'I've got to go in there with my armour on': Adverse Childhood Experiences Among Adults Who Frequently Attend Emergency Departments.

Frequent presentations to emergency departments contribute to increased service demands and healthcare costs. Literature suggests these adult presentations may be influenced by childhood adversity. This qualitatively driven, mixed methods study explored the self-perceived role of childhood adversity in the health of adults who frequently attended Australian Emergency Departments and their perceptions of the healthcare they received. Data were collected using validated instruments and semi-structured interviews with 12 purposefully sampled adults who frequently attended emergency departments. Qualitative data were analysed using interpretive phenomenological analysis. Three major themes were identified-The experience of childhood adversity: articulating challenges related to childhood trauma, and the subsequent impacts on participants' health, behaviours, relationships and sense of control; Pursuing safety: exploring action participants took to keep themselves and others safe, with this requirement extending into adulthood and influencing Emergency Department presentations; and Seeking humanising healthcare: identifying challenges participants experienced while seeking care in the Emergency Department. Participants perceived their mental health to be profoundly affected by their past experiences of trauma, leaving them feeling vulnerable at times and more likely to experience re-traumatisation in the Emergency Department. Feelings of stigmatisation during Emergency Department encounters led participants to employ self-protection strategies creating further barriers to recovery. Participants described Emergency Departments as often failing to comprehensively address their healthcare needs. They offered suggestions for more effective care interventions. Findings highlight the need for further research to inform policy and practice when designing and implementing interventions for these adults. Consolidated Criteria for Reporting Qualitative Research (COREQ) guided study reporting.

Exploring clinicians' knowledge and attitudes toward the care needs of complex adult users of an Emergency Department: A descriptive mixed methods study.

BACKGROUND: Adults who frequently present (FPAs) to emergency departments (EDs) often have a history of adverse childhood experiences (ACEs) and related adult health sequelae. Implications for ED care of this group remains poorly understood. This study explored clinicians' knowledge and attitudes toward the care needs of FPAs who have an ACEs history, providing preliminary evidence to inform further research and interventions. METHODS: A purposive sample of ED clinicians completed an investigator developed mixed-methods survey. Descriptive statistics and content analysis were applied. RESULTS: Forty-three ED clinicians completed the survey. Most perceived that ACEs were common among FPAs and influenced their ED presentations. Clinicians were more aware of the psychosocial impacts of ACEs than the risks to physical health. While most clinicians agreed that FPAs should be asked about ACEs for management planning, most never asked, describing multiple barriers to doing so. Consumer's healthcare needs were often described as unmet by clinicians who desired additional support to provide care for this group. CONCLUSIONS: This study highlights clinicians' perceptions of gaps in healthcare for this patient group and introduces requirements for appropriate knowledge and resources to partner with consumers to provide patient-centred and trauma-informed health care responses.

Fast-Track Training in Emergency Department During the COVID-19 Pandemic: Evaluation of a Hybrid Education Model.

INTRODUCTION: Emergency department (ED) fast track (FT) for the ambulatory, minor injury patient cohort requires rapid patient assessment, treatment, and turnover, yet specific nursing education is limited. The study aimed to test the feasibility and staff satisfaction of an education program to expand nursing skills and knowledge of managing FT patients during the COVID-19 pandemic. METHODS: This quasi-experimental study, including self-rating surveys and interviews, assessed the pre- and postimplementation of an education program for nurses working in FT in a metropolitan hospital ED in Australia. Hybrid (face-to-face and Teams) education sessions on 10 topics of staff-perceived limited knowledge were delivered over 8 months. RESULTS: Participants demonstrated higher knowledge scores after the implementation of short online education sessions to cover the core facets of minor injury management. Overall staff satisfaction with the program was high. Interview discussions involved three key themes, including "benefits to staff learning," "positive impact on patient care and flow," and "preferred mode of delivery." CONCLUSIIONS: Recorded education sessions on minor injury topics for nurses working in FT have proved effective, and this program has now become a core facet of ED education in our hospital.

Assessing cardiovascular disease risk in women with a history of hypertensive disorders of pregnancy: A guidance paper for studies using administrative data.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) are a major cause of maternal morbidity and mortality, and their association with increased cardiovascular disease (CVD) risk represents a major public health concern. However, assessing CVD risk in women with a history of these conditions presents unique challenges, especially when studies are carried out using routinely collected data. OBJECTIVES: To summarise and describe key challenges related to the design and conduct of administrative studies assessing CVD risk in women with a history of HDP and provide concrete recommendations for addressing them in future research. METHODS: This is a methodological guidance paper. RESULTS: Several conceptual and methodological factors related to the data-generating mechanism and study conceptualisation, design/data management and analysis, as well as the interpretation and reporting of study findings should be considered and addressed when designing and carrying out administrative studies on this topic. Researchers should develop an a priori conceptual framework within which the research question is articulated, important study variables are identified and their interrelationships are carefully considered. CONCLUSIONS: To advance our understanding of CVD risk in women with a history of HDP, future studies should carefully consider and address the conceptual and methodological considerations outlined in this guidance paper. In highlighting these challenges, and providing specific recommendations for how to address them, our goal is to improve the quality of research carried out on this topic.

Modelling a two-stream emergency department segregation and admission system from COVID-19 early rapid antigen testing: A pilot study.

OBJECTIVE: Many factors influence patient flow through an ED, including streaming, treatment spaces and staff resources. This pilot study explored and compared real time patient flow using a single-stream system versus varying configurations of possible two-stream systems using computer simulation. METHODS: Simulation modelling was used to assess the delay in treatment of a rapid-antigen-tested-based, two-stream model for patient flow through ED during the peak phase of the COVID pandemic. RESULTS: Modelling two-stream configuration for all patients (minimum time to be seen for both COVID-positive and COVID-negative patients) showed that in the case study ED, a two-stream system and linked changes in bed configuration for managing the risks of infection can impact delays in treatment. CONCLUSIONS: Data-driven modelling within specific clinical settings can inform the (in)efficiency of patient flow processes and help clinicians and managers make evidence-based decisions about patient transition through EDs. This can assist with reconfiguration of ED patient streaming particularly during periods of unique need, such as the recent COVID-19 pandemic.

The development and validation of a standardised eight-station OSCE for registration of undergraduate nursing students: A Delphi study.

AIM: To develop and validate a set of OSCEs for use as a nationally applicable final exam of undergraduate nursing students' clinical and professional competencies. BACKGROUND: Tertiary recommendations for nursing registration require student achievement of a prerequisite level of both nursing knowledge and skill. Assessment of nursing skills prior to provision of nursing registration is an increasingly important focus of university nursing education. Objective Structured Clinical Examinations (OSCEs) are an appropriate tool for assessing the competencies of nursing students, but the mode and content of OSCEs varies widely. Thus, for nationally-based registration, development of a standardized set of OSCEs to determine the clinical competence of nursing students is important. DESIGN: A modified Delphi study, informed by a systematic scoping review of relevant literature. METHODS: A two-phase study was conducted. Initially, a scoping review was conducted to establish internationally agreed competences for graduating nursing students. These were included in an online questionnaire send to national experts to develop a validated and accepted nursing competency framework and associated implementation strategies. This was round 1 of a three-round modified Delphi study. A Content Validity Index (CVI) was calculated and thematic analysis was used to analyze the experts' opinions. RESULTS: Details of a set of OSCEs for final exam of undergraduate nursing students were developed and validated. These OSCEs included nine competencies addressed in eight 10-minute stations. CONCLUSION: A 'best-practice' OSCE evaluation system, designed from both international literature and the opinions of nation-wide experts was achieved. This well-designed OSCE was shown to be a reliable and valid method for assessing the clinical competence of nursing students. It reflected global procedures as well as the local conditions and Iranian expectations. The results of this study can be used by nursing schools across the country. They can also be used to model equivalent development of locally relevant OSCEs in countries around the world.

Factors impacting emergency department clinicians' peripheral intravenous catheter practice: A qualitative analysis.

BACKGROUND: Peripheral intravenous catheters (PIVCs) are commonly used devices in emergency departments (EDs), and yet relatively little is known about factors influencing Australian clinicians' adherence to the national PIVC quality and safety Standard. AIMS: To explore attitudes and experiences of ED clinicians around PIVC insertion and care processes. METHODS: This study used an exploratory qualitative approach to analyse written responses to open-ended questions included in an online national (mixed data) survey. Snowballing methods were used to gather responses. Deductive analysis was used to analyse open-ended questions regarding practice and Standard adherence. RESULTS: There were 340 written responses, mainly from nurses in public EDs, who reported suboptimal practices regarding idle catheters, lack of patient participation in care, antecubital fossa insertion, multiple insertion attempts, inadequate site preparation, poor documentation and insufficient review of PIVC. The main factors inhibiting ED clinicians from adhering to the Standard includes inadequate knowledge, perceptions of infeasibility, disbelief in evidence, ambiguous responsibilities, habitual practice, insufficient training, lack of recognition of good practice and inadequate engagement. CONCLUSION: The factors that impact ED clinicians' PIVC Standard adherence are complex and multifactorial. Strategies and interventions are needed to facilitate the implementation of the Standard into daily practice and achieve sustainable behaviour change.

Systematic review of validated case definitions to identify hypertensive disorders of pregnancy in administrative healthcare databases.

BACKGROUND: Administrative data are frequently used to study cardiovascular disease (CVD) risk in women with hypertensive disorders of pregnancy (HDP). Little is known about the validity of case-finding definitions (CFDs, eg, disease classification codes/algorithms) designed to identify HDP in administrative databases. METHODS: A systematic review of the literature. We searched MEDLINE, Embase, CINAHL, Web of Science and grey literature sources for eligible studies. Two independent reviewers screened articles for eligibility and extracted data. Quality of reporting was assessed using checklists; risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool, adapted for administrative studies. Findings were summarised descriptively. RESULTS: Twenty-six studies were included; most (62%) validated CFDs for a variety of maternal and/or neonatal outcomes. Six studies (24%) reported reference standard definitions for all HDP definitions validated; seven reported all 2×2 table values for ≥1 CFD or they were calculable. Most CFDs (n=83; 58%) identified HDP with high specificity (ie, ≥98%); however, sensitivity varied widely (3%-100%). CFDs validated for any maternal hypertensive disorder had the highest median sensitivity (91%, range: 15%-97%). Quality of reporting was generally poor, and all studies were at unclear or high risk of bias on ≥1 QUADAS-2 domain. CONCLUSIONS: Even validated CFDs are subject to bias. Researchers should choose the CFD(s) that best align with their research objective, while considering the relative importance of high sensitivity, specificity, negative predictive value and/or positive predictive value, and important characteristics of the validation studies from which they were derived (eg, study prevalence of HDP, spectrum of disease studied, methodological rigour, quality of reporting and risk of bias). Higher quality validation studies on this topic are urgently needed. PROSPERO REGISTRATION NUMBER: CRD42021239113.

Introducing a Digital Occupational Violence Risk Assessment Tool Into an Emergency Department: A Pilot Implementation Study.

INTRODUCTION: Occupational violence in emergency departments is prevalent and detrimental to staff and health services. There is an urgent call for solutions; accordingly, this study describes the implementation and early impacts of the digital Queensland Occupational Violence Patient Risk Assessment Tool (kwov-pro). METHODS: Since December 7, 2021, emergency nurses have been using the Queensland Occupational Violence Patient Risk Assessment Tool to assess 3 occupational violence risk factors in patients: aggression history, behaviors, and clinical presentation. Violence risk then is categorized as low (0 risk factors), moderate (1 risk factor), or high (2-3 risk factors). An important feature of this digital innovation is the alert and flagging system for high-risk patients. Underpinned by the Implementation Strategies for Evidence-Based Practice Guide, from November 2021 to March 2022 we progressively mobilized a range of strategies, including e-learning, implementation drivers, and regular communications. Early impacts measured were the percentage of nurses who completed their e-learning, the proportion of patients assessed using the Queensland Occupational Violence Patient Risk Assessment Tool, and the number of reported violent incidents in the emergency department. RESULTS: Overall, 149 of 195 (76%) of emergency nurses completed their e-learning. Further, adherence to Queensland Occupational Violence Patient Risk Assessment Tool was good, with 65% of patients assessed for risk of violence at least once. Since implementing the Queensland Occupational Violence Patient Risk Assessment Tool, there has been a progressive decrease in violent incidents reported in the emergency department. DISCUSSION: Using a combination of strategies, the Queensland Occupational Violence Patient Risk Assessment Tool was successfully implemented in the emergency department with the indication that it could reduce the number of incidents of occupational violence. The work herein provides a foundation for future translation and robust evaluation of the Queensland Occupational Violence Patient Risk Assessment Tool in emergency departments.

Production of Nano Hydroxyapatite and Mg-Whitlockite from Biowaste-Derived products via Continuous Flow Hydrothermal Synthesis: A Step towards Circular Economy.

Biowastes from agriculture, sewage, household wastes, and industries comprise promising resources to produce biomaterials while reducing adverse environmental effects. This study focused on utilising waste-derived materials (i.e., eggshells as a calcium source, struvite as a phosphate source, and CH3COOH as dissolution media) to produce value-added products (i.e., calcium phosphates (CaPs) derived from biomaterials) using a continuous flow hydrothermal synthesis route. The prepared materials were characterised via XRD, FEG-SEM, EDX, FTIR, and TEM analysis. Magnesium whitlockite (Mg-WH) and hydroxyapatite (HA) were produced by single-phase or biphasic CaPs by reacting struvite with either calcium nitrate tetrahydrate or an eggshell solution at 200 °C and 350 °C. Rhombohedral-shaped Mg-WH (23-720 nm) along with tube (50-290 nm diameter, 20-71 nm thickness) and/or ellipsoidal morphologies of HA (273-522 nm width) were observed at 350 °C using HNO3 or CH3COOH to prepare the eggshell and struvite solutions, and NH4OH was used as the pH buffer. The Ca/P (atomic%) ratios obtained ranged between 1.3 and 1.7, indicating the formation of Mg-WH and HA. This study showed that eggshells and struvite usage, along with CH3COOH, are promising resources as potential sustainable precursors and dissolution media, respectively, to produce CaPs with varying morphologies.

Emergency nursing nurse sensitive indicators: An integrative review.

BACKGROUND: Nurse sensitive indicators (NSIs) capture the outcomes of each nursing function impacted by nursing care. NSIs are critical in clarifying foci for emergency nurses when providing care in the emergency department (ED). OBJECTIVE: To establish NSIs key to emergency nursing from existing published literature. METHODS: Ten databases were searched as well as grey literature and Google Scholar in the development of data for this integrative review. Articles underwent a title and abstract review to establish inclusion/exclusion suitability followed by a full text critical appraisal. Data were extracted, synthesized, and analyzed using a structured process. RESULTS: Twenty-eight emergency nursing NSIs were identified from three included studies, with little consensus across the literature. The NSIs established in the literature reflected a broad range of non-specific technical skills. Overall, the quality of the included articles was low due to factors including study design and high risk of bias. CONCLUSIONS: The constrained range of NSIs and the limited literature exploring the outcomes of emergency nursing care perhaps reflects a wide ranging and seemingly evolving scope of emergency nurses. Further research is needed to delineate emergency nursing NSI, perhaps underpinned by a clear definition of an emergency nurse in terms of capability statements, core skills and defining attributes.

Inter-rater reliability of the occupational violence risk assessment tool for emergency departments.

BACKGROUND: The three-item occupational violence (OV) risk assessment tool was developed and validated for use in emergency departments (EDs). It prompts review of each patient's aggression history, behaviours, and clinical presentation. However, confidence around representativeness and generalisability are needed before widescale adoption; hence we measured the inter-rater reliability of the tool among a large group of emergency nurses. METHODS: A cross-sectional study was conducted between Sep 2021 and Jan 2022. Nurses were directed to a website that hosted an e-learning module about the tool. They were asked to apply the tool to two video scenarios of typical patient presentations. Demographic data, including years of emergency experience, were collected to contextualise their responses. Gwet's Agreement Coefficients (AC1) were calculated to determine inter-rater reliability. RESULTS: There were 135 participants: typically female, under the age of 40 years, with more than 3 years of emergency nursing experience. Overall, there was excellent inter-rater agreement (AC1 =0.752, p = 0.001). This was consistent when years of ED experience was stratified: 0-2 years, AC1 = 0.764, p = 0.002; 3-5 years, AC1 = 0.826, p = 0.001; 6-10 years, AC1 = 0.751, p < 0.001; 11-15 years, AC1 = 0.659, p = 0.004; ≥ 16 years, AC1 = 0.799, p < 0.001. CONCLUSION: The three-item OV risk assessment tool has excellent inter-rater reliability across a large sample of emergency nurses.

e-Learning interventions for nurses to prevent venous thromboembolism in patients: A realist review.

AIM: To synthesise published literature exploring online venous thromboembolism (VTE) prevention education programmes to identify, test and refine a program theory supporting translation of knowledge into practice for registered nurses. BACKGROUND: Venous thromboembolism is a leading cause of preventable morbidity and mortality in hospitalised patients. Successful implementation of prevention strategies can be impeded by a lack of education and translation of knowledge to practice. Continuing professional development programs using e-learning platforms are increasingly common, however, there is little published literature exploring effective translation of such education to practice. DESIGN: Realist Review. METHODS: Searches were conducted in seven healthcare databases prior to July 2020 and updated in March 2022. Synthesis was informed by the unified theory of acceptance and use of technology (UTAUT) model and followed stages of a realist review outlined by Pawson et al. The results were reported according to the RAMESES publication standards. RESULTS: Eight context-mechanism-outcome combinations were identified to explain engagement, completion and adoption of VTE e-learning into practice. Mechanisms included valuing content as relevant to practice, having confidence in the ability to use the technology and empowerment to enact change based on learning. Contextual factors that may constrain the completion of learning include the support of managers and organisations through time, and the availability of resources. CONCLUSION: Translation of e-learning is critical to ensure clinical excellence. This realist review demonstrated the varying mechanisms contributing to engagement, completion and adoption of learning. These illustrate the complex nature of education for professional development. It demonstrates that the UTAUT model is suitable for guiding the design, implementation and adoption of e-learning programmes. RELEVANCE TO CLINICAL PRACTICE: This review used a common clinical practice (VTE) to provide a program theory that can guide clinical educators to understand mechanisms which can facilitate engagement with, completion and adoption of e-learning into practice by nurses. NO PATIENT OR PUBLIC CONTRIBUTION: The focus of this realist review was on e-learning for registered nurses. As such, no patient or public contribution was sought or given in the development, progress and writing of the submitted manuscript.

Monthly Identification of High Frequency Emergency Presenters to Improve Care Delivery and Evaluation: A Unique Methodological Approach.

Background: Frequent presenters to emergency departments (EDs) pose many challenges around care delivery and health service management. The aim of this study was to investigate the presentation patterns of people with 5 or more ED visits in any calendar month (5+ frequent presenter [FP5+]) to develop a useful methodological framework on which the real impact of interventions may be assessed. Methods: This study is a retrospective analysis of de-identified frequent ED presentation data using segmented regression analysis of an interrupted time series (ITS). Results: A total of 82 FP5+ to this single ED were identified in a year. Of these presenters, 77% had 10 or more presentations in a year. The total FP5+ presentations in the 12 months preceding and after each participant's ≥5 presentations in 1 month (the trigger month for inclusion in the study) accounted for 1,064 and 1,606 visits, respectively. ITS analysis of frequent ED presentations did not show a significant level change or trend change during the data collection period. Monthly review of people who frequently present to a single ED showed that presentations typically occurred in bouts that may span calendar years. Presentation bouts then typically slow, potentially distorting evaluation of the effects of interventions. Conclusion: Rolling monthly examination of presentation data may facilitate timely case review and care delivery, as well as provide a holistic picture of the impacts of interventions targeting patient care needs. This unique analysis demands a reconsideration of the typical before-and-after analysis of interventions for this vulnerable and high-cost group of patients.

Development and validation of a script concordance test to assess biosciences clinical reasoning skills: A cross-sectional study of 1st year undergraduate nursing students.

BACKGROUND: Developing evaluative measures that assess clinical reasoning remains a major challenge for nursing education. A thorough understanding of biosciences underpins much of nursing practice and is essential to allow nurses to reason effectively. A gap in clinical reasoning can lead to unintended harm. The Script Concordance test holds promise as a measure of clinical reasoning in the context of uncertainty, situations common in nursing practice. The aim of this study is to develop and validate a test for first year undergraduate nursing students that will evaluate how bioscience knowledge is used to clinically reason. METHODS: An international team, teaching biosciences to undergraduate nurses constructed a test integrating common clinical cases with a series of related test items: diagnostic, investigative and treatment. An expert panel (n = 10) took the test and commented on authenticity/ambiguities/omissions etc. This step is crucial for validity and for scoring of the student test. The test was administered to 47 first year undergraduate nursing students from the author sites. Students rated educational aspects of the tool both quantitatively and qualitatively. Statistical and content analyses inform the findings. FINDINGS: Results indicate that the test is reliable and valid, differentiating between experts and students. Students demonstrated an ability to identify relevant data, link this to their bioscience content and predict outcomes (mean score = 50.78 ± 8.89). However, they lacked confidence in their answers when the scenarios appeared incomplete to them. CONCLUSION: Nursing practice is dependent on a thorough understanding of biosciences and the ability to clinically reason. Script concordance tests can be used to promote both competencies. This method of evaluation goes further than probing factual knowledge. It also explores capacities of data interpretation, critical analysis, and clinical reasoning. Evaluating bioscience knowledge and real-world situations encountered in practice is a unique strength of this test.

Peer-support interventions for women with cardiovascular disease: protocol for synthesising the literature using an evidence map.

INTRODUCTION: The leading cause of death for women is cardiovascular disease (CVD), including ischaemic heart disease, stroke and heart failure. Previous literature suggests peer support interventions improve self-reported recovery, hope and empowerment in other patient populations, but the evidence for peer support interventions in women with CVD is unknown. The aim of this study is to describe peer support interventions for women with CVD using an evidence map. Specific objectives are to: (1) provide an overview of peer support interventions used in women with ischaemic heart disease, stroke and heart failure, (2) identify gaps in primary studies where new or better studies are needed and (3) describe knowledge gaps where complete systematic reviews are required. METHODS AND ANALYSIS: We are building on previous experience and expertise in knowledge synthesis using methods described by the Evidence for Policy and Practice Information (EPPI) and the Coordinating Centre at the Institute of Education. Seven databases will be searched from inception: CINAHL, Embase, MEDLINE, APA PsycINFO, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials, and Scopus. We will also conduct grey literature searches for registered clinical trials, dissertations and theses, and conference abstracts. Inclusion and exclusion criteria will be kept broad, and studies will be included if they discuss a peer support intervention and include women, independent of the research design. No date or language limits will be applied to the searches. Qualitative findings will be summarised narratively, and quantitative analyses will be performed using R. ETHICS AND DISSEMINATION: The University of Toronto's Research Ethics Board granted approval on 28 April 2022 (Protocol #42608). Bubble plots (ie, weighted scatter plots), geographical heat/choropleth maps and infographics will be used to illustrate peer support intervention elements by category of CVD. Knowledge dissemination will include publication, presentation/public forums and social media.

Utilising a nurse navigator model of care to improve prisoner health care and reduce prisoner presentations to a tertiary emergency department.

BACKGROUND: Prisoners are a vulnerable population requiring complex care interventions in challenging environments, particularly around provision of emergency care. The aim of this study was to explore the effectiveness of a Nurse Navigator (NN) -led prisoner intervention from the perspective of the emergency department. METHODS: This study undertook a retrospective analysis of the prisoner presentations to a public emergency department. It used time-series analysis of publicly available deidentified data, collected during standard care evaluation, to explore the impact of this unique care model over 24 months (12-pre and 12-post). Synthesis of documents pertaining to this NN model of care provide a summary of key initiatives and interventions. RESULTS: With the introduction of NN, the rate of change of yearly prisoner presentations dropped from + 32.8% to - 2.7%. Interrupted time-series analysis on emergency department presentations per 1000 prisoners in custody confirmed a postintervention level drop of 15.1% (rate ratio 0.849; 95% CI 0.755-0.954) followed by a period of downward trending of presentations resulting in an absolute drop of 31.5% in twelve months (rate ratio 0.685; 95% CI 0.556-0.843). CONCLUSIONS: The bundle of capacity-building initiatives instigated by the NN appear to have contributed to a reduction of prisoner presentations.

Validity and reliability of the novel three-item occupational violence patient risk assessment tool.

AIM: To develop and psychometrically test an occupational violence (OV) risk assessment tool in the emergency department (ED). DESIGN: Three studies were conducted in phases: content validity, predictive validity and inter-rater reliability from June 2019 to March 2021. METHODS: For content validity, ED end users (mainly nurses) were recruited to rate items that would appropriately assess for OV risk. Subsequently, a risk assessment tool was developed and tested for its predictive validity and inter-rater reliability. For predictive validity, triage notes of ED presentations in a month with the highest OV were assessed for presence of OV risk. Each presentation was then matched with events recorded in the OV incident register. Sensitivity and specificity values were calculated. For inter-rater reliability, two assessors-trained and untrained-independently assessed the triage notes for presence of OV risk. Cohen's kappa was calculated. RESULTS: Two rounds of content validity with a total of N = 81 end users led to the development of a three-domain tool that assesses for OV risk using aggression history, behavioural concerns (i.e., angry, clenched fist, demanding, threatening language or resisting care) and clinical presentation concerns (i.e., alcohol/drug intoxication and erratic cognition). Recommended risk ratings are low (score = 0 risk domain present), moderate (score = 1 risk domain present) and high (score = 2-3 risk domains present), with an area under the curve of 0.77 (95% confidence interval 0.7-0.81, p < .01). Moderate risk rating had a 61% sensitivity and 91% specificity, whereas high risk rating had 37% sensitivity and 97% specificity. Inter-rater reliability ranged from 0.67 to 0.75 (p < .01), suggesting moderate agreement. CONCLUSIONS: The novel three-domain OV risk assessment tool was shown to be appropriate and relevant for application in EDs. The tool, developed through a rigorous content validity process, demonstrates acceptable predictive validity and inter-rater reliability. IMPACT: The developed tool is currently piloted in a single hospital ED, with a view to extend to inpatient settings and other hospitals.

Nurses' competency in electrocardiogram interpretation in acute care settings: A systematic review.

AIMS: Identify and synthesize evidence of nurses' competency in electrocardiogram interpretation in acute care settings. DESIGN: Systematic mixed studies review. DATA SOURCES: Cumulative Index to Nursing and Allied Health Literature, Medline, Scopus and Cochrane were searched in April 2021. REVIEW METHODS: Data were selected using the updated Preferred Reporting Items for Systematic Reviews and Meta-Analysis framework. A data-based convergent synthesis design using qualitative content analysis was adopted. Quality appraisal was undertaken using validated tools appropriate to study designs of the included papers. RESULTS: Forty-three papers were included in this review. Skills and attitudes were not commonly assessed, as most studies referred to 'competency' in the context of nurses' knowledge in electrocardiogram interpretation. Nurses' knowledge levels in this important nursing role varied notably, which could be partly due to a range of assessment tools being used. Several factors were found to influence nurses' competency in electrocardiogram interpretation across the included studies from individual, professional and organizational perspectives. CONCLUSION: The definition of 'competency' was inconsistent, and nurses' competency in electrocardiogram interpretation varied from low to high. Nurses identified a lack of regular training and insufficient exposure in electrocardiogram interpretation. Hence, regular, standard training and education are recommended. Also, more research is needed to develop a standardized and comprehensive electrocardiogram interpretation tool, thereby allowing educators to safely assess nurses' competency. IMPACT: This review addressed questions related to nurses' competency in electrocardiogram interpretation. The findings highlight varying competency levels and assessment methods. Nurses reported a lack of knowledge and confidence in interpreting electrocardiograms. There is an urgent need to explore opportunities to promote and maintain nurses' competency in electrocardiogram interpretation.

Optimising emergency department and acute care for people experiencing mental health problems: a nominal group study.

Objective The aim of this study was to identify potential model of care approaches and systems processes for people presenting to acute healthcare settings with mental health problems, including mental illnesses. Methods Five (consensus) nominal group technique sessions were conducted in 2019 with a purposive sample of stakeholders from health, police, ambulance and consumer agencies (n = 21). Sessions were recorded, transcribed and analysed for thematic content. Results Potential model of care approaches and systems processes for people with mental health problems in the emergency department include: a skilled collaborative approach to care; consumer-focused service; knowledge improvement; early assessment; the development of models, systems and processes; and the built environment. In the broader acute care setting, the themes of formal care, linking of services, enhancing informal and innovative care options, improving information sharing and enhancing training and education were identified. Conclusions Coherent and multifaceted approaches to the provision of care to people with mental health problems and diagnosed mental illnesses who are requiring emergency care include the linking and sharing of systems and information, changing the built environment and exploring new models of service delivery. What is known about the topic? There is considerable evidence of interventions used in the emergency department and acute healthcare settings for this vulnerable group of people with mental health problems and diagnosed mental illnesses; however, the evidence for appropriate model of care approaches and systems processes is limited. What does this paper add? For people with mental health problems in emergency departments and for people with diagnosed mental illnesses in acute care settings, targeted directions to further support treatment include the linking and sharing of systems and information, changing the built environment and exploring new models of service delivery. What are the implications for practitioners? Planning changes to services for mental health clients with acute problems needs to incorporate clinicians, health service planners, architects and a range of emergency services personnel.