The Queensland Adult Deterioration Detection System (QADDS) – improving compliance to recognise deteriorating patients in an Emergency Department.

Muireann Wynne1, Joanne Farrell2,

1 Queensland Health, Emergency Department, Logan Hospital, Meadowbrook, QLD, 4131.  muireann.wynne@health.qld.gov.au.
2 Queensland Health, Emergency Department, Logan Hospital, Meadowbrook, QLD, 4131. jo.farrell@health.qld.gov.au.

Abnormalities in physiological observations are known predecessors to adverse patient events such as respiratory and cardiac arrest. Evidence suggests that many of these abnormalities and deteriorations go unreported (Mitchell Scott et al, 2015). Structured processes for recognising and responding to deteriorating emergency department (ED) patients are varied around Australia. The Queensland Adult Deterioration Detection System (QADDS) was implemented at Logan hospital emergency department (LH ED) in 2013, consistent with state wide guidelines. The QADDS tool provides nurses with a framework in which to record observations and with a prescribed escalation process to follow in the event of patient deterioration. In October 2014, the LH ED moved to a new building which led to a threefold increase in nursing staff with a dilution of specialist emergency nursing knowledge and skill mix.

Routine audits of 20 QADDS charts were carried out in LH ED in May 2015.

  • 50% of charts had observations recorded at acceptable frequency.
  • 0% of patients with a numerical score of 4-5 in the first instance had appropriate escalation or an acceptable frequency of observations.
  • 0% of patients with a numerical score of 8 or greater had appropriate escalation or observation frequency recorded.
  • 25% of patients who warranted an emergency response in the last instance had one initiated immediately.

A nursing staff survey was carried out post initial audit results to gain further insight into facilitators and barriers experienced by staff. A qualitative approach was undertaken using a paper based survey tool. A number of barriers experienced by nursing staff when attempting to escalate deteriorating patients were identified.

Further audits in 2016 displayed some improvement in compliance to the QADDS tool.

  • 60% of charts had observations recorded at acceptable frequency.
  • 50% of patients with a numerical score of 4-5 in the first instance were escalated appropriately but 0% of these had an acceptable frequency of observations.
  • 0% of patients with a numerical score of 8 or greater had appropriate escalation or observation frequency recorded.
  • 100% of patients who warranted an emergency response in the last instance had one initiated immediately.

A QADDS quality improvement project was commenced as a priority based on the results. A focus group was formed to address the recommendations of the nursing staff survey. An expression of interest was advertised and self-nominated QADDS champions were formed to be a part of the project. A set of values and role expectations for the QADDS champions were devised using a patient safety model.

The project is ongoing and post project implementation audit results are expected by the end of September 2016.

Reference

Scott, B.M., Considine, J., Botti, M. Unreported clinical deterioration in emergency department patients: A point prevalence study. Australasian Emergency Nursing Journal 2015; 18: 33-41

Biography

Muireann Wynne.
I have worked in emergency nursing for almost my whole career. I started my nursing career in Ireland in and moved to Australia 4 years ago. I have completed a post graduate and masters in emergency nursing. I currently work as a clinical nurse consultant in Logan hospital emergency department and have a background in clinical teaching and education. My area’s of interest are in nursing education and patient safety.

Joanne Farrell.
Jo has worked in many areas in her nursing career, mainly in emergency nursing. She started her career in the UK and has worked in Western Australia for a number of years before moving to Brisbane. Jo has completed her post grad and masters in emergency nursing. She has a background in nursing management and she works as a clinical nurse consultant in Logan hospital emergency department currently. Jo’s area’s of interest are in resuscitation and disaster management.

Calm your farm! De-escalation strategies for potentially violent situations in the emergency department

Karen Thompson1

1 RN, Grad Dip (Emergency) Certified instructor (Non-violent Crisis Intervention) | North West Regional Hospital, Burnie TAS 7320 karen.thompson@dhhs.tas.gov.au

A common public perception of nursing is “the caring profession”, yet ironically, nurses are at ever-increasing risk of exposure to violence in the workplace, and the emergency department is identified as a high risk environment. Indeed, a study conducted by in 2006 found that 63.5% of Tasmanian nurses reported being subjected to some form of work-place violence in the previous four weeks and it is documented as a major stressor contributing to challenging working environments and high turnover.

Today, I’m going to discuss a situation which is challenging from both an environmental and personal perspective, how one challenging situation generated another and the strategies employed to address both.

Obviously action was needed to address this problem and research led to the adoption at my workplace of a program known as Non-violent Crisis Intervention (NVCI). In a perfect world this would seem to be the answer, however the introduction of the program created challenges in itself. Once the preliminary structure of the program was in place, all staff were emailed and either appointed or invited to attend a session – a method which created immediate resistance in many quarters. The primary concern expressed by many nurses was that they would be engaging in some form of hand to hand combat, generated by the historical mindset that Code Black = forcible take-down. They, quite reasonably pointed out that these situations were outside their scope of practice.

Paradoxically this unfavourable situation provided unexpectedly positive outcomes, as it challenged me to find cohesion and acceptance of the program. I used servant leadership theory to support pace-setting leadership as I assured my colleagues that I too am disinclined to be wrestling with aggressive individuals

A full-day workshop format was developed and with no pre-reading or preparation required, staff attend with, hopefully, an open mind, although this is often not the case. During the workshops, interactive learning sessions are presented, covering stages of agitation, the verbal escalation continuum and identifying precipitating factors for deteriorating situations. We focus on understanding and intervening appropriately to certain behaviours rather than making the individual cease the behaviour. Role playing and activities complement the sessions, enabling the staff to experience the situation from the perspective of the person in crisis and learn and practice personal safety techniques. All sessions are underpinned with the message of Care, Welfare, Safety and Security of all, reminding staff at all times that the acting-out individual is a person in crisis; they have no control so the staff member must maintain control of him/herself.

Given that increasingly violence is a global problem – think road-rage, trolley-rage and similar phenomena – the challenge of being faced with violence in the workplace is not going to disappear overnight. As more staff complete the NVCI program, with overwhelmingly positive feedback, the objectives that staff will be equipped with advanced de-escalation skills and more likely to report incidents, leading to a safer workplace environment, are being met. This has generated several recommendations, primarily that NVCI training be adopted for all staff – clinical and non-clinical – as part of mandatory credentialing, and that the name be changed from Code Black Training to NVCI Education

References

Cummings, G, 2012, Editorial: Your leadership style – how are you working to achieve a preferred future? Journal of Clinical Nursing, 21, 3325-3327
Farrell, G A, Bobrowski, C B A, Bobrowski, P. 2006, scoping workplace aggression in nursing: findings from an Australian study, Journal of Advanced Nursing, 55(6):778
Goleman, D 2000, Leadership that gets results, Harvard Business Review, March-April, 78-90.
Greenfield, D. (2007). “The enactment of dynamic leadership.” Leadership in Health Services 20(3): 159-168.
Mannix J, Wilkes L & Daly J (2015) ‘Aesthetic leadership: Its place in the clinical nursing world’, Issues in Mental Health Nursing, Vol 36, No 5, pp 357-361
Stanley, D (2011), Clinical Leadership: Innovation into action, Melbourne: Palgrave Macmillan, pages 265-275

Biography

Karen has a varied background over the past 35 years, beginning her nursing career as a mental health nurse under the “old system” in the early 1980s. She returned to study at the University of Canberra in 2000, to complete a Bachelor of Nursing.  She has worked in the emergency department for over seven years after extended stints in remote health and ICU nursing. She has also practised in women’s health, general practice and drug and alcohol programs. Karen has recently diversified into teaching as a certified instructor in non-violent crisis intervention and works as a sessional teacher of the Diploma of Nursing at TasTAFE. Her other qualifications include Grad Certs in both Critical Care and Rural and Remote Health, as well as a Grad Dip in Emergency Nursing and expects to complete her Masters of Clinical Nursing degree in October 2016. Karen’s clinical interests are education, crisis intervention and an intense fascination with the pathophysiology of trauma, particularly brain injury.Her personal interests include a passion for travel and study of languages, animal welfare, playing netball, volleyball and softball, loud rock music and maintaining an organic mini-farm. Not least, she enjoys spending time with her family and spoiling her four grandchildren, and her greatest supporter through all her academic achievements is her husband David.

The patient safety implications of work-stress among ED nurses

Jacqueline C. Ingram1, Trudy Dwyer2, Kerry Reid-Searl3, Tania Signal4

1 Central Queensland University, Bruce Highway, Rockhampton, QLD, 4700, j.ingram@cqu.edu.au
2 Central Queensland University, Bruce Highway, Rockhampton, QLD, 4700, t.dwyer@cqu.edu.au
3 Central Queensland University, Bruce Highway, Rockhampton, QLD, 4700, k.reid-searl@cqu.edu.au
4 Central Queensland University, Bruce Highway, Rockhampton, QLD, 4700, t.signal@cqu.edu.au
This presentation explores the potential patient safety implications of work-stress among ED nurses. There is no doubt that burnout, compassion fatigue and secondary traumatic stress are among the greatest threats facing ED nurses in the 21st century. Understandably, the study of work-stress among ED nurses has boomed in recent years. The majority of this research has focussed upon the undeniably common and sometimes catastrophically negative impact it has on ED nurses themselves. The negative sequelae identified by past research ranges from sleep and mood disturbance, physical and mental illness to attrition from nursing. However, there is a growing acknowledgement that work-stress among nurses also manifests in demonstrable risks and negative outcomes for patients. While no ED-specific data is currently available, past research has shown that work-stress among nurses in a variety of settings has been associated with increased morbidity and mortality, reduced quality of care and the abuse or neglect of patients by nurses. Past research has also shown that burnout among nurses is associated with reduced engagement with formal reporting processes for adverse events and near misses. From an institutional perspective this clearly undermines the capacity for the early identification and management of potential risks and the prevention of avoidable harm to patients. Unfortunately, all past research into the patient safety implications of work-stress among nursing staff appears to have been limited to an ill-defined labile notion of stress or the narrow scope of burnout. While universally applicable as a measure of work-stress across diverse occupational groups, burnout does little to account for the novel context, manifestation and consequences of work-stress among professional carers. Therefore with a focus upon professional and ethical conduct, new research has just drawn to a conclusion which applies the more holistic measure of professional quality of life to the ED context and the patient safety implications of work-stress among ED nurses.

Biography

Jacqueline is a PhD candidate through Central Queensland University with almost 20 years ED nursing experience.  Jacqueline has completed undergraduate degrees in Nursing, Health Promotion and Health Education. She received 1st class Honours for her research into the abuse of ED nurses by their clients and colleagues. Jacqueline’s key areas of interest are emergency nursing, workplace violence, professional conduct, ethical decision making and patient’s rights.

Staff perception of a patient flow strategy for patients presenting to the ED with mental illness: A qualitative study

Nerolie Bost1,2, Amy N.B. Johnston1,2,3, Julia Crilly1,2,3

1 Gold Coast University Hospital Emergency Care, 1 Hospital Blvd, QLD 4215 Australia.
2 Menzies Health Institute Queensland, Griffith University Gold Coast campus QLD 4222 Australia
3 School of Nursing and Midwifery, Griffith University, Gold Coast Campus, QLD 4222 Australia

Background: Over recent years Emergency Department (ED) overcrowding and access block have been problematic in Australian hospitals. To reduce time to discharge and transfer from ED and admission to hospital, the National Emergency Access Target was introduced across all States. In one Queensland hospital ED, a targeted patient flow strategy was implemented in 2012 to improve time to assessment and treatment in ED and streamline the discharge process for patients who present to ED and are diagnosed with a mental illness. An outcomes evaluation of this strategy indicated that for this cohort, access block improved and overall ED length of stay for mental health patients decreased by 41 minutes over a 6 month timeframe1.

Objective: The aim of this study was to explore ED and mental health clinical staff perceptions of mental health care delivery in relation to the mental health patient flow strategy.

Methods:  This qualitative study used semi-structured interviews with four ED and four mental health clinicians. Interviews were digitally recorded and transcribed verbatim. Meaning was developed through inductive and deductive thematic analysis undertaken independently2 by three experienced researchers.

Findings: Three key themes emerged including: i) ‘Them and us: the gap’, ii) ‘patient ownership of and responsibility for patients’, and iii) ‘discordance in expectations around quality of care and time’.

References

  1. Bost, N., J. Crilly, and K. Wallen, The impact of a flow strategy for patients who presented to an Australian emergency department with a Mental Health illness. Int Emerg Nurs, 2015. 23(4): p. 265-73.
  2. Bogdan, R.C. and S.K. Biklin, Qualitative research for education: An introduction to theory and methods. 5th ed. 2007, Boston: Pearson Education Inc & Alleyn Bacon. 304.

Biography

Amy Johnston is a joint appointment research fellow, working between Griffith University and Gold Coast Hospital and Health Service (GCHHS), Emergency care, seconded from a senior lecturer position at Griffith University.  She has a background in tertiary nurse education, particularly in the biosciences. Her developing research strength in ED research is in collaboration with A/Prof Julia Crilly and the ED research office at GCHHS. Her love of clinical research is heartfelt and (hopefully) infectious. She is involved in HDR student supervision and onsite development of ED staff research skills.

 

Obesity and the emergency short stay unit

Marc Marquez1, William McGuiness3, Rachel Cross1,3, Biswadev Mitra1,2

1 Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
2 Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
3 La Trobe University School of Nursing and Midwifery, Alfred La Trobe Clinical School, Melbourne, Australia

Objectives: To evaluate the health service requirements of obese patients admitted to an Emergency Short Stay Unit (ESSU) and specifically compare length of stay (LOS), failure of ESSU management, and rates of investigations and allied health interventions among obese and non-obese patients.

Methods: A prospective cohort study, using convenience sampling was conducted. The body mass index (BMI) of participants was calculated and those with a BMI of ⩾30 were allocated to the obese group, and those that had a BMI of <30 to the non-obese group. Data collected included demographics, admission diagnosis, time and date of ESSU admission and discharge, discharge disposition, radiological investigations, and referrals made to allied health personnel during ESSU admission.

Results: There were 262 patients that were recruited sub-grouped into 127 (48.5%) obese participants and 135 (51.5%) non-obese participants with similar sex and diagnostic category distributions. The mean LOS in ESSU was similar – 11.5 h (95% CI: 9.9–13.1) for obese patients and, 10.2 h (95% CI: 8.8–11.6) for non-obese patients (p = 0.21). Failure rates of ESSU management, defined as inpatient admission to hospital, were also similar with 29 (22.8%) obese patients admitted to hospital compared to 25 (18.5%) non-obese patients (p = 0.39). Plain X-ray requests were significantly higher among obese patients (71.6 vs 53.3%; p = 0.002), as was the rate of allied health interventions (p = 0.001).

Conclusion: There was no significant difference in inpatient admission rates or LOS between obese and non-obese patients managed in the ESSU. Provisions for increased rate of investigations and allied health interventions for obese patients may facilitate timely assessment and disposition from ESSU.

Biography

Marc Marquez is a Clinical Nurse Specialist in the area of Emergency & Trauma nursing, with a background of six years clinical experience at The Alfred Hospital’s Emergency & Trauma Centre. Marc graduated from Victoria University with a Bachelor of Nursing in 2008. He has recently completed his Master of Nursing (Emergency Care) at La Trobe University, where an original research entitled ‘Obesity and the Emergency Short Stay Unit’ has been submitted and accepted by the International Emergency Nursing Journal for publication.  Since 2008, he’s had a variety of teaching experiences throughout different course levels, ranging from Certificate 3 & 4 Health Services courses to Initial Registration Course for Overseas Nurses (IRON). Marc has also been employed as a consultant and curriculum enhancer for IRON courses, including development of assessments and marking guides. He serves as a Nursing Officer for the Royal Australian Army Nursing Corps, and has been an active serving member of the Army Reserve for ten years. With a strong passion for the development of international healthcare standards, Marc is heavily involved with the Alfred Hospital’s international programs.

Life saved…What now? Lessons learned about Anaphylaxis Discharge Management from an Emergency Department (ED)

BATCHELOR Melanie 1, HUDSON Pam 2,

1 Allergy Clinical Nurse Flinders Medical Centre, Bedford Park, Southern Adelaide Local Health Network (SALHN).South Australia 5048. melanie.batchelor@sa.gov.au
2 Allergy Clinical Practice Consultant Nurse Flinders Medical Centre, Bedford Park, Southern Adelaide Local Health Network (SALHN). South Australia 5048. pam.hudson@sa.gov.au

Background: Acute, life-threatening systemic allergic reactions (anaphylaxis) are increasing with 1.6% of the population having a history of anaphylaxis1.

For patients and their carers the threat of further episodes can lead to significant lifestyle restrictions and psychological consequences.

Death from anaphylaxis is thought to be rare, however there is evidence that anaphylaxis fatality rates in Australia have increased over the last 16 years. This is in contrast with UK and USA – based studies that describe overall lower and static anaphylaxis fatality rates 2

Despite increased awareness of the risks associated with anaphylaxis, up to 50% of patients are discharged from Southern Adelaide Local Health Network (SALHN) ED’s without best practice anaphylaxis discharge management. Anecdotal evidence suggests this is not isolated to SALHN ED’s.

Since 2008, the SALHN Allergy/Clinical Immunology Service nurses have undertaken multiple clinical practice improvement (CPI) projects to understand and ultimately improve compliance with SALHN Anaphylaxis Management Guidelines.

Method: Anaphylaxis (grade 2 and 3) 3 presentations between 2008-2014 were identified using ICD- 10 coding for anaphylaxis and patient referral software (RFL).

Mixed methodology was applied to obtain information about the standard of care being delivered and included:

  • Facilitated incident monitoring
  • ED nurse questionnaire prior to “anaphylaxis blitz” education sessions
  • Patient/carer phone interview
  • Ad hoc clinical audits
  • Retrospective medical record review

Results: Clinical auditing of anaphylaxis discharge management identified:

  • 40% of patients received an Anaphylaxis Action Plan and EpiPen prior to discharge with appropriate instruction and education.
  • 40% of patients have their allergies recorded on case note alert systems.
  • 50% of patients are not referred for Allergy Specialist follow up

The content of anaphylaxis education in existing ED Nurses Clinical Development Pathway was explored in conjunction with senior ED nurses.

ED Nurses knowledge of anaphylaxis was accessed through a questionnaire (n= 40)

  • 75% could list the clinical features of anaphylaxis.
  • 33% could list the first-line treatment for anaphylaxis.
  • 73% recognised the need to observe patients for a biphasic reaction.
  • 17% could list the patient discharge management requirements.

To assist in addressing these gaps, additional clinical resources and tools were developed to assist staff to comply with anaphylaxis management guidelines.

These include:

  • Specific Allergy Specialty referral form inclusive of Anaphylaxis Discharge Checklist sticker to enable direct ED referral
  • Anaphylaxis Discharge Checklist poster and patient instruction aids
  • Consumer follow-up after anaphylaxis information
  • Facilitation of an ED nurses “Anaphylaxis Blitz”
  • Identifying and up skilling of Anaphylaxis Nurse Champions and Pharmacy staff.
  • Developing SALHN Intranet- based anaphylaxis clinical resource page to assist  medical, nursing and pharmacy staff with acute and discharge anaphylaxis management

Conclusion: Embedding anaphylaxis discharge education as a competency amongst ED nursing staff will assist in reducing the omission of care to this vulnerable patient cohort.  ED medical, nursing and pharmacy staff require easy access to clinical resources to provide evidenced base care and appropriate discharge planning to patients presenting with anaphylaxis.

  1. Pumphries RS. Lessons for management of anaphylaxis from study of fatal reactions Clin Exp Allergy 2000;30 1144-50.
  2. Mullins R et al. Increase in anaphylaxis fatalities in Australia 1997-2013. In press
  3. Brown SGA Clinical features and severity grading of anaphylaxis J Allergy Clin Immunol 2004 Aug; 114(2): 37: 1-6

Biography

Background: Registered Nurse.  Bachelor of Nursing, Certificate in Neonatal Nursing and Allergy Nursing Professional Associations:Associate member of Australasian Society of Clinical Immunology and Allergy (ASCIA)  Clinical Nurse in Allergy/ Clinical Immunology at Flinders Medical Centre, providing specialist care to paediatric & adult patients with particular focus on improving patient outcomes through education and applying current research to nursing practice within a multidisciplinary team. Building network opportunities with emergency care providers and community to  enhance patient- focused care to individuals and their carers.

Exploring the behavioural manifestation of work-stress among ED nurses at the point of patient care

Jacqueline C. Ingram1, Trudy Dwyer2, Kerry Reid-Searl3, Tania Signal4

1 Central Queensland University, Bruce Highway, Rockhampton, QLD, 4700, j.ingram@cqu.edu.au
2 Central Queensland University, Bruce Highway, Rockhampton, QLD, 4700, t.dwyer@cqu.edu.au
3 Central Queensland University, Bruce Highway, Rockhampton, QLD, 4700, k.reid-searl@cqu.edu.au
4 Central Queensland University, Bruce Highway, Rockhampton, QLD, 4700, t.signal@cqu.edu.au

This presentation provides preliminary results and an overview of recent research into the behavioural manifestation of work-stress among ED nurses at the point of patient care. The main aim of this research is to explore if/how work-stress among ED nurses impacts upon their professional conduct towards patients and the conflict resolution tactics they employ within the therapeutic relationship. Additionally, this research will explore whether demographic characteristics including work-experience, abuse at the hands of patients, work environment and training are predictive of work-stress, professional conduct or conflict resolution skills.  Historically, it is well established that work-stress such as burnout, compassion fatigue, secondary traumatic stress and poor professional quality of life are common among ED nurses and can have devastating personal consequences. While much is already known about the ways in which work-stress affects nurses’ health and home-lives, nothing is really known about if/how work-stress tangibly affects their behaviour during day-to-day interactions with patients. As such, this research is the first of it’s kind and addresses a significant gap in nursing knowledge.  Due to the underexplored nature of the subject, the current research adopts a sequential explanatory mixed method approach.  Phase-one consists of the collection of quantitative data via an online survey.  Work-stress will be measured using the ProQOL V survey while an adaptation of the Conflict Tactics Scale will be used to assess professional conduct and conflict resolution skills. Analysis of the quantitative data will then inform the specific content of phase-two consisting of semi-structured telephone interviews. Finally, quantitative and qualitative data will be amalgamated to produce a contextualised understanding of the problem.  With an emphasis on ED nurses’ lived experiences and the inclusion of real-life scenarios this research seeks to give voice to font-line ED nurses so that those outside this specialist field can understand the unique challenges and pressures faced by ED nurses and the effect this might have on the nurse-patient relationship.

Biography

Jacqueline is a PhD candidate through Central Queensland University with almost 20 years ED nursing experience. Jacqueline has completed undergraduate degrees in Nursing, Health Promotion and Health Education. She received 1st class Honours for her research into the abuse of ED nurses by their clients and colleagues. Jacqueline’s key areas of interest are emergency nursing, workplace violence, professional conduct, ethical decision making and patient’s rights.

Development of a statewide evidence based Guideline – management of patients with acute severe behavioural disturbance in emergency departments

Sarah Marmara1, Dr Sally McCarthy2

1 NSW Ministry of Health Locked bag 961 North Sydney NSW 2059
2 NSW Agency for Clinical Innovation, PO Box 699 Chatswood, NSW 2067

Development of a statewide evidence based Guideline – Management of Patients with Acute Severe Behavioural Disturbance in Emergency Departments

Violence and aggression in emergency departments (EDs) is increasingly common and increasingly reported in the media. The public interest in behaviour related to use of methamphetamines is also increasing. Patients who present to emergency departments with severe behavioural disturbance, whether through voluntary or involuntary presentation, can require significant use of ED resources to safely assess and manage their care. Inconsistent practice can result in poorer outcomes for patients, and potential risks to staff.

In NSW, it became clear that variation existed among EDs in relation to the management of patients presenting with acute severe behavioural disturbance. Based on clinician feedback through the statewide ‘Whole of Health Program’, an evidence based guideline was developed and implemented. The Guideline follows the key principles of: assessment of the patient in a safe environment; use of de-escalation techniques to allow for assessment; ensuring adherence to legal requirements;  sedation of the patient whose behaviour puts them or others at immediate risk of harm; post sedation care of the patient; disposition decisions and transport of the patient from the ED to the most appropriate place for continuation of their care.

Despite its evidence base, controversy surrounds use of the Guideline for certain clinical groups outside ED due to its inclusion of the drug Droperidol. Implementation of the Guideline has influenced clinical practice outside the ED, in particular prompting a review of clinical guidelines by NSW Ambulance for patients with acute severe behavioural disturbance.

Biography

Sarah Marmara is the Principal Policy Advisor, Emergency Access at the NSW Ministry of Health. Sarah has 20 years’ experience as an Emergency Nurse in a variety of senior nursing roles including Clinical Nurse Consultant and Nurse Educator. Sarah is passionate about supporting Emergency Department staff to enable the delivery of high quality, safe care for patients as well as ensuring that statewide policy on the delivery of emergency care is sensible and applicable in the clinical environment.

Culturally and Linguistically Diverse patients in the Emergency Department: A clinical redesign initiative

Hannah Putland1, Angela Oliphant 2, Vikrant Kalke 3

1 Princess Alexandra Hospital Emergency Department and Metro South Health Equity and Access Unit , Woolloongabba, QLD 4102, hannah.putland@health.qld.gov.au
2 Logan Hospital Emergency Department and Metro South Health Equity and Access Unit, Meadowbrook, QLD, 4131, angela.oliphant@health.qld.gov.au
3 Metro South Health Equity and Access Unit, Eight Mile plains, 4113, vikrant.kalke@health.qld.gov.au

Metro South Health is the most culturally diverse health service in Queensland, with an estimated 28% of the population in the region being born overseas and 41% have a first language other than English  (Queensland Government, 2016). The Metro South Health Equity and Access Unit (HEAU) identified that approximately 15.5% of patients that present to Metro South Emergency Departments (EDs) are patients from Culturally and Linguistically Diverse (CALD) backgrounds.

The HEAU partnered with a Metro South ED to initiate a four month project aimed at; identifying deficiencies in care for CALD patients within the ED. This project aimed to improve ED processes for CALD patients and remove barriers to patient centered care for CALD patients in this ED. Concepts derived from the project would then be evaluated and ones found to be effective would be implemented throughout Metro South’s ED’s.

Utilising a clinical redesign methodology the project team finalised planning, developed a steering committee of key stakeholders and began exploring the CALD patient journey. To understand the CALD patient journey, data was collected about the staff experience via a staff survey (52% response rate) and the patient perspective via patient interviews (67 patients participated). Additionally 19 patients’ journeys were mapped from triage to admission or discharge, attempting to identify key points such as; when to flag the need for interpreters, when should interpreters be utilised and the impact of interpreters on length of stay and re-presentation. Quantitative data was collected via the Emergency Department Information System (EDIS) and the Interpreter Services Information System (ISIS) mostly pertaining to patient demographics, interpreter provision, National Emergency Access Targets (NEAT) and length of stay.

Through the diagnostic phase of the project the multifaceted approach to collecting information allowed a comprehensive insight into the CALD patient journey. It was identified that approximately 1200 patients presented a month from CALD backgrounds and on average CALD patients spend 40 – 60 minutes longer in the ED. Furthermore it was identified that interpreter provision for patients that request interpreters at triage is around 25 %.

The solution implementation phase of the project was focused on ensuring the solutions would address the deficiencies identified in the diagnostic phase of the project. Initially the team developed and updated resources to aid in interpreter engagement and promotion, communication tools, the development of a protocol and centralising all resources for quick and easy access. Subsequently a large emphasise was placed on education for all ED staff both locally and across Metro South ED’s.

Project re-evaluation has been planned for early 2017, however 57% of ED staff received education from the ED CALD project team and since the project commencement Interpreter Provision has already increased by 6%.

References

Queensland Government. (2016, April 5). Culturally and Linguistically Diverse (CALD) people . Retrieved June 20, 2016 from Queensland Government Health Equity and Access: https://metrosouth.health.qld.gov.au/health-equity-and-access/culturally-and-linguistically-diverse-cald-people

Biography

Hannah Putland has spent the last 6 years working in a large tertiary Emergency Department in QLD. After completing her Masters in Emergency Nursing she focused her attention to the Patient Focus Working Group where she developed an interest in Quality projects.

Angela Oliphant started her nursing career in the vascular ward  at a large Queensland hospital. She has worked at the Logan Emergency Department for the last five years, assisting in the transition to a new department. Recently Angela has enjoyed working of quality projects.

CARE-PACT Mobile emergency assessment, care and treatment team: An integral component of an integrated approach to management of acute health-care needs of residents of aged care facilities

Chia Hsin Tony Hsiung1,

1 Nurse Practitioner, Princess Alexandra Hospital, CARE-PACT/Redland Hospital Emergency Department, Brisbane, QLD, tony.hsiung@health.qld.gov.au

The ageing population presents a demand management challenge for modern health care systems. Emergency departments (EDs) are often utilized as the gateway to medical care and are being increasingly faced with growing numbers of geriatric presentations.  This population causes disproportionate impacts on EDs, due to their requirement for more intensive investigation, longer lengths of stay (both in ED and inpatient beds). Whilst the transfer of RACFs residents to the ED may be necessary, many conditions, including pain and symptom relief, indwelling catheter care, wound management and antibiotic therapy can be managed within the RACF with support, skill and expertise. The risk of adverse events for RACF residents’ especially cognitive impaired groups who present to hospitals is well documented. On the other hand, hospital transfers are often distressing for the residents and often contribute to high incidence of pressure area injuries and delirium.

Current acute care substitution models predominantly focus on traditional patient cohorts and fail to consider the unique, accredited professional environment of RACFs. In the current RACF model of care, there is often a failure to address the complex array of factors that influence RACF staffs ability to care for patients in the facility with acute medical needs resulting in unplanned and avoidable presentations to ED, including the RACF staff skill mix and resources, perceived risk, lack of medical support and patient functional and cognitive impairment. Patients and families consistently express desire to receive acute treatment in their home environments. Further, it is well-documented that transferring elderly patients to ED can be distressing and increases the risk of iatrogenic complications. CARE-PACT (Comprehensive Aged Residents Emergency and Partners in Assessment, Care and Treatment) is a partnership between Residential Aged Care Facilities (RACFs), General Practitioners (GPs), Primary Care providers and the Health and Hospital Service. The service aims to support GPs and RACF staff in the provision of best care for residents of RACFs with acute health care needs, in the most appropriate location.  The aim of the CARE-PACT is to deliver high-quality gerontic nursing and emergency specialist assessment, collaborative care planning, skill sharing across the care continuum and an individualised resident-focused approach. Implementing a service with specific focus and training in gerontology can be beneficial across the care continuum in terms of improving gerontic assessment skills, but also provides the opportunity to improve care for this vulnerable group.

One component of the integrated care program, CARE-PACT, entails a mobile ED assessment, care and treatment team.  This is operationally led by an emergency trained nurse practitioner, with further training and interest in geriatric medicine, with clinical governance held by the programs’ dedicated ED physicians.  This emergency substitutive care service and demand management program provides an ED equivalent assessment within the RACF.  It aims to improve quality of emergency healthcare to this vulnerable geriatric population, whilst reducing exposure to the often frightening and high risk ED environment.  The mobile ED assessment service reviews and manages RACF residents with selected acute healthcare needs in the resident’s own environment.   This article provides an in-depth description of the CARE-PACT mobile ED assessment service, with case examples to demonstrate the potential benefits of this program, both at patient and systems level.

Biography

I am a Master of Nursing student from Monash University, Australia. I am particularly interested in disaster preparedness and Emergency Department triage practices. I have also been involved in honours project on “Knowledge, Attitudes and Practices among University Students towards Psychological Counseling”. I administered survey tool and administered quantitative analysis. I have published my research project in Publication at Forum of Sri Lanka Medical Educationists first academic session.