Effect of emergency critical care nurses and emergency department boarding time on in-hospital mortality in critically ill patients.

STUDY HYPOTHESIS: We hypothesized that establishing a program of specialized emergency critical care (ECC) nurses in the ED would improve mortality of ICU patients boarding in the ED. METHODS: This was a retrospective before-after cohort study using electronic health record data at an academic medical center. We compared in-hospital mortality between the pre- and post-intervention periods and between non-prolonged (≤6 h) boarding time and prolonged (>6 h) boarding time. In-hospital mortality was stratified by illness severity (eccSOFA category) and adjusted using logistic regression. RESULTS: Severity-adjusted in-hospital mortality decreased from 12.8% pre-intervention to 12.3% post-intervention (-0.5% (95% CI, -3.1% to 2.1%), which was not statistically significant. This was despite a concurrent increase in ED and hospital crowding. The proportion of ECC patients downgraded to a lower level of care while still in the ED increased from 6.4% in the pre-intervention period to 17.0% in the post-intervention period. (+10.6%, 8.2% to 13.0%, p < 0.001). Severity-adjusted mortality was 12.8% in the non-prolonged group vs. 11.3% in the prolonged group (p = 0.331). CONCLUSIONS: During the post-intervention period, there was a significant increase in illness severity, hospital congestion, ED boarding time, and downgrades in the ED, but no significant change in mortality. These findings suggest that ECC nurses may improve the safety of boarding ICU patients in the ED. Longer ED boarding times were not associated with higher mortality in either the pre- or post-intervention periods.

Hospital Nurses' Willingness to Respond in a Disaster.

OBJECTIVE: This study examined the factors associated with nurses' willingness to respond in a disaster. BACKGROUND: Nurses are key personnel in case of disasters, and therefore, understanding factors associated with willingness to respond is important. METHODS: Questionnaires were distributed to 200 nurses recruited from 2 public hospitals in Seoul, Korea. Data were collected in January and February 2018 and 181 responses were analyzed. RESULTS: Factors predicting willingness to respond in a disaster among public hospital nurses were level of education, self-efficacy, and disaster management competency. CONCLUSIONS: Providing well-organized disaster preparedness and response training programs would enhance nurses' level of knowledge about disasters. In addition, training could improve nurses' self-efficacy and disaster management competency, which should enhance willingness to respond in a disaster.

Triage practice in emergency departments in tertiary hospitals across China: A multicenter national descriptive survey.

Triage procedure remains at a developing stage in mainland China, and few studies have reported the current status. This study aimed to explore the triage practices presently implemented in emergency departments in mainland China. A descriptive online national survey was administered to nurses with experience in emergency department triage who worked in 64 hospitals in 2019. A total of 361 participants completed the survey. Only 210 nurses (58.2%) used triage systems. Approximately 5% of the participants reported that no nurse was allocated to triage during the evening and night shifts in their emergency departments. Most participants had fewer than 5 years of nursing experience (47%) and emergency nursing experience (58.2%) before fulfilling the triage role. This study shows the variability in triage guidelines as well as the inconsistency between different hospitals in nurses' entry qualifications to triage, in hospital workforce arrangements, and in triage training. These problems underscore the need to unify triage guidelines and to establish reasonable entry qualifications and appropriate workforce arrangements for triage nurses that ensure high triage quality and high levels of patient safety.

Registered nurses' understandings of emergency medical dispatch center work: A qualitative phenomenographic interview study.

Non-urgent and urgent telephone nursing services are increasing globally, and phenomenographic research has shown that how work is understood may influence work performance. This descriptive study makes a qualitative inductive investigation of understandings of emergency medical dispatch center work among registered nurses. Twenty-four registered nurses at three mid Swedish emergency medical dispatch centers were interviewed. Analysis based on phenomenographic principles identified five categories in the interviews: (i) Assess, prioritize, direct, or refer; (ii) Facilitate ambulance nursing work; (iii) Perform nursing care; (iv) Always be available for the public; and (v) Have the person behind the patient in mind. The first constitutes the basis of the work. The second emphasizes cooperation with and support for the ambulance staff. The third entails remotely providing nursing care, whilst the fourth stresses serving the entire population. The fifth and most comprehensive way of understanding work involves having a holistic view of the person in need, including person-centered care. Provision of high-quality emergency medical dispatch center work involves all categories. Combined, they constitute a "work map," valuable for reflection, competence development, and introduction of new staff.

Novice nurse's transitioning to emergency nurse during COVID-19 pandemic: A qualitative study.

AIM: To explore the experiences and perceptions of recent nursing graduates working in emergency departments during the COVID-19 outbreak. BACKGROUND: Overcrowding in emergency departments has been one of the most prominent issues arising in these units for more than 20 years. However, it has become even more problematic due to the novelty of the coronavirus pandemic, which has forced hospitals to recruit larger numbers of beginner nursing staff as the number of quarantined health professionals increases. METHODS: Sixteen semi-structured interviews were conducted in Spanish emergency departments, which were analysed and synthesized using content analysis. RESULTS: Three major themes emerged from the data analysis: (a) Fears and concerns, (b) Organisational issues and (c) Support for novice nurses. CONCLUSIONS: Our findings may help to understand how shadowing periods as a learning programme for nurses, continuing professional development, evidence-based apps and better planning are needed to ensure both novice nurses' confidence in emergency departments and expert emergency room nurses' ability to cope with complications in critical situations. IMPLICATIONS FOR NURSING MANAGEMENT: Training periods that include shadowing expert emergency room nurses, along with evidence-based technology, provide an opportunity to support novice nurses' transition into the workplace. These measures would provide a safety net and would increase novice nurses' confidence as well as high-quality care.

Development and validation of an assessment tool for nursing workload in emergency departments.

AIMS: To develop the Workload Assessment of Nurses on Emergency (WANE) tool and to test its validity and reliability to measure nursing workload in the emergency departments. BACKGROUND: Ensuring safe nursing staffing in emergency departments is a worldwide concern. There is no valid tool to measure emergency nursing workload in order to determine the needed nurse staffing in the emergency departments. DESIGN: A two-year, cross-sectional, multicenter study. METHODS: Workload was operationalised as the time nurses spent with nursing activities, classified into direct and indirect care. A board of experts provided content validity. Construct validity was evaluated by examining the WANE's correlations and group-discriminations patterns within the network of variables known to determine nursing workload. Reliability was assessed by the tool's ability to yield consistent results across repeated measurements. Reporting of this research adheres to STROBE guidelines. RESULTS: Seven emergency departments, including 3,024 patients, were involved in the first year and 18 emergency departments and 7,442 patients in the second year. Direct care time correlated positively and significantly with patient dependency on nursing care, age and length of emergency department stay and discriminated between the categories of dependency on nursing care, age and hospitalisation. Both direct and indirect care time discriminated between the emergency departments according to different patient care profiles and unit characteristics. WANE showed consistent results across measurements. CONCLUSIONS: Results support the WANE's reliability and validity to measure emergency nursing workload. This tool could be used to determine, on patient and unit, a baseline nurse staffing and the nursing skill mix in the emergency departments. WANE is also an evidence-based management tool for benchmarking purposes. RELEVANCE TO CLINICAL PRACTICE: The use of an evidence-based workload tool in making staffing decisions in emergency departments is crucial to ensure safe patient care and prevent work overload in nursing staff.

Update: AHA guidelines for CPR and emergency cardiovascular care.

Continuous review of current research and practice has resulted in updates to the American Heart Association guidelines for CPR and emergency cardiovascular care. This article examines the recommendations and their implementation into current healthcare practice.

Disaster Nursing: Taking Your Faith to the Field.

National and global disasters require immense resources, including nurses. Personal, professional, and spiritual preparation is strongly recommended for healthcare workers who desire to serve in disaster settings. Most nurses are underprepared for this role; options for preparation are described along with the ministry of nursing and spiritual care that expresses God's heart of mercy and care for hurting and desperate people.

A study of nurse-based Injury Units in Ireland: An emergency care development for consideration worldwide.

The aim of this 2018 research study was to determine why nurse-based Injury Units were developed in Ireland and how they function in the Irish healthcare system, including what they contribute in relation to addressing the healthcare needs of Irish citizens. A document review was completed and interviews of nurse practitioners and physicians working in Irish Emergency Rooms (ERs) and Injury Units, as well as nurse managers with responsibility for Injury Units and health service executives who helped design Injury Units. A new model of emergency care was needed 20 years ago when two issues were apparent. The first was concern over unsafe care in small ERs as a result of low patient volumes and staff not having ER expertise. The second issue was long waits for ER care. Considerable opportunity for change was present, including financial imperatives and nurse, physician, and political leaders who were together ready to design and move a new-to-Ireland ER services model and nurse practitioner education forward. The Injury Unit model is based on nurse practitioners providing a defined set of services to nonurgent patients in daytime hours. This model was pilot tested and is being implemented across Ireland after it was determined that quality services were being rapidly and safely provided. Nurse practitioner education was also initiated and is now in expansion mode to gain 700 more nurse practitioners by the year 2021 over the current 240.

Implementation of a Nursing Based Order Set: Improved Antibiotic Administration Times for Pediatric ED Patients with Therapy-Induced Neutropenia and Fever.

PURPOSE: For patients with chemotherapy-induced neutropenia and fever, delays in antibiotic administration are associated with poor outcomes, such as ICU admission and need for further interventions. The objective of this quality improvement project was to significantly reduce the time from initiation of triage to antibiotic administration for pediatric patients arriving to the emergency department with therapy-induced neutropenia and fever. METHODS: An interdisciplinary team set an evidence-based goal for time to antibiotics (TTA) at 60-min. A six-month retrospective chart review of Emergency Department (ED) patients revealed a 128 min TTA mean when measured from the initiation of triage to antibiotic administration, which also reflected 0% of patients receiving antibiotics within the goal of 60 min. Members of the interdisciplinary team evaluated delays in patient care workflow and identified three primary interventions to decrease the TTA. These three evidenced-based interventions were implemented and evaluated using the Plan-Do-Check-Act (PDCA) quality improvement methodology. RESULTS: By the end of the implementation period mean TTA improved to 53 min and patients received antibiotics within 60 min (83% of the time). CONCLUSION: The interventions focused on both provider and nursing workflow, however the implementation of an evidence-based practice nursing order set made the greatest impact on timeliness of antibiotic delivery time.

Using Mathematical Modeling to Improve the Emergency Department Nurse-Scheduling Process.

INTRODUCTION: Nurse scheduling within an emergency department can be a very time-consuming process as nursing leadership works to reach sufficient nurse-staffing levels across every day of the schedule while also working to satisfy nurse preferences. METHODS: A mathematical model is formulated to determine nursing shifts to minimize the number of shifts across a day while accounting for staffing level requirements, nurse preferences, and meal breaks. RESULTS: A daily schedule based on nursing shifts was created and used within the self-scheduling process. Implementing the schedule improved nurse-staffing levels while decreasing the time necessary to reconcile the monthly schedule, resulting in the potential to increase nurse satisfaction. DISCUSSION: The emergency department can use mathematical modeling to improve the nurse-scheduling process.

Primary care professionals providing non-urgent care in hospital emergency departments.

BACKGROUND: In many countries emergency departments (EDs) are facing an increase in demand for services, long waits, and severe crowding. One response to mitigate overcrowding has been to provide primary care services alongside or within hospital EDs for patients with non-urgent problems. However, it is unknown how this impacts the quality of patient care and the utilisation of hospital resources, or if it is cost-effective. This is the first update of the original Cochrane Review published in 2012. OBJECTIVES: To assess the effects of locating primary care professionals in hospital EDs to provide care for patients with non-urgent health problems, compared with care provided by regularly scheduled emergency physicians (EPs). SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (the Cochrane Library; 2017, Issue 4), MEDLINE, Embase, CINAHL, PsycINFO, and King's Fund, from inception until 10 May 2017. We searched ClinicalTrials.gov and the WHO ICTRP for registered clinical trials, and screened reference lists of included papers and relevant systematic reviews. SELECTION CRITERIA: Randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series studies that evaluated the effectiveness of introducing primary care professionals to hospital EDs attending to patients with non-urgent conditions, as compared to the care provided by regularly scheduled EPs.  DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We identified four trials (one randomised trial and three non-randomised trials), one of which is newly identified in this update, involving a total of 11,463 patients, 16 general practitioners (GPs), 9 emergency nurse practitioners (NPs), and 69 EPs. These studies evaluated the effects of introducing GPs or emergency NPs to provide care to patients with non-urgent problems in the ED, as compared to EPs for outcomes such as resource use. The studies were conducted in Ireland, the UK, and Australia, and had an overall high or unclear risk of bias. The outcomes investigated were similar across studies, and there was considerable variation in the triage system used, the level of expertise and experience of the medical practitioners, and type of hospital (urban teaching, suburban community hospital). Main sources of funding were national or regional health authorities and a medical research funding body.There was high heterogeneity across studies, which precluded pooling data. It is uncertain whether the intervention reduces time from arrival to clinical assessment and treatment or total length of ED stay (1 study; 260 participants), admissions to hospital, diagnostic tests, treatments given, or consultations or referrals to hospital-based specialist (3 studies; 11,203 participants), as well as costs (2 studies; 9325 participants), as we assessed the evidence as being of very low-certainty for all outcomes.No data were reported on adverse events (such as ED returns and mortality). AUTHORS' CONCLUSIONS: We assessed the evidence from the four included studies as of very low-certainty overall, as the results are inconsistent and safety has not been examined. The evidence is insufficient to draw conclusions for practice or policy regarding the effectiveness and safety of care provided to non-urgent patients by GPs and NPs versus EPs in the ED to mitigate problems of overcrowding, wait times, and patient flow.

Motivation of the nurses in pre-hospital emergency and educational hospitals emergency in the southeast of Iran.

INTRODUCTION: Nurses, as the largest human resource element of health care systems, have a major role in providing ongoing, high-quality care to patients. Therefore, due to the importance of this issue, this study aimed to determine job motivation of the nurses in pre-hospital and educational hospitals emergency in the southeast of Iran. METHODS: In this study, a cross-sectional method was used, and it was conducted in educational hospitals and pre-hospital emergencies under supervision of the Kerman University of Medical Sciences in 2017. Using a valid and reliable questionnaire, we assessed job motivation of the nurses using a census method (N = 275). Data were analyzed by implementing descriptive statistics including mean and standard deviation (SD), and analytical statistics such as Kolmogorov-Smirnov, ANOVA, t-test, X2, Pearson, and multivariate regression tests using SPSS 16 and P ≤ 0.05. RESULTS: Among the pre-hospital emergency nurses, the average of the educational factors was 25.33, financial factors was 6.34, psychological factors was 20.07, welfare factors was 0.63, and administrative factors was 8.16. Among the nurses of the educational hospitals emergency, these factors were 25.33, 6.51, 20.34, 16.55, and 8.39, respectively. Two group's nurses were at the intermediate level of the job motivation. CONCLUSION: Dynamic and predetermined goals of emergency include providing services as soon as possible and stabilizing patient's condition during the golden and vital time of rescue. Findings suggest that national and local policies in Iran may need to examine factors that contribute to the promotion of the motivation as well as focusing on how to improve them.

Registered nurses' perceptions of safe care in overcrowded emergency departments.

AIMS AND OBJECTIVES: To explore registered nurses' perceptions of safe practice in care for patients with an extended length of stay in the emergency department. BACKGROUND: Extended length of stay and overcrowding in emergency departments are described internationally as one of the most comprehensive challenges of modern emergency care. An emergency department is not designed, equipped or staffed to provide care for prolonged periods of time. This context, combined with a high workload, poses a risk to patient safety, with additional medical errors and an increased number of adverse events. From this perspective, it is important to extend our knowledge and to describe registered nurses' experiences of safe practice. DESIGN: A qualitative, inductive and descriptive study. METHODS: Qualitative interview study carried out in five emergency departments. Data were analysed using a qualitative content analysis with a latent approach. RESULTS: Patient safety meets obstacles in the clinical environment involving experiencing deficiencies regarding patient safety in the clinical setting and the impact of working procedures and routines. Moreover, nurses are challenged in their professional responsibilities involving balancing essential nursing care and actual workload; it is common to experience emotional reactions based on feelings of loss of control. CONCLUSIONS: From the nurses' perspective, a prolonged stay in the emergency department may lead to negative consequences for both patient safety and care as well as registered nurses' psychosocial experiences. An extended length of stay significantly reduces the level of nursing and caring that registered nurses can perform in the emergency department. RELEVANCE TO CLINICAL PRACTICE: This study indicates that emergency departments should review their procedures to avoid both deviations from normal practice and moral stress among registered nurses. This can contribute to an increased understanding and insight about the challenge of patient safety in an emergency department setting.

Nurse workforce scheduling in the emergency department: A sequential decision support system considering multiple objectives.

AIM: We propose a nurse scheduling framework based on a set of performance measures that are aligned with multiple outcome measures. A case study for the emergency department is presented. METHODS: A total of 142,564 emergency department attendances over 1 year were included in this study. Operational requirements, constraints and historical workload data were translated into a mixed-integer sequential goal programming model, which considers the following outcome measures: (1) nurse-patient ratios; (2) number of favourable/unfavourable shifts; and (3) dispersion of rest days. Computational studies compared the performance of the mixed-integer sequential goal programming results with manually generated historical nurse schedules. RESULTS: The maximum nurse-patient ratio deviation against the target was approximately 10% compared to 47% generated by the historical rosters (a 10% deviation translates to approximately two nurses). An on-line decision support system, which integrates shift preferences, staff databases and a workload forecasting module, was also developed. CONCLUSION: A decision support system based on the mixed-integer sequential goal programming modelling framework was proposed. The application of the model in a case study for an emergency department demonstrated improvements over existing manual scheduling methods. IMPLICATIONS FOR NURSING MANAGEMENT: This study demonstrates a mathematical, programming-based decision support system, which allows for managerial priorities and nurse preferences to be jointly considered in the automatic generation of nurse rosters.

The Role of Trauma Video Review in Optimizing Patient Care.

Trauma video review allows for monitoring of performance improvement initiatives, leadership skills, system process issues, and guideline compliance. Despite the well-documented benefits, there are persistent barriers to its use including patient privacy concerns, cost, and provider anxiety. Optimizing implementation by ensuring that informed consent processes are in place, as well as a structured peer review process, can help trauma centers overcome these hurdles. Trauma video review is a unique and beneficial tool that helps tie patient care to quantifiable data, as well as serves as a platform for education opportunities.

[Carbon monoxide poisoning, treatment and orientation]. / Intoxication au monoxyde de carbone, prise en charge et orientation.

Colourless and odourless, each year carbon monoxide is responsible for several thousand cases of poisoning. Often collective, their symptoms are non specific and can result in serious neurological sequelae or even death, if they are not detected in time. The (pre-) hospital emergency nurse plays an important role in the management of these patients, in terms of assessment, treatment and monitoring as well as the organisation of the admittance of victims, categorisation and medical triage. As part of a team, the nurse ensures that the patient enters an adapted, regulated pathway, with the most serious cases being directed towards a hospital equipped with a hyperbaric medicine facility.

Influencing Scope of Practice Policy and Health Literacy: An Interview With Dr Joy Deupree.

This department highlights emerging nursing leaders who have demonstrated leadership in advancing innovation and patient care in practice policy, research, education, and theory. This interview profiles Joy Deupree, assistant professor, School of Nursing, The University of Alabama at Birmingham.

A framework for transition to specialty practice programmes.

AIM: To develop a framework for emergency nursing transition to specialty practice programmes. BACKGROUND: Transition to Specialty Practice programmes were introduced to fill workforce shortages and facilitate the transition of nurses to specialty nursing practice. These programmes are recognized as an essential preparation for emergency nurses. Emergency nursing Transition to Specialty Practice programmes have developed in an ad hoc manner and as a result, programme characteristics vary. Variability in programme characteristics may result in inconsistent preparation of emergency nurses. DESIGN: Donabedian's Structure-Process-Outcome model was used to integrate results of an Australian study of emergency nursing Transition to Specialty Practice programmes with key education, nursing practice and safety and quality standards to develop the Transition to Specialty Practice (Emergency Nursing) Framework. METHODS: An explanatory sequential design was used. Data were collected from 118 emergency departments over 10 months in 2013 using surveys. Thirteen interviews were also conducted. Comparisons were made using Mann-Whitney U, Kruskal-Wallis and Chi-square tests. Qualitative data were analysed using content analysis. RESULTS: Transition to Specialty Practice programmes were offered in 80 (72·1%) emergency departments surveyed, to improve safe delivery of patient care. Better professional development outcomes were achieved in emergency departments which employed participants in small groups (Median = 4 participants) and offered programmes of 6 months duration. Written assessments were significantly associated with articulation to postgraduate study (Chi-square Fisher's exact P = <0·001). CONCLUSION: The Transition to Specialty Practice (Emergency Nursing) Framework has been developed based on best available evidence to enable a standardized approach to the preparation of novice emergency nurses.

Evaluating the use of patient pathway scores in medical assessments.

Aim This article describes the modification and testing of a triage tool, the patient pathway assessment score (PPAS), which could be used by all grades of nursing staff to triage patients in a medical assessment area (MAA). The aim was to increase patient satisfaction and reduce waiting times. Method Staff scored all patients using PPAS, but used the existing triage process to assign patients to one of the MAA's two pathways. Two researchers reviewed patients' notes retrospectively to determine which pathway they should have followed and compared this to the outcome that would have occurred if the PPAS score had been used. Results Full, rather than theoretical, use of the PPAS tool could have reduced patient waiting times, as 55 (24%) out of 231 patients would have been allocated to the correct pathway. Conclusion The tool could improve patients' journeys through the MAA by ensuring they are allocated to the correct pathway. It is now implemented in practice.