Nerolie Bost

A comparison of activities undertaken by enrolled and registered nurses on medical wards in Australia: An observational study

BACKGROUND The past decade has seen increasing patient acuity and shortening lengths of stays in acute care hospitals, which has implications for how nursing staff organise and provide care to patients. OBJECTIVE The aim of this study was to describe the activities undertaken by enrolled nurses (ENs) and registered nurses (RNs) on acute medical wards in two Australian hospitals. DESIGN This study used structured observation, employing a work sampling technique, to identify the activities undertaken by nursing staff in four wards in two hospitals. Nursing staff were observed for two weeks. The data collection instrument identified 25 activities grouped into four categories, direct patient care, indirect care, unit related activities and personal activities. SETTING Two hospitals in Queensland, Australia. RESULTS A total of 114 nursing staff were observed undertaking 14,528 activities during 482h of data collection. In total, 6870 (47.3%) indirect, 4826 (33.2%) direct, 1960 (13.5%) personal and 872 (6.0%) unit related activities were recorded. Within the direct patient care activities, the five most frequently observed activities (out of a total of 10 activities) for all classifications of nursing staff were quite similar (admission and assessment, hygiene and patient/family interaction, medication and IV administration and procedures), however the absolute proportion of Level 2 RN activities were much lower than the other two groups. In terms of indirect care, three of the four most commonly occurring activities (out of a total of eight activities) were similar among groups (patient rounds and team meetings, verbal report/handover and care planning and clinical pathways). The six unit related activities occurred rarely for all groups of nurses. CONCLUSION This study suggests that similarities exist in the activities undertaken by ENs and Level 1 RNs, supporting the contention that role boundaries are no longer clearly delineated.

Clinical handover of patients arriving by ambulance to the emergency department – A literature review

AIM To provide a critical review of research on clinical handover between the ambulance service and emergency department (ED) in hospitals. METHOD Data base and hand searches were conducted using the keywords ambulance, handover, handoff, emergency department, emergency room, ER, communication, and clinical handover. Data were extracted, summarised and critically assessed to provide evidence of current clinical handover processes. RESULTS From 252 documents, eight studies fitted the inclusion criteria of clinical handover and the ambulance to ED patient transfer. Three themes were identified in the review: (1) important information may be missed during clinical handover; (2) structured handovers that include both written and verbal components may improve information exchange; (3) multidisciplinary education about the clinical handover process may encourage teamwork, a shared common language and a framework for minimum patient information to be transferred from the ambulance service to the hospital ED. CONCLUSION Knowledge gaps exist concerning handover information, consequences of poor handover, transfer of responsibility, staff perception of handovers, staff training and evaluation of recommended strategies to improve clinical handover. Evidence of strategies being implemented and further research is required to examine the ongoing effects of implementing the strategies.

Clinical handover of patients arriving by ambulance to a hospital emergency department: a qualitative study.

AIM The aims of this study were to (1) explore the clinical handover processes between ambulance and ED personnel of patients arriving by ambulance at one hospital and (2) identify factors that impact on the information transfer to ascertain strategies for improvement. METHODS A focused ethnographic approach was used that included participant observation, conversational interviews and examination of handover tools. Participants included ambulance paramedics, nurses and medical practitioners from an ambulance service and regional hospital located in South East Queensland, Australia. Grounded theory methods of constant comparative data analyses were used to generate categories of findings. FINDINGS Two types of clinical handover were identified: (1) for non-critical patients and (2) for critical patients. Quality of handover appears to be dependent on the personnels expectations, prior experience, workload and working relationships. Lack of active listening and access to written information were identified issues. CONCLUSION Clinical handover between two organisations with different cultures and backgrounds may be improved through shared training programmes involving the use of guidelines, tools such as a whiteboard and a structured communication model such as MIST. Future participatory research to evaluate new handover strategies is recommended.

Patients Who Presented to an Australian Emergency Department and Did Not Wait or Left Against Medical Advice A Prospective Cohort Follow-Up Study

This study aimed to describe characteristics, outcomes, and post–emergency department (ED) departure medical requirements of patients who did not wait (DNW) or left against medical advice (LAMA) after presenting to an Australian hospital ED over a 6-month period. This was a prospective cohort follow-up study. Children and adults were compared in terms of ED characteristics and outcomes. Of the 32,333 patient presentations, 3,293 (10.2%) were recorded as DNW and 470 (1.5%) as LAMA. Of the DNW/LAMA presentations, 1,303 (34.6%) received a telephone call. One in four of the DNW/LAMA patients were children (<16 years). Most (87%) waited longer than the recommended time before leaving the ED, the majority (56%) sought care elsewhere, and some (n = 174, 13%) re-presented to the ED within 7 days; 20 of those required hospital admission. Strategies addressing front-end ED systems are required to mitigate the proportion of patients who DNW/LAMA.

Best-practice pain management in the emergency department: A cluster-randomised, controlled, intervention trial

We aimed to provide ‘adequate analgesia’ (which decreases the pain score by ≥2 and to <4 [0–10 scale]) and determine the effect on patient satisfaction.

Patients who present to the emergency department and leave without being seen: prevalence, predictors and outcomes.

Objective To identify the prevalence, predictors and outcomes of patients who leave without being seen (LWBS) in one hospital emergency department (ED). Materials and methods A descriptive, retrospective cohort study design was used. Data were extracted from the ED Information System. Multivariate logistic regression identified independent predictors of patients who LWBS. Two main outcomes were studied: the proportion of patients who waited longer than recommended and the proportion of patients who represented to the ED within 72 h. Setting A large regional teaching hospital ED in South East Queensland, Australia. Sample A total of 64 292 patient presentations made to the ED from 9 August 2008 to 8 August 2009. Results The prevalence of patients who LWBS was 10.7%. Independent predictors of LWBS included younger age, lower urgency triage category allocation, arrival by means other than ambulance, evening and night shift presentations, winter season, weekend presentations and presenting complaint category of ‘gastrointestinal’ or ‘paediatric’. When compared with patients who waited, those who LWBS comprised higher proportions of waiting longer than recommended (LWBS: 77.2% vs. waited: 52.0%, P<0.001) and higher proportions of representations to ED within 72 h (LWBS: 10.3% vs. waited: 5.4%, P<0.001). Conclusion Outcomes investigated in this study indicate that room for improvement exists not only for patients who LWBS but all patients presenting to the ED. The most powerful predictors of LWBS were lower urgency triage allocation and evening and night shift presentations. This suggests that service improvements could be targeted during ‘out of business hours’ for those with less emergent conditions.

Emergency care workload units: A novel tool to compare emergency department activity

Introduction:  Funding bodies have traditionally used attendance figures as a way of determining the allocation of funding for resources in the EDs. Using attendance figures only might not accurately reflect the funding and resources required. The need to create an easily implemented tool to compare workload and resources required was identified. Using the Australasian Triage Scale, a tool was developed to estimate staffing requirements and resource use within each ED. This, although currently not validated, provides a promising start in finding a way to accurately determine ED workload.

Characteristics and process outcomes of patients presenting to an Australian emergency department for mental health and non-mental health diagnoses

OBJECTIVES To describe and compare characteristics and process outcomes of patient presentations made to a public hospital emergency department (ED) for mental health (MH) and non-mental health (NMH) diagnoses. METHODS This was a descriptive, retrospective cross-sectional study of patients who presented to an Australian hospital ED between September 2011 and September 2012. Demographic, clinical and outcomes data were extracted from the ED information system. MH presentations were compared to NMH presentations. RESULTS Nearly 5% of the 66,678 ED presentations were classified as MH. Compared to the NMH group, a lower proportion in the MH group were seen by a physician within the recommended time frame (39.1% vs. 42.1%, p<0.001); had a higher admission rate (36.6% vs. 20.1%, p<0.001); shorter ED Length of Stay (LoS) if admitted (369 vs. 490min, p<0.001) and longer ED LoS if not admitted (241 vs. 187min, p<0.001). CONCLUSION Time constraints in the busy ED environment are a potential barrier to the delivery of care for all patients who have the right to timely access to health care. Targeted improvements at the front end of the ED system and output processes between ED, community and inpatient admission are recommended for this site.

Expanding emergency department capacity: a multisite study

OBJECTIVES The aims of the present study were to identify predictors of admission and describe outcomes for patients who arrived via ambulance to three Australian public emergency departments (EDs), before and after the opening of 41 additional ED beds within the area. METHODS The present study was a retrospective comparative cohort study using deterministically linked health data collected between 3 September 2006 and 2 September 2008. Data included ambulance offload delay, time to see doctor, ED length of stay (LOS), admission requirement, access block, hospital LOS and in-hospital mortality. Logistic regression analysis was undertaken to identify predictors of hospital admission. RESULTS Almost one-third of all 286037 ED presentations were via ambulance (n=79196) and 40.3% required admission. After increasing emergency capacity, the only outcome measure to improve was in-hospital mortality. Ambulance offload delay, time to see doctor, ED LOS, admission requirement, access block and hospital LOS did not improve. Strong predictors of admission before and after increased capacity included age >65 years, Australian Triage Scale (ATS) Category 1-3, diagnoses of circulatory or respiratory conditions and ED LOS >4h. With additional capacity, the odds ratios for these predictors increased for age >65 years and ED LOS >4h, and decreased for ATS category and ED diagnoses. CONCLUSIONS Expanding ED capacity from 81 to 122 beds within a health service area impacted favourably on mortality outcomes, but not on time-related service outcomes such as ambulance offload time, time to see doctor and ED LOS. To improve all service outcomes, when altering (increasing or decreasing) ED bed numbers, the whole healthcare system needs to be considered.

Health Service Impact from Mass Gatherings: A Systematic Literature Review

BACKGROUND During a mass gathering, some participants may receive health care for injuries or illnesses that occur during the event. In-event first responders provide initial assessment and management at the event. However, when further definitive care is required, municipal ambulance services provide additional assessment, treatment, and transport of participants to acute care settings, such as hospitals. The impact on both ambulance services and hospitals from mass-gathering events is the focus of this literature review. Aim This literature review aimed to develop an understanding of the impact of mass gatherings on local health services, specifically pertaining to in-event and external health services. METHOD This research used a systematic literature review methodology. Electronic databases were searched to find articles related to the aim of the review. Articles focused on mass-gathering health, provision of in-event health services, ambulance service transportation, and hospital utilization. RESULTS Twenty-four studies were identified for inclusion in this review. These studies were all case-study-based and retrospective in design. The majority of studies (n=23) provided details of in-event first responder services. There was variation noted in reporting of the number and type of in-event health professional services at mass gatherings. All articles reported that patients were transported to hospital by the ambulance service. Only nine articles reported on patients presenting to hospital. However, details pertaining to the impact on ambulance and hospital services were not reported. CONCLUSIONS There is minimal research focusing on the impact of mass gatherings on in-event and external health services, such as ambulance services and hospitals. A recommendation for future mass-gathering research and evaluation is to link patient-level data from in-event mass gatherings to external health services. This type of study design would provide information regarding the impact on health services from a mass gathering to more accurately inform future health planning for mass gatherings across the health care continuum. Ranse J , Hutton A , Keene T , Lenson S , Luther M , Bost N , Johnston ANB , Crilly J , Cannon M , Jones N , Hayes C , Burke B . Health service impact from mass gatherings: a systematic literature review. Prehosp Disaster Med. 2017;32(1):71-77.