Do consumers who identify as Muslim experience cultural sensitive care (CSC) in the Emergency Department (ED)? A scoping review

Amy Johnston1,5, Mingshuang Ding2,3, Omer Mohammed3, Debbie Massey4
1Department of Emergency Medicine, Princess Alexandra Hospital, Metro South,2School of Nursing, Faculty of Health, Queensland University of Technology,3Department of Emergency Medicine, Queen Elizabeth II Jubilee Hospital,4School of Nursing, Midwifery and Paramedicine, Faculty of Health, University of Sunshine Coast,5School of Nursing, Midwifery and Social Work, The University of Queensland

Background: Lack of awareness about cultural and religious values and beliefs of patients presenting to emergency departments (EDs) can compromise patient care and safety. Muslim Australians represent the fastest growing religious demographic group, with over a 77% growth in the last decade [1]. The changing face of Australian population requires that Australian health care consider carefully the dominant western cultural paradigm currently underpinning of health care delivery [2-5]. This is particularly critical in EDs, commonly the entry point into healthcare services
Objectives: This scoping review explored evidence of key components and impacts of cultural safe care (CSC) in EDs for staff and care consumers who identify as Muslim.
Methods: A systematic search using electronic (five databases) and heading searching methods for primary research published between 2006 and 2017 was undertaken; followed by a rigorous screening and quality appraisal process. Included articles were assessed for similarities and differences, the content was grouped and synthesized and tested for clinical salience using the six-staged Arksey and O’Malley methodological framework. The Mixed Method Assessment Tool was used to appraise the quality of included literature.
Results: Three studies were included in the analysis.
Conclusion: Religious beliefs and practices are common. Such beliefs and practices could influence patients’ understanding of their conditions, their acceptance of care delivery, their processes of decision-making, and their commitment to treatment regimens and coping strategies. They could also impact on care seeking behaviours and on family and community acceptance of care delivery. There is a serious lack of evidence around the delivery of culturally safe care in EDs locally and internationally. While many EDs may have procedure documents or staff care guides, it is unclear on what basis these have been developed, as there is minimal published evidence exploring any issues around provision of CSC to Muslim ED care consumers


Biography:

Amy Johnston is a conjoint senior lecturer in Emergency Care, based between Metro South Emergency Department (PAH) and School of Nursing, Midwifery and Social Work, The University of Queensland. She is deeply committed to bringing research skills and outcomes to emergency staff. She is a widely published and cited academic and registered nurse with experience in a range of research techniques. 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.

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.

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

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

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


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

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

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

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

Objectives:

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

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

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

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


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

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

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

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


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

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

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

Introduction

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

Objective:

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

Method:

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

Results:

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

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


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

 

Escalation of care for clinical deterioration in the ED

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

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

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

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

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

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


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

Occupational Violence and Aggression in the Emergency Department

Mrs Sharon Klim1, Doctor Ainslie Senz1, Ms. Elisa Ilarda1, Professor Anne Maree Kelly1
1Western Health, St Albans, Australia

Background:  Violence in Emergency Departments (ED) is a significant problem world-wide.  Emergency settings are considered high risk areas with the number of incidents of staff exposure to violence ranging from 60 to 90% (Taylor and Rew, 2010). Despite some research being carried out in Emergency Departments few studies have evaluated the effectiveness of violence management and prevention strategies (Lau, Magarey and Cutcheon, 2005). Most research has focused on the rates of violence and the impact on staff.  There has been a significant gap in research studies so far, to provide a framework and practical interventions for guiding evidence based practice (Taylor and Rew, 2010).
Aim:  To review the outcome of implementation of the Bröset Violence Checklist (BVC); an evidence based violence risk assessment tool to the ED.
Methodology:  A two part study:

  1. A before-and-after survey; to assess changes to staff knowledge, attitudes, perceptions and confidence with respect to risk assessment for aggression/ violence.
  2. A before-and-after point prevalence data collection period; to compare risk assessment rating distribution between unstructured clinical assessment and the BVC.

Results: 76 Pre-implementation and 83 Post-implementation surveys completed.  In both surveys >70% of staff reported being subjected to verbal or physical aggression/violence and no change in confidence to prevent violence. However, there were statistically significant changes in the screening of patients for violence/ aggression risk, and improved confidence in staff ability to assess risk of violence and to identify risk factors. For the point prevalence component, in the pre-implementation cohort, 30% of patients underwent risk assessment (74/250). This increased to 82% after implementation (p<0.001). There was no difference in the distribution of assessed risk (low, moderate, high) after implementation with approximately 1% being assessed as high risk.
Conclusion: Occupational violence is common in ED. Prevention, including risk assessment, is a key strategy for mitigation. Using an assessment tool improves staff confidence in assessing risk, and provides a strategy for early identification and intervention. Reducing violence in all healthcare settings improves staff and patient safety and experience for all patients and visitors.


Biography:
Sharon Klim is a research coordinator for the Joseph Epstein Centre for Emergency Medicine Research at Western Health. Sharon is also a Clinical Nurse Specialist in the Emergency Department at Footscray Hospital where her research knowledge and experience is often sought with assisting staff with quality improvement projects and other innovative ideas.  Sharon’s area of clinical expertise is clinical handover and leadership.

IV cannula use on disposition of Emergency Department patients

Miss Rebekah Bernoth1
1John Flynn Hospital, Tugun, Australia

Peripheral intravenous cannulas are inserted in emergency departments at a high volume. There are various uses for these cannulas, including pathology collection, pain relief, medication administration and intravenous fluid therapy while in the Emergency Department (ED). When a patient is transferred to the ward from the ED the IV cannula is left intact though it may not be utilised as part of care on the ward. The issue examined in this research study is whether this practice increases the risk for infection or trauma to the site of insertion and whether the cannula should be removed at the end of the emergency stay before being discharged to the ward. Our objective is to safely manage our patients treatment and do this by reducing the risk of infection.

Methodology: We have studied 240 random peripheral intravenous cannula insertions from one private ED over a 12 month period. This retrospective qualitative research collected data regarding the insertion at the ED, the use of the cannula in ED, the usage of the cannula on the ward post discharge from ED, infection at site and the removal time of the cannula.
Results: The findings in this data is that over 50% of patients who are sent to the ward with a cannula inserted did not have their cannula used for any treatment and therapy of any sort. Over 60% of the cannulas that were not used on the ward remained insitu for 48 or more hours.
Implications: The results of this study leads to the further discussion on whether IV cannulas should be removed at the end of the ED stay in order to reduce the potential for infection as well as removing the task of the ward nurses flushing the cannula, redressing the site and documentation according to the hospital policy on management of the IV cannula.

 


Biography:
Rebekah Bernoth is a clinical nurse at John Flynn Hospital Emergency Department. Rebekah has been a nurse for 17 years and in that time practised in a wide scope of nursing including medical, surgical, pain management and speaking at overseas conferences before spending many years in Intensive Care and now in an Emergency Department. She is an academic tutor at Southern Cross University, facilitates TAFE and university students in hospital settings. Rebekah has spent most of her years post graduating from Bachelor of Nursing furthering her education and is currently in the middle of her second Masters in Emergency Nursing. She enjoys the study and keeping up with the every changing nursing practises and new therapies with the drive to not stop studying and learning. She is an advocate for the innovation of best-evidence practise to promote better outcomes for patients and staff satisfaction. Rebekah has had a passion for nursing since a young age of 6yrs and never considered another career. Rebekah believes in the quote “When you’re a nurse you know that every day you will touch a life or a life will touch yours”, proving to be true with many experiences and challenges over her nursing career.

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

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

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

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

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

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

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