You dirty wound! – Irrigation of contaminated wounds.

Rob McDonald1

1SCHHS, Sunshine Coast, Australia

It is commonplace to have patients present to the emergency department with contaminated wounds requiring primary closure.  As nurses in the ED we need to give the patient and their wound the best chance possible to heal.  Decontaminating the wound through means of irrigation is important for two reasons: 1. debridement of contaminants and 2. dilution of microbial load.  For effective wound irrigation, there is a need for 8-15 PSI.  There is also a need for 100mls of fluid per cm of wound.  There is good evidence to demonstrate effective pressures can be generated by using a syringe and 18g needle.  This creates an increased workload that requires the clinician to continually draw up fluid into a syringe.  When a wound is large it could mean the drawing up of fluid 50 times or more.  This includes removing the 18g needle and attaching it again 50 times.  What if there was a way to effectively provide adequate pressure while ensuring the process is simple enough to ensure adequate volume is used to decontaminate the wound.  Would you say this is a revelation for both the patient and the clinician.  Then you would be right!

Effective irrigation of contaminated wounds can be achieved using a hand pump IV set and an 18g needle.  This has been tested by constructing a pressure manometer and attaching it to irrigation devices to determine the pressure generated.

The simplicity of using this setup for wound irrigation allows for both adequate volume of irrigation and adequate pressure to remove contaminates.  When an improvement in care can be accomplished using equipment that is commonly found in the ED it has potential for improved patient outcomes at a minimal expense to the health service and the clinician.


Biography:

Rob McDonald is an emergency nurse that is growing in weight, grey hair and love of nursing in the Emergency Department.  He works on the beautiful Sunshine Coast and has recently been endorsed as a Emergency Nurse Practitioner.  He loves his wife, children and reviewing evidence to ensure what we practice is in the best interest of the patient.

Unravel my mind & cast me to the right direction – Queen Elizabeth II Jubilee Hospital Emergency Department Nursing Mentoring Project

Julie Finucane, Angela Devlin, Mingshuang Ding

1Emergency Department Clinical Nurse Consultant, , , 2Emergency Department Research Midwife, , , 3Director of Nursing (Medical), ,

Background/Rational

The hospital workforce environment has been recognised as an important factor for nurse retention and patient safety, yet there is ongoing evidence that inadequate communication, intra-professional oppression, and lack of collaboration and conflict resolution continue to disempower nurses and hinder improvement of workforce conditions.

Methods

A multiphase, nursing lead, quality improving project was implemented at the Queen Elizabeth II Jubilee Hospital (QEII) Emergency Department (ED) by utilising nursing mentoring framework/model.

Senior nurses who are suitable to be mentors were recruited by the project leader.  The mentors were then asked to complete a template allocated under the department drive.  The template informed mentors’ educational and work experience, particular interests within the current position and interests outside work.

Completed mentors’ profile is available for all junior nurses (potential mentees) to view.  All junior nurses are encouraged to contact mentors at their own convenience.  Once the mentorship is established, both mentors and mentees are able to set and work on tailor made goals based on each individual’s availabilities and timeframe.  Documents such as ‘Mentoring Action Plan, Mentoring Agreement Template and Mentoring Session Record Template’ are publicly to access within the department.  A reliable and valid evaluation questionnaire was distributed to all nurses in order to obtain feedback of this project.

Aims

The objectives of this project is to implement a nursing lead mentoring program to reduce high burn out rates within a critical care area and in turn aid in recruitment, retention and overall job satisfaction.

Expected Outcomes

Numbers of positive outcomes are expected throughout this project, and listed below from mentee, mentor and organisation perspectives Figure 1).

References

  1. Bradshaw, M & Lowenstein A 2007, Innovative teaching Strategies in Nursing and Related Health Professions, 4th Edition, Jones and Bartlett, Massachusetts.
  2. Croxon, L., Maginnis, C., 2008, ‘Evaluation of clinical teaching models for nursing practice’, Nurse Education in Practice, vol. 9, pp. 236-243
  3. Elcock, K & Sharples K 2011, A Nurse’s Survival guide to Mentoring, Churchill Livingstone Elsevier, London.
  4. Goodman, B., 2007, ‘Understanding learning’, Nursing Standard, vol. 21, no. 41, pp. 61
  5. Kopp, E., Hinkle, J., 2006, ‘Understanding Mentoring relationships’, Journal of Neuroscience Nursing, vol. 38, no. 2, pp. 126-131
  6. McBrien, B., 2006, ‘Clinical teaching and support for learners in the practice environment’, British Journal of Nursing, vol. 15, no. 12, pp. 672-677
  7. Prescott, C. 2014, Instruction Guide for DOM Mentorship Program Mentors and Mentees
  8. Richman, A., 2013, ‘COVERSTORY’, Long-Term Living: For the Continuing Care Professional, April, pp. 18-24
  9. Stalmeijer, R., Dolmans, D., Wolfhagen, I., Scherpbier, A., 2009, ‘Cognitive apprenticeship in clinical practice; can it stimulate learning in the opinion of students?’, Advances in Health Sciences Education, vol. 14, no. 4, pp. 535-546
  10. Stillwell, C., 2009,’The collaborative development of teacher training skills’, ELT Journal, vol. 63, no. 4, pp. 353-362
  11. Tang, F., Chou, S., Chiang, H., 2005, ‘Students’ perceptions of Effective and Ineffective Clinical Instructors’, Journal of Nursing Education, vol. 44, no. 4, pp. 187-192
  12. Tigelaar, D., Dolmans, D., De Grave, W., Wolfhagen, I., Van Der Vleuten, C., 2006, ‘Participants’ opinions on the usefulness of a teaching portfolio’, Medical Education, vol. 40, pp. 371-378
  13. Tilley, D., Allen, P., Collins, C., Bridges, R., Francis, P., Green, A., 2007, ‘Promoting Clinical Competence: Using Scaffolding Instruction for Practice-Based Learning’, Journal of Professional Nursing, vol. 23, no. 5, pp. 285-289
  14. Wadell, D., Dunn, N., 2005, ‘Peer Coaching: The Next Step in Staff development’, The Journal of Continuing Education in Nursing, vol. 36, no. 2, pp.84-89
  15. Whitehead, D, Weiss, S, & Tappen, R 2007, Essentials of Nursing Leadership and Management , 4th edn, F.A Davis Company, Philadelphia.

Biography:

To come…

Implementation of a triage self – review package: Enabling consistency in triage practice for nurses in the Emergency Department.

Stacey Williamson1, Elizabeth Ward, Tracey Ingvorsen, Vanessa Leonard-Roberts, Danielle Waddell, Adam Watts

1Northern Health, Epping, Australia

Background: Integral to the provision of emergency nursing practice is the ability to safely undertake triage for patients presenting to the emergency department (ED).Triage trained emergency nurses are required to make major decisions which impact on time to treatment for critically ill patients as well as department  performance thresholds 1.

Emergency nurses undertaking postgraduate training within Northern Health undergo extensive theoretical and practical triage training utilising the Emergency Triage Education Kit (ETEK). ETEK provides a nationally consistent approach to the educational preparation of emergency clinicians for the triage role, while promoting consistency in the application of the Australasian Triage Scale (ATS)1.

Aim:   To promote best clinical practice and consistency with the triage process in our ED.  From quality performance indicators there were knowledge deficits and inconsistency in triage practice evident, requiring the development of a structured approach to self-review of triage practice.

Method:  A triage self – review package was developed by the emergency nursing education team with the intent that all practicing triage staff members complete in 2013, and again in 2016-2017.

Each individual package included 12 of the nurses individual triages, randomly selected to include at least 2 from each ATS triage category, 1-5.   A mixture of adult, paediatric and mental health triages were selected.  Self-reflection by the staff member, as well as peer review by a member of the education team, was undertaken utilising the supplied ETEK audit tool.  Expected triage performance was discussed against ETEK criteria and any resultant deficits were identified as opportunities for improvement.

Conclusion: To ensure ongoing competence and consistency in triage practice, the triage self-review package enables a critique of performance and assists with the ongoing professional development of the triage nurse.

References

1.Gerdtz,M.,Considine,J.,Sands, N.,Stewart,C.,Crellin, D., Pollock,W. et al, Emergency Triage Education Kit. Australian Government Department of Health and Ageing, Canberra; 2007


Biography:

Stacey Williamson – Clinical nurse educator in the Emergency Department at The Northern Hospital, Victoria. Responsible for the education and support of nurses undertaking postgraduate emergency nursing studies in conjunction with Deakin and Melbourne University.

Elizabeth ward – Clinical support nurse in the Emergency Department at The Northern Hospital Victoria. Responsible for the education and support of nurses undertaking Postgraduate Emergency nursing studies on conjunction with Deakin and Melbourne University.

Hypocalcaemia induced tetany secondary to total thyroidectomy: An emergency nursing case study

Shannon Bakon1, Dr Judy Craft1, Associate Professor Martin Christensen1

1Queensland University Of Technology, Caboolture, Australia

Presentations to the emergency department with a diagnosis of hypocalcaemia induced tetany, secondary to total thyroidectomy are rare. A patient presented to the emergency department of a regional Australian hospital with hypocalcaemia induced tetany. A case study was employed to reflect on the care provided and identify knowledge practice deficits within this unusual patient presentation.  Calcium plays a central role within the nervous system and is vital for both cardiac and muscular contraction. The clinical manifestations of electrolyte disturbances such as hypocalcaemia can be life threatening and therefore appropriate assessment, monitoring and management is essential to ensure positive patient outcomes. Understanding the importance of calcium imbalance for the Emergency and Critical Care nurse is paramount in preventing complications associated with cardiac conduction and muscle tone especially the potential for airway compromise. Education is central to this, and may include clinical case reviews, the application of pathophysiological presentations of electrolyte imbalance and a review of electrolyte administration guidelines.  Understanding the role of calcium within the body will assist Emergency and Critical Care nurses to assess, monitor and intervene appropriately thereby preventing the life threatening manifestations of hypocalcaemia.


Biography:

Shannon Bakon has completed her Masters in Applied Science (Res) from the School of Nursing at Queensland University of Technology. She is a unit coordinator within the undergraduate curriculum and has published various papers in reputable peer reviewed journals while working on the ground at her local emergency department.

The Northern Hospital Ambulance offload performance improvement – nursing led, nursing driven, nursing success

Jodee Bootle1

1The Northern Hospital, Epping, Australia

The Victorian Department of Health and Human Services require hospitals to rapidly off-load emergency ambulance presentations, to maximise the availability of emergency response to our local community. The Statewide target is 90 per cent of patients transferred from an ambulance service into the care of the hospital in less than 40 minutes. Delivery on this Key Performance Indicator requires a careful balance between emergency department entry and exit, to ensure that a bed is always available for the next ambulance.

Northern Health has implemented an Ambulance Offload strategy which has resulted in significant and sustained improvement, becoming for the first time compliant for a continuous period of six months to present date. Our strategy involved distinct environmental, human resource and process changes, focussed on completing triage, allocation and handover within the 40-minute timeframe.

Environmental changes involved the designation of ambulance offload cubicles during times of peak demand, to create temporary buffer capacity to manage surges in demand. These three cubicles are fully staffed throughout our peak times, to enable offload, handover, and commence early assessment and management. Once occupied, an offload escalation strategy occurs, to ensure that these patients move to an assessment cubicle within 30mins of offload. This is achieved with prioritisation of admissions to ward, and expedition of discharges.

The keystone of this process change was effective accountability, governance and sustainability of proficient and efficient nursing care. The co-implementation of nursing role descriptions, daily performance monitoring, education via a triage self-review package to ensure quality and efficiency of triage as well ED nursing shift reports created staff accountability for this measure. Close monitoring enabled further development of our Ambulance offload process, which is now positioned in the highest performing services of our region.


Biography:

Jodee Bootle explains nursing as her 3rd career after spending 10 years in the Army. After commencing nursing at the  the Royal Melbourne Hospital where she stayed for 13 years. After fulfilling various roles in ED, in Access as an After Hours Hospital Manager and the Nurse Unit Manager (NUM) for the Acute Medical Unit for 5 years. Jodee was the RMH Nurse of the Year for Leadership in 2013 and the recipient of the Hospira Research grant. In July 2016 she has moved to TNH.  She is currently the Nurse Unit Manager of The Northern Hospital (TNH) Emergency Department. Jodee is passionate about leading teams and implementing innovative processes for a sustainable future.

The effect of workplace violence on patient care

Karen Thompson1

1DHHS Tasmania, Burnie, Australia

Background workplace violence (WPV) is commonly experienced by Emergency Department nurses

What is known about this topic. WPV is a long-standing problem for Emergency Department nurses. It takes many forms and has several precipitating factors. The most common form is patient/visitor violence (PVV), but an older and more insidious problem is bullying, harassment and horizontal violence (BHHV)

What this paper adds. PVV and BHHV are recognised and researched problems in nursing; usually studied singularly.  This paper takes a comprehensive approach, looking at the intricate connections between forms, the associated traumatic stress disorders and subsequent effect on patient care.

Implications for practice. The hypothesis is proposed that most horizontal violence is a driven by feelings of oppression and powerlessness to retaliate when subjected to one or more form/s of workplace violence. Consequently, these feelings are projected on a ‘safe’ target, usually a colleague, contributing to compassion fatigue and poorer patient care.

Conclusion WPV contributes to traumatic stress disorders, impacting adversely on patient care.

Key words workplace violence, compassion fatigue, bullying, horizontal violence, case study, effect on patient care, PTSD


Biography:

Karen Thompson comes from a mixed background, with post graduate degrees in remote area nursing and critical care. She is also a certified instructor in de-escalation and management of aggressive situations.   While completing her  Masters in Clinical Nursing (Emergency Nursing) last year, Karen conducted further research into the phenomenon of workplace violence, particularly it’s effect on patient care. Karen works two 0.5FTE positions; After Hours Manager at a small private hospital,  and RN in a medium sized but very busy ED. In 2016, she became a published author and presented at several conferences on this and related topics

The effect of the introduction of the phlebotomist on mislabelled blood specimens within the Emergency Department

Kelly Decker1, Sally Charlton1, Dr Joe D’Agostino1, Donna Williams1, A/Prof DeVilliers Smit1, Rebecca Atkins1

1The Alfred Emergency & Trauma Centre , Melbourne , Australia

BACKGROUND: Pathology collection is a frequent and common procedure performed within the Emergency Department (ED). Despite the frequency and clear process of pathology collection, mislabelled pathology specimens, particularly blood specimens,  were responsible for the highest number of reported clinical incidents in The Alfred Emergency & Trauma Centre in 2014. Delays incurred due to mislabelling ultimately result in delayed patient care, increase risk of harm, and requires further time investment to recollect the specimen.  Overall resulting in a poor patient experience and ineffective use of resources.  To address this issue, the introduction of a phlebotomist within the ED was trailed to study if this would have a positive effect on lowering the number of reported mislabelled blood pathology specimens.

METHODS: A project outline and timeline was developed in conjunction with key stakeholders. This included obtaining scope of practice approval, credentialing of phlebotomy staff in intravenous cannula insertion and development of an education and implementation packages. A single phlebotomist was rostered for one 6-hour shift per day in the peak patient presentation time. The total number of annual reported mislabelled pathology specimen incidents were collected pre, during and post the introduction of the ED phlebotomist.

RESULTS: The results post the introduction of the phlebotomist in the ED showed that the percentage of mislabelled blood specimens (as a proportion of the total number taken) had reduced compared to pre-implementation, however this number does remain high.

CONCLUSION: This study demonstrated a high number of mislabelled blood pathology specimen incidents in the ED. The introduction of the ED phlebotomist decreased the proportion of mislabelled pathology specimens in relation to the number of total pathology specimens collected in ED. Further strategies need to be implemented to continue to reduce the number of mislabelled blood pathology specimen incidents in the ED.


Biography:

To come…

The development of the Northern Health “Paediatric Resuscitation Scribing Tool” to assist with scribing during resuscitation.

Pamela Perera, Adele Berry1,

1 Northern Health, Epping, Australia

Background: During resuscitation, the scribes` role is to document and provide a true and timely representation of the events in a chronological manner1. In a very challenging and stressful situation, the scribe nurse plays a key role in resuscitation. Junior staffing often results in less senior nurses being relied upon to document during a resuscitation.

Aim: In 2015, from quality performance indicators, a paediatric resuscitation scribing tool was developed to address the identified lack of detailed documentation during a paediatric arrest.

Method: The paediatric scribing tool was developed utilising Northern Health (NH) policy and procedures in accordance with the Australian Resuscitation Council (ARC) guidelines. It involved input from key stakeholders including medical and nursing workforce across quality and safety, paediatrics, critical care, emergency and education.

A pilot chart was developed which follows the A-E approach for the deteriorating patient, Basic Life Support (BLS) and Advanced Life Support (ALS) algorithms for Northern Health. A tick box approach was utilised to prompt and lead documentation for the scribe.

The chart was trialled for a period of 6 months in the Emergency Department, paediatric ward and neonatal and paediatric nursing workshop.

Conclusion: Post the 6 month trial period, changes were made according to participant’s feedback. This included extra time slots, highlighting blood sugar level and tick boxes for administration of adrenaline and amiodarone. The chart was approved for use within Northern Health in October 2016.

Reference

  1. Molan E. (2013). Scribe during emergency department resuscitation: Registered Nurse domain or up for grabs? Australasian Emergency Nursing Journal, 45-51.

Biography:

Pamela Perera is Paediatric Clinical Nurse Educator for Northern Health. She has a total of 12 years’ experience as a nurse, but 8 years of emergency nursing with a post graduate certificate in Critical Care.  She has held positions of a Clinical Nurse Specialist, an ANUM, and Clinical Support Nurse before becoming a Clinical Nurse Educator.

The bariatric trauma patients journey – roadside to bedside

Cherylynn Mcgurgan1, Sally Campbell1, Susan Harding1

1Melbourne Health, Melbourne, Australia

Emergency Department Clinicians are confronted daily with complex and difficult trauma cases each with its own set of problems.   Bariatric patients presenting with any medical condition are a challenge for Emergency Departments. This is particularly the case with a hemodynamically unstable bariatric multi – trauma patient, who is required to be nursed in full spinal precautions.

Bariatric patients are defined by the World Health Organization (WHO) as patients who are overweight, obese and morbidly obese, as classified by Body Mass Index (BMI)

This presentation will follow the journey of a morbidly obese bariatric multi-trauma patient, with a BMI in excess of 43 from the roadside to the bedside:

  • It will identify the challenges this patient presented in providing the specialised care he needed, including the patient factors, equipment and staff resources.
  • It will describe this patient’s journey, and the interventions we used to manage this patients care.
  • It will discuss the gaps we identified in specialised equipment required to care for this patient.
  • It will describe how we have addressed the gaps identified and the processes we have put in place to manage future Bariatric trauma patients.

In conclusion: The multi injured bariatric trauma patient presents a unique set of challenges in the provision of emergency care.  We identify some important gaps in the currently available equipment and clinical practice guidelines required to care for these patients. Lastly, we describe our approach to addressing the gaps identified and how we plan to manage these patients in future.


Biography:

Clinical Nurse Specialist and Equipment Nurse RMH Emergency Department, Regional coordinator for EMST  at the Royal Australasian college of surgeons

The application of high fidelity emergency nursing simulation to investigate perceptions towards simulation education and documentation practices after the transition to a digital health record system

Rikki Stanton1, Christie Harding1, Emily Cooper1, Mary Boyde1, Hannah Putland1, Jade Porter1, Clare Thomas1, Ben Learmont1, Elisabeth Fraser1, Lousie Nicholls1

1Princess Alexandra Hospital Emergency Department, Brisbane, Australia

Over the last eighteen months, our Queensland tertiary Emergency Department (ED) has been transitioning to a digital health record system. With this large organisational change, staff have been faced with many challenges including maintaining accurate documentation for deteriorating patients. Within nursing education, simulation has been recognised as an effective learning strategy providing an opportunity to develop verbal and written communication skills, psychomotor skills, and critical thinking skills. Simulation has enabled learning objectives to be met by using realistic scenarios in a safe learning environment. The nursing education team identified that high fidelity nursing simulations were underutilised within the ED, and staff were reluctant to participate as previous experience often related to simulation as an assessment tool. The perception of simulation as a useful education strategy was poor. The education team decided to commence a research project to evaluate an innovative simulation experience for nurses in ED focusing on patient assessment and documentation. A high-fidelity simulation was developed from current incident trends within the ED. This scenario was based on a gradually deteriorating Australian Triage Scale Category 2 toxicology overdose patient. The study, SImulation for EmeRgency Nurses (SIREN), aims to evaluate anxiety levels, self-efficacy in clinical practice and clinical documentation pre and post simulation together with overall satisfaction with the simulation experience. The 15 minute simulation  is followed by a short debrief utilising the advocacy/ inquiry model. This is followed by education of participants on the documentation procedure and individually optimising digital ‘shortcuts’ for mandatory notification. This single centre, prospective study commenced in November 2016, and aims to recruit 50 Registered Nurses. Preliminary results of the 36 participants who have been recruited have been extremely encouraging.


Biography:

Rikki graduated from Australian Catholic University with a Bachelor of Nursing in 2010. She has worked in the Princess Alexandra Hospital Emergency Department for 6 and a half years. During this time she has completed her Graduate Certificate in Emergency Nursing and Masters of Emergency Nursing. Rikki has a passion for education and has spent the majority of her career working in education including Clinical Facilitator, Clinical Nurse and Acting Nurse Educator.

Christie graduated from James Cook University in 2008 with a Bachelor of Nursing Science. She has worked in Plastics, Burns and ENT, then moved into Emergency nursing working in remote, metropolitan and international hospitals. Furthering her education in a Diploma of Midwifery and studied a Post Graduate Certificate in Emergency Nursing. She currently works as a Clinical Facilitator/ Clinical Nurse at the Princess Alexandra Hospital.