Improving care for people with Parkinson’s disease presenting to an Emergency Department: Implementing a care bundle

Prof. Margaret Fry1,3, Mrs Marion Harris2

1University of Technology Sydney, Broadway, Australia, 2Hornsby Hospital NSLHD, Hornsby , Australia, 3Northern Sydney Local Health District, Royal North Shore Hospital, Australia

Introduction:  Hospital presentations to the Emergency Department (ED) can be traumatic for people with Parkinson’s disease (PD) due to the complexity of clinical management and medication regimens and the potential side effects. As a result care can be compromised if not coordinated well, medication regimens are not maintained and or inappropriate prescribing of PD medicines.

Method:  This was a study evaluating the implementation of a care in one Sydney ED. The evaluation involved a pre-post medication record audit, patient interviews and nurse surveys. The care bundle included a: clinical pathway, education program and a learning package, electronic medical record prompt, patient sticker for the medical record, multidisciplinary involvement and clinician electronic alerts, and ED based PD medications.

Results: The pre-post medication audit identified a 13% improvement in the correct prescription of PD medications, although this was not statistically significant (X2 2.101df 2 p=.147).  There was a 21% improvement in timely PD administration in the pre-post audit which was statistically significant (X2 4.024 df 2 p=.041). Twenty-nine patient telephone interviews were conducted with the majority male (n=22, 76%), average age 78years, living in their own home (n=11 38%), with a PD disease duration 7.1years. ED nursing knowledge survey response rate was 51% (n=30).  The majority (n= 25; 84%) of respondents were female with a median of 9.3 years nursing experience and 5 years ED experience. Post care bundle implementation identified improvement in pharmacy alerts (100%) and reviews (76%), medication documentation (94%) and PD sticker usage (74%).

Conclusion: Implementation of the ED care bundle has led to early identification of patients with PD, improved medication regimens, increased nursing knowledge, multidisciplinary engagement, improved documentation, and consistency in pathway adherence, improved patient satisfaction, and access to PD information.


Biography:

Professor Fry is Director of Research and Practice Development for Northern Sydney Local Health District and holds a Professorial Chair position with the University of Technology Sydney. Professor Fry has a strong emergency care background, has held CNC positions and is an authorised Nurse Practitioner (NSW). Professor Fry has extensive senior nursing experience and a proven research track with 118 peer reviewed publications and over $2.2million in grant, research tenders and or scholarship funding.

Post resuscitation management of cardiac arrest patients in the critical care environment: A retrospective audit of compliance with evidence based guidelines

Mrs Annabel Milonas1, Professor Julie Considine2,3, Associate Professor Anatascia Hutchinson2, Dr John Green1, Dr David Charlesworth3, Ms Andrea Doric3

1Northern Health, Epping, Australia, 2Deakin University, Geelong, Australia, 3Eastern Health, Box Hill, Australia

Background: There is a clear relationship between evidence-based post resuscitation care and survival and functional status at hospital discharge. It is clear that resuscitation should not stop after return of spontaneous circulation from a cardiac arrest. The Australian Resuscitation Council recommends protocol driven care to enhance chance of survival for cardiac arrest survivors. Emergency healthcare providers’ are obliged to ensure protocol driven post resuscitation care is timely and evidence based.

Objectives: The aim of this study was to examine adherence to best practice guidelines in the first 24 hours post resuscitation in ED and to the ICU having suffered an out of hospital  cardiac arrest and survived initial resuscitation.

Method: A retrospective audit of medical records of survivors of cardiac arrest was conducted at two health services in Melbourne, Australia. Criteria audited were: primary cardiac arrest characteristics, oxygenation & ventilation management, cardiovascular care, neurological care and patient outcomes.

Findings: Four major findings were: i) Use of FIO2 of 1.0 and hyperoxia was common during the first 24 hours of post resuscitation management, ii) Variability in cardiac care, with timely 12 lead ECG and majority of patients achieving systolic BP greater than 100mmHg, but delays in transfer to cardiac catheterization laboratory, iii) Neurological care was suboptimal with a high incidence of hyperglycaemia and failure to provide therapeutic hypothermia in almost 50% of patients, iv) There was association between in-hospital mortality and specific elements of post-resuscitation care during the first 24 hours of hospital admission.

Conclusion: Evidence-based context-specific guidelines for post resuscitation care that span the whole patient journey are needed. Reliance on national guidelines does not necessarily translate to evidence based care at a local level, so strategies to ensure effective implementation of research evidence are urgently required.

ACKNOWLEDGEMENTS: This study was funded by a Northern Health Research Grant


Biography:

Annabel is Education Coordinator for the Surgical and Cardiac Clinical Service Unit at Austin Health. Her experience includes an extensive career in emergency nursing education both in the clinical and academic arenas as well as Deterioration and Resuscitation Program Coordinator for Austin Health and Northern Health respectively. Her qualifications include a Masters of Education and is currently studying her second Masters in Terrorism and Security Studies, as well as a specialty in emergency nursing. Her responsibilities include workforce professional development and implementation and development of nursing programs for all level of learners in acute and critical care nursing. She has led organizational implementation of National Health standards  including establishing and maintaining systems for recognizing and responding to deteriorating patients across all sectors of the organization: acute care, sub-acute care and community based care.

A large part of her current role is professional leadership.She is an ARC ALS 2 Director and instructor who travels to other health services and interstate to deliver ALS education. She is currently chair of the Victorian expert group of deterioration and resuscitation coordinators that enables focused expertise and bench-marking in matters of clinical deterioration and resuscitation. She reviews for the Australasian Emergency Nursing Journal.

Improving the early identification and management of sepsis: Successful implementation of an evidence-based screening and treatment pathway at Eastern Health

Miss Meredith Symons1, Mrs Andrea  Doric1, Mr Chris Jackson1, Mr Dan Neale1, Dr Hussein Alabodi1

1Box Hill Hospital, Eastern Health, Melbourne, Australia

Introduction: Sepsis is a medical emergency. Research shows that early recognition of sepsis and timely administration of antibiotics can improve patient outcomes and reduce mortality. Performance monitoring identified sepsis as a high prevalence condition contributing to episodes of clinical deterioration in our organisation.

Study Objectives: Enhance sepsis recognition

  • Ensure timely appropriate sepsis management
  • Reduce mortality, morbidity and length of stay from sepsis

Methods: In July 2015, the Improving Sepsis Recognition and Management program was implemented at Eastern Health,  including:

  • A sepsis screening tool
  • An evidence-based sepsis pathway
  • Alignment of antibiotic prescribing guidelines to evidence
  • A sepsis pathology order set
  • Education sessions for clinical staff

Following on from the initial rollout, locally led gains were further enhanced in the ED through participation in the Emergency Care Clinical Network (ECCN) 2016 evidence-based quality improvement sepsis project which included:

  • Raising staff awareness through education, lanyards, posters and regular feedback of audit data
  • Collaboration with pharmacy, antibiotic stewardship, clinical deterioration committee
  • Celebrating World Sepsis Day
  • Holding a Sepsis Screening Challenge

Results: Results pre- and post-ECCN project were significant with key outcomes as follows:

  • Sepsis identified at triage or first nursing contact – increased from 11% to 21%
  • Intravenous antibiotics given within one hour of ED presentation – increased from 11% to 42%
  • Intravenous fluids commenced within one hour of ED presentation – increased from 44% to 63%
  • Serum lactate measured – increased from 78% to 89%
  • Hospital length of stay decreased from 9.5 to 6.0 days for patients presenting to ED with sepsis

Conclusion: The introduction of the sepsis pathway has enhanced clinician capability, improved resilience and is contributing to better patient outcomes. Importantly, providing data showing improvements helps to engage staff to change their practice.


Biography:

Meredith is an Emergency Clinical Nurse Specialist at Box HIll Hospital with a particular interest in quality improvement and safety in the ED.  She has previously presented an initiative to prevent blood transfusion errors at ICEN 2014.  Meredith is currently completing a Masters of Advanced Nursing Practice with the goal of attaining endorsement as an Emergency Nurse Practitioner.

A theory-informed toolkit for implementing a patient-assessment framework into emergency nursing practice

Dr Belinda Munroe1,2, Professor Kate Curtis1,2, Associate Professor Thomas Buckley2, Kate  Ruperto1, Orinda Jones1, Tracey Couttie1, Dr Lou Atkins3

1Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, Australia, 2Sydney Nursing School, University of Sydney, Camperdown, Australia, 3Centre for Behaviour Change, University College, London, UK

Background: The emergency nursing assessment framework ‘HIRAID’ (History, Identify Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) improves patient assessment and communication skills of emergency nurses.¹ A range of facilitators and barriers were identified to potentially impact on the uptake and use of HIRAID.²

Aim: Design interventions to address facilitators and barriers, and optimise implementation of HIRAID in emergency nursing practice.

Methods: Implementation interventions were selected to target facilitators and barriers using the Behaviour Change Wheel.³ Resources were devised to enable delivery of interventions.

Results: A multimodal toolkit was devised to deliver behaviour change techniques selected, including feedback, demonstration, instruction, credible sources and prompts. The toolkit consists of educational and training resources for nurses and educators, an e-learning module, a preceptor program and simulation training exercises. A video was created to persuade nurses to use HIRAID in their practice, modelling executive support and demonstrating how to use the framework in practice. Electronic documentation templates, posters and reference cards were also designed to prompt use of HIRAID in the clinical environment.

Conclusion: This theory-informed toolkit has the potential to optimise implementation of HIRAID in emergency nursing practice. Further evaluation is needed to evaluate the impact of the HIRAID assessment framework and implementation strategy on clinical practice.

  1. Munroe B, Curtis K, Murphy M, Strachan L, Considine J, Hardy J, et al. A structured framework improves clinical patient assessment and nontechnical skills of early career emergency nurses: A pre-post study using full immersion simulation. J Clin Nurs. 2016;25(15-16):2262-74.
  2. Munroe B, Curtis K, Buckley T, Lewis M, Atkins L. Optimising implementation of a patient-assessment framework for emergency nurses: A mixed-method study. Journal of Clinical Nursing. Under review.
  3. Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science. 2011;6:42.

Biography:

Belinda works a Clinical Nurse Consultant for the Emergency Departments across the Illawarra Shoalhaven. She completed her PhD in 2016, which included validating the first emergency nursing assessment tool internationally. Belinda also holds a peer nominated board position with the College of Emergency Nursing Australasia NSW, and is a Clinical Senior Lecturer at Sydney Nursing School.