Vital signs monitoring in Australasian emergency departments: Development of a consensus statement from ACEM and CENA.

BACKGROUND: Emergency Department (ED) care is provided for a diverse range of patients, clinical acuity and conditions. This diversity often calls for different vital signs monitoring requirements. Requirements often change depending on the circumstances that patients experience during episodes of ED care. AIM: To describe expert consensus on vital signs monitoring during ED care in the Australasian setting to inform the content of a joint Australasian College for Emergency Medicine (ACEM) and College of Emergency Nursing Australasia (CENA) position statement on vital signs monitoring in the ED. METHOD: A 4-hour online nominal group technique workshop with follow up surveys. RESULTS: Twelve expert ED nurses and doctors from adult, paediatric and mixed metropolitan and regional ED and research facilities spanning four Australian states participated in the workshop and follow up surveys. Consensus building generated 14 statements about vital signs monitoring in ED. Good consensus was reached on whether vital signs should be assessed for 15 of 19 circumstances that patients may experience. CONCLUSION: This study informed the creation of a joint position statement on vital signs monitoring in the Australasian ED setting, endorsed by CENA and ACEM. Empirical evidence is needed for optimal, safe and achievable policy on this fundamental practice.

Review article: Use of the Team Emergency Assessment Measure in the rating of emergency teams' non-technical skills: A mapping review.

The present study aims to explore the utility of the Team Emergency Assessment Measure (TEAM) in relation to the enhancement of emergency team non-technical skills based on research conducted over the last decade. In this mapping review, a citation mining process identified 22 primary studies for inclusion, published between 2012 and 2022. It provides outcome data on emergency teams' non-technical skills following team training and/or real-life patient emergencies. Emergency team studies related to resuscitation teams (adult, paediatric, newborn and obstetric cases) and medical emergency team (MET) management of patient deterioration. Team performance ratings varied, ranging from approximately 90% for experienced clinical teams down to 38% for students. Statistically significant improvements in performance were notable following training and/or repeated practice. Validity evidence, across 11 studies that provided change data described positive learning outcomes and moderate intervention effects. However, according to Kirkpatrick's model of educational evaluation the studies were limited to professional development phases of learning and immediate post-training assessments rather than care quality improvement. The review highlights a lack of studies evidencing quality improvement or clinical impact such as change of patient care practice or health service performance. There is a need to conduct well-designed studies that explore both technical and non-technical skills of resuscitation teams and METs. Currently, non-technical skills training and repeated performance evaluations using the TEAM contribute immensely to the proficiency of emergency teams.

Effectiveness of interventions to reduce ventriculostomy-associated infections in adult and paediatric patients with an external ventricular drain: A systematic review.

OBJECTIVES: The objective of this review was to methodologically identify, appraise, and synthesise the primary research reporting the effectiveness of interventions to reduce ventriculostomy-associated infections in adult and paediatric neurosurgical patients with an external ventricular drain (EVD). REVIEW METHOD USED: Systematic review DATA SOURCES: A systematic search of five databases was conducted: MEDLINE, CINAHL Plus, Scopus, PubMed, and Cochrane Central. REVIEW METHODS: Key search terms and their variations included external ventricular drain and ventriculostomy-associated infection. The search was limited to studies published in English from 1980 to 2021. Screening, quality appraisal, and data extraction occurred in duplicate by the reviewers. The final search was conducted in June, 2021. RESULTS: A total of 11 699 records were identified from database searches. Fifty-three articles met inclusion criteria. Thirty-eight studies investigated individual interventions, and 15 investigated multi component interventions. Nineteen studies reported interventions effective in reducing the incidence of ventriculostomy-associated infections. For individual interventions, examples included the frequency of sampling of cerebrospinal fluid for biochemical markers, the use of silver-impregnated and antibiotic-impregnated EVDs, different insertion techniques, the application of 2-octyl cyanoacrylate dressings, and the administration of prophylactic intrathecal vancomycin antibiotics. For multi-component interventions (n = 15), examples included barrier precautions, EVD routine exchanges, frequency of cerebrospinal fluid sampling, and impregnated EVDs. CONCLUSIONS: Fifty-three studies were included in this review, and 19 reported single-component or multi component interventions effective in reducing ventriculostomy-associated infection in patients with an EVD. The use of antibiotic- impregnated and silver-impregnated EVDs was reported to be most effective and the majority of these studies were assessed as having the lowest risk of bias across the individual interventions.

Measuring the safety climate in an Australian emergency department.

BACKGROUND: There are numerous intricate human, system and cultural factors that can impact upon the safe and effective implementation of patient safety systems (e.g. rapid response systems). Safety climate is one of these factors and is a measure of frontline healthcare workers' shared perceptions, behaviours, beliefs and attitudes towards the organisation's culture of safety. Safety climate scores are also associated with the frequency of errors and adverse events in the healthcare setting. However, there is little evidence regarding the relationships between attitudes to patient safety and staff characteristics such as emergency care expertise and experience. The aims of this study were to measure perceptions of the safety climate in an Australian metropolitan Emergency Department and examine relationships between safety climate perceptions and staff characteristics. METHODS: The Victorian Managed Insurance Authority Safety Climate Survey was administered to all doctors (n = 44) and nurses (n = 119) at an Australian emergency department. RESULTS: Completed surveys were received from 127 (78%) respondents, 25 (52%) doctors and 100 (84%) nurses. Reliability analysis showed very good internal consistency of all 43-items of the survey (α = 0.94). With the exception of stress recognition, nurses rated the organisation's commitment to patient safety higher than doctors in all remaining attitudinal domains (p < 0.05). Both groups acknowledge that fatigue, increased workload and stress recognition negatively impacts upon patient safety. There was a significant trend for declining safety climate ratings related to participants' clinical competence level and experience across all domains except stress recognition (p < 0.05). CONCLUSIONS: The Safety Climate Survey appears to be a reliable measure of patient safety climate for use in Emergency Departments. Emergency doctors and nurses did not perceive there to be a strong organisational commitment to patient safety in an Australian Emergency Department. Emergency Departments can provide a safer environment through genuine commitment to safety culture improvement which capitalises on the insights, intrinsic strengths and behaviours characteristic of the ED team's expertise and experience. This kind of commitment can positively influence the effectiveness of actions taken to minimise risk to patient safety and improve ED staff job satisfaction and effectiveness.

The prevalence and management of deteriorating patients in an Australian emergency department.

BACKGROUND: Complex human and system factors impact the effectiveness of Rapid Response Systems (RRS). Emergency Department (ED) specific RRS are relatively new and the factors associated with their effectiveness are largely unknown. This study describes the period prevalence of deterioration and characteristics of care for deteriorating patients in an Australia ED and examine relationships between system factors and escalation of care. METHODS: A retrospective medical record audit of all patients presenting to an Australian ED in two weeks. RESULTS: Period prevalence of deterioration was 10.08% (n=269). Failure to escalate care occurred in nearly half (n=52, 47.3%) of the patients requiring a response (n=110). Appropriate escalation practices were associated with where the patient was being cared for (p=0.01), and the competence level of the person documenting deterioration (p=0.005). Intermediate competence level nurses were nine times more likely to escalate care than novices and experts (p=0.005). While there was variance in escalation practice related to system factors, these associations were not statistically significant. CONCLUSION: The safety of deteriorating ED patients may be improved by informing care based on the escalation practices of staff with intermediate ED experience and competence levels.

The nurses' role in antimicrobial stewardship: A scoping review.

BACKGROUND: The role of nurses in antimicrobial stewardship is understated and not well understood. Nurses can have a significant impact on the development of antimicrobial resistant bacteria in hospitals and the wider community through their management of intravenous antibiotics. OBJECTIVE: To investigate the nurse's role in antimicrobial stewardship and examine best practice for preparing, administering and disposing of intravenous antibiotics. METHODS: A systematically conducted scoping review was used. Seven databases were searched for published articles. Retrieved articles were screened for eligibility against pre-set inclusion and exclusion criteria with eligible full-text articles included in the synthesis. Reference lists of eligible articles and social media were reviewed to identify further sources of literature. RESULTS: Forty-three sources of evidence were included. The extracted data indicate that a part of the nurse's role in antimicrobial stewardship is to monitor judicious antibiotic prescribing practices. Other than literature related to medication errors, there was limited research describing best practice when preparing, administering and disposing of intravenous antibiotics. There was also little evidence of consistent policy, guidelines and education for nurses' practice related to antimicrobial stewardship. CONCLUSIONS: The evidence for best practice when nurses prepare, administer and dispose of intravenous antibiotics in hospitals is scarce. When nurses use best practice to manage intravenous antibiotics, the risk of antimicrobial resistant bacteria developing is minimised. The role of nurses in antimicrobial stewardship needs to be supported through education and evidence-based guidelines. Tweetable abstract: Nurse work practices may prevent the development and spread of antimicrobial resistant bacteria.

Investigating emergency nurses' beliefs and experiences with patient handling in the emergency department.

BACKGROUND: Patient handling policy intends to decrease the risk of musculoskeletal injury for nurses. Many factors influence nurses' adherence to patient handling policy, including the context in which the activities take place. The aim of this study was to investigate emergency nurses' beliefs and experiences with patient handling in the emergency department. METHODS: A phenomenological approach was used to explore the participants' experience of patient handling in the ED. Focus group interviews were held in a Victorian emergency department. The interviews were audio-recorded, transcribed, and the data were analysed using thematic analysis. RESULTS: Five interviews were held with 40 nurse participants. Four themes were identified that described participants beliefs and experiences of patient handling: 'Putting the patient first' describes participants prioritisation of patient safety over their own; 'Patient -related challenges' describes the patient factors (e.g. language, mobility, size) that make patient handling more difficult; 'Staff knowledge' of policy and procedure; and 'Inadequate resources' which describes the physical and human resource limitations that made patient handling more difficult. CONCLUSIONS: Issues with equipment, education and patient handling culture are widespread, and this study reaffirms the importance of considering context in developing interventions to improve practice. Introduction of a Safe Patient Handling Program in the ED, that addresses multiple barriers simultaneously, may improve adherence to policy, and reduce the risk of musculoskeletal injury in emergency nurses.

Practice priorities for acute care nursing: A Delphi study.

AIMS AND OBJECTIVES: To describe the risk and frequency of challenges in acute care nursing, and the practice priorities in Australian hospital wards based upon expert consensus. BACKGROUND: Health care is facing increasing demands that are negatively impacting upon the safety and quality of nursing care. DESIGN: Delphi Method. METHOD: A three-round electronic Delphi method was used to collect and synthesise expert consensus opinion of 30 participants in Rounds One and Two of the survey, and 12 participants in Round Three. The study was carried out from July to December 2016. This study complied with the STROBE checklist. RESULTS: High patient acuity or complexity, as well as inadequate bed space on wards, are "very high" risks that occur "often" and "very often," respectively. The pressure to admit patients, delayed medical review and patient boarding are all "high" risks that occur "often." Though only occurring "sometimes," inadequate numbers and skill mix of staff, suboptimal communication and early or inappropriate discharge all pose a "very high" risk to patient care. CONCLUSION: The key practice priorities for nurse managers should include the design, implementation and evaluation of sustainable system-wide frameworks, processes and models of care that address patient boarding, communication and discharge processes, job satisfaction, staffing numbers and expertise. RELEVANCE TO CLINICAL PRACTICE: This study provides a description of the challenges that face acute care nursing in the provision of safe and high-quality care.

The effectiveness of education in the recognition and management of deteriorating patients: A systematic review.

BACKGROUND: Survival from in-hospital cardiac arrest is poor. Clinical features, including abnormal vital signs, often indicate patient deterioration prior to severe adverse events. Early warning systems and rapid response teams are commonly used to assist the health profession in the identification and management of the deteriorating patient. Education programs are widely used in the implementation of these systems. The effectiveness of the education is unknown. AIM: The aims of this study were to identify: (i) the evidence supporting educational effectiveness in the recognition and management of the deteriorating patient and (ii) outcome measures used to evaluate educational effectiveness. METHODS: A mixed methods systematic review of the literature was conducted using studies published between 2002 and 2014. Included studies were assessed for quality and data were synthesized thematically, while original data are presented in tabular form. RESULTS: Twenty-three studies were included in the review. Most educational programs were found to be effective reporting significant positive impacts upon learners, patient outcomes and organisational systems. Outcome measures related to: i learners, for example knowledge and performance, ii systems, including activation and responses of rapid response teams, and iii patients, including patient length of stay and adverse events. All but one of the programs used blended teaching with >87% including medium to high fidelity simulation. In situ simulation was employed in two of the interventions. The median program time was eight hours. The longest program lasted 44h however one of the most educationally effective programs was based upon a 40min simulation program. CONCLUSION: Educational interventions designed to improve the recognition and management of patient deterioration can improve learner outcomes when they incorporate medium to high-fidelity simulation. High-fidelity simulation has demonstrated effectiveness when delivered in brief sessions lasting only forty minutes. In situ simulation has demonstrated sustained positive impact upon the real world implementation of rapid response systems. Outcome measures should include knowledge and skill developments but there are important benefits in understanding patient outcomes.