Clinical significance of an elevated on-admission beta-hydroxybutyrate in acutely ill adult patients without diabetes

OBJECTIVE

To determine the relationship between point-of-care β-hydroxybutyrate (BHB) concentration and outcomes in adult patients without diabetes admitted through ED.

METHODS

This was a prospective study from 10 March to 2 July 2021. Admitted patients without diabetes had capillary BHB sampled in ED. Outcomes of length-of-stay (LOS), composite mortality/ICU admission rates and clinical severity scores (Quick Sepsis Organ Failure Assessment score/National Early Warning Score [qSOFA/NEWS]) were measured. BHB was assessed as a continuous variable and between those with BHB above and equal to 1.0 mmol/L and those below 1.0 mmol/L.

RESULTS

A total of 311 patients were included from 2377 admissions. Median length-of-stay was 4.1 days (IQR 2.1-9.8), 18 (5.8%) died and 37 (11.8%) were admitted to ICU. Median BHB was 0.2 mmol/L (IQR 0.1-0.4). Twenty-five patients had BHB ≥1.0 mmol/L and five were >3.0 mmol/L. There was no significant difference in median LOS for patients with BHB ≥1.0 mmol/L compared to non-ketotic patients, 5.3 days (IQR 2.2-7.5) versus 4.1 days, respectively (IQR 2.0-9.8) (P = 0.69). BHB did not correlate with LOS (Spearman ρ = 0.116, 95% confidence interval: 0.006-0.223). qSOFA and NEWS also did not differ between these cohorts. For those 25 patients with BHB ≥1.0 mmol/L, an infective/inflammatory diagnosis was present in 11 (44%), at least 2 days of fasting in 10 (40%) and ethanol intake >40 g within 48 h in 4 (16%).

CONCLUSIONS

Routine BHB measurement in patients without diabetes does not add to clinical bedside assessment and use should be limited to when required to confirm a clinical impression.

Unscheduled emergency department presentations with diabetes: Identifying high risk characteristics

BACKGROUND

Unscheduled emergency department (ED) presentation by patients with diabetes has seldom been examined. This study aimed to determine the frequency and associated characteristics of presentations in this population.

METHODS

Using a prospective cross-sectional design, data were collected from patients with diabetes presenting and/or admitted to a tertiary metropolitan hospital in New South Wales, Australia (December 2016-September 2017). A screening interview including brief measures of cognitive and executive function, and clinical details from healthcare records were utilised; details around unscheduled presentations within 90 days were extracted. Independent associations with ED presentation were determined.

RESULTS

Unscheduled ED presentations were common; 35.4% had at least one within 90 days, and for 20.1% this occurred within 28 days. The screening tool contributed little towards identifying risk of unscheduled presentation. Those attending any community or outpatient follow-up appointment within the first 28 (OR 0.42, 95% CI 0.23-0.76; p = 0.004) or 90 days (OR 0.25; 0.13-0.47; p < 0.001) from the index presentation were less likely to present within that same period.

CONCLUSIONS

Findings indicated the magnitude of unscheduled ED presentation, care complexity and the value of targeted and timely follow-up. Alternative service support may help maintain and improve diabetes self-management and will require effectiveness and cost-effectiveness evaluation.

The Emergency nurse Protocols Initiating Care-Sydney Triage to Admission Risk Tool (EPIC-START) trial: protocol for a stepped wedge implementation trial

INTRODUCTION

Emergency department (ED) overcrowding is a global problem and a threat to the quality and safety of emergency care. Providing timely and safe emergency care therein is challenging. To address this in New South Wales (NSW), Australia, the Emergency nurse Protocol Initiating Care-Sydney Triage to Admission Risk Tool (EPIC-START) was developed. EPIC-START is a model of care incorporating EPIC protocols, the START patient admission prediction tool, and a clinical deterioration tool to support ED flow, timely care, and patient safety. The aim of this study is to evaluate the impact of EPIC-START implementation across 30 EDs on patient, implementation, and health service outcomes.

METHODS AND ANALYSIS

This study protocol adopts an effectiveness-implementation hybrid design (Med Care 50: 217-226, 2012) and uses a stepped-wedge cluster randomised control trial of EPIC-START, including uptake and sustainability, within 30 EDs across four NSW local health districts spanning rural, regional, and metropolitan settings. Each cluster will be randomised independently of the research team to 1 of 4 dates until all EDs have been exposed to the intervention. Quantitative and qualitative evaluations will be conducted on data from medical records and routinely collected data, and patient, nursing, and medical staff pre- and post-surveys.

ETHICS AND DISSEMINATION

Ethical approval for the research was received from the Sydney Local Health District Research Ethics Committee (Reference Number 2022/ETH01940) on 14 December 2022.

TRIAL REGISTRATION

Australian and New Zealand Clinical trial, ACTRN12622001480774p. Registered on 27 October 2022.

Clean the skin: Reducing blood culture contamination in the emergency department

OBJECTIVE

To determine whether blood culture contamination (BCC) rates could be decreased in the ED by an educational programme.

METHODS

Educational intervention focusing on a 1-min venepuncture cleaning time and providing a larger chlorhexidine alcohol swab. BCC rates were examined retrospectively 12-month pre-, and 9-month post-intervention.

RESULTS

Six thousand nine hundred and fifty-three blood cultures were collected over the study period. The BCC rate was 2.4% pre-intervention versus 1.8% post-intervention, with no significant difference in BCC rates (Z-score = 1.862, P = 0.063).

CONCLUSION

This educational intervention focusing on skin clean time did not significantly decrease BCC rates in a setting of an already low (<3%) BCC rate.

UNPLANNED REPRESENTATION TO HOSPITAL BY PATIENTS WITH DIABETES: DEVELOPMENT AND PILOT FEASIBILITY TESTING OF A SCREENING TOOL

BackgroundUnplanned representation of patients with diabetes recently discharged from emergency department or in-patient hospitals is a common but complex problem worldwide. This study set out to examine the feasibility of a risk screening interview and whether component characteristics may be associated with unplanned representation of patients with diabetes to a tertiary metropolitan hospital.MethodsA screening interview comprised of demographic, social and clinical characteristics was developed and piloted using prospective cross-sectional survey design. A convenience sample of 55 patients was recruited and screened. Outcomes were the occurrence of unplanned representation to hospital within 28 or 90 days of hospital discharge from the index presentation.ResultsThe screening interview was shown to be broadly feasible and acceptable for use by staff and patients, with identified areas for modification. Seventeen participants (30.9%) experienced unplanned representation within 90 days of hospital discharge; for 13 participants (23.6%) this occurred within 28 days. Characteristics linked with unplanned representation to hospital were identified.ConclusionsPreliminary data indicated the feasibility of tool use and informed refinement for future testing of the ability of the screening interview to predict those patients with diabetes at high risk of unplanned representation to hospital to enhance effective care planning.

The relationship between admission glucose and lactate with critical illness amongst adult patients presenting to the emergency department

AIM

Our aim was to determine the relationship between glucose and lactate amongst adult patients admitted to hospital via the emergency department.

METHOD

We performed a cross-sectional observational study of 2541 patients admitted via the emergency department who had an admission glucose and lactate measurement available.

RESULTS

23% of the whole cohort had a diagnosis of diabetes. Glucose and lactate were predictors of the primary outcome of critical illness defined as composite of intensive care unit (ICU) admission or in-hospital death. In the multivariable analysis, lactate but not glucose remained an independent predictor of ICU/in hospital death in the group without diabetes. In the diabetes group, both glucose and lactate remained independent predictors of ICU admission/ in-hospital death.

CONCLUSIONS

Hyperglycaemia and hyperlactataemia are part of the metabolic response to critical illness. Lactate and a diagnosis of diabetes modify the relationship between glycaemia and critical illness.

Applying real-time Delphi methods: development of a pain management survey in emergency nursing

The modified Delphi technique is widely used to develop consensus on group opinion within health services research. However, digital platforms are offering researchers the capacity to undertake a real-time Delphi, which provides novel opportunities to enhance the process. The aim of this case study is to discuss and reflect on the use of a real-time Delphi method for researchers in emergency nursing and cognate areas of practice. A real-time Delphi method was used to develop a national survey examining knowledge, perceptions and factors influencing pain assessment and management practices among Australian emergency nurses. While designing and completing this real-time Delphi study, a number of areas, emerged that demanded careful consideration and provide guidance to future researchers.

Examining the utility of the Violence Prevention Climate scale: In a metropolitan Australian general hospital

AIM AND OBJECTIVES

To evaluate and examine the utility of the Violence Prevention Climate scale by generalist healthcare professionals.

BACKGROUND

Workplace violence in general hospital settings remains a challenge for healthcare organisations. High rates of violence are still being reported towards healthcare workers, despite organisational violence prevention strategies being implemented. There is a major challenge to healthcare organisation in the measurement of the effectiveness of these interventions, traditionally completed via the reporting and monitoring of workplace violent incidents. A novel approach to measuring workplace violence is by studying hospital atmosphere or climate.

DESIGN

A cross-sectional survey using the STARD guidelines was used.

METHODS

The Violence Prevention Climate scale was completed by 194 healthcare staff working in the emergency department, medical/surgical wards, respiratory/infectious disease, spinal care, renal unit, corrections health, and rehabilitation and community services of a major Australian tertiary referral hospital. The Violence Prevention Climate scale has previously been validated and used in mental health settings, but not general hospital settings. A content analysis of an open-ended question on violence prevention management strategies was also conducted.

RESULTS

Comprising of 14 items with two factors (patients and staff), the study revealed a 9-item staff factor scale that can be used in the general hospital setting, the patient factor did not show adequate reliability. The content analysis revealed seven categories of staff identified violence prevention and management strategies.

CONCLUSIONS

The use of the 9-item scale across an organisation annually, or added to existing organisational workforce surveys, could prove to be practical way of measuring the social climate of violence in a general hospital setting.

RELEVANCE TO CLINICAL PRACTICE

The results of which could guide clinical practice, workplace safety, policy and educational initiatives for the prevention and management of workplace violence.

Association between shift work and cognitive performance on the Trail Making Test in emergency department health officers

OBJECTIVE

Shift work has been proposed to disturb alertness and decrease cognitive efficiency. However, studies so far have had varied findings. The aim of the present study was to compare cognitive function following shifts at different times of the day in an Australian ED context.

METHODS

A prospective, self-controlled observational study was conducted on medical and nursing staff at a tertiary referral centre and regional hospital ED. Participants were required to complete the Trail Making Test (TMT), a neurocognitive test consisting of two parts (TMT-A and TMT-B), at baseline (at the start of the day) and at the end of their shift (day, evening or night). Related samples Wilcoxon signed-rank tests were used to compare post-shift TMT performance to baseline in medical and nursing staff.

RESULTS

Over a 5-month period, 140 ED staff were recruited including 109 doctors and 31 nurses. After a night shift, medical staff (n = 85) and nursing staff (n = 29) took longer to complete the TMT-B by 3.4 s (P < 0.001) and 7.1 s (P = 0.01), respectively, compared to baseline. Post-evening shift, medical staff (n = 59) took longer to complete the TMT-A by 0.3 s (P = 0.02).

CONCLUSIONS

Night shift work was associated with a longer TMT time. This may indicate a decrease in cognitive performance, in particular, visual attention, processing speed, task switching and executive function and may implicate the quality of care for patients and worker safety.

Pain assessment and interventions by nurses in the emergency department: A national survey

AIM

The aim of this study was to examine the knowledge, perceptions and factors influencing pain assessment and management practices among Australian emergency nurses.

BACKGROUND

Pain is the most commonly reported symptom in patients presenting to the emergency department, with over half rating their pain as moderate-to-severe. Patients unable to communicate, such as critically ill intubated patients, are at greater risk of inadequate pain management.

DESIGN

This cross-sectional exploratory study used survey methodology to explore knowledge, perceptions and factors influencing pain management practices among Australian emergency nurses.

METHODS

Australian emergency nurses were invited to complete an online survey comprising 91 items. The response rate was 450 of 1,488 (30.2%). STROBE guidelines were used in reporting this study.

RESULTS

Variations in level of acute pain management knowledge, especially in older, cognitively impaired or mechanically ventilated patients were identified. Poor interprofessional communication, workload and staffing negatively impacted on nurses' intention to administer analgesia. For intubated patients, validated observation pain assessment instruments were rarely used, although respondents recognised the importance of pain management in critically ill patients.

CONCLUSIONS

Emergency nurses recognise the importance of pain relief. The ability to nurse-initiate analgesia, education and training in pain management education is variable. Little education is provided on assessing and managing acute pain in elderly, cognitively impaired or mechanically ventilated patients. Use of validated pain assessment instruments to assess pain in critically ill patients is poor.

RELEVANCE TO CLINICAL PRACTICE

While pain management is the responsibility of all healthcare professionals, in the emergency department, it is a core role of emergency nursing. This study highlights the variation in ability to nurse-initiate analgesia, level of acute pain knowledge, education and training, and use of validated pain assessment instruments to guide pain management in critically ill intubated patients.

Use of the Delphi method to generate guidance in emergency nursing practice: A systematic review

AIM

To examine the application and methodological quality of the Delphi method used in developing guidance for emergency nursing practice.

BACKGROUND

Emergency nursing scope of practice has rapidly expanded in response to increasing patient acuity, complexity and technological innovation. Determining best practice is crucial for delivering high quality, safe and effective emergency nursing care. The Delphi method has been used to identify, prioritise complex issues and develop evidence-driven guidance in emergency nursing practice. The use and quality of the Delphi method in emergency nursing practice has not been examined.

DESIGN

Systematic literature review.

DATABASES AND DATA TREATMENT

A systematic literature search was conducted using the following databases: SCOPUS, EMBASE, Medline and ProQuest from date of inception to August 2019. The database search was limited to scholarly articles or peer-reviewed journals. No language restrictions were applied. The Cochrane Collaboration method and PRISMA checks were utilized to conduct the review.

RESULTS

Of 246 records identified 22 (8.9%) studies met the inclusion criteria. A modified Delphi method was commonly used (n = 15; 68.2%) and often conducted online (n = 11; 50.0%). Eight practice guidance themes were identified. Overall study quality was high (score 12/14; range 4-13), transparency of reporting varied.

CONCLUSION

Based on this review, the Delphi method is an appropriate method for exploring emergency nursing practice. The studies reviewed demonstrated that knowledge, skills and clinical expertise has progressively expanded in the specialty of emergency nursing. Variation in the application, conduct and transparency of reporting in Delphi studies developing guidance for emergency nursing practice is discussed.

Timing of respiratory virus molecular testing in emergency departments and its association with patient care outcomes: a retrospective observational study across six Australian hospitals

OBJECTIVE

A rapid molecular diagnostic test (RMDT) offers a fast and accurate detection of respiratory viruses, but its impact on the timeliness of care in the emergency department (ED) may depend on the timing of the test. The aim of the study was to determine if the timing of respiratory virus testing using a RMDT in the ED had an association with patient care outcomes.

DESIGN

Retrospective observational study.

SETTING

Linked ED and laboratory data from six EDs in New South Wales, Australia.

PARTICIPANTS

Adult patients presenting to EDs during the 2017 influenza season and tested for respiratory viruses using a RMDT. The timing of respiratory virus testing was defined as the time from a patient's ED arrival to time of sample receipt at the hospital laboratory.

OUTCOME MEASURES

ED length of stay (LOS), >4 hour ED LOS and having a pending RMDT result at ED disposition.

RESULTS

A total of 2168 patients were included. The median timing of respiratory virus testing was 224 min (IQR, 133-349). Every 30 min increase in the timing of respiratory virus testing was associated with a 24.0 min increase in the median ED LOS (95% CI, 21.8-26.1; p<0.001), a 51% increase in the likelihood of staying >4 hours in ED (OR, 1.51; 95% CI, 1.41 to 1.63; p<0.001) and a 4% increase in the likelihood of having a pending RMDT result at ED disposition (OR, 1.04; 95% CI, 1.02 to 1.05; p<0.001) after adjustment for confounders.

CONCLUSION

The timing of respiratory virus molecular testing in EDs was significantly associated with a range of outcome indicators. Results suggest the potential to maximise the benefits of RMDT by introducing an early diagnostic protocol such as triage-initiated testing.

The use and feasibility of an online software system to support assessment of accuracy and consistency in applying the Australasian Triage Scale

BACKGROUND

The purpose of this study was to evaluate the use and feasibility of a software system called the Triage Quality Assessment Software in New South Wales emergency departments, to assist in evaluating triage decision accuracy and consistency of emergency nurses in applying the Australasian Triage Scale.

METHOD

A descriptive, exploratory study comprising of retrospective audit data and survey, was conducted 12-months post-implementation of the Triage Quality Assessment Software system.

RESULTS

Between January to December 2018, a total of 39 audits were completed comprising 4214 triage records, of which 3952 (93.3%) contained sufficient information to be evaluated. Triage decision accuracy was 58.3% with a moderate level (K_W=0.57) of consistency demonstrated. Overall feasibility was high (4.2). Findings confirmed learnability (4.3), usability (4.2) and acceptability (4.2) of Triage Quality Assessment Software.

CONCLUSION

This is the first software system to be developed to assist in evaluating triage decision accuracy and consistency in applying the Australasian Triage Scale. This study provides evidence that triage decision accuracy and consistency are detectable and quantifiable. The feasibility of Triage Quality Assessment Software is supported, with further testing needed to fully evaluate its role in emergency department triage quality improvement.

Triage in Australian emergency departments: Results of a New South Wales survey

AIM

To describe current models of triage, the preparation and education of triage nurses, and methods of auditing triage practice in New South Wales emergency departments.

BACKGROUND

Triage is a critical component of emergency department practice; affecting patient safety and access to emergency care. Within Australia, triage is an autonomous role predominantly conducted by trained emergency nurses. Patient safety and timely access to emergency care relies upon the experience, education and training of emergency triage nurses. To date, little is known about triage models of care, the preparation and education of triage nurses, and assessment of triage practice and decision accuracy.

METHOD

Descriptive, exploratory study design employing a self-reporting cross-sectional survey of clinical nurse consultants and educators in New South Wales.

RESULTS

The survey results reveal variability in models of triage, and the eligibility, preparation and education requirements of triage nurses; that appear geographically related. Auditing of triage practice was commonly undertaken retrospectively; feedback to triage nurses was infrequent. The survey found evidence of locally developed guidelines directing triage category allocation for specific conditions or symptoms.

CONCLUSION

The purpose of triage is to ensure that the level of emergency care provided is commensurate with clinical urgency. Variability in the preparation, education and evaluation of triage nurses may in and of itself, contribute to poor patient outcomes. Further, workforce size and geography may impede auditing and the provision of feedback, which are critical to improving triage practice and triage nurse performance. It is imperative that the Emergency Triage Education Kit be revised and maintained in tandem with future revisions of the Australasian Triage Scale.

The Significance of an Increased Beta-Hydroxybutyrate at Presentation to the Emergency Department in Patients with Diabetes in the Absence of a Hyperglycemic Emergency

The significance of hyperketonemia in adults with diabetes presenting to the emergency department with acute illness, not due to a diabetic hyperglycemic emergency, has not been well characterized. Adult patients with diabetes presenting to the emergency department who had venous blood gas and beta-hydroxybutyrate levels measured whilst in the emergency department were retrospectively evaluated for the relationship between BHB and clinical outcomes. Over 6 months, 404 patients with diabetes had at least one beta-hydroxybutyrate level measured in the emergency department. There were 23 admissions for diabetic ketoacidosis (DKA) or hyperosmolar state. Of the remainder, 58 patients had a beta-hydroxybutyrate ≥ 1 mmol/L; this group had a higher glucose at presentation (19.0 (8.8) versus 10.4 (9.9) mmol/L), higher HbA1c (8.8 (5.4) versus 8.0 (3.3)%), lower bicarbonate (22.6 (6.2) versus 24.8 (4.7) mmol/L), and higher anion gap (14.8 (6.1) versus 12.6 (4.2)) than had those with BHB < 1 mmol/L. There was no association between the presence of ketosis and the length of stay (4.2 (7.3) versus (3.0) (7.2) days). Acute illness in those with diabetes associated with ketosis in the absence of DKA is associated with worse glycaemic control than in those without ketosis. Ketosis may represent an intermediate state of metabolic dysregulation rather than being associated with a more severe acute illness, as suggested by no relationship between BHB and length of stay.

Development and preliminary testing of an online software system to facilitate assessment of accuracy and consistency in applying the Australasian Triage Scale

PURPOSE

The aim of this project was to design and evaluate an online software system to facilitate the assessment of triage decision accuracy and consistency in applying the Australasian Triage Scale.

BACKGROUND

Triage is a critical component of emergency nursing practice, which affects patient access to emergency care. Accurate and consistent triage decisions are vital to ensuring patient safety, timely access to care and ED operation. Presently, there is no standard process to examine triage decisions, measure current performance and support department and individual performance development activities to improve patient safety and quality of emergency care.

METHOD

An iterative design guided by a human factors development approach was used to develop a retrospective, focus-based analysis system to evaluate triage decision accuracy and consistency, and enable the exploration of service gaps and opportunities for practice change and professional development.

RESULTS

Triage decision accuracy and consistency, including areas for improvement are detectable and quantifiable. Findings generated may aid in departmental performance and professional development of triage nurses.

CONCLUSION

This is the first system developed to assess decision accuracy and consistency in applying the Australasian Triage Scale. This paper has described the development and preliminary testing of a user-centred design process and implementation of a web-based system to evaluate triage decision accuracy and consistency.

Quality and impact of nurse-initiated analgesia in the emergency department: A systematic review

AIM

This paper reports a systematic literature review evaluating the impact and quality of pain management associated with nurse initiated analgesia in patients presenting to the emergency department (ED).

BACKGROUND

Pain is a major presenting complaint for individuals attending the ED. Timely access to effective analgesia continues to be a global concern in the ED setting; emergency nurses are optimally positioned to improve detection and management of pain.

DESIGN

Systematic review.

DATABASES AND DATA TREATMENT

Four databases - CINAHL, EMBASE, Medline, ProQuest - the Cochrane Library and the National Institute of Clinical Excellence were searched from date of inception to December 2017; with no language restrictions applied. Studies were identified using predetermined inclusion criteria. Data were extracted and summarised and underwent evaluation using published valid criteria.

RESULTS

Twelve articles met inclusion, comprising a wide range of analgesics and administration routes to manage mild to severe pain. Overall study quality was high; 7 studies included a form of comparison group. Patient outcome measures included time to analgesia (n = 12; 100%), change in pain score (n = 6; 50.0%); adverse events (n = 6; 50.0%); patient satisfaction (n = 5; 41.7%) and documenting pain assessment (n = 2; 16.7%).

CONCLUSION

Nurse-initiated analgesia was associated with safe, timely and effective pain relief.

Exploring how nurses assess, monitor and manage acute pain for adult critically ill patients in the emergency department: protocol for a mixed methods study

Background

Many critically ill patients experience moderate to severe acute pain that is frequently undetected and/or undertreated. Acute pain in this patient cohort not only derives from their injury and/or illness, but also as a consequence of delivering care whilst stabilising the patient. Emergency nurses are increasingly responsible for the safety and wellbeing of critically ill patients, which includes assessing, monitoring and managing acute pain. How emergency nurses manage acute pain in critically ill adult patients is unknown. The objective of this study is to explore how emergency nurses manage acute pain in critically ill patients in the Emergency Department.

Methods

In this paper, we provide a detailed description of the methods and protocol for a multiphase sequential mixed methods study, exploring how emergency nurses assess, monitor and manage acute pain in critically ill adult patients. The objective, method, data collection and analysis of each phase are explained. Justification of each method and data integration is described.

Discussion

Synthesis of findings will generate a comprehensive picture of how emergency nurses’ perceive and manage acute pain in critically ill adult patients. The results of this study will form a knowledge base to expand theory and inform research and practice.

A systematic review of observational pain assessment instruments for use with nonverbal intubated critically ill adult patients in the emergency department: an assessment of their suitability and psychometric properties

AIM AND OBJECTIVE

To examine the psychometric properties and suitability of the available observational pain instruments for potential use with nonverbal critically ill adult patients in the emergency department.

BACKGROUND

In the emergency department, assessing pain in critically ill patients is challenging, especially those unable to communicate the presence of pain. Critically ill patients are commonly unable to verbally communicate pain due to altered oral communication (e.g. endotracheal intubation) and/or diminished consciousness (e.g. sedation, delirium), placing them at great risk of inadequate pain management. Over half of intensive care critically ill intubated patients experience moderate-to-severe pain whilst intubated and mechanically ventilated.

DESIGN

Systematic review.

DATA SOURCES

The CINAHL, EMBASE, MEDLINE, ProQuest databases, and the Cochrane Library and the National Institute of Clinical Excellence were also searched from their date of inception to April 2016, with no language restrictions applied.

REVIEW METHOD

Studies were identified using predetermined inclusion criteria. Data were extracted and summarised and underwent evaluation using published classification of psychometric tests for consistency of interpretation.

RESULTS

Twenty-six studies evaluating five observational pain assessment instruments that had been used with critically ill intubated patients were identified. All five instruments included behavioural indicators, with two including physiologic indicators. All five instruments have undergone validity and reliability testing involving nonverbal critically ill intubated patients, three were examined for feasibility, and one instrument underwent sensitivity and specificity testing. None have been tested within the emergency department with nonverbal critically ill intubated adult patients.

CONCLUSION

The use of an appropriate and valid observational pain assessment instrument is fundamental to detecting and optimising pain management in nonverbal critically ill intubated patients in the emergency department. Of the observational pain assessment instruments reviewed, the Critical-Care Pain Observation Tool was identified as most appropriate for testing in a prospective trial in an emergency department setting.

Emergency nurses' perceptions of sedation management practices for critically ill intubated patients: a qualitative study

AIMS AND OBJECTIVES

The aim of this study was to explore factors influencing practices in assessing, titrating and managing sedation for the critically ill intubated patients, from the perspective of emergency nurses.

BACKGROUND

The number of critically ill patients presenting to Australian public Emergency Departments has increased by over 30% since 1980. Emergency nurses are increasingly relied upon to manage sedation of critically ill intubated patients. There is little evidence within international literature relating to how emergency nurses accomplish this.

DESIGN

Descriptive qualitative study.

METHOD

A purposive sample of 15 experienced emergency nurses participated in semi-structured face-to-face interviews. Transcribed data were analysed using thematic analysis.

RESULTS

The qualitative analysis yielded five themes: becoming the resuscitation nurse; becoming confident as the resuscitation nurse; communicating about sedation; visual cues and the vanishing act. The safety and quality of sedation experienced by critically ill intubated patients in ED was the responsibility of emergency nurses, yet uncertainties and barriers were evident.

CONCLUSION

Patient continuity of care, including optimisation of comfort relies upon the knowledge, skills and expertise of the emergency nurse allocated to the resuscitation area. For most nurses transitioning into the resuscitation nurse role, it represents the first time they will have had contact with patients with highly complex needs and sedation. The use of self-directed clinical workbooks and supervised clinical practice alone may be insufficient to adequately prepare nurses for the spectrum of critically ill sedated patients managed in the resuscitation area; a situation made worse in the presence of poor team communication.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study should assist in the development of policy and formal education of emergency nurses transitioning into the resuscitation area and the management of continuous intravenous sedation to critically ill mechanically ventilated patients is required.

Assessing, monitoring and managing continuous intravenous sedation for critically ill adult patients and implications for emergency nursing practice: A systematic literature review

BACKGROUND

Critically ill mechanically ventilated patients in ED have complex needs; chief among these is adequate sedation in addition to effective pain-relief. Emergency nurses are increasingly responsible sedation and analgesia for this complex cohort of patients. The aim of this review was to examine (1) the evidence around assessing, monitoring and managing continuous intravenous sedation for critically ill adult patients, and (2) the implications for emergency nursing practice.

STUDY DESIGN

Systematic review.

METHOD

The review of literature extended from 1946 to 2013 and examined peer review journal articles, policy and guidelines to provide a more complex understanding of a phenomenon of concern. A total of 98 articles were incorporated and comprehensively examined.

RESULTS

Analysis of the literature identified several implications for emergency nursing practice and the management of continuous intravenous sedation: workload, education, monitoring and assessing sedation and policy.

CONCLUSION

Limited literature was found that directly addressed Australasian emergency nursing practices' in managing on-going intravenous sedation and analgesia for patients. Balancing patient sedation and analgesia requires highly complex knowledge, skills and expertise; the degree of education and training required is above that obtained during pre-registration nurse training. No state or national models of education or training were identified to support ED nurses' practices in managing sedation. Little research has addressed the safety of continuous sedation use in ED.

Emergency nurses practices in assessing and administering continuous intravenous sedation for critically ill adult patients: a retrospective record review'

AIM

To generate an initial profile of emergency nurses' practices in and factors influencing the assessment and administration of continuous intravenous sedation and analgesia for critically ill mechanically ventilated adult patients.

BACKGROUND

Emergency nurses are relied upon to assess and manage critically ill patients, some of whom require continuous intravenous sedation. Balancing sedation is a highly complex activity. There is however little evidence relating to how emergency nurses manage continuous intravenous analgesia and sedation for the critically ill intubated patients.

DESIGN

Descriptive study.

METHOD

A 12-month retrospective medical record review was undertaken from January to December 2009 of patients (>16 years) administered continuous intravenous sedation in ED.

RESULTS

Fifty-five patients received ongoing intravenous sedation within the ED during a median length of stay of 3.4 h. Assessment of patient depth/quality of sedation and pain-relief varied and were rarely documented. Adverse events were documented, majority (16%) drug administration related. Thematic analysis identified three themes: 'Maintaining sedation', 'Directionless-directions', and 'Navigating the balance'.

CONCLUSION

Emergency nurses provide continuity of patient care and optimisation of analgesia and sedation for critically ill sedated patients. The safety and effectiveness of continuous intravenous sedation for the critically ill adult patient in ED are dependent on the expertise and decision-making abilities of the nurse.

The validity, reliability, responsiveness and applicability of observation sedation-scoring instruments for use with adult patients in the emergency department: a systematic literature review

AIM

This paper reports a systematic literature review examining the range of published observational sedation-scoring instruments available in the assessment, monitoring and titration of continuous intravenous sedation to critically ill adult patients in the Emergency Department, and the extent to which validity, reliability, responsiveness and applicability of the instruments has been addressed.

BACKGROUND

Emergency nurses are increasingly responsible for the ongoing assessment, monitoring and titration of continuous intravenous sedation, in addition to analgesia for the critically ill adult patient. One method to optimise patient sedation is to use a validated observational sedation-scoring tool. It is not clear however what the optimal instrument available is for use in this clinical context.

METHODS

A systematic literature review methodology was employed. A range of electronic databases were searched for the period 1946-2013. Search terms incorporated "sedation scale", "sedation scoring system", "measuring sedation", and "sedation tool" and were used to retrieve relevant literature. In addition, manual searches were conducted and articles retrieved from those listed in key papers. Articles were assessed using the Critical Appraisal Skills Program (CASP) making sense of evidence tools.

RESULTS

A total of 27 observational sedation-scoring instruments were identified. Sedation-scoring instruments can be categorised as linear or composite, the former being the most common. A wide variety of patient behaviours are used within the instruments to measure depth and quality of patient sedation. Typically sedation-scoring instruments incorporated three patient behaviours, which were then rated to generate a numerical score. The majority of the instruments have been subjected to validity and reliability testing, however few have been examined for responsiveness or applicability.

CONCLUSIONS

None of the 27 observational sedation-scoring instruments were designed or trialled within ED. The Richmond Agitation and Assessment Scale was identified as most suitable to be trialled prospectively within an Australian ED.

A review of the quality assurance processes for the Australasian Triage Scale (ATS) and implications for future practice

Triage is a critical component in the delivery of time-sensitive emergency care. Decision-making and the activity of the triage nurse affect patient access to care and allocation of emergency department (ED) resources. It is important to be able to evaluate decision-making at triage to ensure patient safety, and to identify opportunities for professional and service development. At present, there is no standard approach to retrospective examination of triage decisions using the Australasian Triage Scale. The aim of this literature review is to identify the quality control strategies used in triage and the factors that appear to influence triage decisions in relation to the Australasian Triage Scale.