The effect of implementing adult trauma clinical practice guidelines on outcomes of trauma patients and healthcare providers

ObjectivesThis study aimed to 1) Assess the effects of implementing the initial assessment and management practices of the Adult Trauma Clinical Practice Guidelines (ATCPGs) on the outcomes of multiple trauma patients and healthcare providers in the emergency department (ED) and hospital; 2) Evaluate the effects of implementing the ATCPGs on missed injuries in ED and hospital Length of Stay (LOS); 3) Examine the effect of implementing initial assessment and management on healthcare providers’ compliance with ATCPGs.MethodsA quasi-experimental design with three months before and three month after implementing ATCPGs was used. A total of 464 patient's files were reviewed in the study. However, 66 patients met the inclusion criteria, with 33 patients in each phase. The second sample was composed of 30 nurses and 13 physicians working at the ED.ResultsUsing multiple strategies of implementation of ATCPGs decreased the LOS for multiple trauma patients in the ED. Although the missed injuries did not differ significantly in the study's phases; it was lower in the post-intervention than in the pre-intervention phase. The mean of nurses’ and physicians’ compliance with post intervention was higher than preintervention (p < .001).ConclusionThe results will help the decision-makers to facilitate interdisciplinary ATCPGs training sessions, and establish policies and procedures to introduce ATCPGs in the ED to improve multiple trauma patients' outcomes.     

Identifying feelings engendered during triage assessment in the accident and emergency department: the use of visual analogue scales

• ? Feelings engendered during 585 triage nursing assessments made by a total of 10 nurses were studied.
• ? Marked differences in nurses' feelings were demonstrated towards patients attending the accident and emergency (A&E) department with ‘primary care’ needs compared with those assessed as having ‘A&E&’ needs. In particular, nurses demonstrated more negative feelings, in the form of less sympathy, more irritation and less motivation to help, towards patients with ‘primary care’ needs. Nurses' feelings were adversely affected by delays in patient presentation following the occurrence of illness or injury.
• ? Nurses perceived patients' attendance as illegitimate when it had deviated from expected norms of health-care-seeking behaviour.
• ? These findings were elicited using visual analogue scales completed immediately following the triage assessment of the patients. This work is part of a larger study into developing the primary care role of accident and emergency nurses.
• ? The culture of the A&E department is discussed, and the need to challenge and change this culture to ensure it becomes more responsive to individual patients' needs is advocated. This paper calls for development of triage training and education and further investigation into the effects of nurses' attitudes on patient assessment.

     

Caring for older patients at an emergency department -- emergency nurses' reasoning

Aim. The aim of the study was to use the experiences of emergency nurses to illuminate what constitutes good nursing care for patients 75 years or older transferred to emergency departments. Background. Emergency departments have a medical technical character and the number of visits there increases dramatically as people age. Older patients require increased healthcare services in terms of nursing care, interventions and hospitalizations due to an increased complexity of their problems. For these reasons it is important to study what good nursing care of the older patients consists of at an emergency department from the emergency nurses’ point of view. Method. Ten emergency nurses from a university hospital emergency department in Sweden were interviewed. A thematic content analysis was performed. Results. The study showed that it was necessary to be knowledgeable, to be understanding of the older patients’ situation and to take responsibility for them in order to be able to provide good nursing care. The emergency nurses shifted focus from describing the central aspect of good nursing care to describing what hinders the provision of it. Their experience was that prioritizing medical procedures, everyday tasks and routines threatens good nursing care of older patients in emergency departments. The emergency nurses held that the older patient is often sent to an emergency department where the level of care is not appropriate to their needs. Conclusions. The result can be seen as a challenge for the organization and the nurses in the future; to prioritize differently, thereby maintaining a balance between good nursing and medical/technical tasks when treating older patients. Relevance to clinical practice. The present day healthcare system is not organized to appropriately meet the needs of the older patients. Nurses themselves hold they can better serve the older patient. By sharing their experiences, both can be accomplished.     

医护患共同参与情景模拟教学在护理应急预案演练中的应用

目的探讨医护患共同参与情景模拟教学在护理应急预案演练中的应用效果。方法 2014年9月至2016年9月,选取某院内科系统工作的、需进行护理应急预案演练培训的N0、N1级护士189名为研究对象。按随机数字表法将其分为观察组、对照组。观察组采用医-护-患共同参与的情景模拟教学培训,对照组采用由培训护士扮演医、护、患三种角色的情景模拟教学进行培训,培训期为1个月。培训结束后对两组护士进行理论考试、操作考核及培训方法满意度调查,以评价培训效果。结果培训后,观察组、对照组理论考试分别为(91.5±5.5)、(80.5±4.5)分;操作考核分别(93.5±3.5)分、(85.5±3.5)分;对培训方法的满意率分别为91.1%、52.3%,差异均有统计学意义(均P0.05)。结论医护患共同参与的情景模拟教学较培训护士扮演医护患三种角色的情景模拟教学培训效果更好,护士对该培训方法的满意度更高,值得推广。     

Nurses' perspectives of the impact of the older person on nursing resources in the emergency department and their profile: A mixed methods study

BackgroundNurses provide the majority of care in the ED, so increases in the number of older people (≥60 years) may impact nursing workload and provision of care.AimTo determine whom, of older people, emergency nurses perceive as using the most nursing resources and to profile this subgroup from the ED dataset, including illustrative cases.MethodA mixed-methods design study in a metropolitan hospital. Data were collected from focus group interviews with emergency nursing staff (n = 27), from the patient dataset for the corresponding year, and an audit of 13 patients' medical records.ResultsEmergency nurses perceived that the highest demand for their resources came from the older persons representing multiple times in short timeframes (cluster presenter). Cluster presenters had a longer length of stay and required intensive nursing time and vigilance because they had one or more chronic illnesses and comorbid conditions such as limited mobility and dementia. Cluster presenters had to have a full assessment each presentation, were usually admitted to the hospital and admitting specialists were reluctant to assume care.ConclusionEmergency nurses associate a high workload with cluster presenters for reasons including ED processes and availability of expertise. Further research should examine more objectively and precisely nursing workload in this area.     

Improving Timeliness of Pediatric Emergency Department Admissions

IntroductionThe goal of this quality improvement project was to improve timing, communication, and continued care for pediatric patients who present to the emergency department at a Level I pediatric trauma center and require inpatient admission.MethodsUsing continuous improvement methodology, a patient flow process was created to improve the throughput of pediatric patients requiring inpatient admission from the emergency department, aimed at decreasing the time from decision to admit to actual admission. The new workflow included ED and inpatient nursing collaboration, with nursing leaders coordinating patient transfer.ResultsBaseline data indicated that, in 2019, patients admitted to a short-stay pediatric unit from the emergency department had an average time of 106.8 minutes from decision to admit to the actual admission. After the implementation of a new admission process, time from decision to admit to actual admission decreased from a mean of 106.8 minutes to 82.84 minutes for patients admitted to a short-stay unit. This illustrates an improvement from 59.75% to 68.75% of patients admitted within 60 minutes from ED admission to arrival on a short-stay unit. This model was then replicated throughout other units in the hospital.DiscussionThere are no known benchmark data to guide practice for rapid admission from the pediatric emergency department to inpatient units and continuing care. This quality improvement project demonstrates a model that has been successful admitting patients in an efficient, time-controlled manner. Additional research is needed to document benchmarks for admission timing and to demonstrate other measurable outcomes in patient care.     

Determining emergency physicians' and nurses' views concerning older patients: a mixed-method study

The number of elderly patients presenting to emergency services is gradually increasing. Given that the needs of older patients differ from those of other patients, the quality of emergency care for this patient group also varies. This mixed-method study aimed to reveal the views of emergency service staff concerning ageing and elderly patients. Participants were 19 physicians and 17 nurses employed by the adult emergency service of a university hospital. Data were gathered using questionnaires and focus group interviews. Frequency and percentages were used to evaluate quantitative data. Open-ended questions used to gather quantitative data were analysed using thematic analysis and four themes (including understanding older patients' situations, good nursing care and medical treatment, affecting good nursing care and medical treatment, emotions experienced) were determined. Emergency department staff identified older patients as dependent individuals requiring health care. Nurses indicated that good care for older patients included ensuring that their physical, social, and psychological needs were met; whereas, physicians identified good treatment as improving the quality of life. Impediments to the care and treatment of older patients were identified as staff shortages, emergency service crowding, and lack of proper training for emergency department staff. Emergency department staff also indicated that they experienced weariness and exhaustion while providing health care for older patients. Emergency nurses and physicians were aware of older patients and their needs but experienced difficulties regarding patient density, physical settings, staff shortages, and a lack of training.     

Improving 3-Hour Sepsis Bundled Care Outcomes: Implementation of a Nurse-Driven Sepsis Protocol in the Emergency Department

ProblemSepsis, a life-threatening condition, can rapidly progress to death. The Hospital Inpatient Quality Reporting program has implemented bundled care metrics for sepsis care, but timely completion of these interventions is challenging. Best-practice interventions could improve patient outcomes and reimbursement. The purpose of this project was to improve the timeliness of sepsis recognition and implementation of bundled care interventions in the emergency department.MethodsThis evidence-based practice improvement project implemented a Detect, Act, Reassess, Titrate (DART)-based nursing protocol embedded within a checklist communication tool in the emergency department of a tertiary level-2 trauma center. Data comparisons between preintervention and post-DART protocol/checklist implementation included compliance with the individual Inpatient Quality Reporting 3-hour bundled elements, number of hospital days, and time to screen. Staff also completed a survey designed to assess their satisfaction with the DART algorithm/checklist. The Pearson χ² test was used to assess bundled-care intervention variables. Wilcoxon rank sum tests were used to explore hospitalization outcomes. Staff satisfaction survey results were summarized.ResultsImprovement was statistically significant for lactate levels, blood cultures, and early antibiotic administration in the intervention period compared with baseline. Time to screen, ED length of stay, and number of hospital days improved between baseline and the intervention period, with an average number of hospital days decreasing by 2.5 days. Compliance with all Inpatient Quality Reporting metrics increased from 30% to 80%.DiscussionWhen the nurse-driven protocol and communication tool were implemented, compliance with time-sensitive sepsis bundled interventions improved significantly. The outcomes suggest nurse-driven protocols can improve sepsis outcomes.     

基于个性化创新培训模式对急诊急救专科护士核心能力的影响

目的 探究基于个性化创新培训模式对急诊急救专科护士核心能力的提升效果和意义.方法 选取2012年1月1日~2016年1月1日该院急诊急救专科护士20名为观察组,2011年该院急诊急救专科培训护士20名为对照组,观察组实行个性化创新培训模式,对照组采取常规的培训模式.对比两组护士对培训的满意度、自我核心能力提升(领导能力、管理能力、临床护理能力、教育与指导能力、专业发展能力、评判性思维能力)及患者对其的满意度.结果 观察组护士对培训的满意度为100%,对照组的满意度为90%,差异有统计学意义(P<0.05);患者对观察组护士的满意度为95%,对照组为30%,差异有统计学意义(P<0.05);观察组的核心能力与对照组比较,差异有统计学意义(P<0.05).结论 基于个性化创新培训模式有利于提升急诊急救专科护士的核心能力,提升急诊急救专科护士对培训的满意度,提升患者对护士的满意度,有利于建立良好的护患关系,值得在培训中推广及应用.     

Using tabletop exercises to evaluate nurses' clinical performance of hazardous materials disaster management: A cross-sectional study

BackgroundHazardous materials (Hazmat) disaster is a specific event with low probability but may be a heavy burden on public health. Competence in Hazmat disaster emergency management is necessary for nurses who care about mass casualties in the first line, especially for nurses in military hospitals. However, less attention has been paid to evaluation of competence of Hazmat disaster emergency responses using tabletop exercises.ObjectiveTo identify competence in Hazmat disaster emergency response and factors influencing performance on tabletop exercises.MethodsA cross-sectional design was employed in this study. Competence of nurses responding to a hazardous materials invasion was evaluated by a tabletop exercise. In each case the “Task Based Checklist” was used for evaluation. Multivariate analysis of covariance was conducted to detect the effects of traditional training on performance in Hazmat disaster tabletop exercises.ResultsA total of 161 nurses were recruited for this study. A checklist with 12 items comprised of two dimensions of disaster management was created and validated (CVI = 0.90). Inter-rater reliability for the evaluators ranged from 0.88 to 1. Performance on Hazmat site control, debris management and individual skills in decontamination were found to be suboptimal. Traditional disaster nursing training had no significant influence either on performance on Hazmat site control or patient care after controlling for differences in education level, age and gender.ConclusionsThe tabletop exercise is an innovative method for disaster nursing educators seeking to evaluate response competence in Hazmat disaster simulation exercises. It is necessary to consider the characteristics of the participants when designing the training program and educational strategies. Participants from the military hospital were shown to have limited competence in Hazmat disaster emergency management.     

The Use of a Nurse-Initiated Pain Protocol in the Emergency Department for Patients with Musculoskeletal Injury: A Pre-Post Intervention Study

Background and Aim: As a common complaint of patients with traumatic injuries, pain remains undermanaged in emergency departments (EDs). Our aim was to evaluate the effects of a nurse-initiated pain management protocol in patients with musculoskeletal injuries in an ED in Iran.Material and MethodsThis pre-post intervention design study was conducted on 240 patients with orthopedic injuries selected through sequential sampling over two phases. The intervention consisted of case study sessions and the implementation of the nurse-initiated pain management protocol. The outcomes were assessed based on the Numeric Rating Scale (NRS) pain scores, the pain management satisfaction questionnaire, the nursing performance checklist and the waiting time evaluation form.ResultsThe mean pain intensity 30 and 60 min after triage and at discharge decreased significantly in the post-intervention group (p < .001). The patients' satisfaction with pain management (p < .01) and the nurses’ performance (p < .001) improved in the post-intervention group. Waiting time: there was a significant reduction in the post-intervention group from the end of triage by the nurse to the visit by the physician, and from patient’s arrival in ED to discharge or transferring, and also the time to initial analgesic.ConclusionsEducation based on case study and the implementation of the nurse-initiated pain management protocol resulted in a significant increase in multimodal analgesia administration and a reduction in pain intensity, an increase in patient satisfaction, an improvement in the triage nurses’ performance and the reduction of potential delays in pain management while maintaining the safety of patients with musculoskeletal trauma.