Take-home naloxone administered in emergency settings: feasibility of intervention implementation in a cluster randomized trial.

BACKGROUND: Opioids kill more people than any other class of drug. Naloxone is an opioid antagonist which can be distributed in kits for peer administration. We assessed the feasibility of implementing a Take-home Naloxone (THN) intervention in emergency settings, as part of designing a definitive randomised controlled trial (RCT). METHODS: We undertook a clustered RCT on sites pairing UK Emergency Departments (ED) and ambulance services. At intervention sites, we recruited emergency healthcare practitioners to supply THN to patients presenting with opioid overdose or related condition, with recruitment across 2019-2021. We assessed feasibility of intervention implementation against four predetermined progression criteria covering site sign up and staff training; identification of eligible patients; issue of THN kits and Serious Adverse Events. RESULTS: At two intervention sites, randomly selected from 4, 299/687 (43.5%) clinical staff were trained (ED1 = 107, AS1 = 121, ED2 = 25, AS2 = 46). Sixty THN kits were supplied to eligible patients (21.7%) (n: ED1 = 36, AS1 = 4, ED2 = 16, AS2 = 4). Across sites, kits were not issued to eligible patients on a further 164 occasions, with reasons reported including: staff forgot (n = 136), staff too busy (n = 15), and suspected intentional overdose (n = 3), no kit available (n = 2), already given by drugs nurse (n = 4), other (n = 4). Staff recorded 626 other patients as ineligible but considered for inclusion, with reasons listed as: patient admitted to hospital (n = 194), patient absconded (n = 161) already recruited (n = 64), uncooperative or abusive (n = 55), staff not trained (n = 43), reduced consciousness level (n = 41), lack of capacity (n = 35), patient in custody (n = 21), other (n = 12). No adverse events were reported. CONCLUSION: Staff and patient recruitment were low and varied widely by site. This feasibility study did not meet progression criteria; a fully powered RCT is not planned. TRIAL REGISTRATION: ISRCTN13232859 (Registered 16/02/2018).

Paediatric ED reattendance rates: comparing nurse practitioners and other clinicians.

OBJECTIVE: The aim of this project is to establish the unplanned reattendance rate for paediatric emergency nurse practitioners (PENPs) working in a designated paediatric emergency department (PED) while identifying the case mix of patients seen by PENPs compared with their medical counterparts. DESIGN: Quantitative data regarding patient characteristics and reattendance were collected during retrospective review of case notes across two representative 2-week periods. SETTING: The study site is a tertiary urban PED with an annual attendance of 32 000 patients aged from birth to 15 years. MAIN OUTCOME MEASURES: Reattendance rates, patient characteristics, triage scores, presenting complaint and numbers of patients discussed with a paediatric emergency medicine consultant were evaluated. RESULTS: The results showed that PENPs have a lower reattendance rate (1.75%) when compared with senior and junior doctors in training (4.29%, 5.76%); however, PENPs treat a different population of children. When the odds of PENP reattendance are adjusted for this, the significance of the difference becomes less certain. CONCLUSIONS: PENPs work autonomously when seeing children presenting with minor trauma and make a positive contribution in achieving the reattendance Clinical Quality Indicator.

Diagnosing meniscal tears in the emergency department.

Acute meniscal knee injuries can lead to instability of the joint if they are left untreated, but clinical examinations of patients' acutely injured knees can be challenging because of the pain and swelling involved. Although magnetic resonance imaging and arthroscopy are the gold standard investigations for the diagnosis of meniscal tears they cannot always be carried out in acute or emergency department settings. It is therefore essential that emergency care practitioners have good clinical examination skills to ensure safe and effective patient management, diagnosis, and outcomes, as well as the skills and knowledge required to carry out meniscal tear tests. This article reviews the literature on the most common examination techniques associated with acute injuries, especially meniscal injuries, to knees: joint line tenderness assessment, McMurray's test and the Apley's grind test. It analyses the sensitivity and specificity for each test to help practitioners understand the clinical significance of positive and negative findings.

What is the burden of alcohol-related injuries in an inner city emergency department?

BACKGROUND: The annual cost to the NHS of alcohol-related injury and illness is estimated to be £2.7 billion. Alcohol-related violence has become a concerning public health issue. This study set out to establish the burden of alcohol-related violence in an inner city UK emergency department (ED). METHODS: This single centre study was undertaken in the ED of the Bristol Royal Infirmary. This department serves an inner city population. An independent researcher administered a questionnaire to every patient who attended during the study period. A questionnaire was also administered to the treating clinician to ascertain the diagnosis, and whether the patient's attendance was related to alcohol use. RESULTS: 14% (n=111) of participants felt that their attendance at the ED was related to alcohol. 11% of all injured patients felt it was due to alcohol consumption. 3% of patients attended with an alcohol-related illness. The treating clinicians reported that 21% of all patients in this study attended with a problem either directly or indirectly attributable to alcohol. DISCUSSION: The number of attendances attributable to alcohol-related injury and illness was at least 14% of all patients. One third of patients presenting with an alcohol-related illness or injury required admission to hospital. If these figures are extrapolated, the number of patients presenting with alcohol-related injury is in excess of 7000 attendances to the Bristol Royal Infirmary annually, or nearly 2 million ED patients every year in England and Wales, resulting in 640,000 admissions.

Health promotion in emergency care settings: investigating staff views and experiences.

BACKGROUND: Emergency departments (EDs) afford 'teachable moments' for health behaviour change, but staff may not see themselves as public health practitioners and it can be challenging to undertake health promotion activities in emergency care settings. Furthermore, the evidence on health promotion in these settings is limited. AIM: To investigate the views and experiences of emergency nurses and ambulance service paramedics regarding health promotion in emergency care settings. METHOD: A convenience sample of emergency nurses (n=3) and ambulance service paramedics (n=3) was recruited. An inductive and descriptive qualitative study design using semi-structured interviews and thematic analysis was employed. FINDINGS: The participants understood health promotion and were willing to have conversations about it with patients. However, they cited several barriers to health promotion, including understaffing, a lack of understanding of the relevance of health promotion among staff, a lack of training and information, and the sensitivity of topics such as body weight and sexual health. Lack of time was not cited as a barrier. CONCLUSION: There are opportunities for developing the health promotion aspect of practice in emergency care settings, where staff and patients would benefit from a more structured, system-wide approach to health promotion.

How do emergency department staff respond to behaviour that challenges displayed by people living with dementia? A mixed-methods study.

OBJECTIVES: To investigate staff experiences of, and approaches to behaviour that challenges displayed by patients with dementia in the emergency department (ED). Behaviour that challenges is defined as 'actions that detract from the well-being of individuals due to the physical or psychological distress they cause within the settings they are performed', and can take many forms including aggressive physical actions, shouting and verbal aggression and non-aggressive behaviour including repetitive questioning, inappropriate exposure and resistance to care. DESIGN: Mixed-methods study consisting of an online survey and semistructured telephone interviews. Quantitative data were analysed and presented using descriptive statistics. Qualitative data were analysed thematically. SETTING: The EDs of three National Health Service (NHS) Hospital Trusts in Southwest England. PARTICIPANTS: Multidisciplinary NHS staff working in the ED. RESULTS: Fifty-two online survey responses and 13 telephone interviews were analysed. Most (24/36, 67%) survey respondents reported that they had received general training in relation to dementia in the last 2-5 years, however, less than a fifth (4/23, 17%) had received any ED-specific dementia training. All (48/48) felt that behaviour that challenges could potentially be prevented, though resource constraints and practice variation were identified. Four main themes emerged from the qualitative data: (1) the 'perfect storm' of the ED; (2) behaviour that challenges is preventable with the right resources; (3) improvisation and (4) requirement for approaches that are specific to the ED. CONCLUSIONS: The findings of this study suggest that ED staff do not feel that they are prepared to respond effectively to behaviour that challenges displayed by people living with dementia. Future work could adapt or develop an intervention to support ED staff in responding to behaviour that challenges.

Interprofessional working or role substitution? A discussion of the emerging roles in emergency care.

AIMS: This article presents a discussion of emerging non-medical roles in emergency care against the current policy context and the issues of role substitution and interprofessional working. BACKGROUND: Non-medical roles in emergency care have grown internationally in response to an increasing demand for emergency care services and to address the growing importance of the quality healthcare agenda. The blurring of role boundaries between professional groups has become more common. Data sources. Searches were made of three electronic databases; CINAHL, Medline and EMBASE. The literature relating to interprofessional healthcare roles, and new roles in emergency care was searched from 1980 to 2010 and underpinned the discussion. DISCUSSION: A theoretical framework that has emerged from the literature is that task, role substitution and interprofessional working lie on a spectrum and evolving non-medical roles can be plotted on the spectrum, usually starting at one end of the spectrum under task substitution and then potentially moving in time towards true interprofessional working. CONCLUSIONS: There is still a great deal of progress to be made until non-medical roles in emergency care can truly be encompassed under the umbrella of interprofessional working and that a more robust critical mass of evidence is required to substantiate the theory that interprofessional working within teams contributes to effective, cost-effective care and better patient outcomes. RELEVANCE TO CLINICAL PRACTICE: It is essential to understand the underlying motivation, policy context and key drivers for the development of new nursing and non-medical roles. This allows services to be established successfully, by understanding and addressing the key predicable barriers to implementation and change.

Protocol for Take-home naloxone In Multicentre Emergency (TIME) settings: feasibility study.

BACKGROUND: Opioids, such as heroin, kill more people worldwide by overdose than any other type of drug, and death rates associated with opioid poisoning in the UK are at record levels (World Drug Report 2018 [Internet]. [cited 2019 Nov 19]. Available from: http://www.unodc.org/wdr2018/; Deaths related to drug poisoning in England and Wales - Office for National Statistics [Internet]. [cited 2019 Nov 19]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2018registrations). Naloxone is an opioid antagonist which can be distributed in 'kits' for administration by witnesses in an overdose emergency. This intervention is known as take-home naloxone (THN). We know that THN can save lives on an individual level, but there is currently limited evidence about the effectiveness of THN distribution on an aggregate level, in specialist drug service settings or in emergency service settings. Notably, we do not know whether THN kits reduce deaths from opioid overdose in at-risk populations, if there are unforeseen harms associated with THN distribution or if THN is cost-effective. In order to address this research gap, we aim to determine the feasibility of a fully powered cluster randomised controlled trial (RCT) of THN distribution in emergency settings. METHODS: We will carry out a feasibility study for a RCT of THN distributed in emergency settings at four sites, clustered by Emergency Department (ED) and catchment area within its associated ambulance service. THN is a peer-administered intervention. At two intervention sites, emergency ambulance paramedics and ED clinical staff will distribute THN to adult patients who are at risk of opioid overdose. At two control sites, practice will carry on as usual. We will develop a method of identifying a population to include in an evaluation, comprising people at risk of fatal opioid overdose, who may potentially receive naloxone included in a THN kit.We will gather anonymised outcomes up to 1 year following a 12-month 'live' trial period for patients at risk of death from opioid poisoning. We expect approximately 100 patients at risk of opioid overdose to be in contact with each service during the 1-year recruitment period. Our outcomes will include deaths, emergency admissions, intensive care admissions, and ED attendances. We will collect numbers of eligible patients attended by participating in emergency ambulance paramedics and attending ED, THN kits issued, and NHS resource usage. We will determine whether to progress to a fully powered trial based on pre-specified progression criteria: sign-up of sites (n = 4), staff trained (≥ 50%), eligible participants identified (≥ 50%), THN provided to eligible participants (≥ 50%), people at risk of death from opioid overdose identified for inclusion in follow-up (≥ 75% of overdose deaths), outcomes retrieved for high-risk individuals (≥ 75%), and adverse event rate (< 10% difference between study arms). DISCUSSION: This feasibility study is the first randomised, methodologically robust investigation of THN distribution in emergency settings. The study addresses an evidence gap related to the effectiveness of THN distribution in emergency settings. As this study is being carried out in emergency settings, obtaining informed consent on behalf of participants is not feasible. We therefore employ novel methods for identifying participants and capturing follow-up data, with effectiveness dependent on the quality of the available routine data. TRIAL REGISTRATION: ISRCTN13232859 (Registered 16/02/2018).

Celebrating nursing.

International Nurses Day is celebrated around the world each year on May 12, Florence Nightingale's birth date (1820). Her theories were published in Notes on Nursing in 1860 and contributed significantly to the development of public health and leadership in hospital management. On Nurses Day, however, it is important to acknowledge the contribution of other great nurses in history, such as Mary Seacole, and to celebrate the contribution that nurses continue to make to the health and wellbeing of society.

Accidental digital injection of adrenaline.

Nurses working in emergency care often have to manage patients with undifferentiated and previously undiagnosed conditions. This month, Emergency Nurse continues to look at how emergency nurses across the UK have tackled them.

A study exploring drug use and management of patients presenting to an inner city emergency department.

Patients who present to an emergency department (ED) with a problem related to illegal drug use can be difficult to identify and are perceived to generate a significant workload for staff. This study suggests that illicit drug use may be more common than previously reported and also that the impact on the ED is perceived by staff to be disproportionately high compared with the actual numbers of patients presenting with complaints related to illicit drug use. We conclude that the over estimation by staff is directly related to the challenges that staff working within the ED setting believe this group of patients pose.

Evaluating new roles within emergency care: a literature review.

INTRODUCTION: In recent years economic and political drivers have strongly influenced the development and introduction of new roles such as medical substitution roles within emergency care in the National Health Service (NHS) in the United Kingdom (UK). AIMS: The aims of this literature review were to establish the national and international evidence available which examine the scope of practice of emergency nurse practitioners, emergency care practitioners and extended scope physiotherapists; to establish the national and international evidence which explores patient satisfaction with non-medical roles in emergency care; to establish the national and international evidence which explores the acceptability of emergency nurse practitioner, emergency care practitioner and extended scope physiotherapists services from a healthcare professional perspective. METHODS: A search of the literature was undertaken using BNI, CINAHL plus, International Bibliography of the Social Sciences, MEDLINE and SPORTDiscus databases combined with searches of the Cochrane library collection, NICE and the grey literature. Critical assessment of the literature is presented. RESULTS: A high level of patient satisfaction was found with all the new roles. Interestingly the scope of practice of Emergency nurse practitioners appears to be most limited in the UK. Five major themes were identified from healthcare professionals' perceptions of these new roles. CONCLUSION: There is general agreement that non-medical roles help to reduce waiting times in emergency departments, as well as attracting a high level of patient satisfaction, confidence and acceptance of these roles. Several issues were identified which warrant further study; including the current UK evidence surrounding the limited scope of practice of these roles.

Student life - Beyond the call of duty.

Supernumerary status for nursing students in clinical practice settings is a relatively recent policy. Previously education had been based in hospital nursing schools and followed an apprenticeship model.

Should aspiring consultant nurses follow a medical training programme?

AIM: To investigate the level of educational preparation current consultant nurses felt was required to prepare aspiring consultant nurses for the role. BACKGROUND: The radical introduction of the consultant nurse role was thought to be groundbreaking. This new role was to provide better outcomes for patients by improving the service and quality of care delivered to patients. With such great expectations of these professionals there was little guidance available as to the appropriate preparation for such a new and innovative role. METHOD: A national survey was undertaken of the Department of Health Consultant Nurse Emergency Care group (n=18). RESULTS: Key themes emerged around the development of a medical model of educational preparation for this role, as well as the development of a national programme of preparation. The majority favoured the current medical model and certainly supported the concepts of interprofessional programmes of study in universities. CONCLUSIONS: Further work is required in developing a nationally recognised programme of preparation for the role.