Heather McClelland

Wound healing in pre-tibial injuries - an observation study

Pre‐tibial lacerations are complex wounds affecting a primarily aged population, with poor healing and a potentially significant impact on social well‐being. Management of these wounds has changed little in 20 years, despite significant advances in wound care. A retrospective observational study was undertaken to observe current wound care practice and to assess the effect of various medical factors on wound healing time on 24 elderly patients throughout their wound journey. Wound length was found to be substantively and significantly associated with wound healing time, with a reduction in instantaneous healing rate of about 30% for every increase of 1 cm in wound length. Hence, longer wounds are associated with longer wound healing times. Prescription of several categories of drugs, including those for ischaemic heart disease (IHD), hypertension, respiratory disease or asthma; and the age of the patient were not significantly associated with wound healing times, although substantive significance could be inferred in the case of prescription for IHD and asthma. Despite the small sample size, this study identified a clear association between healing and length of wound. Neither the comorbidities nor prescriptions explored showed any significant association although some seem to be more prevalent in this patient group. The study also highlighted other issues that require further exploration including the social and economic impact of these wounds.

The Future of Nursing for Emergency Care

The recent publication of the report on The Future of Nursing generated by the Institute of Medicine and the Robert Wood Johnson Foundation (Institute of Medicine, 2010) has been welcomed by the healthcare community in the United States of America. Their aimwas to ‘assess and transform the nursing profession’ in light of recent government policy which has the potential to greatly increase the demand for healthcare, and as such, nursing. They examine the barriers for nursing and set out recommendations to enhance the profession in the future. Some readers may feel the report describes a limited context, but these are global issues for the nursing profession, and closely reflect similar recommendations in Australia (ANF) and Europe (Buscher et al., 2010). The demands are the same; an aging population, shrinking workforce and increasing costs so it is not surprising our global communities are looking for future direction. The contribution of nursing is acknowledged across the spectrum of age and health/illness, but also the age-old limitations that may constrict nursing achieving its full potential in the healthcare industry. Issues of education (Preparation), scope of practice (Practice), involvement in leading healthcare (Partnerships), and the generation of evidence for workforce planning (Planning) have been debated throughout the 25 years that I have been practicing, so it is interesting to see that these are still the issues that need to be addressed at policy level. As well as addressing the plight of nursing in the future, these documents also frustrate. As a clinician, leader and editor I see nursing achieving its potential every day. Whether reading a paper from a first time researcher, or working alongside an inquisitive student, whose eyes are shining with enthusiasm for nursing? Although I know we may need to challenge legislation and policy, I also see how nurses are already delivering at every level of healthcare. In order to better understand the context of these papers, it is helpful to examine them in terms of our specialty, as a microcosm of the wider nursing workforce. The scope of nursing, and especially the drive towards advanced nursing practice is highly relevant to emergency care. We have been at the forefront in extending the scope

Trauma – Who Really Cares?

What is emergency care if not the rapid assessment and treatment of patients with undifferentiated, and undiagnosed conditions? We claim to be the experts in clinical assessment, resuscitation, establishment of differential diagnoses, and emergency treatment. We are the team players of the health service, working with a multitude of clinical teams and professions to ensure effective and efficient patient care. It is all the more difficult then to be told that in all our efforts to improve the organisation and delivery of care over the past 10 years, that those patients who are most vulnerable, continue to receive sub-standard care. The NCEPOD Trauma service review (2007) makes for uncomfortable reading. Mortality and morbidity in the UK continue to be high in contrast to much of the rest of the developed world, and the survey itself identifies significant flaws in both clinical care and the organisation of trauma systems. The review collated data on patients with severe trauma (ISS P 16), admitting teams, and organisational structure, from 183 hospitals (83% response rate). The report examines every aspect of emergency trauma care, providing recommendations within each section. A number of key themes emerge, including communication, leadership, and exposure. Communication is a common criticism in any report, and one that is identified repeatedly in this report – between pre-hospital and hospital teams, between specialties, and during transfer. NCEPOD identify that in only 50% of cases, hospitals were given a pre-alert by the pre-hospital team. This may simply be down to lack of documentation, in the cases examined. From experience, this figure does seem relatively low, especially in relation to trauma, but does not address the quality of that communication, which is often through a third party, is fragmented, or lacking in sufficient detail

Patient flow in the ED

As we rush hesitantly into another winter (in the northern hemisphere) the term ‘patient flow’ will be become part of our daily routine – whether in our descriptions of our individual departments or in the media’s analysis of the problems in emergency care. It seems our teams continuously crisis manage the demand from increasing emergency department (ED) attendances with the supply of ED space (relatively fixed) or in-patient beds (decreasing). I only say ‘‘relatively fixed’’ as throughout the world, day-in, day-out ED clinicians work to create some other space for a patient who needs to be seen. In this issue, Nugus et al. (2014) provide an analysis of patient flow using a ‘carousel’ as a metaphor for how patients arrive, move through and leave the ED. They describe a service where there is continual motion and rhythmical, almost choreographed, movement between clinicians and patients to maintain the momentum. Timeliness is one of the central tenets of delivering quality healthcare (IOM, 2001), which, in the ED means measuring times to assessment, investigations and treatments, clinician review, outcome decisions and discharge or transfer. Efficient systems have been shown to improve patient outcomes, reduce harm and increase patient satisfaction, as seen in the improvements in outcomes in cardiac, stroke and trauma services. But the same is also true for the whole system of emergency care, not just the individual patients within it. Efficient, timely, patient flow through the service enables a constant supply of cubicles or space to assess and treat the next patient. It also provides psychological space by freeing up capacity to think about the needs of the next or future patients. Equally, when that system slows down or becomes completely blocked there is limited capacity for the next assessment, concern about the next resus call, or a tension in the waiting area that is almost palpable. There is a constant balance of risk with the waiting room patients for whom we cannot initiate investigations or treatments. There are many reasons for the process slowing down, only some of which ED staff have control over. Staffing, whether medical, nursing, administration or therapies, all impact on patient flow and a mis-match between patient need and supply of the staff required will have a direct impact on the journey through the service. Clearly, peaks and troughs in attendance enhance this effect. Knowledge and skills within the ED team may impact on efficiency, with some staff lacking the ability to predict and initiate care, or to make and act upon diagnoses. The ED is reliant on external services such as labs, radiology or specialty advice to make decisions about discharge or admission. Departments are also dependent on in-patient bed capacity or external agencies, such as family or ambulance services to move patients on at the end of their ED stay. All

Protection of vulnerable adults.

We use the term ‘vulnerable’ in a vast range of contexts, whether talking about patients, systems or, indeed, whole populations. The central meaning is the same, i.e. being at risk of abuse, or injury, or damage. If we think of the populations living on flood plains or fault lines, whole communities are vulnerable to massive devastation, and change at a global level. If national intelligence systems are vulnerable, the data of individuals and populations will at risk of abuse. As emergency nurses these global vulnerabilities are rarely our major concern, but the authors of our guest editorial very clearly demonstrate just how important recognition of, and action against, vulnerability is when it comes to the patients we meet every day. Protection of adults at risk of injury or abuse is highlighted strongly in the case used by Dr. Hale, and Ms. Tippett. Currently, the UK is introducing its most robust system to date for the Protection of Vulnerable Adults (DH, 2009), by establishing of a list of individuals who will be unable to work with patients or clients in any care setting. The definition of vulnerable used to guide legislation and regulation is of a person:

Learning from the past to build the future.

Being caught up in our busy, purpose-built departments with cutting edge technology and highly designed flow systems it is easy to forget where the specialty of emergency nursing has come from. There are few staff left who were involved in the early days of the specialty when care was delivered in poor facilities by a variety of staff with little or no specialist training. Reading about the experiences of one such emergency nurse recently reminds me how much the lessons from our past can inform how we develop services for the future. We are privileged in the specialty that it is still developing, whether in pushing the boundaries of practice in welldeveloped systems, or in simply establishing the specialty where it has never previously existed. We have the opportunity to work together to avoid repetition of our previous mistakes and to use our emerging body of evidence to inform service development. It was an honour, then, to be asked to participate in the African Federation of Emergency Medicine Consensus Conference to establish essential standards and advocacy statements for the specialty as it develops across the continent. The discussions at the meeting reminded me of the journey we have taken in the UK (and I’m sure in many other highly developed emergency care systems) and of the role of nurses throughout this period. The Emergency Department (or A&E, or Casualty) has long been the entry point for patients into the acute hospital system, often situated either in a single, cramped room or someone’s abandoned outpatient area. In my first job in ED, we had to take patients outside to get from the department into the hospital if the patient needed theatre or an in-patient bed. Although established initially to treat the injured the ED has become a melting pot of diverse and complex disease processes. We have become the experts in undifferentiated presentations, at taking histories and making rapid decisions about investigation or treatments, and in resuscitation. As the departments grew in popularity with the public they quickly out-grew their facilities, meaning conditions were often difficult for both staff and patients. It is not so long ago that there was no specialist emergency medicine training and our consultants trained as either physicians or surgeons. In the days of the old ‘casualty’ there might have been permanent nursing staff, but there were only rotational or on-call medical staff whose primary responsibility was their patients outside the emergency department and who were called to the ED by the department sister who had decided and prioritised the needs of the patients. And these are the experiences as the specialism develops in the African nations – stories of nursing staff working well beyond their scope of practice to deliver a service, of single-handed specialist trainees trying to negotiate for a department with hospital management, and of services reaching maturity through the dogged determination of the nursing and medical staff who have a clear vision of the future. It was amazing to discuss with the participants the things that really mattered to them, from clinical care to administration, from staffing to supplies. And they are the same things that matter to all of our teams and make departments successful – a skilled, educated workforce; evidence-based standards of care; a well-resourced department to deliver care and effective systems of documentation and administration to capture data for patients, clinicians and the organisation. We cannot afford to repeat our own history, allowing services 20 years to develop organically when we have the facilities not only to share practice, but also to modify it so that the best version of emergency care can be provided whatever the setting. And there are differences. Major road-traffic injuries account for a significant workload in developing services so there is much to learn from current trauma management systems and work to be done outside the ED on legislation and public awareness. Resources for education and training are limited for many, so alternative learning opportunities must be explored, whether in conjunction with overseas universities or hospitals or through innovative use of modern technology. But these are differences of time and place only. These were the challenges to our specialty when we started, when no College of Emergency Medicine or Nursing existed to create a homogenous voice and to defy the non-believers. These are the challenges of different continents with different clinical complexities and disease profiles. But as the world converges and people migrate there is essential learning for all in how best to care for our patients. The journal has a key role in sharing and spreading best practice, in defining our specialist field of knowledge and in enabling a shared vision for our future. It is essential that our papers are accessible globally and that we find ways to support developing services. We all have the same battles – excessive workload, lack of resources and access to education – it’s just the context that’s different. In pulling together this issue I was conscious of this diversity and similarity of patients and systems. Tadesse et al.’s (2015) paper on interpersonal violence in Ethiopia reflects well the prevalence and nature of presentations across the world. It reminded me of Sr Kate O’Hanlon’s (2008) description of her department in Belfast in the middle of the Northern Ireland troubles in the 1970s – not much changes when it comes to interpersonal violence. This issue has a strong clinical practice focus incorporating the most basic principles of emergency care in pain management with more specialist practices such as non-invasive ventilation. We present papers across the spectrum of emergency care, extending out from the ED

Innovation and loss.

As with any journal, here at IEN we strive to continually reflect on the progress of the journal, whether our aims and scope are clear and correlate to the papers we publish, whether our board members are active and engaged with the scholarly activity of the specialty and whether we serve our readers. In order to do that we need to engage in activities that allow us to identify what has and has not worked for the journal, to understand our readers and authors perspectives, and to engage active academics in the future development of the journal. With sadness, and excitement, we have made some changes to the Editorial Board. One of the longest-standing members of the Board, Ms. Clair Ramsden (Australia) will move onto the International Board, as will Dr. Mark Cooper (UK) and Dr. Felicity Johnson (Ireland). Clair has been working with the journal for over 16 years, nine of these on the Editorial Board. She has been steadfast in her support both for the founding editor, Bob Wright, and in my transition to current editor, even through her own emigration across the world. She has remained close to emergency nursing, despite a career that now sees her as Director of Nursing and Midwifery, and she will continue to review and promote the journal into the future. Mark and Felicity have both worked closely with colleagues to promote submission and the journal in their academic fields. In 2012 Felicity co-edited the special issue on Aged Care with Dr. Rob Crouch. It has been a pleasure to work with Clair, Mark and Felicity on the Board and their ongoing involvement will be of great value. It is with pleasure then that I am able to announce the arrival of two new Editorial Board members who are active scholars in the emergency care field. Dr. Geraldine Lee qualified as a nurse in 1990 and has a background in cardiac/cardiothoracic nursing. She is a lecturer in adult nursing & is based in the department of postgraduate research. She worked in Melbourne, Australia for 11 years coordinating the nurse practitioner programme and undertaking research in emergency care, focusing on the benefits of nurse practitioners in the emergency department. Gerry is currently employed at King’s College, London where she is the programme leader for the Masters in Advanced Practice, and is a link lecturer at the Emergency Department, King’s College Hospital. Dr. Lee’s research has primarily been in emergency nursing and also in the field of chronic disease (primarily in cardiovascular disease and diabetes). Professor Margaret Fry is Director of Research and Practice Development for Northern Sydney Local Health District. Since 1990 Dr. Fry has been Principal Investigator of a program of research designed to investigate emergency care services. She has been establishing a track record and program of research in emergency nursing and patient care services. Professor Fry has a strong clinical background and is an authorised Nurse Practitioner

The work of emergency nurses

This issue brings together a number of papers using qualitative methods to examine the work of emergency care nurses (Elmqvist et al., 2012; Lau et al., 2012; Fry, 2012; Bost et al., 2012). By using qualitative methods the authors have been able to deconstruct emergency nursing, primarily within the context of initial assessment or triage. Ethnography, used in three of the papers, is a method based in anthropology and sociology and simply defined means to write about people. It is a method which aims to explore and understand the culture that underpins normal activity and how a social group works (Robson, 1993). The emphasis is simply on telling it like it is, so that the reader can connect with the researcher and the group being examined. The social group might be a nation or a village, an organisation or a profession, or even a single department. All these groups will have traditions, rules and beliefs that create their cultural identity, the aim of the researcher being to immerse themselves in this culture to understand and share these rules (van Maanen, 2011). Emergency care, although a relatively young specialty, has a strong cultural identity associated with timely, efficient systems which allow for decisions to be made quickly and patients moved through the service. Staff rapidly become immersed in this specialty work. However, the culture of emergency care is not so much about what work we do, as how it is delivered. Behavioural rules and departmental traditions establish ‘how things are done around here’, which new staff are expected to learn. These behavioural norms are created by the interpersonal relationships and leadership in the team and are affected by the wider societal culture within which a department is set. The team in an ED of a deprived urban society is often exposed to high levels of interpersonal violence, which may create a strongly bonded team who are defensive in their dealings with patients. (Of course, this is an utterly personal assumption, based on my own experience – a very real threat to the authenticity of ethnographic research.) The culture of a department is almost palpable and certainly anyone who has visited or worked in different EDs will have ‘felt’ the impact of culture

Emergency care – More than just a collection of tasks

There is little doubt that emergency nursing is a skilful and technical specialty. An efficient patient journey through the emergency department is dependent on a wide range of interventions, investigations and treatments. As such, emergency nurses must learn, and become competent in, a variety of skills; from cannulation to application of Plaster of Paris, and from preparation for thoracotomy to ankle splinting. However, excellence in emergency care is not just about technical expertise. It is essential that the staff are competent in undertaking observations, but if they do not know what to do with the information, or are not confident enough to discuss their findings with a colleague, then the patient is still at significant clinical risk. I am really enthusiastic about expanding the nursing role but if we cannot communicate effectively, then the patient may be left feeling scared, and vulnerable. Two very different papers in this issue highlight the importance of technical proficiency, but also how skill in itself is only a small element in the overall picture of care – Unhasuta et al. (P. 3–7) describe the process of generating a national competency framework for trauma in Thailand, and Sheppard et al. (To be published in next issue) report their study on patient experience in the emergency department. Unhasuta et al. (P. 3–7) identified that there were inconsistencies in trauma care due to a deficit in medical staff with the requisite skills, with significant implications for patient outcomes. They recognise how fundamental nurses are to effective service delivery as they are seen as the stable workforce, gaining extensive knowledge about their patient groups and departments and how the local healthcare services work. Doubtless, Thailand is not the only country where medical staff with the appropriate skills are in short supply. This leaves the specialist emergency nurses to initiate and ‘guide’ patient management. This happens globally and is often the basis for expansion of the nursing role – they already advise and manage the care episode, so why not deliver it themselves? We simply have to look at the development of the advanced nurse practitioner across the globe, to see this in action.

Learning and contributing

A statement made recently by Professor Tony Redmond, Professor in International Emergency Medicine at Manchester University during a visit to China, reminding us that everyone has something to learn, but more importantly, something to contribute. The trip to China arose from some work we did in Sichuan province last May immediately after the Wenchuan earthquake, where approximately 80,000 people were killed, and approximately 5 million were left homeless. We were invited back to the province to speak about disaster management and spinal injuries rehabilitation. Having the capability to move 100,000 people a day during the disaster, this request made us feel somewhat humble, but we all felt that this would be a great opportunity to share knowledge. Many of the team had extensive previous experience of major disaster, and were able to share what had been learned, and also some of the key public health issues from each situation. As a nation, Britain has never had a disaster on the magnitude of the Wenchuan earthquake, and despite all our planning it is difficult to say if we would have the capacity, or capability, to manage in this type of situation. However, what we do have are national, regional and local requirements (based on legislation) to plan for major incidents, and catastrophic natural or manmade events, and it was this that the Chinese (and Sichuan) authorities were keen to learn about. There is a very real desire to learn from their experiences in the earthquake, and also to work with teams, such as ours, to plan for the future. As a team, we were also keen to learn from them, about their coping mechanisms, about the lines of authority, and just how they were able to manage mass population movement. However, we were also conscious that one size does not fit all. What is appropriate in terms of planning in Britain, within a National Health Service, may not be relevant in Sichuan. There may be a lot of common ground, especially at hospital level, but local and regional arrangements may differ significantly, which must be accounted for. In the future we hope to work with the individual hospitals, to build and train around a