- Email: [email protected]
National development and validation of the Emergency Triage Education Kit (ETEK)
6th International Conference for Emergency Nurses
201
Simulation is stimulation Julie Gawthorne Emergency Department, linghurst, NSW, Australia
St
Vincent’s
Hospital,
Dar-
While simulation training has been part of the aviation industry for decades it is relatively new to health care, particularly as a regular feature of in service programs. In 2003 the Patient Safety Simulation Centre opened at St Vincent’s Hospital with a primary focus on clinicians working within the hospital. The emergency department has been heavily involved with the centre since its opening, and weekly simulation sessions have been a permanent part of ED education for the past 3 years. The sessions involve immersive scenarios that include both ED nursing and medical staff. Scenarios include trauma, advanced life support, and medical and surgical emergencies. The main focus is on team performance, team roles, communication and leadership. Following the scenario a formal debrief gives participants and observers the opportunity to discuss both technical and non-technical aspects of the scenario. This paper will discuss our experience with weekly simulation training including engaging staff, writing scenarios, conducting a formal debrief, and the impact on team performance in the ED. Simulation training has bought a new, invaluable dimension to education in the ED. Weekly sessions mean staff are now very familiar with the simulation environment and are able to fully immerse themselves in the scenarios. While we have not measured the direct benefits of simulation training observation suggests it has improved team performance and communication, and provides staff with increased confidence in the clinical setting. doi:10.1016/j.aenj.2007.09.034 Closing the gap on pain is worth the trauma Julie Gawthorne 1,∗ , Andrew Finckh 1 , Susie Welch 2 , 3 2 Karon McDonell , Fiona Robertson , Gary Nichols 4 , Brad Hancock 3 1
Emergency Department, St Vincent’s Hospital, Darlinghurst, NSW, Australia 2 Pharmacy Department, St Vincent’s Hospital, Darlinghurst, NSW, Australia 3 Trauma Service, St Vincent’s Hospital, Darlinghurst, NSW, Australia 4 Clinical Pharmacology and Toxicology, St Vincent’s Hospital, Darlinghurst, NSW, Australia Background: Despite pain being one of the most common symptoms experienced by patients in the emergency department (ED) evidence shows patients continue to receive suboptimal pain relief. St Vincent’s Hospital Emergency Department identified that patients presenting with traumatic injuries were receiving limited analgesia, particularly intubated patients. Aim: To improve pain management for patients presenting to the emergency department with traumatic injuries, through the development and implementation of a trauma pain guideline.
Methods: A retrospective review of 100 ED trauma patients (50 intubated, 50 non-intubated) was conducted in June 2005. Analysis of analgesic use revealed 64% of intubated patients received no analgesia. Pain Management Guidelines were developed by the project group and implemented through intensive staff education in December 2005 and again in February 2006. A second review focusing on intubated ED trauma patients was conducted April—June 2006 and captured 28 patients. Results: An improvement in the proportion of intubated patients receiving analgesia was observed, rising from 32% (16/50) to 68% (19/28) (p = 0.02) in the pre- and postimplementation group, respectively. Use of Morphine and Midazolam infusions, a specific recommendation of the Guideline, increased from 8% (3/50) to 18% (5/28) in the preand post-implementation group, respectively. Propofol infusion with a morphine bolus or infusion was used in 29% (9/28) of patients, and combination sedative agents with analgesia bolus in 18% (5/58) of patients. 32% (9/28) of patients received sedation only. Conclusion: Implementation of Trauma Pain Management Guidelines and associated education has resulted in an improvement in analgesic use in intubated trauma patients in the ED. doi:10.1016/j.aenj.2007.09.035 National development and validation of the Emergency Triage Education Kit (ETEK) Marie Gerdtz 1,2 1
The University of Melbourne, Carlton, VIC, Australia Commonwealth Department of Health and Ageing, Canberra, ACT, Australia 2
Background: The Emergency Triage Education Kit (ETEK) is the product of an ongoing collaboration between the Commonwealth Department of Health and Ageing (Acute Care Division), the College of Emergency Nursing Australasia (CENA) and the Australasian College for Emergency Medicine (ACEM). The ETEK aims to provide a nationally consistent approach to the educational preparation of nurses for the triage role, and in particular the consistent application of the Australasian Triage Scale (ATS). This presentation will provide information about the development and validation of the educational tools provided in the ETEK, due to be launched in October 2007. Aims: 1. To develop a large set (>200) of paper-based triage scenarios for inclusion in the ETEK. 2. To assess the above scenarios for content validity and determine inter-rater reliability. 3. To achieve a weighted kappa of at least 0.6 for the scenarios set using 50 expert emergency nurse raters (10,000 occasions of triage). Methods: A convenience sample of 50 expert triage nurses was accessed for this study. Stratification of the sample occurred according to the location in which participants were employed and hospital classification type. Participants completed a basic demographic questionnaire
202 and 235 paper-based triage scenarios. Analysis included calculation of percentage agreement and weighted Kappa. Outcomes: A valid set of 200 triage scenarios was produced for inclusion in the ETEK. Keywords: Triage; Decision making; Simulations doi:10.1016/j.aenj.2007.09.036 Improving the ED management of acute stroke by prevention of early complications Bree McGillivray 1,∗ , Julie Considine 1,2 1
Emergency Department, The Northern Hospital, Epping, VIC, Australia 2 Deakin University, Melbourne, VIC, Australia Best evidence suggests that an important part of acute stroke management and decreasing stroke-related mortality is preventing complications within the first 24—48 h. For many patients, a considerable part of the first 24—48 h after stroke will be spent in the emergency department. It is therefore important that the ED manages aspects of care that were traditionally considered the realm of specialist stroke units, for example: monitoring and control of blood sugar and temperature, adequate hydration and oxygenation, preventing clots such as deep vein thrombosis, assessing ability to swallow and nutritional status, and early walking and mobilisation. Many of these aspects of stroke care are primarily influenced by emergency nurses. The aim of this study is to improve the ED care of acute stroke by enhancing the use of evidence regarding preventing early complications. A guideline for ED management of stroke will be developed for local use and its implementation will be supported by tutorials. This project will use a pre-test/post-test design to measure the effect of the guideline on the following outcomes: triage category, waiting time, ED length of stay, time to assessment by speech pathology and physiotherapy, assessment and monitoring of vital signs, temperature and blood glucose, management of fever, hyperglycaemia and hypoxia (if present), IV fluid regimes and compliance with venous-thromboembolism and pressure injury risk assessment and interventions. It is anticipated that data collection will be complete in mid 2007 and this paper will present the study findings. Keywords: Emergency nursing; Stroke; CVA doi:10.1016/j.aenj.2007.09.037 Registered nurse-led emergency department triage Katarina E. G¨ oransson ¨ ¨ Department of Health Sciences, Orebro University, Orebro, Sweden Background: Successful triage is the basis for sound emergency department (ED) care, whereas unsuccessful triage could result in adverse outcomes. This three phase doctoral thesis focuses on the organisation, performance, and decision making in Swedish ED triage. Methods: Quantitative and qualitative data were collected using telephone interviews, patient scenarios and
Abstracts think aloud method, and the participating 69 nurse managers and 423 registered nurses (RNs) were included by convenience and purposeful sampling. Results: The results showed of variation regarding the use of various triageurs, designated triage nurses, and triage scales. In addition, accuracy and concordance of the RNs’ allocated acuity ratings varied while statistical methods provided limited explanations for these variations. The RNs used several thinking strategies during the triage process, such as searching for additional information, generating hypotheses about the fictitious patients and providing explanations for the interventions chosen. The RNs structured the triage process in several ways, beginning the process by searching for information, generating hypotheses, or allocating acuity ratings. Comparison of RNs’ use of thinking strategies and the structure of the triage process based on triage accuracy revealed only slight differences. Conclusions: The research project revealed that Swedish ED triage is permeated by variation, both in the way it is organised and performed. However, no explanations for these variations were found. Keywords: Emergency department; Inter-rater agreement; Nursing; Patient scenarios; Think aloud method; Triage doi:10.1016/j.aenj.2007.09.038 Does gender matter at triage? Fredrik Ahlstr¨ om, Katarina E. G¨ oransson ∗ , Anette von Rosen Department of Emergency Medicine, Karolinska University Hospital and Karolinska Institute, Solna, Sweden Background: The current five-level triage system used at the Karolinska University Hospital Solna in Sweden is based on the Canadian ED Triage and Acuity Scale and the Manchester Triage Scale. Methods: The aim was to investigate the current triage system’s prediction regarding admission rate, in hospital time and mortality from a gender perspective. Data on age, gender, day of visit, admission rate, in-hospital time, triage level and 30-days mortality were extracted from medical records from 450 visits during the 2-week study period in the surgical emergency department at the Karolinska Hospital. Results: The total number of patients per day varied between 53 and 80, where women comprised 40.4% and men 59.6% of the studied patient population. Women were more often allocated to a lower triage level than men (p < 0.0009) while at the same time being admitted to the hospital wards more frequently than men. The admission difference based on gender occurred both in the whole patient material and in the separate triage groups except in triage level 5. In triage levels 2 and 3, 37% of the women were admitted compared to 26% of the men (p < 0.06). Conclusions: In spite of being significantly more often triaged to lower acuity levels by the triage nurse, female patients are more often than men admitted to in-hospital care. This indicates that the presently applied triage system does not recognise a possible gender associated difference in symptom presentation or that there is a subjective rather than strictly medical component in the triage process.
201
Simulation is stimulation Julie Gawthorne Emergency Department, linghurst, NSW, Australia
St
Vincent’s
Hospital,
Dar-
While simulation training has been part of the aviation industry for decades it is relatively new to health care, particularly as a regular feature of in service programs. In 2003 the Patient Safety Simulation Centre opened at St Vincent’s Hospital with a primary focus on clinicians working within the hospital. The emergency department has been heavily involved with the centre since its opening, and weekly simulation sessions have been a permanent part of ED education for the past 3 years. The sessions involve immersive scenarios that include both ED nursing and medical staff. Scenarios include trauma, advanced life support, and medical and surgical emergencies. The main focus is on team performance, team roles, communication and leadership. Following the scenario a formal debrief gives participants and observers the opportunity to discuss both technical and non-technical aspects of the scenario. This paper will discuss our experience with weekly simulation training including engaging staff, writing scenarios, conducting a formal debrief, and the impact on team performance in the ED. Simulation training has bought a new, invaluable dimension to education in the ED. Weekly sessions mean staff are now very familiar with the simulation environment and are able to fully immerse themselves in the scenarios. While we have not measured the direct benefits of simulation training observation suggests it has improved team performance and communication, and provides staff with increased confidence in the clinical setting. doi:10.1016/j.aenj.2007.09.034 Closing the gap on pain is worth the trauma Julie Gawthorne 1,∗ , Andrew Finckh 1 , Susie Welch 2 , 3 2 Karon McDonell , Fiona Robertson , Gary Nichols 4 , Brad Hancock 3 1
Emergency Department, St Vincent’s Hospital, Darlinghurst, NSW, Australia 2 Pharmacy Department, St Vincent’s Hospital, Darlinghurst, NSW, Australia 3 Trauma Service, St Vincent’s Hospital, Darlinghurst, NSW, Australia 4 Clinical Pharmacology and Toxicology, St Vincent’s Hospital, Darlinghurst, NSW, Australia Background: Despite pain being one of the most common symptoms experienced by patients in the emergency department (ED) evidence shows patients continue to receive suboptimal pain relief. St Vincent’s Hospital Emergency Department identified that patients presenting with traumatic injuries were receiving limited analgesia, particularly intubated patients. Aim: To improve pain management for patients presenting to the emergency department with traumatic injuries, through the development and implementation of a trauma pain guideline.
Methods: A retrospective review of 100 ED trauma patients (50 intubated, 50 non-intubated) was conducted in June 2005. Analysis of analgesic use revealed 64% of intubated patients received no analgesia. Pain Management Guidelines were developed by the project group and implemented through intensive staff education in December 2005 and again in February 2006. A second review focusing on intubated ED trauma patients was conducted April—June 2006 and captured 28 patients. Results: An improvement in the proportion of intubated patients receiving analgesia was observed, rising from 32% (16/50) to 68% (19/28) (p = 0.02) in the pre- and postimplementation group, respectively. Use of Morphine and Midazolam infusions, a specific recommendation of the Guideline, increased from 8% (3/50) to 18% (5/28) in the preand post-implementation group, respectively. Propofol infusion with a morphine bolus or infusion was used in 29% (9/28) of patients, and combination sedative agents with analgesia bolus in 18% (5/58) of patients. 32% (9/28) of patients received sedation only. Conclusion: Implementation of Trauma Pain Management Guidelines and associated education has resulted in an improvement in analgesic use in intubated trauma patients in the ED. doi:10.1016/j.aenj.2007.09.035 National development and validation of the Emergency Triage Education Kit (ETEK) Marie Gerdtz 1,2 1
The University of Melbourne, Carlton, VIC, Australia Commonwealth Department of Health and Ageing, Canberra, ACT, Australia 2
Background: The Emergency Triage Education Kit (ETEK) is the product of an ongoing collaboration between the Commonwealth Department of Health and Ageing (Acute Care Division), the College of Emergency Nursing Australasia (CENA) and the Australasian College for Emergency Medicine (ACEM). The ETEK aims to provide a nationally consistent approach to the educational preparation of nurses for the triage role, and in particular the consistent application of the Australasian Triage Scale (ATS). This presentation will provide information about the development and validation of the educational tools provided in the ETEK, due to be launched in October 2007. Aims: 1. To develop a large set (>200) of paper-based triage scenarios for inclusion in the ETEK. 2. To assess the above scenarios for content validity and determine inter-rater reliability. 3. To achieve a weighted kappa of at least 0.6 for the scenarios set using 50 expert emergency nurse raters (10,000 occasions of triage). Methods: A convenience sample of 50 expert triage nurses was accessed for this study. Stratification of the sample occurred according to the location in which participants were employed and hospital classification type. Participants completed a basic demographic questionnaire
202 and 235 paper-based triage scenarios. Analysis included calculation of percentage agreement and weighted Kappa. Outcomes: A valid set of 200 triage scenarios was produced for inclusion in the ETEK. Keywords: Triage; Decision making; Simulations doi:10.1016/j.aenj.2007.09.036 Improving the ED management of acute stroke by prevention of early complications Bree McGillivray 1,∗ , Julie Considine 1,2 1
Emergency Department, The Northern Hospital, Epping, VIC, Australia 2 Deakin University, Melbourne, VIC, Australia Best evidence suggests that an important part of acute stroke management and decreasing stroke-related mortality is preventing complications within the first 24—48 h. For many patients, a considerable part of the first 24—48 h after stroke will be spent in the emergency department. It is therefore important that the ED manages aspects of care that were traditionally considered the realm of specialist stroke units, for example: monitoring and control of blood sugar and temperature, adequate hydration and oxygenation, preventing clots such as deep vein thrombosis, assessing ability to swallow and nutritional status, and early walking and mobilisation. Many of these aspects of stroke care are primarily influenced by emergency nurses. The aim of this study is to improve the ED care of acute stroke by enhancing the use of evidence regarding preventing early complications. A guideline for ED management of stroke will be developed for local use and its implementation will be supported by tutorials. This project will use a pre-test/post-test design to measure the effect of the guideline on the following outcomes: triage category, waiting time, ED length of stay, time to assessment by speech pathology and physiotherapy, assessment and monitoring of vital signs, temperature and blood glucose, management of fever, hyperglycaemia and hypoxia (if present), IV fluid regimes and compliance with venous-thromboembolism and pressure injury risk assessment and interventions. It is anticipated that data collection will be complete in mid 2007 and this paper will present the study findings. Keywords: Emergency nursing; Stroke; CVA doi:10.1016/j.aenj.2007.09.037 Registered nurse-led emergency department triage Katarina E. G¨ oransson ¨ ¨ Department of Health Sciences, Orebro University, Orebro, Sweden Background: Successful triage is the basis for sound emergency department (ED) care, whereas unsuccessful triage could result in adverse outcomes. This three phase doctoral thesis focuses on the organisation, performance, and decision making in Swedish ED triage. Methods: Quantitative and qualitative data were collected using telephone interviews, patient scenarios and
Abstracts think aloud method, and the participating 69 nurse managers and 423 registered nurses (RNs) were included by convenience and purposeful sampling. Results: The results showed of variation regarding the use of various triageurs, designated triage nurses, and triage scales. In addition, accuracy and concordance of the RNs’ allocated acuity ratings varied while statistical methods provided limited explanations for these variations. The RNs used several thinking strategies during the triage process, such as searching for additional information, generating hypotheses about the fictitious patients and providing explanations for the interventions chosen. The RNs structured the triage process in several ways, beginning the process by searching for information, generating hypotheses, or allocating acuity ratings. Comparison of RNs’ use of thinking strategies and the structure of the triage process based on triage accuracy revealed only slight differences. Conclusions: The research project revealed that Swedish ED triage is permeated by variation, both in the way it is organised and performed. However, no explanations for these variations were found. Keywords: Emergency department; Inter-rater agreement; Nursing; Patient scenarios; Think aloud method; Triage doi:10.1016/j.aenj.2007.09.038 Does gender matter at triage? Fredrik Ahlstr¨ om, Katarina E. G¨ oransson ∗ , Anette von Rosen Department of Emergency Medicine, Karolinska University Hospital and Karolinska Institute, Solna, Sweden Background: The current five-level triage system used at the Karolinska University Hospital Solna in Sweden is based on the Canadian ED Triage and Acuity Scale and the Manchester Triage Scale. Methods: The aim was to investigate the current triage system’s prediction regarding admission rate, in hospital time and mortality from a gender perspective. Data on age, gender, day of visit, admission rate, in-hospital time, triage level and 30-days mortality were extracted from medical records from 450 visits during the 2-week study period in the surgical emergency department at the Karolinska Hospital. Results: The total number of patients per day varied between 53 and 80, where women comprised 40.4% and men 59.6% of the studied patient population. Women were more often allocated to a lower triage level than men (p < 0.0009) while at the same time being admitted to the hospital wards more frequently than men. The admission difference based on gender occurred both in the whole patient material and in the separate triage groups except in triage level 5. In triage levels 2 and 3, 37% of the women were admitted compared to 26% of the men (p < 0.06). Conclusions: In spite of being significantly more often triaged to lower acuity levels by the triage nurse, female patients are more often than men admitted to in-hospital care. This indicates that the presently applied triage system does not recognise a possible gender associated difference in symptom presentation or that there is a subjective rather than strictly medical component in the triage process.