists of patients under the age of 18 years, Australasian Triage Scale (ATS) category one, having a PIVC inserted by Ambulance Services or inter-hospital transfers. The multi-modal CREDIT intervention will be implemented over a three-month period including information sessions, posters, educational material, and change champions. The primary outcome will be proportion of PIVC placed. We estimate 65% of our ED patients have a PIVC placed.  The secondary outcomes will be PIVC utilisation within 24 hours, ED length of stay and proportion of haemolysed blood tests. Our current haemolysis rates are 10% of all blood tests performed. Data from 150 patient’s pre-implementation and 150 post-implementation will be collected. The proportion of patients with PIVCs inserted will be compared across pre-and-post intervention groups. Secondary analyses will also compare the proportion of PIVCs inserted by diagnosis. Cost benefit will be considered as a final outcome measure.

Conclusion: This next phase of research is expected to validate the original research results and show a reduction in the placement of unused PIVC within the ED. With the probable reduction in insertions, it is likely there will be an equivalent cost saving and reduction in the risk of patient pain and infection. It is unclear as to the effect this trial will have on the ELOS; however, haemolysis rates should be reduced by the use of venepuncture over cannulation blood collection methods.


Biography:

Karen Smith is a Registered Nurse who is driven to improve patient care. She works in a clinical role that allows her to combine her clinical knowledge and research passion to enhance clinical practice.

Karen started her nursing career in 2002, studying at Central Queensland University, Rockhampton. After a number of years of rural and regional nursing throughout Central Queensland, she commenced work in Mackay in 2010 and completed her Master of Nursing (Emergency) through Queensland University of Technology in 2017. This gave her the enthusiasm for research and improving clinical practice through evidence based research. She currently resides in Mackay with her husband and two children.

Know the flow: A mixed-method analysis of patient flow through a regional ED

Alex Pryce1,2, Maria Unwin1,2, Leigh Kinsman1,2, Damhnat McCann2

1Tasmanian Health Service, 2University of Tasmania

Introduction

The equivalent of one in three Australians present to an Emergency Department (ED) in a single 12-month period. The increasing demand for ED care and ED crowding has heightened focus on the movement of patients through the ED (ED patient flow). We set out to map the patient flow through a regional ED in a 300-bed hospital with the aim of recording the movement of patients through the input, throughput, and output phases, and identifying factors contributing to extended ED length of stay.

Methods

We undertook a mixed methods study based on retrospective presentation data, prospective observational data and a subsequent focus group with the observers based in a regional Tasmanian hospital ED.

Results

Key findings identified from the retrospective analysis of 89,013 ED presentations and observational data from 382 patient journeys included: arrival numbers were not a predictor of ED crowding; waiting times at triage and in the waiting room created significant risks to patient safety; ED crowding triggers the use of ‘makeshift’ space to assess and treat patients; and access block is the major contributor to crowding. Analysis from the focus group identified four key themes: coping under pressure, compromising care and safety, makeshift spaces, and makeshift roles.

Discussion

Our mixed methods observational study revealed an environment of crowding and chaos that impacted patient flow and compromised patient and staff safety. Despite this, ED staff maintained outstanding standards of care.

This presentation will highlight key findings and stimulate discussion regarding the need for strategies to address ED crowding that address contributing factors external to ED.


Biography:

Alex Pryce is an Associate Nurse Unit Manager (ANUM) at the Launceston General Hospital ED. Alex also works with undergraduate students for the University of Tasmania School of Nursing and in the high-fidelity sim-lab for the Launceston Clinical School. Data analysis for this project was undertaken as part of a Nursing Honours program. This project is a collaboration between the Tasmanian Health Service and the University of Tasmania.

Future Emergency Nursing workforce, what is the evidence telling us?

Mrs Vanessa Gorman1

1The Royal Women’s Hospital, Melbourne, Australia

OBJECTIVE: High nursing turn-over, and low retention rates amongst the field of emergency nursing according to current evidence is a global phenomenon. How is the current evidence influencing managers and organisations to identify key factors that may improve not only retention, but recruitment, into the speciality of emergency nursing?

METHODS:
This study utilised a bibliographic search as well as the authors own experience when performing the integrative review.

RESULTS:
26 articles were identified as meeting the criteria of the integrative review. Both national and international articles that met inclusion criteria were included.
4 key themes were identified that may impact on the recruitment and retention of emergency nurses: workplace environment, demands on emergency nurses, resilience, and education and training.
The key themes identified all impact on emergency nurse recruitment and retention, but the evidence is conclusive that a multi-level approach needs to be adopted internationally.

CONCLUSIONS:
Emergency nursing recruitment and retention is a multi-faceted issue that requires urgent attention to develop tools and strategies to support organizations to build a sustainable workforce. This study has highlighted the need for further studies to understand why emergency nurses lack the knowledge or capability for a long-term career in emergency nursing.


Biography:

Vanessa commenced her emergency nursing career in 1996 and across her career in emergency nursing she has held positions such as Nurse Unit Manager, Senior Policy Advisor – Department of Health, and State Trauma Manager. Vanessa is the appointed Emergency Services manager at the Royal Women’s Hospital, Melbourne. Vanessa is an appointed member of the International Advisory Council for the Emergency Nursing Association (USA), and is appointed to the CENA membership committee. In 2017, Vanessa was awarded the Australasian Emergency Nurse of the year as she strives to improve emergency care for both patients, and the nursing workforce, through various quality projects.

Exploring interventions used in emergency departments to reduce occupational stressors and or improve staff coping: A scoping review of the literature

Ms Elizabeth Elder1, Dr.  Amy N. B. Johnston2,5,6, Prof. Marianne Wallis2,4, Prof. Julia Crilly2,3

1School of Nursing & Midwifery, Griffith University, Southport, Australia, 2Menzies Health Institute Queensland Griffith University , Southport, Australia, 3Department of Emergency Medicine  Gold Coast Hospital and Health Service , Southport, Australia, 4School of Nursing Midwifery and Paramedicine, University of the Sunshine Coast, Sunshine Coast, Australia, 5School of Nursing Midwifery and Social Work, University of Queensland , Brisbane, Australia, 6Department of Emergency Medicine Princess Alexandra Hospital Metro South, Brisbane, Australia

Introduction: Emergency departments (EDs) are stressful places to work (1). Staff are exposed to many occupational stressors and rely on varying coping strategies (2). Exposure of ED staff to occupational stressors has been linked to increased absenteeism and burnout, higher staff turnover and low staff morale (3). The aim of this review was to examine and synthesize existing evidence relating to interventions designed to reduce the impacts of occupational stressors and/or improve ED staff coping.

Methods: The review involved searching five databases using terms related to stress/or, coping, and emergency department for papers published in English from 2007-2017. Study quality of quantitative studies was assessed using National Health and Medical Research Council Level of Evidence Guidelines (5).

Findings: A total of 45 studies met criteria for review inclusion. The level of evidence of included studies varied from level I (n = 1) to IV (n = 11). Interventions discussed in the literature that targeted occupational stressors included organizational/environmental redesign, policy/protocol change and staff education. Interventions targeted towards improving coping strategies of staff included mindfulness, debriefing and relaxation techniques. Most studies reported some degree of positive effect/s on either reducing exposure to occupational stressors and/or improving staff coping.

Conclusion: This review highlights the limited existing literature relating to interventions designed to ameliorate a wide range of occupational stressors experienced by ED clinicians. The findings of this review support the need for additional research to underpin and guide interventions designed to address occupational stressors and or improving coping strategies used by ED clinicians.

References:

  1. Basu S., et al. Occupational stress in the ED: a systematic literature review. EMJ. 2017;34(7):441-7.
  2. Abraham LJ., et al. Morale, stress and coping strategies of staff working in the emergency department: A comparison of two different-sized departments. EMA. 2018.
  3. Ahwal S. & Arora S. Workplace Stress for Nurses in Emergency Department.
  4. Arksey H. & O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8.
  5. National Health & Medical Research Council. NHMRC Levels of evidence and grades. Canberra 2009.

Biography:

Elizabeth is a credentialed emergency nurse with a passion for education, research and clinical practice.  Believing research is the juncture of clinical practice and academe Elizabeth enrolled in her PhD in 2016.

Staff wellbeing program

Mrs Elizabeth Bradbury1
1
Clinical Nurse Manager, Melbourne Health, North Warrandyte

The Royal Melbourne Hospital (RMH) is a state-wide trauma service seeing around 78,000 presentations annually. The 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 to be an employer of choice.
The ED Leadership team worked in consultation with our the RMH Health & Wellbeing Coordinator to promote Compassion Fatigue workshops in 2017. The aim of these workshops was to increase staff education regarding psychological first aid, identify individual triggers and promote self-care strategies for staff. To compliment our wellbeing program we encouraged our nursing staff to join the MH peer support program, equipping and training this core group with skills to provide `real time’ support and care for clinical staff.
January 2018 marked the introduction of the Wellbeing Dog program which was trialled for 4 months at two days per week in our non-clinical space. The overwhelming response to this trial has now marked a Monday – Friday implementation with feedback from staff stating an increase in morale, reduction in stress and improved staff relationships.
Our ED Leadership Team is committed to the vision of being “First in Care” and an employer of choice. The introduction of our Wellbeing Program aims to promote mental health awareness, minimise the impact of OVA and trauma and implement staff support strategies. At RMH ED we fully acknowledge that these programs do not eliminate the volume, acuity and stress related to Emergency nursing, but we are very clear that we cannot achieve our vision without addressing the needs of the people that provide that care. We believe that we are getting a significant return on our most valuable assets through our innovative investments in wellbeing.


Biography: 
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

Breaking nursing silos: A collaborative approach to improving transitional care

Emma Staines1

1Clinical Nurse, Emergency and Trauma Center, Royal Brisbane and Women’s Hospital, QLD

The transfer of patients from emergency to the ward environment is a critical point in the patient’s journey, with wide ranging impacts on patient safety, patient flow, and staff relationships. Poor interdepartmental transitional care and nursing handover are associated with increased adverse events, errors, and poorer patient outcomes. Communication between emergency and inpatient departments must be clear, collaborative, and consistent, in order to ensure patient safety during this transitional point in their care. The Collaborative Care Enterprise (CCE) is a project developed at the Royal Brisbane and Women’s Hospital (RBWH) in 2017, specifically to address the relationship between emergency and inpatient nursing staff.

The CCE has been a collaboration between emergency and inpatient staff, bringing front-line nurses together to discuss issues and concerns related to transitional care, and forge actionable strategies for improved teamwork and patient care. Initiatives of the CCE include conducting education sessions regarding patient flow and scope of emergency care, inviting ward staff for structured walk-throughs of the department to increase understanding of departmental processes, and providing case studies of occasions when the transfer of a patient was concerning to ward staff.

The CCE has provided nurses in emergency and inpatient departments a platform for open dialogue regarding concerns, constructively discuss options for process and policy change, and develop a better understanding of their colleagues work environment. This has resulted in improved relationships and communication between departments, and process changes that have optimised transitional care for patients, such as facilitating ward staff to collect patients from emergency and collect data from the Emergency Department Information System.

Building on the success of the past six month, there are plans for the CCE to expand and incorporate other wards within RBWH, in order to further improve the safety of patients as they are transferred out of the emergency department.


Biography:

Emma Staines is a Clinical Nurse in the Emergency and Trauma Center at the Royal Brisbane and Women’s Hospital. Emma holds post-graduate qualifications in Acute Care, Immunisation and Emergency Nursing and is currently undertaking her Master’s in Public Health, majoring in Disaster Health and Humanitarian Assistance. For the past year, Emma’s focus has been designing and implementing a quality improvement project targeted toward improving interdepartmental nursing team work, relationships and transitional care. Leading a multi-specialty nursing team, Emma is working toward breaking down departmental silos, turning clinical incidents in transitional care into practical change and thereby developing forward-thinking, professional, evidence-based clinicians.

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.

Triage of obstetric presentations to the ED. Who are they and how are they triaged? Analysis of an obstetric triage decision aid.

Ms Mary McCarthy1, Dr Wendy Pollock1,2,3, Professor Susan  McDonald1,2
1Mercy Hosptial For Women, Heidelberg, Australia, 2La Trobe University, Bundoora, Australia, 3Melbourne University, Parkville, Australia

Background: Emergency nurses are typically not well-versed in the triage of pregnant and postpartum women. The obstetric triage decision aid (OTDA) was developed to provide structured and standardised triage of pregnant and postpartum women with obstetric and non-obstetric complaints. The validated OTDA consists of 10 common pregnancy complaints with key signs and symptoms, generating an Australasian Triage Scale category based on the targeted questioning responses. The aim of this analysis was to examine the characteristics of obstetric presentation and explore how they were triaged using the OTDA.
Method: In February 2017, the OTDA was introduced to the ED of a metropolitan hospital in Melbourne. New procedures on obstetric triage and support processes were provided to underpin the introduction, and the OTDA was embedded into the ED triage software. Data were extracted for September2017 and underwent non-parametric analysis using SPSS v24. Ethics approval was obtained.
Results: Of the 228 obstetric presentations, ED nurses conducted triage without using the OTDA for 68 (29.8%) women. The majority of presentations were for bleeding and pain in the first trimester (n=29; 43%), of these 21 (72%) were given the equivalent triage score to the OTDA, two (7%) were under triaged and six (21%) had insufficient details to provide a score using the OTDA. Of the presentations for problems over 20 weeks’ gestation (n=24; 35%) only 42% (n= 10) received the same triage score. Seven (29%) were under triaged and 25% (n=6) had insufficient details to give a score in the OTDA. Whilst only six (9%) presentations were in the postnatal period, four (67%) were under triaged and two (33%) received the same score as the OTDA.
Conclusion: The most common pregnancy related problem was early pregnancy bleeding and pain and had the highest concordance with the OTDA score, however under-triage with women over 20 weeks and postnatal problems remained a concern. Under-triage is a known clinical risk and  the OTDA was useful in assisting in the application of a triage score in the ED.


Biography:
Project lead for the BCV Obstetric triage decision Aid. Is a Registered Nurse/ Midwife, Bachelor of Health Science Nursing, Masters Midwifery. As Manager of the Mercy Women’s Emergency Department has worked extensively to improve the consistency of obstetric triage, customised the Australasian Triage Scale to emergency maternity care and published :“Triage of pregnant women in the emergency department: evaluation of a triage decision aid. EMJ”. Further refinement has produced an Obstetric Triage Decision Aid which has been successfully implemented in both the general emergency setting and maternity unit. In addition has an interest on improving communication in the ED for women who experience early pregnancy loss and developed an evidence base education package for staff who work in the ED.

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