Retrospective observational study of aged care facility residents presenting to ED post fall: A case for person-centred shared decision making.

OBJECTIVE: Identify the incidence of intracranial haemorrhage in people from residential aged care facilities following falls who had a CT head performed. The secondary objectives were to identify predictor variables for intracranial haemorrhage to inform person-centred shared decision making. METHODS: Retrospective chart review of aged care residents who presented to ED with a triage of fall. Documented evidence of vomiting, headache, external signs of head injury, deviation from baseline neurology and the presence of anticoagulation or antiplatelet agents was reviewed. The rates of CT head, intracranial haemorrhage, emergent interventions, disposition and mortality were assessed. RESULTS: Of the 2546 presentations, 1732 (68.0%) had a CT head and intracranial haemorrhage was found in 76 (4.4%) patients. External signs of head injury and deviation from neurological baseline have a strong association with intracranial haemorrhage in 26 (22.2%) patients, only 4 (0.61%) patients with intracranial haemorrhage had neither. There was a strong association between these clinical features and identification of intracranial haemorrhage on CT head. Anticoagulation and antiplatelet use had no association with intracranial haemorrhage. A 30-day mortality was increased in patients with deviation from neurological baseline. No neurosurgical intervention was performed, and there was inconsistent advice regarding anticoagulation or antiplatelet agents. CONCLUSIONS: Deviation from neurological baseline or external signs of head injury may be predictors of intracranial haemorrhage. Vomiting, headache, anticoagulation or antiplatelets were not associated with intracranial haemorrhage. A person-centred decision-making approach, that is informed by treatment options could better guide clinicians on when to order a CT head after a fall.

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.

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.

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.

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.

Soft collar for acute cervical spine injury immobilisation -patient experiences and outcomes: A single centre mixed methods study.

BACKGROUND: Cervical collars are used as standard care for neck immobilisation after cervical spine injury. Although evidence for the most effective type of collar is lacking, there is evidence regarding adverse patient outcomes when managed in a semi or rigid collar. In response to the evidence of complications and adverse effects when using a hard collar, a large Australian adult trauma hospital that specializes in spinal care, changed its policy from hard to soft collars when managing acute cervical spine injury. OBJECTIVE: The aim of this study was to investigate patients' experiences and outcomes when wearing a soft collar for acute cervical spine injury management in hospital. METHOD: A single centre mixed method sequential study design was used. RESULTS: Medical records from 136 patients were examined and no adverse events resulting from collar use were recorded. Interviews with 20 patients revealed that they understood the value of wearing a soft collar. The soft collars were considered supportive and well tolerated, with good adherence to recommendations for use. CONCLUSIONS: Understanding the patients' experiences informs better care management. This study suggests that soft collars are well tolerated, do not result in pressure injuries or other adverse events and are suitable for managing acute cervical spine injury.

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.

Effects of mobile mindfulness on emergency department work stress: A randomised controlled trial.

OBJECTIVE: High-occupational stress among ED staff has a detrimental impact on both staff wellness and patient care. The objective of the study is to determine whether 4 weeks of smartphone app-guided mindfulness practice reduces stress levels of ED staff. METHODS: This two-arm randomised controlled trial was conducted in two Australian EDs in 2019-2020. Eligible participants were randomly assigned (1:1) to either an App group or a Wait to Treat group to practice daily 10 min app-guided mindfulness for 4 weeks. Online surveys were collected for both groups at three time periods: before (T1), immediately after (T2) and 3 months after cessation (T3). Then the Wait to Treat group received the same intervention, followed by surveys immediately after the intervention (T4) and 3 months later (T5). Primary outcome was measured using the Perceived Stress Scale. Secondary outcomes were measured using the Maslach Burnout Inventory (three subscales: emotional exhaustion, depersonalisation and personal accomplishment), Mindfulness Attention Awareness Scale and Warwick-Edinburgh Mental Well-being Scale. Both intention-to-treat and per-protocol analysis were performed. Repeated measurement data were analysed by the linear mixed model. RESULTS: Of 148 enrolled participants 98 completed all the surveys, but only half (48%) reported continuous use of the app. Based on the results of the intention-to-treat analysis, there was a statistically significant improvement of perceived stress levels (F = 15.70, P < 0.001), all three components of burnout (emotional exhaustion [F = 14.22, P < 0.001], depersonalisation [F = 3.62, P = 0.030], personal accomplishment [F = 7.51, P < 0.001]), mindfulness (F = 8.83, P < 0.001) and wellbeing levels (F = 10.71, P < 0.001) from pre-intervention to 3 months later with small effect sizes. CONCLUSION: Results of the present study demonstrate that brief mindfulness training via innovative digital technology had a small positive effect in improving emergency staff stress, burnout, mindfulness and wellbeing.

Effect of computed tomography scanner location on time-to-computed tomography in the emergency department: A before and after study.

OBJECTIVES: To compare time metrics associated with a temporary disruption to ED computed tomography (CT) scanner location from adjacent to the ED with direct access from resuscitation rooms, to a location remote to the ED. METHODS: A retrospective before and after study was conducted in a public metropolitan ED with over 66 000 presentations annually. Time-to-CT metrics, operational time metrics and ED length of stay were extracted and analysed from presentations between October 2020 and January 2021. RESULTS: There were 3031 CT scans during the study period. Overall, the disruption was associated with a significant 27-36 min delay (P < 0.01) in time-to-CT start; these delays were also observed in a subset of trauma patients. In a subset of presumed stroke patients, time-to-brain perfusion was significantly delayed by up to 10 min (P < 0.01). There was a 14% (P < 0.01) greater demand for operational services and a time imposition of up to 8 min (P < 0.01) to transport patients to or from CT scanning when the CT scanner was located away from the ED. ED length of stay was consistent at all time points. CONCLUSION: Although rapid, proximate access to CT scanning is often considered desirable in terms of the management of trauma and other time-critical emergencies, the wider time and resource implications demonstrated in this study suggest a potential broader benefit to co-located CT scanning in ED. Our experience could be considered in future re-design of EDs.

A mobile mindfulness intervention for emergency department staff to improve stress and wellbeing: A qualitative study.

BACKGROUND: Occupational stress and burnout in emergency departments (ED) are prominent issues requiring effective solutions. In other health settings use of a smartphone mindfulness app have been shown to be a cost-effective strategy for stress management. AIM: To understand ED staff's experiences of practicing mindfulness using a smartphone app. METHOD: A qualitative study was undertaken with 24 ED staff at two Australian EDs who had used a mindfulness app for 4 weeks. Semi-structured, one-to-one interviews were conducted between late 2019 and early 2020. Interviews were audio recorded and transcribed. Descriptive description was utilised in content analysis. RESULTS: Four main themes were identified: individuality in use of the app, perceived benefits and impacts on life, perceived barriers and enablers to use. Participants reported that mindfulness practice had numerous benefits including better stress and anxiety management, as well as improved general wellbeing. The main barriers to mindfulness practice were poor time management for mindfulness and lack of motivation. Reported enablers included a strong desire for promoting wellbeing and the ability to embed practice into existing routine. CONCLUSION: Practicing mindfulness with a smartphone app is a useful strategy to promote ED staff wellness and manage stress. Healthcare organisations should consider the implementation of a mindfulness app for staff.

Sensory Devices for Older Adults With Behavioral Disturbance in the Emergency Department: A Descriptive Study.

Nonpharmacological strategies are advocated for the management of behavioral disturbance in older adults due to risk of harm from pharmacological therapy; however, limited evidence supports their use in emergency departments (EDs). The current descriptive study was conducted to investigate the use of sensory devices for nonpharmacological management of behavioral disturbance and their perceived impact. Data were collected from the sensory device registry, electronic medical records, and survey. Patient-level data (N = 33) showed that sensory devices, such as tactile blankets or toys and music, can be used in EDs to alleviate behavioral disturbance among older adults. ED staff (n = 22) expressed an interest to increase device supply. A patient and caregiver (n = 2) suggested that the devices be initiated earlier in ED care. Further research is required to strengthen evidence on the impact of these devices on patient outcomes. [Journal of Gerontological Nursing, 47(4), 22-27.].

A Retrospective Observational Study of Presentations to an Australian Emergency Department for Injuries Sustained in Exercise Pursuits Over 14 Years.

Background: Concurrent with the increase in the number of local gyms and the number of people engaged in fitness pursuits, exercise-related emergency department (ED) presentations have also increased. Identifying these injuries and the associated activities and equipment will help inform prevention strategies and potentially reduce the burden on the healthcare system. Methods: We reviewed the presentations to an Australian tertiary hospital ED resulting from running/jogging and gym-based exercise from 2005 to 2018. Results: From more than 750,000 ED visits, we identified 1,402 exercise-related presentations. Approximately two-thirds of the patients were males. Nontrauma such as chest pain and shortness of breath accounted for 11% of the presentations. Running and jogging contributed 47% of the total presentations, followed by combat activities (boxing and martial arts) with 31% of the total presentations. In the latter group, most injuries were to the head (25%) and upper limbs (39%). Injuries associated with weights/resistance activities (n=94) and falls from treadmills (n=49) accounted for 55% of the 260 injuries from use of noncombat-sports-related gym equipment. Twenty-three percent of all presentations arrived by ambulance, and overall, 9% of presentations required hospital admission. Over a 14-year period, the annual presentations rate rose from <1 to >2.5 per 1,000. Conclusion: Although the annual rate of presentations to the ED from exercise has more than doubled, exercise-related presentations still constitute only a small proportion of total presentations. Nevertheless, any reduction would be advantageous to an already overstretched health system. Risk awareness and effective education about equipment and its use at point of sale and in gyms could potentially prevent many presentations.

Effectiveness of interventions to reduce emergency department staff occupational stress and/or burnout: a systematic review.

OBJECTIVE: The objective of this review was to synthesize the best evidence for the effectiveness of interventions to reduce occupational stress and/or burnout in the emergency department. INTRODUCTION: The prevalence of occupational stress and burnout among busy emergency department staff requires urgent attention. This review summarizes the current evidence to provide recommendations on interventions to reduce occupational stress in the emergency department. INCLUSION CRITERIA: Studies reporting on all health personnel working in emergency departments were included in the review. Any individual-focused or organizational-directed intervention was considered. Both published and unpublished studies including experimental and quasi-experimental studies were considered for inclusion in the review. The outcomes of interest included occupational stress, burnout, compassion fatigue, anxiety, and depression. METHODS: A three-step search strategy was utilized to search seven databases (PubMed, CINAHL, Cochrane Central Register of Controlled Trials, Embase, Scopus, PsycINFO, Web of Science) and five gray literature resources (MedNar, Google Scholar, ProQuest Dissertations and Theses, Conference Proceedings). The search was limited to papers published in English between January 1, 2008, and February 1, 2019. Titles and abstracts of the studies were screened. Two reviewers independently appraised the full text of selected studies and extracted data using standardized tools from JBI. Where possible, data were pooled in statistical meta-analysis. Effect sizes were expressed as standardized mean differences, and their 95% confidence intervals were calculated for analysis. RESULTS: A total of 14 studies were included in the systematic review. Sample sizes of the included studies ranged from 14 to 392 participants. Of the included studies, four were randomized controlled trials and 10 were quasi-experimental studies. The overall quality of the included studies was compromised due to lack of true randomization, concealment, blinding, or the use of a single-group without a comparator. Educational-style interventions were investigated in six included studies and mindfulness-based interventions in four studies. The remaining four studies investigated organizational-directed interventions that incorporated a variety of strategies. The top three most commonly used tools were the Maslach Burnout Inventory, the Perceived Stress Scale, and the Professional Quality of Life Scale. The studies that investigated educational interventions reported a statistically significant reduction in both stress and/or burnout. Three of the four studies that investigated mindfulness-based interventions reported reduced stress levels. A fixed-effects meta-analysis of two of the studies demonstrated a non-significant difference in stress between groups receiving mindfulness-based interventions and those who did not (n = 58, SMD = -0.32, 95% CI -0.84 to 0.20, P = 0.23; heterogeneity: x = 0.01, P = 0.93, I = 0%). Organizational-based interventions were found to reduce stress levels but increase burnout. CONCLUSIONS: Individual-focused interventions, including both educational interventions and mindfulness-based interventions, have the potential to reduce occupational stress and/or burnout for staff working in emergency departments. However, inconsistencies in reporting and outcome measurements impact certainty of results. More high-quality randomized controlled trials are recommended with larger sample sizes as well as measurement of long-term effects to improve knowledge in this field.

Engaging with nurses to develop an occupational violence risk assessment tool for use in emergency departments: A participatory action research inquiry.

BACKGROUND: Early detection of occupational violence (OV) risk factors could facilitate timely and appropriate management of patients in the emergency department. For this purpose, an OV risk assessment could be useful and best initiated at triage. AIMS: To understand the need for and determine potential utility and desirable components of an OV risk assessment tool; and to determine specific challenges to its implementation if appropriate. METHODS: A participatory action research was conducted. Data were collected through focus groups and semi-structured interviews. Thematic analysis was done inductively and collaboratively using Braun and Clarke's technique. FINDINGS: Six themes were identified from triage nurses (N = 15) pertaining to: i) OV risk assessment; ii) communication of OV risk; iii) clinical implications of risk assessment; iv) tool attributes; v) future implementation challenges; vi) unintended consequences. CONCLUSION: The development of an OV risk assessment tool is supported, but with very specific attributes. Findings herein also have implications on the implementation and evaluation of this tool in emergency settings.

Effectiveness of interventions to reduce occupational stress among emergency department staff: a systematic review protocol.

REVIEW QUESTION: The aim of the review is to synthesize the best available evidence on interventions targeting occupational stress and burnout among emergency department (ED) staff. The specific review questions are.

Medical Scribes in the Emergency Department: The Scribes' Point of View.

Background: Studies report the benefit of medical scribes in the emergency department on patient throughput, clinical documentation, patient outcomes, and provider and patient satisfaction. However, studies are silent on the benefits of being a scribe for premedical and medical students. Methods: The senior author interviewed 8 scribes who were applying for medical school and 9 medical students who had been scribes prior to medical school. Discussion was prompted on undergraduate education; scribe recruitment and training; career intentions; experience as a scribe; and the value of being a scribe to themselves, to the doctors with whom they worked, and to the hospital where they were employed. Results: The typical scribe had become a scribe to support his or her chances of entry into medical school. Those already in medical school were not convinced that this experience had actually made a difference in their acceptance. All 17 scribes were emphatic that the role had benefitted them in other ways, specifically, by learning medical terminology, observing communication between doctor and patient, and understanding the practice of medicine in an emergency department. For many scribes, the experience reinforced the desire to become a doctor. The scribes recognized their value in the areas of process and finance. They also recognized that many doctors, particularly those working in academic health centers, derived satisfaction from the training and mentoring that they offered. Conclusion: Scribes perceive the role of a scribe to be highly valuable in terms of their career decision making and future medical education.

Perceptions of nursing workloads and contributing factors, and their impact on implicit care rationing: A Queensland, Australia study.

AIMS: To explore nurses' perceptions of factors affecting workloads and their impact on patient care. BACKGROUND: Fiscal restraints and unpredictable patient illness trajectories challenge the provision of care. Cost containment affects the number of staff employed and the skill-mix for care provision. While organisations may acknowledge explicit rationing of care, implicit rationing takes place at the point of service as nurses are forced to make decisions about what care they can provide. METHOD: A self-report cross sectional study was conducted using an on-line survey with 2,397 nurses in Queensland, Australia. RESULTS: Twenty to forty per cent reported being unable to provide care in the time available; having insufficient staff; and an inadequate skill-mix. The respondents reported workload and skill-mix issues leading to implicit care rationing. Over 60% believed that the processes to address workload issues were inadequate. CONCLUSIONS: Institutional influences on staffing levels and skill-mix are resulting in implicit care rationing. IMPLICATIONS FOR NURSE MANAGERS: Adequate staffing should be based on patient acuity and the skill-mix required for safe care. Managers should be more assertive about adequate clinical workloads, involve staff in decision-making, and adopt a systematic planning approach. Failure to do so results in implicit care rationing impacting on patient safety.

Factors influencing variation in investigations after a negative CT brain scan in suspected subarachnoid haemorrhage: a qualitative study.

INTRODUCTION: Variation in the approach to the patient with a possible subarachnoid haemorrhage (SAH) has been previously documented. The purpose of this study was to identify factors that influence emergency physicians' decisions about diagnostic testing after a normal CT brain scan for ED patients with a headache suspicious of a SAH. METHODS: We conducted an interview-based qualitative study informed by social constructionist theory. Fifteen emergency physicians from six EDs across Queensland, Australia, underwent individual face-to-face or telephone interviews. Content analysis was performed whereby transcripts were examined and coded independently by two co-investigators, who then jointly agreed on the influencing factors. RESULTS: Six categories of influencing factors were identified. Patient interaction was at the forefront of the identified factors. This shared decision-making process incorporated 'what the patient wants' but may be biased by how the clinician communicates the benefits and harms of the diagnostic options to the patient. Patient risk profile, practice evidence and guidelines were also important. Other influencing factors included experiential factors of the clinician, consultation with colleagues and external influences where practice location and work processes impose constraints on test ordering external to the preferences of the clinician or patient. The six categories were organised within a conceptual framework comprising four components: the context, the evidence, the experience and the decision. CONCLUSIONS: When clinicians are faced with a diagnostic challenge, such as the workup of a patient with suspected SAH, there are a number of influencing factors that can result in a variation in approach. These need to be considered in approaches to improve the appropriateness and consistency of medical care.