Implementation and use of the Safewards model in healthcare services: A scoping review.

Safewards is a multi-intervention mental health nursing model of practice improvement aimed at preventing and reducing conflict and containment. The use of Safewards has now extended beyond mental health settings. Implementation of Safewards has been reported to be challenging and therefore requires an evidence-informed and structured approach. This review's objectives were to: (i) Comprehensively map approaches used to implement Safewards interventions; (ii) Characterise the outcomes measured in Safewards implementation studies; and (iii) Identify the facilitators and barriers to Safewards training and its implementation in practice. All quantitative, qualitative and mixed-methods publications of Safewards, the interventions, evaluations, barriers and facilitators from all healthcare services internationally were included. The Joanna Briggs Institute scoping review and Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews were used to guide methodology. Data were reported according to the 12 items of the TIDieR. Twenty-seven publications reported the implementation of Safewards. Descriptions were limited for reporting items such as intervention descriptions, materials, resources, specific procedures and processes, modifications made to interventions and delivery of interventions and training. No consistent theoretical implementation framework was reported. Collaboration, leadership, feedback and co-design were strong drivers for staff buy-in, engagement and success for implementation in mental health and acute settings. Transparency, replicability and generalisation require a detailed description of all elements of an intervention being implemented. Without adequate information, only assumptions can be drawn about the clinical governance and process of the implementation and training, and it is difficult to conclude when attempting to replicate the interventions.

Complex health service needs for people who are homeless.

BACKGROUND: Homeless people face many challenges in accessing and utilising health services to obtain psychosocial supports offered in hospital and community settings. The complex nature of health issues is compounded by lack of accessibility to services and lack of appropriate and safe housing. OBJECTIVE: To examine the perceptions and experiences of homeless people in relation to their health service needs as well as those of service providers involved with their care. DESIGN: A purposive sampling approach was undertaken with a thematic framework analysis of semi-structured interviews. Participants. Interviews were undertaken with 20 homeless people who accessed the emergency department in an acute hospital in Melbourne, Australia and 27 service providers involved in hospital and community care. RESULTS: Six key themes were identified from interviews: complexity of care needs, respect for homeless people and co-workers, engagement as a key strategy in continued care, lack of after-hour services, lack of appropriate accommodation and complexity of services. CONCLUSIONS: Findings revealed the complex and diverse nature of health concerns in homeless people. The demand on hospital services continues to increase and unless government policies take into consideration the psychosocial demands of the communities most vulnerable people efforts to divert hospital demand will continue to fail.

Republished paper: Emergency department triage revisited.

Triage is a process that is critical to the effective management of modern emergency departments. Triage systems aim, not only to ensure clinical justice for the patient, but also to provide an effective tool for departmental organisation, monitoring and evaluation. Over the last 20 years, triage systems have been standardised in a number of countries and efforts made to ensure consistency of application. However, the ongoing crowding of emergency departments resulting from access block and increased demand has led to calls for a review of systems of triage. In addition, international variance in triage systems limits the capacity for benchmarking. The aim of this paper is to provide a critical review of the literature pertaining to emergency department triage in order to inform the direction for future research. While education, guidelines and algorithms have been shown to reduce triage variation, there remains significant inconsistency in triage assessment arising from the diversity of factors determining the urgency of any individual patient. It is timely to accept this diversity, what is agreed, and what may be agreeable. It is time to develop and test an International Triage Scale (ITS) which is supported by an international collaborative approach towards a triage research agenda. This agenda would seek to further develop application and moderating tools and to utilise the scales for international benchmarking and research programmes.

Emergency department triage revisited.

Triage is a process that is critical to the effective management of modern emergency departments. Triage systems aim, not only to ensure clinical justice for the patient, but also to provide an effective tool for departmental organisation, monitoring and evaluation. Over the last 20 years, triage systems have been standardised in a number of countries and efforts made to ensure consistency of application. However, the ongoing crowding of emergency departments resulting from access block and increased demand has led to calls for a review of systems of triage. In addition, international variance in triage systems limits the capacity for benchmarking. The aim of this paper is to provide a critical review of the literature pertaining to emergency department triage in order to inform the direction for future research. While education, guidelines and algorithms have been shown to reduce triage variation, there remains significant inconsistency in triage assessment arising from the diversity of factors determining the urgency of any individual patient. It is timely to accept this diversity, what is agreed, and what may be agreeable. It is time to develop and test an International Triage Scale (ITS) which is supported by an international collaborative approach towards a triage research agenda. This agenda would seek to further develop application and moderating tools and to utilise the scales for international benchmarking and research programmes.

Medication use across transition points from the emergency department: identifying factors associated with medication discrepancies.

BACKGROUND: As patients move across transition points of care, medication discrepancies are likely to occur. In the emergency department (ED), patients are vulnerable to medication discrepancies because they are in an environment in which rapid decisions need to be made under high levels of stress. OBJECTIVE: To identify the patient-, environment-, and medication-related factors involving unexplained medication discrepancies across transition points after ED presentation. METHODS: Using a retrospective chart review design, a stratified, random sampling of data was undertaken over a 12-month period. Information was obtained from an electronic administrative database and medical records as patients moved from the ED to another transition point of care. Medication discrepancies were classified into 2 outcome groups: (1) no discrepancies and situations in which discrepancies were adequately explained and (2) discrepancies that had no adequate explanation. RESULTS: For the 12-month period, 210 randomly selected patients were included; 73 (34.8%) had at least one unexplained medication discrepancy. Binary logistic regression modeling showed 4 factors that were statistically significant in determining the incidence of at least one unexplained medication discrepancy. Benefit card holders (individuals who receive benefits from government insurance programs comparable to the US-based Medicare and Medicaid initiatives, which include the elderly, the disabled, low income earners, and unemployed persons) had 3.73 greater odds of experiencing an unexplained medication discrepancy (95% CI 1.72 to 8.07; p = 0.001). Patients prescribed 5 or more drugs at discharge from the ED had 12.22 greater odds of having at least one unexplained medication discrepancy (95% CI 5.52 to 27.08; p < 0.001). Patients who were first seen by a physician within 1 hour of a change in working shift had 3.70 greater odds of having an unexplained medication discrepancy (95% CI 1.67 to 8.18; p = 0.001). For each additional minute of wait time for a physician, the odds of having an unexplained medication discrepancy increased by a factor of 1.01 (95% CI 1.00 to 1.01; p = 0.042). CONCLUSIONS: Patient-, environment-, and drug-related factors contribute to the risk of medication discrepancies across transition points from the ED.

An evaluation of the use of management care plans for people who frequently attend the emergency department.

OBJECTIVE: To evaluate the use of management plans for people who frequently attend the emergency department (ED). BACKGROUND: Management plans are used to decrease ED utilisation by people who frequently attend. There is limited evidence regarding the use management plans for this population and the perspectives of staff who use them has previously not been considered. DESIGN: A descriptive observational design including before and after measures of attendance (November 2010 to September 2014) and survey of staff perceptions (July to November 2014). The setting was a major metropolitan hospital ED in Australia. METHODS: The date for commencement of each plan was determined. Data were extracted regarding ED attendance 12 months before and after implementation. Staff perspectives were obtained via an online survey. RESULTS: Fifty-seven patients made 1482 ED attendances. Of these 830 occurred in the 12 months before the management plan was implemented and 652 during the 12 months after. The number of attendances per patient decreased from a median of 11 to 4. Staff considered management plans to be beneficial to care planning practices and individual patient outcomes. CONCLUSIONS: Management plans were acceptable to staff, and implementation of management plans was associated with a decrease in ED attendance.

Disaster preparedness and learning needs among community health nurse coordinators in South Sulawesi Indonesia.

BACKGROUND: The number of natural disasters occurring worldwide has increased, including Indonesia, a country that continues to experience natural disasters of varying level of severity. Despite this evidence, limited information is available about nurses' disaster preparedness in Indonesia particularly in community settings. This study aims to identify the current level of disaster preparedness and learning needs for managing natural disasters as perceived by community health nurse (CHN) coordinators who are working in community health settings in South Sulawesi, Indonesia. METHODS: This study used a descriptive study design. A self-administered survey, the Disaster Preparedness Evaluation Tools (DPET®) was utilized to determine the current levels of disaster preparedness and management of the CHN coordinators. In addition, structured questions were used to identify learning needs. It was distributed to 254 CHN coordinators working in community health settings in South Sulawesi Province, Indonesia. RESULTS: In total 214 CHN coordinators completed the survey. There were around 6.5% respondents perceived their current disaster preparedness as weak; 84.6% moderate; and 8.9% rated their preparedness as strong. Around one-third of the participants considered frequent disaster drills as the best learning method to achieve effective disaster preparedness. CONCLUSION: Although overall disaster preparedness levels of the CHN coordinators in South Sulawesi province Indonesia were moderate, continuing disaster training that integrates CHN coordinators specific learning needs is still required to achieve effective disaster preparedness and management in community levels.

Mental health nurses' dispositional decision-making for people presenting to the emergency department with deliberate self-harm: an exploratory study.

BACKGROUND: There is no clear treatment pathway for people presenting to Australian emergency departments with deliberate self-harm. PURPOSE: To explore variations in mental health nurses' disposition decisions for patients following risk assessment for deliberate self-harm. DESIGN AND METHOD: A survey was distributed to mental health nurses. This survey comprised demographic items and questions in response to nine vignettes describing episodes of deliberate self-harm. Dispositional decision and reasoning were also sought for each vignette. FINDINGS: Poor levels of agreement for disposition were found. PRACTICE IMPLICATIONS: There was a lack of consensus regarding dispositional outcomes. This suggests a high level of subjectivity in decision-making which needs to be taken into account within clinical governance.

The outcome of a rapid training program on nurses' attitudes regarding the prevention of aggression in emergency departments: a multi-site evaluation.

BACKGROUND: Patient aggression is a common source of occupational violence in emergency departments. Staff attitudes regarding the causes for aggression influence the way they manage it. The Management of Clinical Aggression - Rapid Emergency Department Intervention is a 45 min educational program that aims to promote the use of de-escalation techniques and effective communication skills to prevent patient aggression. OBJECTIVE: We sought to evaluate the impact of the program on staff attitudes regarding the prevention and early management of patient aggression. DESIGN: A mixed methods approach was used including a pre-test post-test survey of training participants and individual interviews with key stakeholders. SETTING AND SAMPLE: The setting was public sector hospital emergency departments located in metropolitan and regional Victoria, Australia. A convenience sample of eighteen emergency departments was recruited via the Victorian Department of Health. PARTICIPANTS: Survey participants were nurses and midwives who were employed at the study sites. Interview participants were a purposive sample of nurse unit managers and trainers. METHODS: The Management of Aggression and Violence Attitude Scale was administered to training participants immediately before and 6-8 weeks after training. Semi-structured telephone interviews with trainers and managers occurred 8-10 weeks after the intervention. RESULTS: Four hundred and seventy one participants completed the pre-test and post-test. Statistically significant shifts were observed in 5/23 items (Wilcoxon Signed Ranks Test: p ≤ 0.01). Despite training, participants were undecided if it was possible to prevent patient aggression, and continued to be unsure about the use of physical restraint. Twenty-eight (82.3%) of managers' and trainers' eligible to be interviewed provided their perceptions of the impact of the program. Overall, these perceptions were consistent with the significant shifts observed in the survey items. CONCLUSION: There was limited evidence to demonstrate that the program significantly modified staff attitudes towards the prevention of patient aggression using the Management of Aggression and Violence Attitude Scale. Additional survey items that specifically measure staff attitudes about the use of restraint in emergency settings are needed to better understand decision making about restraining practices. Further work is indicated to quantify the impact of training in practice.

Prospective validation of a predictive model that identifies homeless people at risk of re-presentation to the emergency department.

OBJECTIVE: To prospectively evaluate the accuracy of a predictive model to identify homeless people at risk of representation to an emergency department. METHODS: A prospective cohort analysis utilised one month of data from a Principal Referral Hospital in Melbourne, Australia. All visits involving people classified as homeless were included, excluding those who died. Homelessness was defined as living on the streets, in crisis accommodation, in boarding houses or residing in unstable housing. Rates of re-presentation, defined as the total number of visits to the same emergency department within 28 days of discharge from hospital, were measured. Performance of the risk screening tool was assessed by calculating sensitivity, specificity, positive and negative predictive values and likelihood ratios. RESULTS: Over the study period (April 1, 2009 to April 30, 2009), 3298 presentations from 2888 individuals were recorded. The homeless population accounted for 10% (n=327) of all visits and 7% (n=211) of all patients. A total of 90 (43%) homeless people re-presented to the emergency department. The predictive model included nine variables and achieved 98% (CI, 0.92-0.99) sensitivity and 66% (CI, 0.57-0.74) specificity. The positive predictive value was 68% and the negative predictive value was 98%. The positive likelihood ratio 2.9 (CI, 2.2-3.7) and the negative likelihood ratio was 0.03 (CI, 0.01-0.13). CONCLUSION: The high emergency department re-presentation rate for people who were homeless identifies unresolved psychosocial health needs. The emergency department remains a vital access point for homeless people, particularly after hours. The risk screening tool is key to identify medical and social aspects of a homeless patient's presentation to assist early identification and referral.

Optimizing triage consistency in Australian emergency departments: the Emergency Triage Education Kit.

OBJECTIVE: The Emergency Triage Education Kit was designed to optimize consistency of triage using the Australasian Triage Scale. The present study was conducted to determine the interrater reliability of a set of scenarios for inclusion in the programme. METHODS: A postal survey of 237 paper-based triage scenarios was utilized. A quota sample of triage nurses (n = 42) rated each scenario using the Australasian Triage Scale. The scenarios were analysed for concordance and agreement. The criterion for inclusion of the scenarios in the programme was kappa >or= 0.6. RESULTS: Data were collected during 2 April to 14 May 2007. Agreement for the set was kappa = 0.412 (95% CI 0.410-0.415). Of the initial set: 92/237 (38.8%, 95% CI 32.6-45.3) showed concordance >or=70% to the modal triage category (kappa = 0.632, 95% CI 0.629-0.636) and 155/237 (65.4%, 95% CI 59.3-71.5) showed concordance >or=60% to the modal triage category (kappa = 0.507, 95% CI 0.504-0.510). Scenarios involving mental health and pregnancy presentations showed lower levels of agreement (kappa = 0.243, 95% CI 0.237-0.249; kappa = 0.319, 95% CI 0.310-0.328). CONCLUSION: All scenarios that showed good levels of agreement have been included in the Emergency Triage Education Kit and are recommended for testing purposes; those that showed moderate agreement have been incorporated for teaching purposes. Both scenario sets are accompanied by explanatory notes that link the decision outcome to the Australasian College for Emergency Medicine Guidelines on the Implementation of the Australasian Triage Scale. Future analysis of the scenarios is required to identify how task-related factors influence consistency of triage.