Endodontic sequelae associated with repetitive impacts to the dentofacial region during boxing activities.

AIM: To explore self-reported dentofacial trauma and their potential endodontic sequelae in boxers using a questionnaire, followed by clinical and radiographic assessment to (1) compare the nature and number of self-reported dentofacial injuries with physical evidence of injury sequelae; and (2) investigate potential risk factors influencing dentofacial trauma and their endodontic sequelae. METHODOLOGY: A focus group validated questionnaire was completed by 176 boxers recruited from 16 London boxing clubs; 61 boxers from this cohort then attended a London dental hospital, for a clinical and radiographic assessment. Data from the questionnaire and clinical assessments were then collated and analysed using Chi-squared or t-tests. RESULTS: Questionnaire data revealed 87.5% of boxers reported a history of dentofacial trauma during boxing activity. The clinical and radiographic assessment detected evidence of dentofacial trauma in 91.8% of boxers and dental injury or endodontic-related injury sequelae in 68.9% of boxers. There was a significant association between dentofacial trauma and boxers who did not participate in weekly neck weight sessions (p < .001), and there was a significant association between trauma-related endodontic sequelae and: boxer age (p = .01); competitions per month (p = .002); and defensive skill (p = .007). CONCLUSIONS: A majority of the cohort had suffered dentofacial injuries and endodontic sequelae. The questionnaire data under-reported musculoskeletal injuries and endodontic sequelae, suggesting that some hard-tissue injuries following repetitive dentofacial trauma may have a subclinical presentation. Injury risk may be related to increased boxer age, defensive skills, frequency of participation in competitions, and frequency of neck weight sessions per week.

Review article: Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation in the emergency department: A systematic review.

The use of cricoid pressure (CP) to prevent aspiration during rapid sequence induction (RSI) has become controversial, although CP is considered central to the practice of RSI. There is insufficient research to support its efficacy in reducing aspiration, and emerging concerns it reduces the first-pass success (FPS) of intubation. This systematic review aims to assess the safety and efficacy of CP during RSI in EDs by investigating its effect on FPS and the incidence of complications, including gastric regurgitation and aspiration. A systematic review of four databases was performed for all primary research investigating CP during RSI in EDs. The primary outcome was FPS; secondary outcomes included complications such as gastric regurgitation, aspiration, hypoxia, hypotension and oesophageal intubation. After screening 4208 citations, three studies were included: one randomised controlled trial (n = 54) investigating the incidence of aspiration during the application of CP and two registry studies (n = 3710) comparing the rate of FPS of RSI with and without CP. The results of these individual studies are not sufficient to draw concrete conclusions but do suggest that aspiration occurs regardless of the application of CP, and that FPS is not reduced by the application of CP. There is insufficient evidence to conclude whether applying CP during RSI in EDs affects the rate of FPS or the incidence of complications such as aspiration. Further research in the ED, including introducing CP usage into other existing airway registries, is needed.

Rural emergency care facilities may be adapting to their context: A population-level study of resources and workforce.

OBJECTIVE: To provide a structured understanding of rural hospital-based emergency care facility workforce and resources. DESIGN: The resources of regional training hubs were used to survey eligible emergency care facilities in their surrounding region. SETTING: Rural emergency care facilities manage more than one third of Australia's emergency presentations. These emergency care facilities include emergency departments and less-resourced facilities in smaller towns. PARTICIPANTS: Hospital facilities located outside metropolitan areas that report emergency presentations to the Australian Institute of Health and Welfare. INTERVENTIONS: A survey tool was sent by email. MAIN OUTCOME MEASURES: Presence of human, diagnostic and other resources as reported on a questionnaire. RESULTS: A completed questionnaire was received from 195 emergency care facilities. Over 60% of Small hospitals had on-call doctors only. General practitioners/generalists and nurses with extended emergency skills were found in all hospital types. Emergency physicians were present across all remoteness areas, but more commonly seen in larger facilities. All Major/Large facilities and most Medium facilities reported having onsite pathology and radiology. Point of care testing and clinician radiography were more commonly reported in smaller facilities. Among Small hospitals, Very Remote hospitals were more likely than Inner Regional hospitals to have an onsite doctor in the emergency care facility and/or a high dependency unit. CONCLUSION: Smaller and more remote facilities appear to adapt by using different workforce structures and bedside investigations.

P2/N95 respirators & surgical masks to prevent SARS-CoV-2 infection: Effectiveness & adverse effects.

BACKGROUND: Millions of people have acquired and died from SARS-CoV-2 infection during the COVID-19 pandemic. Healthcare workers (HCWs) are required to wear personal protective equipment (PPE), including surgical masks and P2/N95 respirators, to prevent infection while treating patients. However, the comparative effectiveness of respirators and masks in preventing SARS-CoV-2 infection and the likelihood of experiencing adverse events (AEs) with wear are unclear. METHODS: Searches were carried out in PubMed, Europe PMC and the Cochrane COVID-19 Study Register to 14 June 2021. A systematic review of comparative epidemiological studies examining SARS-CoV-2 infection or AE incidence in HCWs wearing P2/N95 (or equivalent) respirators and surgical masks was performed. Article screening, risk of bias assessment and data extraction were duplicated. Meta-analysis of extracted data was carried out in RevMan. RESULTS: Twenty-one studies were included, with most having high risk of bias. There was no statistically significant difference in respirator or surgical mask effectiveness in preventing SARS-CoV-2 infection (OR 0.85, [95%CI 0.72, 1.01]). Healthcare workers experienced significantly more headaches (OR 2.62, [95%CI 1.18, 5.81]), respiratory distress (OR 4.21, [95%CI 1.46, 12.13]), facial irritation (OR 1.80, [95%CI 1.03, 3.14]) and pressure-related injuries (OR 4.39, [95%CI 2.37, 8.15]) when wearing respirators compared to surgical masks. CONCLUSION: The existing epidemiological evidence does not enable definitive assessment of the effectiveness of respirators compared to surgical masks in preventing infection. Healthcare workers wearing respirators may be more likely to experience AEs. Effective mitigation strategies are important to ensure the uptake and correct use of respirators by HCWs.

Identifying the activities of physiotherapy practitioners through primary and secondary models of care provided in New South Wales emergency departments.

BACKGROUND: Following the introduction of the emergency department (ED) primary contact physiotherapy role, emergency physiotherapy models of care have evolved and are increasingly being adopted in the Australian ED. This has occurred due to growing ED patient demand and a need for greater workforce flexibility. Since introduction, there here has been limited evaluation of the scope of work physiotherapists are providing in Australian ED. OBJECTIVES: To identify the activities of ED physiotherapists provided through different models of care in NSW. METHODS: Prospective observation study in 19 participating EDs conducted over 6 months between September 2014 and April 2015. RESULTS: The study identified different models of care across participating hospitals where physiotherapists worked independently or in conjunction with a team through a referral service. The individual's scope of work was determined by organisational policy, culture, individual competence, knowledge and skills, and varied significantly between sites. CONCLUSIONS: These findings could guide both ED work flow and the development of multidisciplinary workforce structures to improve the utilisation of the physiotherapy service in EDs. This will allow for better service levels in hospitals, better access for patients and better use of resources.

Current airway management practices after a failed intubation attempt in Australian and New Zealand emergency departments.

OBJECTIVE: The aims of the present study were to describe current airway management practices after a failed intubation attempt in Australian and New Zealand EDs and to explore factors associated with second attempt success. METHODS: Data were collected from a multicentre airway registry (The Australian and New Zealand Emergency Department Airway Registry). All intubation episodes that required a second attempt between March 2010 and November 2015 were analysed. Analysis for association with success at the second attempt was undertaken for patient factors including predicted difficulty of laryngoscopy, as well as for changes in laryngoscope type, adjunct devices, intubator and intubating manoeuvres. RESULTS: Of the 762 patients with a failed first intubation attempt, 603 (79.1%) were intubated successfully at the second attempt. The majority of second attempts were undertaken by emergency consultants (36.8%) and emergency registrars (34.2%). A change in intubator occurred in 56.5% of intubation episodes and was associated with higher second attempt success (unadjusted odds ratio [OR] 1.85; 95% confidence interval [CI] 1.29-2.65). In 69.7% of second attempts at intubation, there was no change in laryngoscope type. Changes in laryngoscope type, adjunct devices and intubation manoeuvres were not significantly associated with success at the second attempt. In adjusted analyses, second attempt success was higher for a change from a non-consultant intubator to a consultant intubator from any specialty (adjusted OR 2.31; 95% CI 1.35-3.95) and where laryngoscopy was not predicted to be difficult (adjusted OR 2.58; 95% CI 1.58-4.21). CONCLUSIONS: The majority of second intubation attempts were undertaken by emergency consultants and registrars. A change from a non-consultant intubator to a consultant intubator of any specialty for the second attempt and intubation episodes where laryngoscopy was predicted to be non-difficult were associated with a higher success rate at intubation. Participation in routine collection and monitoring of airway management practices via a Registry may enable the introduction of appropriate improvements in airway procedures and reduce complication rates.

Case series and review of emergency front-of-neck surgical airways from The Australian and New Zealand Emergency Department Airway Registry.

BACKGROUND: An emergency front-of-neck access (eFONA), also called can't intubate, can't oxygenate (CICO) rescue, is a rare event. Little is known about the performance of surgical or percutaneous airways in EDs across Australia and New Zealand. OBJECTIVE: To describe the management of cases resulting in an eFONA, and recorded in The Australian and New Zealand Emergency Department Airway Registry (ANZEDAR). METHODS: A retrospective case series and review of ED patients undergoing surgical or percutaneous airways. Data were collected prospectively over 60 months between 2010 and 2015 from 44 participating EDs. RESULTS: An eFONA/CICO rescue airway was performed on 15 adult patients: 14 cricothyroidotomies (0.3% of registry intubations) and one tracheostomy. The indication for intubation was 60% trauma and 40% medical aetiologies. The intubator specialty was emergency medicine in eight (53.3%) episodes. Thirteen (86.7%) cricothyroidotomies and the sole tracheostomy (6.7%) were performed at major referral hospitals with 12 (80%) surgical airways out of hours. In four (26.7%) cases, cricothyroidotomy was performed as the primary intubation method. Pre-oxygenation techniques were used in 14 (93.3%) episodes; apnoeic oxygenation in four (26.7%). CONCLUSIONS: Most cases demonstrated deviations from standard difficult airway practice, which may have increased the likelihood of performance of a surgical airway, and its increased likelihood out of hours. Our findings may inform training strategies to improve care for ED patients requiring this critical intervention. We recommend further discussion of proposed standard terminology for emergency surgical or percutaneous airways, to facilitate clear crisis communication.

Management of adult cardiac arrest in the COVID-19 era: consensus statement from the Australasian College for Emergency Medicine.

INTRODUCTION: The global pandemic of coronavirus disease 2019 (COVID-19) has caused significant worldwide disruption. Although Australia and New Zealand have not been affected as much as some other countries, resuscitation may still pose a risk to health care workers and necessitates a change to our traditional approach. This consensus statement for adult cardiac arrest in the setting of COVID-19 has been produced by the Australasian College for Emergency Medicine (ACEM) and aligns with national and international recommendations. MAIN RECOMMENDATIONS: In a setting of low community transmission, most cardiac arrests are not due to COVID-19. Early defibrillation saves lives and is not considered an aerosol generating procedure. Compression-only cardiopulmonary resuscitation is thought to be a low risk procedure and can be safely initiated with the patient's mouth and nose covered. All other resuscitative procedures are considered aerosol generating and require the use of airborne personal protective equipment (PPE). It is important to balance the appropriateness of resuscitation against the risk of infection. Methods to reduce nosocomial transmission of COVID-19 include a physical barrier such as a towel or mask over the patient's mouth and nose, appropriate use of PPE, minimising the staff involved in resuscitation, and use of mechanical chest compression devices when available. If COVID-19 significantly affects hospital resource availability, the ethics of resource allocation must be considered. CHANGES IN MANAGEMENT: The changes outlined in this document require a significant adaptation for many doctors, nurses and paramedics. It is critically important that all health care workers have regular PPE and advanced life support training, are able to access in situ simulation sessions, and receive extensive debriefing after actual resuscitations. This will ensure safe, timely and effective management of the patients with cardiac arrest in the COVID-19 era.

Impact of the Four-Hour Rule policy on emergency medical services delays in Australian EDs: a longitudinal cohort study.

INTRODUCTION: Delayed handover of emergency medical services (EMS) patients to EDs is a major issue with hospital crowding considered a primary cause. We explore the impact of the 4-hour rule (the Policy) in Australia, focusing on ambulance and ED delays. METHODS: EMS (ambulance), ED and hospital data of adult patients presenting to 14 EDs from 2002 to 2013 in three jurisdictions were linked. Interrupted time series 'Before-and-After' trend analysis was used for assessing the Policy's impact. Random effects meta-regression analysis was examined for associations between ambulance delays and Policy-associated ED intake, throughput and output changes. RESULTS: Before the Policy, the proportion of ED ambulances delayed increased between 1.1% and 1.7% per quarter across jurisdictions. After Policy introduction, Western Australia's increasing trend continued but Queensland decreased by 5.1% per quarter. In New South Wales, ambulance delay decreased 7.1% in the first quarter after Policy introduction. ED intake (triage delay) improved only in New South Wales and Queensland. Each 1% ambulance delay reduction was significantly associated with a 0.91% reduction in triage delay (p=0.014) but not ED length of stay ≤4 hours (p=0.307) or access-block/boarding (p=0.605) suggesting only partial improvement in ambulance delay overall. CONCLUSION: The Policy was associated with reduced ambulance delays over time in Queensland and only the immediate period in New South Wales. Associations may be due to local jurisdictional initiatives to improve ambulance performance. Strategies to alleviate ambulance delay may need to focus on the ED intake component. These should be re-examined with longer periods of post-Policy data.

Paediatric intubation in Australasian emergency departments: A report from the ANZEDAR.

OBJECTIVES: To describe the epidemiology, clinical practice and outcomes of paediatric ED intubation in Australia and New Zealand. METHOD: Prospectively collected airway management audit data from 43 EDs in Australia and New Zealand that was submitted to the Australia and New Zealand Emergency Department Airway Registry between 2010 and 2015. RESULTS: Paediatric cases accounted for 4.94% (270/5463) of cases (median age = 3, interquartile range [IQR] = 2-9). A median of 5 (IQR = 2-9) intubations were reported per department per year. Most intubations were performed for medical indications (72.2%), including seizure (25.2%) and respiratory failure (15.2%). Patients were physiologically compromised prior to intubation with 69.5% comatose, 50.9% outside of the normal age-adjusted range for respiratory rate, 15.9% hypoxic and 12.6% hypotensive. Complication rate was 33.3% and desaturation was the most common (18.5%). The ED mortality rate was 3.8%. First pass success (FPS) was 80% (95% CI 75.2-84.8). Infants less than 1 year of age had lower FPS, higher rates of difficult laryngoscopy and higher rates of desaturation than other age groups. CONCLUSION: Paediatric intubation in Australasian EDs is rare from a departmental and individual provider viewpoint. Success rates are similar to contemporary international registries. Complications are common and ongoing collaborative multicentre audit with resultant quality improvement is desirable to facilitate improved success and reduced complications.

When a health policy cuts both ways: Impact of the National Emergency Access Target policy on staff and emergency department performance.

OBJECTIVE: To explore the impact of the Four-Hour Rule/National Emergency Access Target (4HR/NEAT) on staff and ED performance. METHODS: A mixed-methods study design was used to link performance data from 16 participating hospitals with the experiences reported by 119 ED staff during policy implementation. Quantitative and qualitative measures were triangulated to identify the staff and organisational effects on hospital performance. An overall score was developed to categorise hospitals into: high, moderate and low performers, then compared with four qualitative themes: social factors, ED management, ED outcomes and 4HR/NEAT compliance. RESULTS: Key factors identified were stress and morale; intergroup dynamics; interaction with patients; resource management; education and training; financial incentives; impact on quality and safety; perceived improvements on access block and overcrowding. High performing hospitals reported increased stress and decreased morale, decreased staff-patient communication and staff shortages; significant changes in ED management and effective use of the whole-of-hospital approach. Moderate performing hospitals reported similar characteristics to a lesser degree, and the perception that 4HR/NEAT did not impact ED practice. Low performing hospitals also reported increased stress and low morale and a less effective whole-of-hospital approach. ED staff also reported a reduction in communication with patients. CONCLUSIONS: There was strong evidence of an association between high stress and low morale and the implementation of the 4HR/NEAT across all levels of performance. These adverse consequences of the 4HR/NEAT implementation indicate that a more nuanced approach to efficiency improvements is required. This would balance processes measured by 4HR/NEAT against a range of other clinical and organisational performance measures.

Impact of the primary contact physiotherapy practitioner role on emergency department care for patients with musculoskeletal injuries in New South Wales.

OBJECTIVES: To determine the impact of the emergency physiotherapy service provided through different models of care on service quality indicators, patient flow, staff and patient satisfaction. METHOD: A mixed method prospective observation study was conducted between September 2014 and April 2015 in 19 EDs where a physiotherapy service is provided. RESULTS: Patients seen by the primary contact physiotherapist (PCP) were associated with a significant reduction in ED length of stay by 108 min, wait time to treatment by 10 min (n = 4 EDs) and time-to-first analgesia by 18 min (n = 19 EDs) compared to those seen through usual care processes. Patients who received care by a doctor first and then physiotherapist (secondary contact model) had a prolonged length of stay compared to other care pathways. High levels of satisfaction with the PCP role were expressed by ED staff (n = 17 EDs) and patients (n = 19 EDs). More than 95% of patients who received care by PCP were satisfied with the management of their condition, understood the advice and discharge information provided and had enough time to ask questions. CONCLUSION: ED implementation of the PCP model may improve patient flow and efficiency of clinical skill utilisation in a complex, high demand workplace.

One hundred and counting: Centenarian use of emergency departments in New South Wales.

OBJECTIVE: To study ED utilisation by people aged 100 years and over with a focus on patient demographics, reasons for presentation and patient flow factors. METHODS: This is a retrospective descriptive analysis of linked ED Data Collection Registry for presentations to New South Wales (NSW) EDs over a 5 year period. Patients were included if they presented to an ED and were aged 100 years and over at the time of presentation. Demographics, triage category, presenting problem, ED length of stay, disposition and ED re-presentation were determined for this age group. RESULTS: A total of 4033 presentations to 115 NSW EDs during 2010-2014 were analysed. We found that 78% of the patients were females and 76% still living at home. This group were the second most common age group to present to ED, after the 90-99 year age group, with 87% arriving via ambulance. Most presentations were triaged as a category 3 or 4, with the most common presenting problem being because of injury (28.5%) followed by respiratory disease (11.4%) and cardiovascular disease (10.0%). Overall, 64% required hospital admission and the average length of stay for all patients was 5.7 h. CONCLUSIONS: Centenarians ED presentations are increasing over time with injuries as the most common reason for presentation. Most patients have prolonged ED length of stay and many require hospital admission. Early streaming of these patients through specialised geriatric assessment units may be more appropriate to reduce the demand on EDs and improve patient care. Models that facilitate rapid access to supported living arrangements and improved advanced care planning may be more realistic for many centenarians and different models of care need to be considered for this age group.

Perceptions and experiences of emergency department staff during the implementation of the four-hour rule/national emergency access target policy in Australia: a qualitative social dynamic perspective.

BACKGROUND: The Four-Hour Rule or National Emergency Access Target policy (4HR/NEAT) was implemented by Australian State and Federal Governments between 2009 and 2014 to address increased demand, overcrowding and access block (boarding) in Emergency Departments (EDs). This qualitative study aimed to assess the impact of 4HR/NEAT on ED staff attitudes and perceptions. This article is part of a series of manuscripts reporting the results of this project. METHODS: The methodology has been published in this journal. As discussed in the methods paper, we interviewed 119 participants from 16 EDs across New South Wales (NSW), Queensland (QLD), Western Australia (WA) and the Australian Capital Territory (ACT), in 2015-2016. Interviews were recorded, transcribed, imported to NVivo 11 and analysed using content and thematic analysis. RESULTS: Three key themes emerged: Stress and morale, Intergroup dynamics, and Interaction with patients. These provided insight into the psycho-social dimensions and organisational structure of EDs at the individual, peer-to-peer, inter-departmental, and staff-patient levels. CONCLUSION: Findings provide information on the social interactions associated with the introduction of the 4HR/NEAT policy and the intended and unintended consequences of its implementation across Australia. These themes allowed us to develop several hypotheses about the driving forces behind the social impact of this policy on ED staff and will allow for development of interventions that are rooted in the rich context of the staff's experiences.

Impact of the National Emergency Access Target policy on emergency departments' performance: A time-trend analysis for New South Wales, Australian Capital Territory and Queensland.

OBJECTIVE: To evaluate the impact of the Australian National Emergency Access Target (NEAT) policy introduced in 2012 on ED performance. METHODS: A longitudinal cohort study of NEAT implementation using linked data, for 12 EDs across New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD) between 2008 and 2013. Segmented regression in a multi-level model was used to analyse ED performance over time before and after NEAT introduction. The main outcomes measures were ED length of stay ≤4 h, access block, number of ED presentations, short-stay admission (≤24 h), >24 h admissions, unplanned ED re-attendances within 7 days and 'left at own risk' (including 'did not wait for assessment'). RESULTS: Two years after NEAT introduction, ED length of stay ≤4 h increased in NSW and QLD (odds ratio [OR] = 2.48 and 3.24; P < 0.001) and access block decreased (OR = 0.41 and 0.22; P < 0.001), but not in ACT (OR = 1.28; P > 0.05). ED presentations increased over time before and after NEAT introduction with a significant increase above the projected trend in NSW after NEAT (mean ratio = 1.07). Short-stay admissions increased in QLD (OR = 2.60), ACT (OR = 1.68) and NSW (OR = 1.35). Unplanned ED re-attendances did not change significantly. Those who left at their own risk decreased significantly in NSW and QLD (OR = 0.38 and 0.67). CONCLUSION: ED presentations continued to increase over time in all jurisdictions. NSW and QLD, but not ACT, showed significant improvements in time-based measures. Significant increases in short-stay admissions suggest a strategic change in ED process associated with NEAT implementation. Rates of unplanned ED re-attendances and those leaving at their own risk showed no evidence for adverse effects from NEAT.

Qualitative analysis of perceptions and experiences of emergency department staff in relation to implementation and outcomes of the Four-Hour Rule/National Emergency Access Target in Australia.

OBJECTIVE: The implementation of the time target policy (Four-Hour Rule/National Emergency Access Target [4HR/NEAT]) constituted a major change for ED, and potentially on quality of care. The present study aimed to understand perceptions and experiences of ED staff during 4HR/NEAT implementation. METHODS: A semi-structured interview was used to explore views and perceptions of 119 ED staff from 16 EDs in New South Wales, Australian Capital Territory, Queensland and Western Australia. The interviews covered aspects such as perceived changes in quality of clinical care, whether the capacity to deliver education was diminished or enhanced and whether the policy affected access to care. Interviews were transcribed, imported to NVivo 11 and analysed using content and thematic analysis. RESULTS: Three themes were identified: quality and safety of care; access block and overcrowding; and medical education and training. Participants described both positive and negative aspects of the policy. Although some reported negative impacts on care quality and access block, more cited overall improvements in these areas. The majority perceived that medical education and training was negatively affected, mainly because of restricted training opportunities and reduced time for procedural skills. CONCLUSIONS: ED staff perceived important effects on quality and safety of care; access block and overcrowding; and medical education and training. In relation to an optimised ED role, quality of care and access block were overall felt to be improved, while education and training deteriorated. Our study increases understanding of the complexity of policy implementation processes and its impact on staff. Staff perceptions are a valuable measure of system performance and should be incorporated into system change evaluations.

Impact of the Four-Hour Rule/National Emergency Access Target policy implementation on emergency department staff: A qualitative perspective of emergency department management changes.

OBJECTIVE: It has been 10 years since the ACEM Access Block Solutions Summit and 5 years since the introduction of the Four-Hour Rule/National Emergency Access Target (4HR/NEAT) policy. The impact of this policy on ED management and on ED staff has been poorly understood. The aim of the present study was to identify changes in ED management resulting from the policy based on ED staff experiences. METHODS: Semi-structured interviews were conducted and transcribed, imported to NVivo 11 and analysed using a combination of content, thematic analysis and phenomenological focus within a theoretical framework known as the 'logic model'. RESULTS: One hundred and nineteen ED staff participated in 2015-2016 to assess the impact of the policy implementation. Participants were drawn from 16 EDs in New South Wales, Queensland, Western Australia and Australian Capital Territory. In relation to ED management, three themes were identified: changes in ED management; activities and changes driven by the hospital in relation to 4HR/NEAT; and participant experiences in relation to policy compliance by staff. CONCLUSIONS: Policy implementation is a complex process that had both positive and negative consequences on how ED staff managed the implementation of the 4HR/NEAT policy and how it changed their work environment. Understanding the perceptions of staff involved in policy implementation has significance for the design of future implementation strategies. The biggest insight from the present study is that ED management is very complex and the policy generated multiple positive and negative changes demonstrating the wide range of processes involved in this area of health services research.