Kathryn Eastwood

Numeracy skills of nursing students

Research has highlighted poor mathematical ability amongst qualified and student nurses. Three major classifications of errors: i)conceptual, ii)arithmetical and iii)computational have been identified. These errors involve being unable to formulate an equation from information given, unable to operate a given equation, or simple arithmetical errors respectively. The objective of this study was to determine if a sample of Australian second year undergraduate nursing students, from the state of Victoria, could accurately calculate drug dosages and perform some basic mathematical calculations that would be required in the workplace. A descriptive survey collecting demographical data, attitudes towards drug calculation performance and basic mathematical and drug calculation questions was administered to the 52 undergraduate nurses who participated in the study. The average score was 56.1%. Interestingly 63.5% of the students denied any drug calculations issues. On average those who completed a minimum of year 12 mathematics, or who had entered the course directly from secondary education achieved scores over 50%. Of all the errors that occurred 36.0% were conceptual, 38.9% were arithmetical and 25.1% were computational. Some Victorian nursing students currently have deficiencies in performing accurate calculations, with both arithmetical and conceptual errors, indicating fundamental flaws in their mathematical understanding and demonstrating an unacceptable level to practice safely.

A novel approach for managing the growing demand for ambulance services by low-acuity patients

Objective The aim of the present study was to describe the Ambulance Victoria (AV) secondary telephone triage service, called the Referral Service (RS), for low-priority patients calling triple zero. This service provides alternatives to ambulance dispatch, such as doctor or nurse home visits. Methods A descriptive epidemiological review of all the cases managed between 2009 and 2012 was conducted, using data from AV case records, the Victorian Admitted Episodes Dataset and the Australian Bureau of Statistics. Cases were reviewed for patient demographics, condition, final disposition and RS outcome. Results In all, 107148 cases were included in the study, accounting for 10.3% of the total calls for ambulance attendance. Median patient age was 54 years and 55% were female. Geographically based socioeconomic status was associated with the rate of calls to the RS (r=-0.72; 95% confidence interval CI -0.104, -0.049; P<0.001). Abdominal pain and back symptoms were the most common patient problems. Although 68% of patients were referred to the emergency department, only 27.6% of the total cases were by emergency ambulance; the remainder were diverted to non-emergency ambulance or the patients own private transport. The remaining 32% of cases were referred to alternative service providers or given home care advice. Conclusions This paper describes the use of an ongoing secondary triage service, providing an effective strategy for managing emergency ambulance demand. What is known about the topic? Some calls to emergency services telephone numbers for ambulance assistance consist of cases deemed to be low-acuity that could potentially be better managed in the primary care setting. The demand on ambulance resources is increasing each year. Secondary telephone triage systems have been trialled in ambulance services in the US and UK with minimal success in terms of overall impact on ambulance resourcing. What does this paper add? This study describes a model of secondary telephone triage in the ambulance setting that has provided an effective way to divert patients to more suitable forms of health care to meet their needs. What are the implications for practitioners? The implications for practitioners are vast. Some of the issues that currently face paramedics include: fatigue because of high workloads; skills decay because of a lack of exposure to patients requiring intervention with skills the paramedics have, as well as a lack of time for paramedics to practice these skills during their downtime; and decreasing job satisfaction linked to both these factors. Implications for patients include quicker response times because more ambulances will be available to respond and increased patient safety because of decreased fatigue and higher skill levels in paramedics.

Secondary triage in prehospital emergency ambulance services: a systematic review

Objective Secondary telephone triage to divert low-acuity patients to alternative non-ambulance services before ambulance arrival has been trialled in the UK and USA as a management strategy to cope with the increase in ambulance demand. The objective of this systematic review was to examine the literature on the structure, safety and success of secondary triage systems. Methods For inclusion in the study, the telephone triage system had to be a secondary process, receiving referred patients who had already been categorised as low priority by a primary triage process. Two independent reviewers conducted the search to identify relevant studies. Six articles and one report were identified. Results The major theme of the papers was the safety and accuracy of secondary telephone triage in identifying low-acuity patients. Two studies also discussed patient satisfaction. There was a low incidence of adverse events, as expected as these patients had already been subjected to primary telephone triage. In the studies identifying ambulance dispatch as a potential final disposition, at least half of the patients were diverted away from ambulance dispatch. In the studies that identified self/home care as a final disposition, a maximum of 31% of patients were categorised to this outcome. Otherwise all patients were recommended for assessment by a healthcare professional other than ambulance clinicians. Patients appeared to be satisfied with secondary telephone triage on follow-up. Conclusions These results suggest that, while secondary triage of these patients is safe, further research is required to determine its most appropriate structure and its effect on ambulance demand.

Mathematical and drug calculation abilities of paramedic students

Aim The objective of this study was to determine if undergraduate paramedics could accurately perform common drug calculations and basic mathematical computations normally required in the workplace. Method A descriptive paper-based questionnaire collecting demographical data, student attitudes regarding their drug calculation performance, and answers to a series of basic mathematical and drug calculation questions was administered to undergraduate paramedic students. Results The mean score was 39.5% with only 3.3% of students (n=3) scoring greater than 90%, and 63% (n=58) scoring 50% or less. Conceptual errors made up 48.5%, arithmetical 31.1% and computational 17.4%. Conclusion This study suggests undergraduate paramedics have deficiencies in performing accurate calculations with conceptual errors indicating a fundamental lack of mathematical understanding.

Appropriateness of cases presenting in the emergency department following ambulance service secondary telephone triage: A retrospective cohort study

Objective To investigate the appropriateness of cases presenting to the emergency department (ED) following ambulance-based secondary telephone triage. Design A pragmatic retrospective cohort analysis of all the planned and unplanned ED presentations within 48 hours of a secondary telephone triage. Setting The secondary telephone triage service, called the Referral Service, and the hospitals were located in metropolitan Melbourne, Australia and operated 24 hours a day, servicing 4.25 million people. The Referral Service provides an in-depth secondary triage of cases classified as low acuity when calling the Australian emergency telephone number. Population Cases triaged by the Referral Service between September 2009 and June 2012 were linked to ED and hospital admission records (N=44,523). Planned ED presentations were cases referred to the ED following the secondary triage, unplanned ED presentations were cases that presented despite being referred to alternative care pathways. Main outcome measures Appropriateness was measured using an ED suitability definition and hospital admission rates. These were compared with mean population data which consisted of all of the ED presentations for the state (termed the ‘average Victorian ED presentation’). Results Planned ED presentations were more likely to be ED suitable than unplanned ED presentations (OR 1.62; 95% CI 1.5 to 1.7; p<0.001) and the average Victorian ED presentation (OR 1.85; 95% CI 1.01 to 3.4; p=0.046). They were also more likely to be admitted to the hospital than the unplanned ED presentation (OR 1.5; 95% CI 1.4 to 1.6; p<0.001) and the average Victorian ED presentation (OR 2.3, 95% CI 2.24 to 2.33; p<0.001). Just under 15% of cases diverted away from the emergency care pathways presented in the ED (unplanned ED attendances), and 9.5% of all the alternative care pathway cases were classified as ED suitable and 6.5% were admitted to hospital. Conclusions Secondary telephone triage was able to appropriately identify many ED suitable cases, and while most cases referred to alternative care pathways did not present in the ED. Further research is required to establish that these were not inappropriately triaged away from the emergency care pathways.

Mathematical ability of first year undergraduate paramedic students—A before and after study

BACKGROUND An ability to accurately perform drug calculations unassisted is an essential skill for all health professionals, with various occupational-specific stressors exacerbating mathematical deficiencies. OBJECTIVES The objective of this study was to determine the unaided mathematic ability of first year undergraduate paramedic students before and after mathematical and drug calculation tutorials. METHODS Students were administered a questionnaire containing demographic, drug calculation and arithmetic questions during week one of the semester before the tutorials. During the semester students participated in three 2-hour tutorials which included both mathematical and drug calculation questions without assistance of computational devices. At the end of semester was a summative drug calculation examination of which five key questions were compared to similar questions from the first questionnaire. Descriptive statistics describe the demographic data with a paired t-test comparing the questionnaire and exam results. RESULTS Drug calculation and mathematical ability was markedly improved following the tutorials, mean score of correct answers before 1.74 (SD 1.4) and after 4.14 (SD 0.93), p<0001. When comparing the correct results for the same question type, there were statistically significant differences in four of five different drug calculations: volume of drug drawn up 10 v 57 p<0.0001, infusion rate 29 v 31 p=0.717, drip rate 16 v 54 p<0.0001, volume from a syringe 30 v 59 p<0.0001, and drug dose 42 v 62 p<0.0001. Total errors reduced from 188 to 45. CONCLUSIONS First year undergraduate paramedic students initially demonstrated a poor ability to complete mathematical and drug calculations without the assistance of computational devices. This improved significantly following appropriate education and practice. Further research is required to determine the retention of this ability over time.

Drug calculation ability of qualified paramedics: A pilot study

BACKGROUND The inability of paramedics to perform accurate calculations may result in a compromise of patient safety which may result from under or over dosing of drugs, incorrect joules for defibrillation, or a major adverse event such as death. The objective of this study was to identify the drug calculation and mathematical ability of qualified operational paramedics. METHODS The study used a cross-sectional design with a paper-based calculation questionnaire. Twenty paramedics enrolled in an intensive care paramedic course were eligible to participate in the study. The questionnaire consisted of demographic, drug calculation (seven questions), and mathematical (five) questions. Students were given no notice of the impending study and use of a calculator was not permitted. RESULTS All eligible students participated in the study. The average time employed as a paramedic was 7.25 years, SD 2.5 years, range four years to twelve years. Four (20%) students got all 12 questions correct, and five (41.6%) got 50% or less. The average score was 8.6 (71.7%) correct, SD 2.8 correct, range 3 to 12 correct questions. There were eight (40%) conceptual errors, 12 (60%) arithmetical errors, and five (25%) computational errors. CONCLUSION The results from this study supports similar international studies where paramedics ability to undertake mathematical and drug calculations without a calculator varies, with some results highlighting the paramedics mathematical skills as a potential risk to patient safety. These results highlight the need for regular continuing mathematical and drug calculation practice and education to ensure a lower error rate.