Julie Considine

Part 3: Adult Basic Life Support and Automated External Defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This review comprises the most extensive literature search and evidence evaluation to date on the most important international BLS interventions, diagnostics, and prognostic factors for cardiac arrest victims. It reemphasizes that the critical lifesaving steps of BLS are (1) prevention, (2) immediate recognition and activation of the emergency response system, (3) early high-quality CPR, and (4) rapid defibrillation for shockable rhythms. Highlights in prevention indicate the rational and judicious deployment of search-and-rescue operations in drowning victims and the importance of education on opioid-associated emergencies. Other 2015 highlights in recognition and activation include the critical role of dispatcher recognition and dispatch-assisted chest compressions, which has been demonstrated in multiple international jurisdictions with consistent improvements in cardiac arrest survival. Similar to the 2010 ILCOR BLS treatment recommendations, the importance of high quality was reemphasized across all measures of CPR quality: rate, depth, recoil, and minimal chest compression pauses, with a universal understanding that we all should be providing chest compressions to all victims of cardiac arrest. This review continued to focus on the interface of BLS sequencing and ensuring high-quality CPR with other important BLS interventions, such as ventilation and defibrillation. In addition, this consensus statement highlights the importance of EMS systems, which employ bundles of care focusing on providing high-quality chest compressions while extricating the patient from the scene to the next level of care. Highlights in defibrillation indicate the global importance of increasing the number of sites with public-access defibrillation programs. Whereas the 2010 ILCOR Consensus on Science provided important direction for the “what” in resuscitation (ie, what to do), the 2015 consensus has begun with the GRADE methodology to provide direction for the quality of resuscitation. We hope that resuscitation councils and other stakeholders will be able to translate this body of knowledge of international consensus statements to build their own effective resuscitation guidelines.

Effect of emergency department fast track on emergency department length of stay: a case- control study

Objective: To examine the effect of fast track on emergency department (ED) length of stay (LOS). Design and setting: Pair-matched case–control design in a public teaching hospital in metropolitan Melbourne, Australia. Participants: Patients treated by the ED fast track (cases) between 1 January and 31 March 2007 were compared with patients treated by the usual ED processes (controls) from 1 July to 15 November 2006 (n  =  822 matched pairs). Intervention: ED fast track was established in November 2006 and focused on the management of patients with non-urgent complaints. Main outcome measures: The primary outcome measure was ED LOS for fast-track patients. Secondary outcomes were waiting times and ED LOS for other ED patients. Results: Median ED LOS for non-admitted patients was 132 minutes (interquartile range (IQR) 83–205.25) for controls and 116 minutes (IQR 75.5–159.0) for cases (p<0.01). Fast-track patients had a significantly higher incidence of discharge within 2 h (53% vs 44%, p<0.01) and 4 h (92% vs 84%, p<0.01). Conclusions: ED fast track decreased ED LOS for non-admitted patients without compromising waiting times and ED LOS for other ED patients.

Part 3: Adult Basic Life Support and Automated External Defibrillation

This Part of the 2015 International Consensus on Cardiopul monary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science With Treatment Recommendations (CoSTR) presents the consensus on science and treatment recommendations for adult basic life support (BLS) and automated external defibrillation (AED). After the publication of the 2010 CoSTR, the Adult BLS Task Force developed review questions in PICO (population, intervention, comparator, outcome) format.1 This resulted in the generation of 36 PICO questions for systematic reviews. The task force discussed the topics and then voted to prioritize the most important questions to be tackled in 2015. From the pool of 36 questions, 14 were rated low priority and were deferred from this round of evidence evaluation. Two new questions were submitted by task force members, and 1 was submitted via the public portal. Two of these (BLS 856 and BLS 891) were taken forward for evidence review. The third question (368: Foreign-Body Airway Obstruction) was deferred after a preliminary review of the evidence failed to identify compelling evidence that would alter the treatment recommendations made when the topic was last reviewed in 2005.2 Each task force performed a systematic review using detailed inclusion and exclusion criteria, based on the recommendations of the Institute of Medicine of the National Academies.3 With the assistance of information specialists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library). Reviewers were unable to identify any relevant evidence for 3 questions (BLS 811, BLS 373, and BLS 348), and the evidence review was not completed in time for a further question (BLS 370). A revised PICO question was developed for the opioid question (BLS 891). The task force reviewed 23 PICO questions for the …

Emergency nurse practitioner care and emergency department patient flow: case-control study.

Objective:  The present study aimed to compare ED waiting times (for medical assessment and treatment), treatment times and length of stay (LOS) for patients managed by an emergency nurse practitioner candidate (ENPC) with patients managed via traditional ED care.

Factors influencing consistency of triage using the Australasian Triage Scale: Implications for guideline development

Objective:  To examine the influence of the nurse, the type of patient presentation and the level of hospital service on consistency of triage using the Australasian Triage Scale.

An evidence‐based practice approach to improving nursing care of acute stroke in an Australian Emergency Department

AIMS The aim of this study was to improve the emergency nursing care of acute stroke by enhancing the use of evidence regarding prevention of early complications. BACKGROUND Preventing complications in the first 24-48 hours decreases stroke-related mortality. Many patients spend considerable part of the first 24 hours following stroke in the Emergency Department therefore emergency nurses play a key role in patient outcomes following stroke. DESIGN A pre-test/post-test design was used and the study intervention was a guideline for Emergency Department nursing management of acute stroke. METHODS The following outcomes were measured before and after guideline implementation: triage category, waiting time, Emergency Department length of stay, time to specialist assessment, assessment and monitoring of vital signs, temperature and blood glucose and venous-thromboembolism and pressure injury risk assessment and interventions. RESULTS There was significant improvement in triage decisions (21.4% increase in triage category 2, p = 0.009; 15.6% decrease in triage category 4, p = 0.048). Frequency of assessments of respiratory rate (p = 0.009), heart rate (p = 0.022), blood pressure (p = 0.032) and oxygen saturation (p = 0.001) increased. In terms of risk management, documentation of pressure area interventions increased by 28.8% (p = 0.006), documentation of nil orally status increased by 13.8% (ns), swallow assessment prior to oral intake increased by 41.3% (p = 0.003), speech pathology assessment in Emergency Department increased by 6.1% (ns) and there was 93.5 minute decrease in time to speech pathology assessment for admitted patients (ns). RELEVANCE TO CLINICAL PRACTICE An evidence-based guideline can improve emergency nursing care of acute stroke and optimise patient outcomes following stroke. As the continuum of stroke care begins in the Emergency Department, detailed recommendations for evidence-based emergency nursing care should be included in all multidisciplinary guidelines for the management of acute stroke.

Predictors of critical care admission in emergency department patients triaged as low to moderate urgency

AIM This paper is a report of a study to identify predictors of critical care admission in emergency department patients triaged as low to moderate urgency that may be apparent early in the emergency department episode of care. Background. Observations of clinical practice show that a number of emergency department patients triaged as low to moderate urgency require critical care admission, raising questions about the relationship between illness severity and physiological status early in the emergency department episode of care. METHODS A retrospective case control design was used. All participants were aged over 18 years, triaged to Australasian Triage Scale categories 3, 4 or 5, and attended emergency department between 1 July 2004 and 30 June 2005. Cases were admitted to intensive care unit or coronary care unit and controls were admitted to general medical or surgical units. Cases (n = 193) and controls (n = 193) were matched by age, gender, emergency department discharge diagnosis and triage category. RESULTS Critical care admission associated with: (i) a presenting complaint of nausea, vomiting and diarrhoea (OR = 3.40, 95%CI:1.22-9.47, P = 0.019), (ii) heart rate abnormalities at triage (OR = 2.10, 95%CI:1.19-3.71, P = 0.011), (iii) temperature abnormalities at triage (OR = 2.87 95%CI:1.05-7.89, P = 0.041), (iv) respiratory rate at first nursing assessment (OR = 1.66, 95%CI:1.05-2.06, P = 0.31) or (v) heart rate abnormalities at first nursing assessment (OR = 1.57, 95%CI = 1.04-2.39, P = 0.033). CONCLUSION Derangements in temperature, respiratory rate and heart appear to increase risk of critical care admission. Further work using a prospective approach is needed to establish which physiological parameters have the highest predictive validity, the level(s) of physiological abnormality with highest clinical utility, and the optimal timing for collection of physiological data.

Recognising clinical deterioration in emergency department patients

BACKGROUND The use of rapid response systems such as Medical Emergency Team (MET) improves recognition and response to clinical deterioration in in-patient settings. However, few published studies have investigated use of rapid response systems in Australian emergency departments (ED). AIM To examine the frequency, nature and outcomes of clinical deterioration in ED patients and compare the utility of hospital MET calling criteria with ED specific Clinical Instability Criteria (CIC) for recognition of deteriorating patients. The outcomes of interest were the prevalence of deterioration in ED patients, the utility of MET versus ED CIC, and the outcomes (MET activation, in-hospital mortality at 30 days) of patients who experienced deterioration during ED care. METHOD An exploratory descriptive design was used. Vital sign data were prospectively collected from 200 patients receiving ED care in the general treatment areas of regional, publicly funded health service in Victoria, Australia, during May 2012. Outcome data were collected by follow up medical record audit. RESULTS Of the 200 ED patients recruited, 2% fulfilled the study site MET criteria and 7.5% fulfilled ED CIC. The median age of patients fulfilling MET criteria was 85 years compared with a median age of 74 years for patients fulfilling the ED CIC criteria. Of the 136 ED patients admitted to in-patient wards, 5.9% required MET activation during admission and 3.7% of these MET activations occurred within 24h of emergency admission. Five percent of patients died in-hospital within 30 days of ED attendance. CONCLUSIONS ED specific criteria for activation of a rapid response system identifies more ED patients at risk of clinical deterioration. The results of this study highlight a need for EDs to implement and evaluate systems to increase recognition of deteriorating patients designed specifically for the emergency care context.

Effect of clinician designation on emergency department fast track performance

Objective To examine the effect of clinician designation on emergency department (ED) fast track performance. Design and Setting A retrospective audit of patients managed in the fast track area of an ED in metropolitan Melbourne, Australia. Participants Patients triaged to ED fast track from 1 January 2008 to 31 December 2008 (n=8714). Main Outcome Measures Waiting times in relation to Australasian triage scale (ATS) recommendations and ED length of stay (LOS) for non-admitted patients were examined for each clinician group. Results Compliance with ATS waiting time recommendations was highest (82.5%) for emergency nurse practitioners/candidates and lowest (48.2%) for junior medical officers. Median ED LOS was less than 3 h for non-admitted patients, and 85.8% of non-admitted fast track patients (n=6278) left the ED within 4 h. Patients managed by emergency nurse practitioners/candidates had the shortest ED LOS (median 1.7 h) and patients managed by junior medical officers and locum medical officers the longest ED LOS (median 2.7 h) (χ2=498.539, df=6, p<0.001). Conclusions Clinician designation does impact on waiting times and, to a lesser extent, ED LOS for patients managed in ED fast track systems. Future research should focus on obtaining a better understanding of the relationship between clinician expertise, time-based performance measures and quality of care indicators.

Sustainable workforce reform : case study of Victorian nurse practitioner roles

Nurse practitioner (NP) roles have been identified as a key strategy in the development of a sustainable and responsive health workforce. To date, the focus of research related to NP roles has been on implementation and short-term evaluation of aspects of NP care; however, little is known about the sustainability of NP roles. A major challenge for the healthcare sector is to demonstrate long-term outcomes of NP care and shift the research focus from individual NPs to the effectiveness of healthcare teams that incorporate NPs. This paper draws on a framework of the following domains of sustainability in primary care: political, institutional, financial-economic, workforce and client (or patient) and applies these domains to NP planning in the Victorian context.