Violence in the Emergency Department: Code Black Audit

Experiencing violence at work is one of the most problematic issues faced by emergency department (ED) staff. Rates of violence are increasing and this, combined with the increased incidence of people presenting with mental illness and drug and alcohol use, makes the ED a dangerous and volatile workplace. When an individual’s behaviour escalates to behaviour that threatens staff, patients, visitors or property, a code black alert (CBA) is called. However, there is limited evidence regarding the factors that lead to this escalation in behaviour and this makes it difficult to implement strategies that are effective in reducing violence. This study aimed to explore the organisational and individual characteristics associated with CBAs in one northern Tasmanian hospital.
We undertook a retrospective chart audit of all CBAs occurring in the ED at the LGH (treatment areas, triage area/waiting room and ambulance bay) during a 12 month period (July 2015 – June 2016). Organisational factors were obtained from security reports and individual characteristics were obtained from individual medical records.
There were 73 CBAs during the study period, the majority occurring after-hours (48% between 2200 and 0700). Injury to staff or patient occurred in 12% of CBAs. Mental health was the underlying reason for ED presentation in more than half of all CBAs and 53% of patients had a previously recorded mental health diagnosis. The impact of drugs or alcohol was difficult to determine due to limited testing for these substances.
This study provides preliminary data about organisational and individual factors associated with CBAs in one Tasmanian hospital. The study is being replicated in a regional Victorian hospital, hopefully leading to increased understanding about key triggers involved in CBAs in the ED. Incorporating improved mental health approaches may be an important factor in future strategies aimed at reducing ED violence.

Author:

Dr Damhnat McCann

Damhnat McCann is a Senior Lecturer in the School of Health Sciences at the University of Tasmania. Her research and clinical interests focus primarily on the care of children with complex needs and health service improvement in the acute care setting. Recent projects have focused on the emergency setting as part of the LGH ED/UTAS research collaboration. Damhnat particularly enjoys mentoring nurses undertaking research that is focused on improving clinical practice and patient outcomes.

Point of View Telemedicine at Point of Care

Study Objectives: Increasingly in recent foreign conflicts and disaster zones, forward deployed healthcare providers strive to communicate with their physician and specialist extra-theater counterparts with the aim of providing improved patient care and outcomes. So far, these efforts have been limited to email consultation, with the exception of specialized teams with limited video capability. Several organizations have attempted to provide real-time video audio interaction in an attempt to extend the capabilities of modern medicine to rural settings and various natural disasters. So far these efforts have required expensive, large pieces of equipment and technological expertise. We aimed to show that ultra-portable live-streamed point of view video consultation had a significant impact on simulated patient outcomes and is feasible with current technology.

Methods: We utilized a double-blinded randomized crossover design. Each tester was evaluated on various patient outcomes to include: time to identification of life threats, time to critical interventions, triage categories, and time to evacuation decision.

Results: Results showed there was a significant decrease in the time to evacuation for patients with video feed (p=0.009) Otherwise the data showed no significant difference in the addition of video as opposed to sole two way radio in terms of the number of interventions, time to interventions, or operator or teleconsultant confidence in care or procedures performed. Subjects did not perform significantly more interventions in the second iteration indicating no training effect.

Conclusion: It is possible that given the teleconsultant was able to visualize the injuries and vitals, evacuation was impressed upon the operator as the priority, without sacrificing life-saving interventions. This study demonstrated the feasibility and ease of a highly portable (weight less than 3 lbs. in total) and economical (total cost <$500) rugged telemedicine platform with live video and two way radio capabilities.

Dr Wells Weymouth

Wells Weymouth is co-Chief Resident of the Emergency Medicine Residency at the San Antonio Military Medical Center located in San Antonio, Texas, the only Medical Command Level I trauma center in the United States and which serves over 80,000 patients in the emergency department annually. Also a Captain in the United States Army, he attended the military’s medical school located in Washington D.C. Awards include Chief ’s Award, City of Gaithersburg Fire and Rescue, Air Assault, Airborne, Antarctic Service Award, and the Fulbright Scholarship to New Zealand. He is a graduate of the University of Florida, and originally from the St. Petersburg  area.

Changing Transfusion Practice

The practice of transfusion in the critically bleeding patient continues to evolve. The balanced ratio-based approach is now being challenged by the emergence of ROTEM and TEG driving the provision of goal directed transfusion. The evidence for this change is developing but further studies are required to clarify best practice. However transfusion is a domain where practice change frequently precedes the evidence. Introducing any change in practice presents its own problems. How can we best drive change in clinicians practicing the art of transfusion?
This presentation reviews the changing practice of haemostatic resuscitation in a large tertiary teaching hospital and the challenges that have been encountered with the introduction of unfamiliar technologies and new guidelines.

Author

Dr Catherine Hurn

Cath is an exiled Tasmanian.  Born and raised in Tasmania she has now been living in the warmer climes of Queensland for almost 20 years.  She is an Emergency Physician at the Royal Brisbane and Womens Hospital where she has an eclectic range of interests.  Trauma resuscitation, with a particular focus on haemostatic resuscitation, is one area she is passionate about.  She has been a key driver in the widespread adoption of ROTEM guided transfusion in critical bleeding at her hospital. Cath chairs the M&M committee for the Emergency and Trauma Centre which fits well with her interest in quality improvement. She has also recently branched off in a different direction completing a Masters of Bioethics at the University of Sydney and is currently exploring avenues by which ethical issues in healthcare can be addressed in a robust and timely fashion.  Outside of work Cath spends a lot of time around rowing sheds both watching her sons achieve their goals and trying to achieve her own goal of attaining speed and style.  With that in mind she now owns a small property overlooking the Huon rowing shed where the water is always beautiful and pristine.

Rapid MI TAS

Mr Ryan Posselt

Background
ST-segment elevation myocardial infarction (STEMI) is a time critical, life-threatening medical emergency. Time to reperfusion is the primary predictor of clinical outcomes. This study aims to benchmark the time-to-treatment performance of emergency systems in southern Tasmania, as measured by first medical contact to balloon time (FMC2B), for patients undergoing percutaneous coronary intervention (PCI) for STEMI against the relevant guidelines.

Methods
Study participants were identified using existing medical coding systems. A retrospective chart audit of this patient group was undertaken to identify patients whose treatment involved transport by ambulance and subsequent emergent PCI. Various pre-hospital and in-hospital time points were taken and measured against guideline recommendations. A multivariate linear regression analysis was used to investigate the relationship between time of day and time-to-treatment.

The emergency department and non-urgent presentations: What is northern Tasmania’s experience?

Each year there are in excess of 7.5 million presentations to emergency departments (EDs) across Australia, half of these are triaged into the two least urgent triage categories. A total of 3.8 million presentations arrived at EDs across Australia between July 2016 and June 2017 with non-urgent conditions, the equivalent of the entire population of Melbourne. Within Tasmania, just under 84,000 (54%) were triaged into these least urgent categories. Recent research in Northern Tasmania demonstrated that 40% of patients presenting with non-urgent conditions had unsuccessfully attempted to access alternative services before arriving at the ED, 29% indicated they had been referred to the ED by their GP or practice nurse. This current body of work aims to identify the healthcare needs of patients presenting to the ED with non-urgent conditions who have been unsuccessful in accessing alternative services.
Initial findings demonstrate an over-representation of patients from suburbs with low socio-economic index for advantage (SEIFA) scores, with individuals from the lowest ranking suburbs being up to four times more likely than those from mid to high ranked suburbs in their incidence of ED access. Patients under 25 years of age were also over represented whilst the most frequent discharge diagnosis was the result of minor injuries.
This presentation will also include discussion from patient and general practice interviews in order to identify factors contributing to ED access with non-urgent conditions. It is anticipated that findings from this project will be used in future planning of healthcare services across Tasmania.

Author:

Maria Unwin RN, BN(Hons), GradDip Nurs, PhD Candidate

Maria has spent her nursing career mostly within the clinical environment working in paediatric and emergency units in regional Tasmania. Over the past 25 years she has observed a continued increase in the demand for healthcare services and is acutely aware of the impact this has on her local emergency department and community. This concern lead to undertaking an Honours research project in 2015 focusing on patients’ perspectives for accessing the emergency department with non-urgent conditions. Following from this Maria commenced a PhD in 2017 continuing to investigate the issues raised in her Honours research and aiming to identify what services would best suit this patient group.

With family, research, nursing, the national CENA board and a small family business to juggle spare time does not happen often but when it does Maria enjoys travelling, camping, bushwalking and gardening.

Know the flow: A mixed method analysis of patient flow through a regional Emergency Department.

Access block, emergency department (ED) crowding, and ambulance ramping are a modern-day epidemic for emergency clinicians. Evidence demonstrates that these phenomena increase patients’ length of stay (LOS) and contribute to increased patient morbidity and mortality, whilst annual national reports show that EDs are busy places that keep getting busier.

There has been heavy investment in government initiatives and patient flow management systems, but ED LOS rates continue to exceed targets. Tasmania is no exception to this trend. The Launceston General Hospital (LGH) serves a population of approximately 143,500 and has been experiencing steadily climbing admission rates. Average ED LOS was 22.5 hours for patients admitted to the LGH in 2016-17, whilst the average ED LOS for all patients was around 4 hours longer than the national average.

This project aimed to identify “bottle necks” that contribute to crowding in the ED. Observational data was collected over four consecutive 24 hour periods to measure and track the mean time spent at each stage of the patient journey through the ED at the LGH. More than 350 patient journeys were tracked and key time points in service delivery recorded. Qualitative data obtained from a focus group with the nursing students who undertook the observational data collection provides unique insights into what was done well in the ED and the processes that could be improved. This presentation will focus on the key findings from the project, particularly the identified delays in patient flow through and out of the ED. Recommendations for improvement of service delivery will be discussed.

Author:

Ms Alex Pryce

Alex Pryce is a Registered Nurse and Associate Nurse Unit Manager (ANUM) at the LGH ED. Alex is currently undertaking this project as a part of her Bachelor of Nursing with Honours program, under the supervision of Dr Damhnat McCann and Ms Maria Unwin. Alex lives in Launceston and enjoys camping with her young family, lego building, mountain biking and running. In her spare time she dabbles in tutoring for the School of Health Sciences and assisting in the high fidelity simulation lab for the Launceston Clinical School.

Conference Committee

Dr Brian Doyle
Australasian College for Emergency Medicine (ACEM)

Bess Swinton & Ryan Posselt
Paramedics Australasia (PA)

Michael Browne
College of Emergency Nursing Australasia (CENA)

Important Dates

Early Bird - June 2018
Conference - 10 - 12 August 2018

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