Understanding Respiratory Rate Assessment by Emergency Nurses: A Health Care Improvement Project.

INTRODUCTION: Respiratory rate is the first sign of patient decline. Monitoring and recording respiratory rate are essential nursing competencies. However, health care system emergency nurses' ability to differentiate normal from abnormal respiratory rates was unknown. We conducted a health care improvement project to assess emergency nurses' accuracy in "spot" and "formal" assessments, understand assessment practices, and determine competency and training needs. METHODS: In an anonymous cross-sectional survey, 78 emergency nurses from 1 health care system viewed 3 "spot" and 3 "formal" mock patient videos and answered questions in REDCap (Vanderbilt University, Nashville, TN). Accuracy (abnormal/normal), systematic error (bias), and random error (imprecision) were assessed. Descriptive statistics, bivariate analyses, and qualitative content analysis of open-ended questions were reported. RESULTS: Most emergency nurses identified respiration as abnormal in spot and formal assessment videos. Accuracy was lowest for the video displaying 6 breaths per minute. Emergency nurses were more likely to identify abnormal breathing in all formal assessment videos (n = 59, 75.7%) than in all spot assessment videos (n = 41, 52.6%) (McNemar χ2 = 10.32, P = 0.001). Most emergency nurses reported a willingness to use formal assessments and thought that respiratory rate was a good indicator of a patient's condition. The barriers to accurate assessment included time limitations, prior training focusing on assessments lasting less than 30 seconds, and monitor and staff errors. DISCUSSION: Respiratory rate assessment may be best assessed formally, particularly for bradypnea, where formal checks may outperform spot checks. The results present areas for improving respiratory rate assessment training and clinical practice.

The implementation and usability of HIRAID, a structured approach to emergency nursing assessment.

BACKGROUND: Emergency nurses are responsible for the initial assessment, management and safety of critically ill patients. HIRAID, an evidence-informed emergency nursing assessment framework, is known to improve emergency nursing patient-assessment in the simulated environment however has not been evaluated in the clinical setting. METHODS: A pre-post design was used to assess the usability and impact of HIRAID on emergency nurses self-efficacy in the emergency department (ED). Nursing and medical staff from three Australian EDs were surveyed. Descriptive and optimal pooled sample t-tests statistics were conducted. RESULTS: One hundred and two emergency nurses completed the pre-intervention self-efficacy survey and 63 completed the post-intervention self-efficacy and satisfaction survey. Forty-two and 17 medical officers completed the pre- and post-intervention satisfaction surveys, respectively. Nursing staff self-efficacy levels were unchanged pre- and post-HIRAID implementation (Mean (SD): 8.8 (0.21) vs. 8.7 (0.20)) as was medical staff satisfaction (Mean (SD):7.5 (1.43) vs. 7.8 (1.07)), although there was a trend towards improved communication. CONCLUSION: The HIRAID structured approach to patient assessment is acceptable, feasible, practical and appropriate for use in the clinical environment. Further research will demonstrate the direct effects of HIRAID on clinical performance.

The use and feasibility of an online software system to support assessment of accuracy and consistency in applying the Australasian Triage Scale.

BACKGROUND: The purpose of this study was to evaluate the use and feasibility of a software system called the Triage Quality Assessment Software in New South Wales emergency departments, to assist in evaluating triage decision accuracy and consistency of emergency nurses in applying the Australasian Triage Scale. METHOD: A descriptive, exploratory study comprising of retrospective audit data and survey, was conducted 12-months post-implementation of the Triage Quality Assessment Software system. RESULTS: Between January to December 2018, a total of 39 audits were completed comprising 4214 triage records, of which 3952 (93.3%) contained sufficient information to be evaluated. Triage decision accuracy was 58.3% with a moderate level (KW=0.57) of consistency demonstrated. Overall feasibility was high (4.2). Findings confirmed learnability (4.3), usability (4.2) and acceptability (4.2) of Triage Quality Assessment Software. CONCLUSION: This is the first software system to be developed to assist in evaluating triage decision accuracy and consistency in applying the Australasian Triage Scale. This study provides evidence that triage decision accuracy and consistency are detectable and quantifiable. The feasibility of Triage Quality Assessment Software is supported, with further testing needed to fully evaluate its role in emergency department triage quality improvement.

A comparative study on the frequency of simulation-based training and assessment of non-technical skills in the Norwegian ground ambulance services and helicopter emergency medical services.

BACKGROUND: Inadequate non-technical skills (NTSs) among employees in the Norwegian prehospital emergency medical services (EMSs) are a risk for patient and operational safety. Simulation-based training and assessment is promising with respect to improving NTSs. The frequency of simulation-based training in and assessment of NTSs among crewmembers in the Norwegian helicopter emergency medical service (HEMS) has gained increased attention over recent years, whereas there has been much less focus on the Norwegian ground emergency medical service (GEMS). The aim of the study was to compare and document the frequencies of simulation-based training in and assessment of seven NTSs between the Norwegian HEMS and GEMS, conditional on workplace and occupation. METHOD: A comparative study of the results from cross-sectional questionnaires responded to by employees in the Norwegian prehospital EMSs in 2016 regarding training in and assessment of NTSs during 2015, with a focus on the Norwegian GEMS and HEMS. Professional groups of interest are: pilots, HEMS crew members (HCMs), physicians, paramedics, emergency medical technicians (EMTs), EMT apprentices, nurses and nurses with an EMT licence. RESULTS: The frequency of simulation-based training in and assessment of seven generic NTSs was statistically significantly greater for HEMS than for GEMS during 2015. Compared with pilots and HCMs, other health care providers in GEMS and HEMS undergo statistically significantly less frequent simulation-based training in and assessment of NTSs. Physicians working in the HEMS appear to be undergoing training and assessment more frequently than the rest of the health trust employees. The study indicates a tendency for lesser focus on the assessment of NTSs compared to simulation-based training. CONCLUSION: HEMS has become superior to GEMS, in terms of frequency of training in and assessment of NTSs. The low frequency of training in and assessment of NTSs in GEMS suggests that there is a great potential to learn from HEMS and to strengthen the focus on NTSs. Increased frequency of assessment of NTSs in both HEMS and GEMS is called for.

Emergency nursing students' and nurse educators' perception of care delivery: A comparison study of self-assessment ratings.

BACKGROUND: Postgraduate emergency nursing studies strengthen the emergency nursing workforce and contribute to specialist patient care. Formative and summative assessments in postgraduate study are important for student learning as they enable self-reflection and feedback. AIM: To compare formative and summative appraisal assessments between postgraduate emergency nursing students and nurse educators. METHOD: Retrospective review of assessments completed by postgraduate student and educator in the final multi-system complex subject of the postgraduate emergency nursing course during 2015. Data were extracted from university records. Data for the two appraisal periods were compared using chisquare test of independence. RESULTS: Data from 52 emergency nursing students and 16 educators were extracted. Significant differences were detected between most student and educator ratings for both assessment appraisals. The lowest self-ratings of independence for students and educators at the summative assessment were for the provision and coordination of patient care and critical analysis of research evidence. Educators did agree that students were performing independently on domains relating to legal, professional and ethical frameworks. CONCLUSION: Postgraduate emergency nursing study is important for the emergency nursing workforce. Examining student learning and educator assessment in this context enables a broader understanding of student learning and transition to emergency nursing speciality practice.

The impact of geriatric focused nurse assessment and intervention in the emergency department: A systematic review.

BACKGROUND: Nursing assessment of elderly patients is imperative in Emergency Departments (ED) while providing interventions that increase independence facilitating discharge to primary healthcare. AIMS: To systematically review the impact of geriatric focused nurse assessment and intervention in the ED on hospital utilisation in terms of admission rate, ED revisits and length of hospital stay (LOHS). METHODS: Search strategy used following databases; Cochrane, Medline, CINAHL, Embase, Scopus and Web of Knowledge; And terms; geriatric nurse assessment, nurse discharge planning, geriatric nurse specialist, nurse intervention, emergency department, accident and emergency, patient outcomes, discharge, admissions, readmissions, hospital utilization, hospitalization, length of stay/hospital stay. RESULTS: Nine studies were included: seven RCTs and two prospective pre/post-intervention designed studies. Geriatric focused nursing assessment and interventions did not have a statistical impact on hospitalization, readmissions, LOHS and ED revisits. Risk screening and comprehensive geriatric assessment extending into primary care may reduce readmission rates but not affect hospitalization. An increase in ED visits in the intervention group at 30 days post-intervention was noted. CONCLUSION: Inconsistencies in assessment and interventions for the older person in ED are apparent. Further research evaluating a standardised risk assessment tool and innovative interventions extending into primary healthcare is required.

Accuracy and Reliability of Emergency Department Triage Using the Emergency Severity Index: An International Multicenter Assessment.

STUDY OBJECTIVE: We assess accuracy and variability of triage score assignment by emergency department (ED) nurses using the Emergency Severity Index (ESI) in 3 countries. In accordance with previous reports and clinical observation, we hypothesize low accuracy and high variability across all sites. METHODS: This cross-sectional multicenter study enrolled 87 ESI-trained nurses from EDs in Brazil, the United Arab Emirates, and the United States. Standardized triage scenarios published by the Agency for Healthcare Research and Quality (AHRQ) were used. Accuracy was defined by concordance with the AHRQ key and calculated as percentages. Accuracy comparisons were made with one-way ANOVA and paired t test. Interrater reliability was measured with Krippendorff's α. Subanalyses based on nursing experience and triage scenario type were also performed. RESULTS: Mean accuracy pooled across all sites and scenarios was 59.2% (95% confidence interval [CI] 56.4% to 62.0%) and interrater reliability was modest (α=.730; 95% CI .692 to .767). There was no difference in overall accuracy between sites or according to nurse experience. Medium-acuity scenarios were scored with greater accuracy (76.4%; 95% CI 72.6% to 80.3%) than high- or low-acuity cases (44.1%, 95% CI 39.3% to 49.0% and 54%, 95% CI 49.9% to 58.2%), and adult scenarios were scored with greater accuracy than pediatric ones (66.2%, 95% CI 62.9% to 69.7% versus 46.9%, 95% CI 43.4% to 50.3%). CONCLUSION: In this multinational study, concordance of nurse-assigned ESI score with reference standard was universally poor and variability was high. Although the ESI is the most popular ED triage tool in the United States and is increasingly used worldwide, our findings point to a need for more reliable ED triage tools.

Multiple morbidities assessment.

Essential facts Multimorbidity, in which a person has two or more long term health conditions, is associated with reduced quality of life, higher mortality, polypharmacy and high treatment burden, higher rates of adverse drug events, and much greater health services usage, including unplanned or emergency care.

A short mnemonic to support the comprehensive geriatric assessment model.

With an increasing number of older people using emergency services, researchers have raised concerns about the quality of care in an environment that is not designed to address older patients' specific needs and conditions. The comprehensive geriatric assessment (CGA) model was developed to address these issues, and to optimise healthcare delivery to older adults. This article introduces a complementary mnemonic, FRAIL, that refers to important elements of health information to consider before initiating care for older patients - falls/functional decline, reactions, altered mental status, illnesses, and living situation. It is not intended to replace the CGA, but can help to quickly identify high-risk older patients who warrant a more in-depth clinical assessment with CGA.

Misidentification of English Language Proficiency in Triage: Impact on Satisfaction and Door-to-Room Time.

We examined triage nurses' assessment of patients' language proficiency compared to patients' self-reported proficiency and the impact of language discordance on door-to-room time and patient satisfaction. This was a prospective study of emergency department walk-in patients. Patients completed a survey in which they identified their language proficiency. On a Likert scale, patients ranked how well they felt they were understood and how satisfied they were with the triage process. Nurses completed surveys identifying the patient's primary language and how well they felt they understood the patient. Door-to-room times were obtained from medical records. 163 patients were enrolled. 66% of patients identified themselves as having good English proficiency, while 34% of patients had limited English proficiency. Nurses misclassified 27% of self-identified Spanish-speaking patients as being English proficient. Spanish-speakers felt less satisfied with triage than English-speakers (p < 0.01). There were no differences in door-to-room time. Triage nurses overestimate patient language skills. Spanish-speaking patients feel less satisfied with triage than English-speakers.

The impact of senior doctor assessment at triage on emergency department performance measures: systematic review and meta-analysis of comparative studies.

STUDY QUESTION: To determine if placing a senior doctor at triage versus standard single nurse in a hospital emergency department (ED) improves ED performance by reviewing evidence from comparative design studies using several quality indicators. DESIGN: Systematic review. DATA SOURCES: Cochrane Library, MEDLINE, EMBASE, CINAHL, Cochrane Effective Practice and Organisation of Care (EPOC), Web of Science, Clinical Trials Registry website. In addition, references from included studies and citation searches were used to identify relevant studies. REVIEW METHODS: Databases were searched for comparative studies examining the role of senior doctor triage (SDT), published from 1994 to 2014. Senior doctor was defined as a qualified medical doctor who completed high specialty training in emergency medicine. Articles with a primary aim to investigate the effect of SDT on ED quality indicators such as waiting time (WT), length of stay (LOS), left without being seen (LWBS) and left without treatment complete (LWTC) were included. Articles examining the adverse events and cost associated with SDT were also included. Only studies with a control group, either in a randomised controlled trial (RCT) or in an observational study with historical controls, were included. The systematic literature search was followed by assessment of relevance and risk of bias in each individual study fulfilling the inclusion criteria using the Effective Public Health Practice Project (EPHPP) bias tool. Data extraction was based on a form designed and piloted by the authors for dichotomous and continuous data. DATA SYNTHESIS: Narrative synthesis and meta-analysis of homogenous data were performed. RESULTS: Of 4506 articles identified, 25 relevant studies were retrieved; 12 were of the weak pre-post study design, 9 were of moderate quality and 4 were of strong quality. The majority of the studies revealed improvements in ED performance measures favouring SDT. Pooled results from two Canadian RCTs showed a significant reduction in LOS of medium acuity patients (weighted means difference (WMD) -26.26 min, 95% CI -38.50 to -14.01). Another two RCTs revealed a significant reduction in WT (WMD -26.17 min, 95% CI -31.68 to -20.65). LWBS was reduced in two Canadian RCTs (risk ratio (RR)=0.79, 95% CI 0.66 to 0.94). This was echoed by the majority of pre-post study designs. SDT did not change the occurrence of adverse events. No clear benefit of SDT in terms of patient satisfaction or cost effectiveness could be identified. CONCLUSIONS: This review demonstrates that SDT can be an effective measure to enhance ED performance, although cost versus benefit analysis is needed. The potential high risk of bias in the evidence identified, however, mandates more robust multicentred studies to confirm these findings.

Everyone is working together to ease the pressures in A&E.

Nurse consultant Janet Youd, chair of the RCN Emergency Care Association, says nurses struggling to cope with unprecedented pressures in A&E departments should be awarded an extra half day's annual leave (Online News January 8).

Recognising clinical deterioration in emergency department patients.

BACKGROUND: The use of rapid response systems such as Medical Emergency Team (MET) improves recognition and response to clinical deterioration in in-patient settings. However, few published studies have investigated use of rapid response systems in Australian emergency departments (ED). AIM: To examine the frequency, nature and outcomes of clinical deterioration in ED patients and compare the utility of hospital MET calling criteria with ED specific Clinical Instability Criteria (CIC) for recognition of deteriorating patients. The outcomes of interest were the prevalence of deterioration in ED patients, the utility of MET versus ED CIC, and the outcomes (MET activation, in-hospital mortality at 30 days) of patients who experienced deterioration during ED care. METHOD: An exploratory descriptive design was used. Vital sign data were prospectively collected from 200 patients receiving ED care in the general treatment areas of regional, publicly funded health service in Victoria, Australia, during May 2012. Outcome data were collected by follow up medical record audit. RESULTS: Of the 200 ED patients recruited, 2% fulfilled the study site MET criteria and 7.5% fulfilled ED CIC. The median age of patients fulfilling MET criteria was 85 years compared with a median age of 74 years for patients fulfilling the ED CIC criteria. Of the 136 ED patients admitted to in-patient wards, 5.9% required MET activation during admission and 3.7% of these MET activations occurred within 24h of emergency admission. Five percent of patients died in-hospital within 30 days of ED attendance. CONCLUSIONS: ED specific criteria for activation of a rapid response system identifies more ED patients at risk of clinical deterioration. The results of this study highlight a need for EDs to implement and evaluate systems to increase recognition of deteriorating patients designed specifically for the emergency care context.

The trauma report nurse: a trauma triage process improvement project.

INTRODUCTION: Accurate trauma triage is imperative to facilitate appropriate resource mobilization for severely injured trauma patients. A critical window of opportunity exists to prevent secondary injury or death. Timely assessment with a multidisciplinary trauma team is essential to facilitate rapid diagnosis and treatment. However, consistent and accurate trauma triage proved daunting at our institution, resulting in instances of undertriage. METHODS: A process improvement strategy aimed at improving trauma triage accuracy was implemented. An innovative role, the trauma report nurse (TRN), was created and became the trauma nurse expert. The TRN was responsible for assigning a trauma triage level to all incoming adult and pediatric trauma patients. In parallel, improvements were made to the prehospital report format, increasing standardization and clarifying hand-off verbiage. RESULTS: Undertriage rates dropped from 14% to 4.8%. Qualitative data demonstrated acceptance and support of the TRN role among physicians, nurses and nursing and ancillary staff. DISCUSSION: Designating trauma triage to an ED registered nurse proved to reduce undertriage rates. By providing staff education, infrastructure improvements, and leadership support, the role continues to thrive, resulting in improved care for severely injured trauma patients.

Disaster preparedness and response: challenges for Australian public health nurses - a literature review.

To date, Australia has not had to respond to a nationwide catastrophic event. However, over the past decade, heat waves, bushfires, cyclones, and floods have significantly challenged Australia's disaster preparedness and the surge capacity of local and regional health systems. Given that disaster events are predicted to increase in impact and frequency, the health workforce needs to be prepared for and able to respond effectively to a disaster. To be effective, nurses must be clear regarding their role in a disaster and be able to articulate the value and relevance of this role to communities and the professionals they work with. Since almost all disasters will exert some impact on public health, it is expedient to prepare the public health nursing workforce within Australia. This paper highlights issues currently facing disaster nursing and focuses on the challenges for Australian public health nurses responding to and preparing for disasters within Australia. The paper specifically addresses public health nurses' awareness regarding their roles in disaster preparation and response, given their unique skills and central position in public health.