International Emergency Nursing: Sciencedirect

International Emergency Nursing 22 (2014) 237–260
Contents lists available at ScienceDirect
International Emergency Nursing

journal homepage: www.elsevier.com/locate/aaen
Oral abstracts – 1st Global Conference on Emergency Nursing

& Trauma Care
Dublin, Ireland, 18–21 September 2014q
PLE01 Background: The purpose of the study was to measure the effect
Workplace reciprocity of emergency nurses: a qualitative study of trauma case management (TCM) on patient outcomes, using
practice-specific outcome variables such as in-hospital complication
Christine Corcoran rates, length of stay, resource use and allied health service interven-
Concordia College, NY, USA tion rates. Methods: TCM was provided 7 days a week to all trauma
patient admissions. Data from 754 patients were collected over
Emergency nurses work with other health care providers under 14 months. These data were compared with 777 matched patients
uncertain conditions to provide care to patients with all kinds of ill- from the previous 14 months. Results: TCM greatly improved time
nesses and afflictions from all walks of life. Despite implications that to allied health intervention (P < 0.0001). Results demonstrated a
they must work together to accomplish their tasks, there are few decrease in the occurrence of deep vein thrombosis (P < 0.038) and
studies that explore the relationships among emergency department a trend towards decreased patient morbidity, unplanned admissions
personnel. Furthermore, there are even fewer that focus on the way to the intensive care unit and operating suite. A reduced hospital
emergency nurses work together to provide care to their patients. stay LOS, particularly in the paediatric and 45–64 years age group
The purpose of the study was to understand the lived experience was noted. Six thousand six hundred twenty-one fewer pathology
of workplace reciprocity of emergency nurses through the use of a tests were performed and the total number of bed days was 483 days
qualitative phenomenological method. Nurses with three or more less than predicted from the control group. Conclusion: The intro-
years of current emergency nursing experience were recruited using duction of TCM improved the efficiency and effectiveness of trauma
a purposive technique to obtain a convenient sample. Each partici- patient care in our institution. This initiative demonstrates that TCM
pant was interviewed. The data were analyzed and interpreted using results in improvements to quality of care of trauma patients.
Giorgi’s Phenomenological Method. Findings from this study identi-
fied six essences: emergency department culture, balancing, tech-
nology, caring, bridging, and connection. These essences of the
participants’ experiences were synthesized. Workplace reciprocity PLE03
between and among emergency department nurses is influenced Bedside behaviors and their impact on patient safety
by the emergency department culture, balancing, and technology
on caring for patients and each other as seen in the bridging and con- D. Brecher
nection for the purpose of creating and maintaining workplace rela- Emergency Nurses Association, USA
tionships. This statement synthesized the meaning of workplace
reciprocity among this sample of emergency nurses for this study. It’s easy to say ‘‘I am a safe ED nurse’’. I always check my five rights
Paterson and Zderad’s Humanistic Nursing Theory emerged as a before administering a medication. I check the patient’s identification
way to reflect on the findings in a way that was meaningful to nurs- before performing any test or procedure. I put the side rails of the
ing. Implications for nursing practice and recommendations for stretcher up and the call bell within the patient’s reach . . . always.
future research are identified. While these actions are critical to maintaining patient safety, we
often forget that our behaviors at the bedside contribute to the cul-
ture of safety in the department. A lack of true teamwork, inability
PLE02 to provide constructive feedback, team members unwilling to hold
Trauma nursing case management improves patient outcomes each other accountable and fostering an environment where only
the ‘‘weak’’ ask for help put our patients and ourselves in harm’s
way. This presentation will identify destructive bedside behaviors
K. Curtis 1,2, R. Morris 1,3, D. Black 1
1 that are currently alive and well in emergency departments all across
St George Hospital, Australia
2 the globe. The teamwork concepts of ‘‘mutual support’’ and ‘‘situation
University of Sydney, Australia
3 awareness and monitoring’’ will be presented and discussed during
University of NSW, Australia
the session. Tools and strategies to utilize these concepts in your
own emergency department will be provided to participants.
q
Publisher’s Note: The abstracts printed were correct at the time of
going to press. There may been subsequent changes in the
programme that are not reflected.
http://dx.doi.org/10.1016/j.ienj.2014.08.007
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238 Absract / International Emergency Nursing 22 (2014) 237–260
O1.1 between 1 July 2007 and 30 November 2013 was completed. Patient
How to make a really good emergency nurse practitioner! satisfaction was measured using the Chinese Medical Interview Sat-
isfaction Scale Revised (C-MISS-R). Results: 6180 patients, 74% aged
R. Hoskins 1,2 between 16 and 60 years were seen. 93% patients were triage cate-
1
University Hospitals Bristol NHS Foundation Trust, UK gory 4. Problems were:- soft tissue injury to limbs 37%, wounds
2
University of the West of England, UK 16%, limb fracture 11%, soft tissue infection 9%, eye condition 6%, for-
eign body in soft tissue or throat 6%, minor head injury 5%, animal
Internationally published work evaluating and exploring the bite 3%, scald 3%, gout 3% and joint dislocation 1%. Retrospective
acceptability to both patients and healthcare professionals of emer- review of the patient record by a senior doctor showed 100% accu-
gency nurse practitioners (ENPs) in the delivery of emergency care; racy in choice of investigation and 99.5% accuracy of X-ray interpre-
has shown that generally such roles have become widely accepted. tation. Waiting time (registration to consultation) and processing
The United Kingdom (UK) College of Emergency Medicine has pub- time (registration to discharge) were reduced by 56 minutes and
lished a task force interim report, written in response to the work- 98 minutes respectively. The re-attendance rate was 0.4% with no
force challenges that emergency departments (EDs) in the UK are inaccuracy of initial diagnosis in this group. Patient satisfaction
facing in light of crowding caused by increasing patient acuity and was positive. Conclusion: Outcome of this analysis showed that
attendances as well as a significant reduction in junior doctors seek- the international collaboration successfully established a corner-
ing to train in the speciality. This report recommends that, despite a stone of ENP service in Hong Kong. Patients received safe, effective
lack of national competencies and standardisation in education prep- and holistic treatment in a timely manner.
aration and scope of practice, non-medical roles such as ENPs are a
solution to stable and sustainable core staffing in EDs in the future. References
Increasingly UK ENPs are expected to have moved from a limited
scope of practice characterised by protocol driven care to a broader Fotheringham, D., Dickies, S., Cooper, M., 2011. The evolution of
scope of practice encompassing any patient who presents at the the role of the Emergency Nurse Practitioner in Scotland: a
‘‘minors’’ area of an ED. Without a nationally agreed standard of longitudinal study. Journal of Clinical Nursing. 20, 2958–2967.
preparation or competence, as seen in the UK approach to indepen- Link, D.G., Perry, D., Cesarotti, E., 2014. Meeting new health care
dent prescribing for nurses, local universities have developed non challenges with proven innovation: nurse-managed health
standardised approaches to the educational preparation of ENPs. care clinic. Nursing Administration Quarterly. 38, 128–132.
The strongest and most positively evaluated education programmes
appear to share common characteristics which will be discussed in
this presentation.
This presentation will explore the issues which currently prevent O1.3
the title of ‘nurse practitioner’ being a registered standardised qual- Measuring the patient experience with a nurse practitioner led
ification in the UK. A successful approach to the educational and fast track area in an academic inner city emergency department:
clinical preparation of ENPs will also be explored in order that they development and findings of an in situ survey
can work in a variety of urgent and emergency settings in the UK and
quickly develop a broad and safe scope of practice.
G. Maguire 1,2, M. McGowan 1, M. Postic 1,2, M. Dimeo 1,2, K. Gaunt 1
1
St. Michael’s Hospital, Canada
2
University of Toronto, Canada
O1.2
Development of an emergency nurse practitioner service in Hong Introduction: Patient-centredness is at the core of quality. His-
Kong through international collaboration: evaluation of the torical focus towards the assessment of physician and nurse pro-
service development vider has often omitted the midlevel provider, such as the Nurse
Practitioner (NP), with patient-satisfaction surveys, while the
J. Chung 1,2, R. Way 3, T.H. Rainer 1,2 exclusion of marginalized groups (homeless, low literacy, mental
1
Prince of Wales Hospital, Hong Kong health, non-English speaking), along with the time between ED
2
Chinese University of Hong Kong, Hong Kong encounter and survey, limits its interpretation and generalizability
3
Oxford University Hospital NHS Trust, UK within an inner city ED. Methods: An inter-professional team
developed a survey instrument in stages: (i) scoping review derived
Introduction: Evidence suggests that nurse-led services may content; (ii) survey design encompassed a blend of Likert scale and
provide part of the solution to the increases in patient attendances open-ended questions; (iii) survey was piloted among ED patients
and shortage of medical staff in emergency care (Fotheringham to refine usability, comprehension and content prior to deploy-
et al., 2011; Link et al., 2014). Through international collaboration ment. All patients triaged to the NP-led Fast Track area (December
between the Prince of Wales Hospital, Hong Kong and the John Radc- 2012–April 2013) were offered the survey upon arrival and
liffe Hospital, Oxford an Emergency Nurse Practitioner service and a returned at discharge. Results: 565 surveys were returned, includ-
post-graduate education programme was established in Hong Kong. ing 13% who self-identified as homeless or NFA. Overall patient-
Objectives: To evaluate the ENP service development in terms of: satisfaction with NP care was high (30% agree; 67% strongly),
though differed when asked if further care would be sought (41%
Patient characteristics agree, 36% disagree). The NP care experience was appraised as very
Adequacy of documentation good, including dimensions of thoroughness (89%), listening (90%),
Patient waiting time and length of stay put at ease (83%), involvement in decisions (81%), explanation of
Accuracy of diagnosis and treatment plan problem (80%), and time spent (81%). Upon discharge, patients
Reattendance rate reported: (i) understanding health problem more (49% agree, 37%
Patient satisfaction strongly); (ii) able to cope better (51% agree, 37% strongly); and
(iii) felt NP understood their health concern (41% agree; 55%
Methods: A retrospective observational study of all patients strongly). Analysis of open-ended comments revealed patients val-
attending the emergency nurse clinic in the Prince of Wales Hospital ued most (i) care by NP (friendliness, empathy); (ii) being seen
Abstract / International Emergency Nursing 22 (2014) 237–260 239
promptly; and (iii) communication (information, explanation). O2.2

Conclusions: Quality patient care includes incorporating the The PENS acronym in emergency medicine and nursing: a
patient voice to augment objective time-based quality metrics in structured communication tool to manage pain and suffering
emergency care, such as PIA and LOS. Both patient-level satisfaction
and experience were found to be positive with the care provided by M.J. Greenwood, E.J. Bennett
NPs in Fast Track. Aero Med Spectrum Health, USA
Purpose: The primary objective in healthcare, at its most basic, is

to manage pain and reduce suffering. But the nature of the emer-
O2.1 gency care and out-of-hospital settings may constrain a healthcare
A comparison in independent non-medical prescribing and provider’s ability to achieve this objective. Constraints include acuity
patient group directions by nurse practitioners in the emergency (of the patient’s condition), intensity (in providing time-critical
department: a cross sectional review care), and environment (in emergency and out-of hospital locations).
The aim of the authors is to describe a tool that can facilitate rapid
and effective management of a patient’s pain and suffering despite
A. Black, M. Dawood
the constraints of these settings. Methods: Managing a patient’s pain
Imperial College Healthcare NHS Trust, UK
and suffering requires that healthcare providers be aware of the
Purpose: To explore nurse prescribing in an emergency depart- unpleasant sensations experienced by the patient. These sensations
ment using patient group directions versus independent nurse pre- may be caused by illness or injury (i.e., their pain). And their pain
scribing. Introduction: Patient group directions allow restricted may be associated both with mental and emotional distress, such
access to medication in unselected patients using pre-set criteria as fear, anxiety, and uncertainty; and with physical sensations
(Royal College of Nursing, 2004). Independent nurse prescribing is caused by hunger and thirst; nausea and fatigue; and unpleasant fea-
a flexible method of medication provision (Department of Health, tures of ambient light, temperature, and noise (i.e., their suffering).
2006). Limited data exist on the application of either method in clin- Results: PENS is a tool for structured communication between the
ical practice (Kroezen et al., 2011). Methods: Exploration of patient patient and provider. An acronym pronounced as a word, PENS is
group directions and independent nurse prescribing application in an abbreviation for the elements of pain; emotions/expectations;
an emergency department using 617 nurse practitioners’ clinical nausea/nutrition; and sensory-stimuli/sleep/screening. PENS is eas-
notes; 235 and 382 respectively. Patient attendances from 01/07/ ily tailored to apply in emergency settings. Conclusions: In the
2009 to 30/06/2010 were randomly sampled. Prescribing frequency; emergency care and out-of-hospital settings factors of acuity, inten-
range of medications and diagnoses; independent episode comple- sity, and environment may preclude effective management of a
tion and prescribing safety were explored. Results: Statistical differ- patient’s pain and suffering. The PENS tool provides a structured
ence exists in prescribing frequency between the independent nurse approach to communication between a provider and patient
prescribers (51.6%, n = 197) and patient group directions (32.3%, whereby a patient’s pain, emotions, nausea, and unpleasant sensory
n = 76). Appropriate medication given by 99.7% (n = 381) of indepen- stimuli are addressed as a first-step in rapidly and effectively man-
dent nurse prescribers, with 1 contraindicated drug provided. The aging pain and suffering. PENS is used at the bedside, is patient-cen-
limitations of patient group directions was highlighted in 11.8% tered, and appears to be easy-to-remember, and simple to apply.
(n = 9) of cases, however all drugs given were appropriate for the
diagnosis. No statistical difference in independent episode comple-
tion. Conclusions: Nurses provide appropriate medication in an
emergency department. Patients being managed by nurse prescrib- O2.3
ers were more likely to receive medication. Further investigation is A retrospective study examining the role of Patient Controlled
required to justify this. Analgesics (PCA) and thoracic epidural analgesia in the
prevention of respiratory complications post blunt chest trauma
References E.J. Baker 1,2, G. Lee 1

1
King’s College London, UK
Department of Health, 2006. Medicines matters: a guide to 2
King’s College Hospital NHS Trust, UK
mechanisms for the prescribing, supply and administration
of medicines. Available at: http://www.dh.gov.uk/prod_cons Introduction: Thoracic trauma is associated with significant
um_dh/groups/dh_digitalassets/@dh/@en/documents/digitala mortality and morbidity including respiratory failure, pneumonia
sset/dh_064326.pdf (accessed 10.09.10). and pleural sepsis. In those with three or more rib fractures, there
Kroezen, M., van Dijk, L., Groenewegen, P.P., Francke, A.L., 2011. is a greater risk of these respiratory complications. It is understood
Nurse prescribing of medicines in Western European and that poor mobility and chest expansion due to associated pain are
Anglo-Saxon countries: a systematic review of the literature. responsible for these potential respiratory complications. However,
BMC Health Services Research. 11 (127), Available at: http:// it remains unclear whether adequate analgesia is directly linked to
www.biomedcentral.com/1472-6963/11/127 (accessed decreased incidence of respiratory complications. Purpose: The
14.02.13). objective of this retrospective service evaluation study is to examine
Royal College of Nursing, 2004. Patient group directions: the relationship between analgesia and the incidence of respiratory
guidance and information for nurses. Available at: http:// failure/pneumonia post blunt traumatic chest injuries with one or
www.rcn.org.uk/__data/assets/pdf_file/0008/78506/001370. more rib fractures. Patients who have received thoracic epidural will
pdf (accessed 14.02.13). be compared to those who received PCA. The hypothesis to be tested
is that there will be fewer respiratory complications and a greater
therapeutic benefit in patients who are treated with thoracic epidu-
ral compared to PCA. Method: Based on the existing literature, a data
collection tool was created. The tool will collate data from patients’
records, the hospital radiological database and electronic prescrip- examined the epidemiology of fall injuries among older adults who
tion charts. Other data to be collected include demographic data sustained traumatic brain injuries from same level (slip and trip)
(i.e. age, gender, previous illnesses, etc.) and respiratory complica- falls. Methods: Records were extracted from the Healthcare Cost
tions related to their admission are recorded. These will be catego- and Utilization Project State Inpatient Database for New York hospi-
rised as the following: infection-related (e.g. pneumonia), tals in 2009. Inclusion criteria were age 65 years and older, primary
pulmonary embolism and ventilation-related respiratory failure E-code of same level fall, and primary diagnosis of traumatic brain
(i.e. patients requiring respiratory support during their stay in hospi- injury. The primary outcomes were mortality and trauma center
tal). The setting is an inner London Level 1 emergency department. admission. Variables of interest included sociodemographic factors,
Results: The results will present the demographic data from this ret- fall mechanism, injury types, injury severity, trauma center admis-
rospective evaluation and present key variables from both groups. It sion, number and type of chronic conditions and number of diagno-
is anticipated that this service evaluation will provide information ses. Descriptive statistics were used to report sample characteristics
comparing epidural analgesia and PCA. and variables of interest. Two logistic regression models were devel-
oped to identify predictors of mortality and trauma center admis-
sion. Results: Three thousand three hundred thirty-one patients
O3.1 sustained traumatic brain injuries from slipping, tripping and falling.
‘‘Cutting off the clothes’’: emergency nurses’ experiences of Slightly more than half of these patients were admitted to trauma
working in a major trauma centre centers. Nearly two-thirds of all patients sustained intracranial
bleeds and 10.4% died during hospitalization. Age, median household
H. Jarman 1,2 income, primary and secondary payers, geographic region, ethnicity,
1
St George’s Healthcare NHS Trust, UK race, number of diagnoses and number of chronic conditions pre-
2
King’s College London, UK dicted trauma center admission. Age, certain chronic diseases, intra-
cranial bleeding, moderate injury severity and trauma center
This paper presents findings of a doctoral study exploring the admission predicted mortality. Discussion/conclusion: Nearly half
perspective of nursing staff towards working in the Emergency of the older adults with slip, trip and fall injuries who sustained sig-
Department of a Major Trauma Centre. There has been considerable nificant brain injuries were admitted to nontrauma center hospitals.
investment in the development of trauma care in the UK. Drawing on Prehospital care providers and emergency nurses must evaluate all
the principles of focused ethnography, observation and interviews older slip, trip and fall patients carefully and maintain vigilance for
were used to generate understanding of the cultural context of a clinical indicators of brain injury and subsequent deterioration.
Major Trauma Centre in a large London hospital. Analysis revealed
a complex picture of the experiences of emergency nursing staff,
with interrelated themes emerging. These themes are summarised O4.1
as: Transferring aged care residents to the emergency department:
strengths and limitations in communication
How the accreditation to do major trauma work is perceived
to have led to an increase to status and profile of the
D.L. Griffiths, J. Morphet, K. Innes, A. Willliams, K. Crawford, T. Jones
hospital.
Monash University, Australia
The nature and organisation of the major trauma work in
the ED Introduction: People living in residential aged care facilities
The ED nurses’ accounts of their task-orientated role in (RACF) are transferred to the Emergency Department (ED) for many
looking after trauma patients reasons. Transfers can be distressing for the resident and their family
The idea of the ‘‘decent’’ trauma patient, examining the hier- members. Inadequate communication and gaps in the documenta-
archy of interest within trauma work tion accompanying residents make it difficult for staff to make
informed decisions, which may result in excessive or unwanted
The development of Major Trauma Centres is an innovation in the investigations and inefficient patient management. Unnecessary
UK NHS and is expected to increase survival rates for victims of treatment and investigations contribute to resident and family dis-
major accidents. Nursing staff in this study are attracted by the tress, increase ED length of stay and health care costs, in a currently
excitement and status of major trauma work but find the fragmenta- unsustainable health care system. Aims: 1. Identify the incidence
tion of tasks unsatisfying. They are enthusiastic in their talk of and relevance of information gaps in the documentation accompany-
‘decent’ trauma patients but are also concerned about the corollary ing residents transferred to the ED from RACF; and 2. Investigate the
of this emphasis which leads to an undervaluing of care for patients experiences of people who had a family member in a RACF who was
with less dramatic conditions. These tensions currently remain unre- transferred to the ED. Methods: Medical histories of residents trans-
solved and pose an implicit challenge to the work of emergency ferred to two Melbourne EDs (Australia) in 2012 were retrospec-
nurses. tively audited (n = 408, 14%). Information was extracted from
patient transfer and patient management data records. The data
were analysed using descriptive and inferential statistics using SPSS.
O3.2 Twenty-four in-depth interviews were undertaken with family
Slip, trip and fall: injury morbidity, mortality and trauma center members of residents who were transferred to the ED in 2012. The
admission among older adults interview transcripts were thematically analysed. Results: Informa-
tion gaps occurred in 89% of cases (n = 367), with 97 patients (23%)
L.J. Scheetz arriving with no transfer documentation. Specific information that
Lehman College and The Graduate Center, CUNY, USA was repeatedly absent included: the reason for transfer to the ED
(n = 197, 48%); allergies (n = 181, 44%); baseline cognitive function
Introduction: Falls are the leading cause of injury death among (n = 244, 60%); mobility (n = 253, 62%); and advance care directives
adults age 65 and older in the United States. In 2010 falls accounted (n = 320, 78%). The dominant themes which emerged included: the
for 52.4% of unintentional injury deaths in this population. The desire to accompany their relative; the absence of communication
majority of these fall mechanisms were unspecified. This study between staff and relatives and a failure to discuss end of life wishes.
Conclusion: This study identified significant written and oral com- individuals needed to influence change. The ‘That’s not my name’
munication deficits. Inadequate communication resulted in initiative was launched to address these issues. Subsequent audit
extended ED length of stay and the provision of care that was not showed an increase in the use of wristbands and a repeat of the staff
in keeping with resident wishes. safety questionnaire demonstrated improved understanding of the
‘never events’ initiative and reduced confusion around trauma alias
names. Thematic analysis of the focus group responses exposed
O4.2 more subtle causes of patient misidentification in our department.
The number of patients simultaneously present at the emergency Experience of misidentification incidents was common amongst
department as an indicator of unsafe waiting times: a receiver emergency department staff; areas of particular risk were at stream-
operated curve-based evaluation ing/waiting area, assessment and resuscitation. Conclusions: There
remains a culture of identifying patients by their condition or cubi-
J. Bergs 1, S. Verelst 2, J.-B. Gillet 2, P. Deboutte 2, C. Vandoren 2, cle, and a reliance on the nurses to identify patients to other mem-
D. Vandijck 1,3 bers of the team. By making staff aware of these risks the use of
1
Hasselt University, Belgium emergency patient wristbands has increased and understanding of
2
Leuven University Hospitals, Belgium the ‘never events’ initiative improved. Clarification of the use of
3
Ghent University, Belgium trauma alias names has been broadly welcomed.
Introduction: Emergency department (ED) crowding and pro-

longed waiting times have been associated with adverse conse- O5.1
quences towards patient safety. Aim: To investigate whether the A baseline analysis on knowledge, attitudes and practices of
number of patients simultaneously present at the ED might be an nurses in emergency care in a volatile environment: Bossaso
indicator of unsafe waiting and at what threshold hospital-wide General Hospital
measures to improve patient outflow could be justified. Methods:
Data were retrospectively collected during a 1-year period; all ED
I. Muya, A. Mohamed, M. Van Der Plas
patients aged <16 years, and triaged as ESI-1 or ESI-2 were eligible
Africa Federation of Emergency Medicine, Kenya
for inclusion. The number of patients simultaneously present was
used as occupancy rate. Waiting time was considered unsafe if it Bossaso General Hospital is located in Puntland, Somalia, an area
was longer than 10 min for ESI-1 patients, or longer than 30 min affected by prolonged civil conflict, terrorism, clan fighting and
for ESI-2 patients. Differences in waiting time and occupancy piracy. Challenges faced in the study area include limited levels of
between patients with safe and unsafe waiting times were analysed basic and specialized education, cultural aspects and attitudes, gaps
using Mann–Whitney U test. The ability of the occupancy rate to dis- in human and financial resources, limited teaching aids and equip-
criminate unsafe waiting times was analysed using a receiver oper- ment, time constraints, language barriers, high turn-over of nurses
ating characteristic curve. Results: Overall median waiting time was and other medical staff, and an extremely volatile security situation.
5 min (IQR = 4–8) for ESI-1, and 12 min (IQR = 6–24) for ESI-2 Purpose: To identify the gaps in delivering emergency medicine
patients. Unsafe waiting times occurred in 16.0% of ESI-1 patients education in an unstable and resource-deprived environment in
(median waiting time = 17 min, IQR = 13–23), and in 18.9% of ESI-2 Somalia, with the aim of developing innovative methods of teaching.
patients (median waiting time = 48 min, IQR = 37–68). The occupancy Methods: The method used will be a descriptive cross-sectional
rate was a weak indicator for unsafe waiting times in ESI-1 patients study, using data collection techniques such as focus group inter-
(AUC = 0.625, 95% CI 0.537–0.713) but a fair indicator for unsafe views, observation, key informant interviews and any available
waiting times in ESI-2 patients (AUC = 0.740, 95% CI 0.727–0.753) scholarly article review. Results: Preliminary research among health
for which the threshold to predict unsafe waiting times with 90% care staff at the hospital (n = 20) showed that 19% of the nurses felt
sensitivity was 51 patients. Conclusion: The number of patients that visiting nurses offer some knowledge on emergency care, while
simultaneously present is a moderate indicator of unsafe waiting 38% of knowledge was gained from visiting doctors. Regarding
times. Future initiatives to improve safe waiting times should not knowledge of emergency medicine, 88.9% of the nurses felt that
focus solely on occupancy, rather the focus should expand towards emergency medicine is basically first aid. Whereas 75% followed
other factors affecting waiting time. emergency medicine protocols, these were from a variety of refer-
ence books. Conclusions: Conclusions drawn suggest that the
knowledge of emergency medicine is limited. Therefore, the devel-
O4.3 opment of field curricula, practical and theoretical training by visit-
‘That’s not my name’ a patient safety project to improve accurate ing practitioners, provision of additional teaching aids, tools and
identification of patients in a UK emergency department equipment, integration of multiple disciplines in training, and finan-
cial resource mobilization would be beneficial in improving knowl-
J.F.C. Gamston edge, attitudes and practices in emergency care.
Imperial NHS Trust, UK
Introduction: The incorrect identification of patients was out- O5.2

lined as a global issue in healthcare. The UK College of Emergency ‘Fit for future’ – expanding the senior clinical workforce in
Medicine has highlighted misidentification as a ‘never event’ that emergency care. Lived experience of the health education Wessex
is particularly relevant to emergency departments. Methods: In this trainee consultant practitioner development programme
project process mapping was used to highlight the areas of the emer-
gency pathway particularly prone to misidentification. Current iden-
E. Freshwater, P. Evans
tification practice and adherence to trust policy were audited and
Health Education Wessex, UK
the emergency nursing team was asked to complete a safety atti-
tudes questionnaire. Staff focus groups were formed to gain some Consultant nurses are well established within the Emergency
deeper understanding of the issues. Results: Analysis of this qualita- Department environment (Charters et al., 2005; Crouch et al., 2003;
tive and quantitative data highlighted the areas of risk and the key Fontaine et al., 2007) and similar roles are now being developed for
paramedics, nurses and Allied Health Professionals (AHPs) in the pre- by medical/surgical nurses and wound care specialists. Despite the
hospital environment (Hodge, 2014). These positions provide clinical frequency of emergency wound care, there is surprisingly little formal
leadership and deliver expert patient care whilst also encompassing education provided for emergency nurses. Wound care product
functions of teaching, research and service development. The current choices have evolved with newer technology and based on the phys-
challenges in Emergency Medicine (College of Emergency Medicine, iology of wound healing, yet these products have not found their
2014) make it increasingly important that this alternative workforce way into our EDs. Old habits are hard to break, and it is challenging
is identified and developed; to ensure provision of high quality care to convince emergency nurses that sometimes ‘less is more’ so the
to increasing numbers of patients seeking emergency care in England. body can heal itself. Products that actually harm tissue and can
Health Education Wessex runs a preparation programme in order to impede healing should be removed from bedside care choices. This
develop experienced nurses and AHPs and furnish them with the presentation will profile how two Canadian emergency nurses with
experiences, skills and attributes required to perform at the level of an interest in acute wound care, have developed and disseminated
the consultant practitioner. This new wave of consultant practitioners educational opportunities on a local, provincial and national basis.
must be able to robustly demonstrate skills and knowledge to provide These opportunities include local workshops, conference presenta-
sound clinical leadership across professional boundaries helping to tions, emergency orientation education, and contributions to formal
stabilise workforce needs. As trainee consultant practitioners we have education modules and online education programs. The education
been engaged in a variety of activities in order to demonstrate skill in ideas can be applied and adapted on a global basis. The education
the four domains of the consultant practitioner. The programme has includes a comprehensive review of best practices for acute wound
supported us with coaching, support and mentorship from experi- care assessment, cleansing, irrigation, closure and dressing options.
enced consultant practitioners across the region. We have developed The specific products available will vary around the world, but the
clinical skills as advanced practitioners in all areas of emergency care – principles of wound healing are universal.
from the incident scene to the admission ward environment. We have
been demonstrating our leadership through service development pro-
jects taking us well outside the comfort of the pure clinical environ-
ment. We have embarked on both formal lecturing and informal O6.1
teaching alongside engagement in doctoral research projects. This Family presence during resuscitation (FPDR): a mixed methods
presentation describes the highs, lows, challenges and successes of study of implementation and practice in the emergency
experienced clinicians expanding into consultant-level roles and their department
lived experiences of a regional training and educational programme
which straddles the entire emergency care pathway. J. Porter 1, S. Cooper 2, B. Taylor 1
1
Federation University Australia, Australia
References 2
Charters, S., Knight, S., Currie, J., Davies-Gray, M., Purpose: The aim of this paper is to report the findings from a mixed
Ainsworth-Smith, M., Smith, S., et al., 2005. Learning from methods PhD study investigating the implementation and practice of
the past to inform the future – a survey of consultant nurses family presence during resuscitation (FPDR) in the emergency depart-
in emergency care. Accident & Emergency Nursing. 13 (3), ment. Introduction: There is evidence that the practice and implemen-
186–193. doi:10.1016/j.aaen.2005.05.001. tation of FPDR is inconsistent despite formal endorsement of adult
College of Emergency Medicine, 2014. Resolving the emergency paediatric FPDR in the year 2000 by leading Emergency Associations
crisis. Available from http://secure.collemergencymed.ac.uk/ and Resuscitation Councils (American Heart Association, 2000). This
Shop-Floor/Professional%20Standards/10%20priorities%20for% study aimed to identify the benefits, barriers and enablers (Porter
20Emergency%20Medicine/ (accessed 14. 01.21). et al., 2013a), evaluating the role of the family support person, and
Crouch, R., Buckley, R., Fenton, K., 2003. Consultant nurses: the assessing the level of education and training of emergency personnel.
next generation. Emergency Nurse. 11 (7), 15–17. doi:10.774 Method: A mixed methods sequential explanatory design was utilized
8/en2003.11.11.7.15.c1041. to investigate the extent to which FPDR is implemented and practiced.
Fontaine, N., Lynch, T., McMaster, B., Way, R., 2007. The four Phase One questionnaire ascertained the extent to which FPDR was
functions of a consultant nurse. Emergency Nurse: The Journal endorsed and supported and to explore current training and education.
of the RCN Accident and Emergency Nursing Association. 15 Phase Two incorporated observational approaches over four weeks, in
(6), 14–17. two Victorian, emergency departments. Results: A total of 347 question-
Hodge, A., 2014. Developing leadership in the UK’s ambulance naires (65 doctors, 282 nurses), a 27% response rate, representing emer-
service: a review of the consultant paramedic role. Journal of gency personnel from Victoria, Australia. The staff greatly agreed that a
Paramedic Practice. 6 (3), 138–146. designated support person was essential when allowing family to be
present (89% of doctors and 92% of nurses) (Porter et al., 2014). Following
a content analysis of the open ended responses the acronym ER-DRIP (E –
O5.3 emergency personnel, R – reassurance, D – diagnosis, R – regular updates,
Incorporating best practices evidence into emergency wound P – prognosis) was developed which helped to define the essential infor-
care education mation that family required during a resuscitation event (Porter et al.,
2013b). In Phase Two, 29 interviews were conducted together with
C.L. Rush, J. Boyd observation of six rural and 18 metropolitan resuscitations. A content
Alberta Health Services, Canada analysis was conducted and six major themes emerged including; the
importance of the care coordinator, balance of power, delivering bad
Wound care is a frequent need of emergency patients around the news, life experience generates confidence, allocating roles and family
world, yet the practices used by emergency nurses and physicians centre care in action. Conclusion: FPDR, although widely endorsed is
have not evolved with best practice recommendations. It is common practiced inconsistently in the emergency department clinical setting,
to still see toxic chemicals used for wound cleansing, dry gauze in particular with adult presentations. Additional training and education
applied to a wound bed and daily dressing changes! Emergency around the implementation and practice of FPDR was identified as
patients will benefit from the incorporation of current evidence used essential.
References O6.3
Training of bedside in addition to triage nurses to use the
American Heart Association, 2000. Guidelines 2000 for Canadian c-spine rule increases the rate of RN c-spine clearance
cardiopulmonary resuscitation and emergency cardiopulmo- prior to MD assessment in immobilized minor trauma patients
nary care. Circulation. 102 (8 Suppl. ), 1–374. presenting to the emergency department
Porter, J., Cooper, S., Sellick, K., 2013a. Family presence during
resuscitation (FPDR): perceived benefits, barriers and enablers S. Armstrong, L. Barratt, M. McGowan, K. Gaunt
to implementation and practice. International Emergency St. Michael’s Hospital, Canada
Nursing Journal. doi:10.1016/j.enj.2013.07.001 (in press).
Porter, J., Cooper, S., Taylor, B., 2013b. Emergency resuscitation Purpose: The Canadian C-Spine Rule (CCR) is a clinical decision
team roles: what constitutes a team and who’s looking after rule that enables Emergency Department (ED) practitioners to assess
the family? Journal of Nursing Education and Practice (in press). minor trauma patients who present on a backboard with a collar and
Porter, J., Cooper, S., Taylor, B., 2014. Family presence during ‘‘clear the c-spine’’ clinically without imaging. A medical directive
resuscitation (FPDR): a survey of emergency personnel in Vic- was created to support application by ED triage RNs. Front line staff
toria, Australia. Australasian Emergency Nursing Journal – identified that in times of overcrowding and high triage volumes, the
AENJ (in press). opportunity to utilize the CCR by ED triage RNs was diminished, cre-
ating missed opportunities to reduce patient discomfort and
improve patient flow to lower acuity areas. Methods: All ED non-tri-
O6.2 age RNs attended a 4-hour course providing evidence-based theory
Burns trauma education for emergency services – patient centred and CCR application along with 4 high-fidelity simulation scenarios.
approach Knowledge and competency was assessed by multiple choice exam
and ‘‘initial authorization’’ phase required CCR evaluation with 13
patient cases, including 3 inter-observer cases with a high level of
K. Stiles 1, S. Whiting 2, E. Danícková 3, K. Lambourne 4
1 agreement between the ED non-triage RN and a second rater. An
Queen Victoria Hospital NHS Foundation Trust, UK
2 authorized implementer of the CCR RN medical directive was only
Stoke Mandeville Hospital, UK
3 upon successful completion of all educational components and dem-
Chelsea and Westminster Hospital, UK
4 onstrated consistent assessment findings. Results: In 6 months, 24
St Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, UK
non-triage RNs (30%) have undergone education and remain in ini-
Purpose: Patients with burns trauma are currently initially trea- tial authorization phase. Of the 8 patients ‘‘cleared’’ with the CCR
ted by non-specialist clinicians (GPs, Practice Nurses, Paramedics medical directive in this time, 1 (12.5%) was done at the bedside
and Emergency Departments) and then referred to a specialist burns by an ED non-triage RN. Missed opportunities for CCR are being for-
service. Burn Care Advisors (BCAs) were appointed to the London mally reviewed by the ED CCR nurse content expert to identify struc-
and South East of England Burn Network (LSEBN) in response to tural and personal barriers to application of CCR, however,
National Burn Care Review Committee Report (2001), which preliminary data suggest departmental volumes and time pressures
identified the need for formal education and training to emergency are significant barriers. Discussion: Expansion of the training and
departments. The purpose of this presentation is to introduce and application of the CCR to include all ED RNs enables bedside RNs
appraise the BCA role. Methods: BCAs provide high quality, evidence to ‘‘clear the c-spine’’ in immobilized minor trauma cases in addition
based, multi-professional training and education to all pre-hospital, to triage RNs. In doing so, patient comfort can be improved with
primary and secondary services within the catchment area of the more timely collar removal following ED presentation without neg-
LSEBN, in relation to the initial assessment, management and refer- atively affecting patient flow.
ral of patients with a burn injury. BCA training meets the require-
ments of the National Network for Burn Care (2013) and the role
is dedicated to ensuring a patient-centred, coordinated and consis- O7.1
tent approach to emergency burn care with an aim that all patients Interruptions and disturbances in emergency department work
with burn injury have access to timely, specialist-guided, standard- assignments
ised treatment regardless of where they receive their immediate
care. Results: As a result of BCA role, initial burns assessment, L.M. Berg 1, A-S. Källberg 1, K.E. Göransson 1, J. Östergren 1, J. Florin 2,
management and referrals are more accurate, improving outcomes A. Ehrenberg 2
for patients with burns. The development of the BCA role has 1
Karolinska Institutet, Sweden
contributed greatly to the education of emergency health care work- 2
Dalarna University, Sweden
ers and to an improvement in the final outcome for burns patients.
Conclusions: As lead specialists for burns education in the burns Introduction: Research literature assumes that interruptions
team, BCAs have demonstrated a high level of expertise within the overall are perceived as negative by the emergency department
specialist service, providing specialist advice, education and support (ED) clinicians (Rivera-Rodriguez and Karsh, 2010). However, our
to referring emergency clinicians. previous research indicates that some interruptions were perceived
as negative/disturbing by ED clinicians, while others were perceived
References as positive or neutral (Berg et al., 2013). Based on our study we
wanted to explore the concepts interruption and disturbance fur-
National Burn Care Review Committee Report, 2001. ther. The aim was to describe the concepts interruption and distur-
Standards and Strategy for Burn Care: A Review of Burn bance in an ED context. Methods: The study had a qualitative design.
Care in the British Isles, first ed. Data were collected by semi-structured, open-ended interviews with
National Network for Burn Care, 2013. National burn care 10 physicians and 10 registered nurses at two Swedish EDs regarding
standards (2013). their experiences and perceptions of interruptions and disturbances
in the ED environment. The interviews were analyzed using induc-
tive content analysis. Results: An interruption was an observable
event that could be perceived as positive, neutral or negative by
the clinicians, while a disturbance was non-observable and always Changes in teamwork practice are crucially important to improve
perceived as negative. Several factors that were affected if an inter- patient safety. Although team members must have the knowledge
ruption was perceived as positive, neutral or negative/disturbing by and skills to perform the role tasks, research should focus on the
the ED clinicians were identified. These factors were either internal interactions and processes rooted within these tasks. Some of the
(age, state of mind, level of competence) or external (workload, characteristics of high performing interprofessional teams described
interruption frequency and experienced relevance of the interrup- in this review are also evident in effective teams in other settings
tion). Positive interruptions often had an experienced relevance, (Nancarrow et al., 2013) and provide a useful foundation for future
such as tasks with higher priority or information regarding patients’ investigations.
deteriorating conditions. Neutral interruptions occurred in un-prior-
itized assignments that did not require concentration. Frequent References
interruptions in situations where the clinicians needed to focus/con-
centrate, like preparing medications or dealing with issues of high Courtenay, M., Nancarrow, S., Dawson, D., 2013.
priority, were often perceived as disturbing. Conclusions: The clini- Interprofessional teamwork in the trauma setting: a scop-
cians perceived an increased risk of conducting errors when being ing review. Human Resources for Health. 11, 57.
disturbed and thus it is important from a patient safety perspective McCulloch, P., Rathbone, J., Catchpole, K., 2011. Interventions
to decrease the frequencies of external factors by making the clini- to improve teamwork and communications among health-
cians aware of them. ‘Interruption-free zones’ could be introduced care staff. The British Journal of Surgery. 98, 469–479.
to safeguard situations that are especially sensitive to disturbances, Nancarrow, S.A., Booth, A., Ariss, S., Smith, T., Enderby, P.,
like preparation of medications. Roots, A., 2013. Ten principles of good interdisciplinary
team work. Human Resources for Health. 11 (1), 19.
References Reeves, S., Perrier, L., Goldman, J., Freeth, D., Zwarenstein, M.,
2013. Interprofessional Education: Effects on Professional
Berg, L.M., Kallberg, A.S., Goransson, K.E., Ostergren, J., Practice and Health Care Outcomes (Update) (Review),
Florin, J.,Ehrenberg, A., 2013. Interruptions in emergency issue 3. The Cochrane Collaboration: John Wiley and Sons
department work: an observational and interview study. Ltd.
BMJ Quality Safety. 22, 656–663
Rivera-Rodriguez, A.J., Karsh, B.T., 2010. Interruptions and
distractions in healthcare: review and reappraisal. Quality
and Safety in Health Care. 19, 304–312. O7.3
Patient safety and non-technical skills during handover in the
accident & emergency department
O7.2 C. Deiana, A. Bagnasco, L. Sasso

Inter-professional teamwork in the trauma setting: a scoping University of Genoa, Italy
review
Purpose: To explore the following three aspects of physician–
1,3 1,2 1 nurses communication models in an A&E Department:
M. Courtenay , S. Nancarrow , D. Dawson
1
University of Surrey, UK
2 1. Handover communication during shift change;
Southern Cross University, Australia
3 2. Shift handoffs model
University of California, USA
3. The patient’s perception after discharge about the quality of
Introduction: Despite the well documented benefits of interpro- medical communication while in the A&E
fessional education and interprofessional collaborative practice
(Reeves et al., 2013), communication failure between healthcare Method: A quantitative research study including a 28-item sur-
team members remains a frequent cause of patient harm (McCulloch vey submitted to health professionals working in the A&E. The sur-
et al., 2011). High-risk environments, such as the trauma setting, are vey analysed the organizational aspects, the work environment
where the majority of healthcare errors occur. This presentation will and explored the health professionals’ need to define and use a stan-
describe the findings of a scoping review (Courtenay et al., 2013) dardized framework during handovers. The survey was tested for
designed to identify the extent and nature of the literature on inter- internal consistency reliability with the split-half adjusted (using
professional teamworking across these settings. Methods: Medline the Spearman–Brown prophecy formula), the Kuder–Richardson
(via OVID) using keywords and MeSH in OVID, and PubMed via NCBI formula 20, and Cronbach’s alpha. A quantitative research was
using MeSH, and CINAHL were searched from January 2000 to April conducted on patients 3 days after discharge through a structured
2013 for results of interprofessional teamworking in the trauma set- telephone interview based on a Likert scale.
ting. Results: Twenty eight published articles were identified. Stud- Results: The expected results are four critical issues that will
ies were both descriptive and evaluative. Descriptive studies need to be addressed: the first is the ratio of nursing-patient hand-
reinforced the need for shared activities, teamwork and communica- offs; the second is the large number of information deemed impor-
tion. Effective interprofessional teamwork was seen as a continuum tant to communicate; the third is the need to define which
from coordinated independent behavior through to coordinated information you should give to ensure patient safety; and the fourth
interdependent behavior. Team members had a shared mental is to identify a standardized communication model. Discussion: In
model, and leaders made collaborative decisions across disciplines. the emergency department the handover process requires speed
Evaluative studies placed a greater emphasis on specialized roles and precision. There are a number of key features for successful
and individual tasks (i.e. a multiprofessional model of teamwork) handoffs in any situation (adequate time, minimal distraction, ade-
and little or no information was provided on group structure and quate allowance for interactive discussion where the recipient
processes. Conclusion: Medical errors occur primarily due to system reviews all relevant material and has the opportunity to ask ques-
failure not the action of an individual and are grounded in shared tions, using clear language, use of ‘‘read-back’’, ‘‘repeat-back’’ and
activities as opposed to profession-specific technical expertise. ‘‘hear-back’’). The most successful handoffs utilize both a written/
computerized component and a verbal component, and meet confi- O8.2

dentiality standards. During a handoff we are passing on not only How well suited are emergency nurses to work in humanitarian
information but also accountability for patient safety. More research disasters?
is needed to explore critical issues.
K. Livingstone, H. McClelland, C. Alcock, D. Lau
UK International Emergency Trauma Register, UK
O8.1
Healthcare voluntourism: virtuous or injurious? Humanitarian emergencies are on the increase with the number
of aid organisations at an all time high. By 2015, it is anticipated that
humanitarian emergencies will affect over 375 million people a year
J.A. Proehl 1–3
1 compared to 263 million in 2009 (Oxfam International, 2009).
Proehl PRN, LLC, USA
2 Nurses are recognised as an integral part of any foreign medical team
Dartmouth-Hitchcock Medical Center, USA
3 response to major disasters (World Health Organization, 2006). The
Gifford Medical Center, USA
earthquakes in Pakistan and Haiti saw large numbers of healthcare
Nurses by their very nature are giving individuals who want to professionals from the UK responding to these disasters overseas.
help those in need. However, the value of short term humanitarian For many, this was the first time they had responded and therefore
missions has been called into question by many. Benefits and risks, were inexperienced in the humanitarian field. Emergency nurses are
and ethical considerations will be discussed. highly skilled, well trained individuals constantly working in stress-
ful environments and could be assumed to have skills transferable to
I. Benefits the humanitarian context, including:
A. Volunteers
1. New skills Triage
2. Deeper global understanding of health care Critical care skills
3. Advanced cultural sensitivity Major and minor injury management
4. ‘‘Feel good’’ Strong multidisciplinary team working
B. Patients Major incident training
1. Direct care
2. Education Does this alone however, adequately prepare nurses in disaster
3. Validation of self-worth response?
C. Populations The authors have all worked in humanitarian disasters as mem-
1. Economic bers of foreign medical teams, with differing levels of prior experi-
2. Political ence and preparation. They will describe how these perspectives
3. Intellectual influenced their practice in the field and their ongoing contribution
4. Changing healthcare practices to humanitarian preparation. They recognise how formal prepara-
tion in dealing with this unique environment can enhance practice
II. Risks and team performance. This presentation will explore:
A. Volunteers
1. Illness/injury What preparation is required
2. Safety concerns How this can enhance the effectiveness within the interna-
3. Emotional tional arena
B. Patients How standards of practice are maintained
1. Errors
2. Lack of follow-up care Emergency care nurses clearly have skills transferable to human-
3. Adverse interactions itarian disasters. However, to maximise their impact in the field they
C. Population need to understand this challenging environment and the wider
1. Introduction of new diseases humanitarian factors involved.
2. Premature introduction of new ideas and technology
3. Dependency References
III. Ethical concerns Oxfam International, 2009. The right to survive. Available:
A. Primum non nocere http://www.oxfam.org/sites/www.oxfam.org/files/right-
1. Preparation to-survive-report.pdf (accessed 12.01.05).
2. Evidence-based practices World Health Organization, 2006. The Contribution of Nursing
3. Seek local input and Midwifery in Emergencies, WHO, Geneva.
B. Sustainability
1. Care versus education
2. What happens after you go home
C. Ethical voluntouring O8.3
1. Go with an established group The tragic case of the three-year-old girl Shabana, working as an
2. Clinical preparation emergency nurse with doctors without borders after the floods of
3. Take only the best healthcare practices 2010 in Pakistan
4. Prepare patient education materials
5. Volunteer at home N.P. Frankhuizen
AmbulanceZorg Rotterdam-Rijnmond, The Netherlands
Introduction: In August 2010 the river Indus flooded big parts of 11 domains. These results identify important differences in
Pakistan. Many people had to abandon their homes for safety. Fam- discharge planning, age related issues, stereotypes, medications
ilies tried to find sanctuary in Sukkur, one of the bigger cities in the and pain management in different geographic areas. Scores were sig-
area. The family of Shabana left their home, their stock and their rel- nificantly higher for nurses from metropolitan areas for most items;
atives. The mother and two boys and two girls found a ‘safe’ place except for practice related items. Discussion: These data represent
alongside of a road. There, without food and clean water Shabana opportunities for nurses to improve their knowledge, attitudes and
got sick. Doctors without Borders (Médecins Sans Frontières, MSF) clinical practices associated with caring for older people in the ED.
started working in the area only two days after the floods. I was Addressing these areas has the potential to improve the quality of
there as an emergency nurse/nurse practitioner to assess the health therapeutic interactions, and the acute care experience for older peo-
care issues and to respond with proper programmes. My task specif- ple and can result in reductions in length of stay, adverse events and
ically was to assess all refugee camps. As malnutrition was one of the readmissions for older people.
main problems, our team, consisting of 4 expats, started a therapeu-
tic feeding centre. Case report: In one of my assessment rounds I
found Shabana, nearly responding. Her mother told me the three- O9.2
year-old girl started coughing before the floods, but was developing Cognitive impairment is a risk factor for delayed analgesia in
normally until a week ago. Shabana suffered of diarrhoea since then older people with long bone fracture: an exploratory
and declined. Shabana was obviously malnourished and dehydrated. correlational study
Her weight was 3.6 kg, although her size was 89 cm. I could hear cre-
pitations on auscultation of her lungs, her belly was tender and her M.M. Fry 1,2, G. Arendts 4, L. Chenoweth 3, C. MacGregor 3
neurological state was worrying. I persuaded the mother that this 1
child needed hospitalization. Shabana received treatment according 2
Northern Sydney Local Health District, Australia
to MSF protocols. She had severe infectious problems (skin, intesti- 3
University of Technology, Australia
nal, pulmonary) which were treated with antibiotics and medication 4
University of Western Australia, Australia
against worms. But, most important, she received therapeutic milk
to recover. Unfortunately, the mother felt she needed to leave the Introduction: Older persons who present to the ED often experi-
hospital. As all their possessions they could save lay alongside of ence a delay in analgesia. This study compares the time to analgesia
the road, she was afraid they would be stolen. Above this, the father for cognitively impaired and cognitively intact older people diag-
of the family was not present as he returned to their homes to find nosed with a long bone fracture. Aim: To determine if cognitive
survivors and left belongings. Therefore, against our advice, Shabana impairment is associated with a delayed analgesia. Method: The
left. I found the family of Shabana a week later. Unfortunately, Sha- study was conducted across four metropolitan emergency depart-
bana died. I cried together with the mother. She did not want to ments of older patients (>64 years) with long bone fractures. The
leave. She wanted to save the child. But, how could she choose 12-month audit (January to December 2012) consisted of a random
against the will of the husband and risking losing everything? Sha- sample from each site (n = 255). Results: Across the four EDs, of the
bana didn’t die for nothing. I advocated with MSF we needed ambu- patients aged 65 and over, 7501 (16.7%) had a musculoskeletal con-
lant feeding centres. A week after her death, MSF had functioning dition or injury diagnosed including 1343 (17.9%) with a long bone
feeding centres in all of the 250 refugee camps near Sukkur. Conclu- fracture. Across four sites, 255 medical records were analysed.
sion: In this presentation I will explain the tasks of a nurse practi- Women (n = 200; 78.4%) were more frequently represented. The
tioner emergency care working with MSF in disaster areas. average age was 81 years (SD ± 8.4 years; median 82 years) with cog-
Shabana’s case will be used to explain the different roles and difficul- nitively impaired patients significantly older (median 86 years ver-
ties one will have to face. sus 79 years, Mann–Whitney U test, P < 0.001). Of the 255 patients,
204 (80%) received analgesia in the ED. The overall median time to
analgesia was 83 minutes (IQR 38–180 minutes). The median time
O9.1 to analgesia for the cognitively intact group was 72 minutes com-
Care of the older person in emergency (COPE): an Australian pared with 149 minutes for the cognitively impaired group, with
study on ED nurses’ attitudes and knowledge towards older the difference statistically significant (Mann–Whitney U test,
people P < 0.001). Of the patients with long bone fractures, 51 (20%) received
no analgesia while in the ED. After adjusting for age, triage code, gen-
der, ambulance analgesia and whether a pain score was documented
D. Deasey, A. Kable, S. Jeong
for the patient in a binary logistic model, patients with cognitive
University of Newcastle, Australia
impairment were more likely to suffer a delay to analgesia beyond
Introduction: Some previous studies have reported nurses’ 60 minutes (P = 0.045, OR 2.14, 95% CI 1.01–4.50). Conclusion: This
knowledge and attitudes towards older persons, however no study suggests that cognitive impairment is a significant risk factor
national Australian study of ED nurses has been conducted. This for delayed analgesia response in the ED.
study identified emergency department (ED) nurses’ knowledge
and understanding of the ageing process and attitudes towards the
older person in Australia. Methods: The Older Persons in Acute Care O10.1
(OPAC) Survey was distributed to members of the College of Strengthening emergency nursing in Africa: a strategic action
Emergency Nursing Australasia Ltd (n = 973) in 2013. This validated plan
questionnaire assessed 14 domains of nursing practice, knowledge
and attitudes related to older people in the acute care setting and P. Brysiewicz 1, T. Heyns 2, T. Scott 3
included the Palmore’s Facts of Ageing Survey. Results: The response 1
University of KwaZulu Natal, South Africa
rate was 39% (n = 383). Data were compared between regional and 2
University of Pretoria, South Africa
metropolitan areas, for ED nurses knowledge, attitudes and practices 3
University of Hertfordshire, UK
across 14 domains. Significant differences were determined in mean
scores between geographic areas for Knowledge items: 2 of 7 Standards of emergency nursing in Africa remain variable and
domains; Attitude items: 3 of 9 domains; and Practice items: 3 of obstacles to standardisation comprise e.g. limited country specific
resources and deficiencies in educational strategy and health sys- An understanding of the views and attitudes of ED staff towards this
tems. The project aims to standardise emergency nursing across cohort of patients can lead to improvements in the care provided.
Africa over an extended duration, of benefit to emergency patients. Aim and objectives: The aim of this research study was to explore
This project is responsive to the increasing trauma and other disease the views of nursing and medical staff towards alcohol misusers
burdens in the WHO Millennium Development Goals. The Institute who attend the ED of a large regional teaching hospital in the West
for Health Metrics predicts that road accidents will be the fifth lead- of Ireland. Methods: A descriptive qualitative approach was selected
ing cause of death in the developing world by 2030; violent crime as the research methodology. Three focus group interviews were
and conflict contributing significantly to this public health emer- conducted among the nursing and medical staff. Along with demo-
gency. Dialogue to standardise emergency nursing practice across graphic data, six pre-set questions were presented to participants
Africa emerged over five years; largely driven by African emergency on the day of the interviews. The focus group interviews were
nurses, educators and the Emergency Nursing Society of South tape-recorded, transcribed and analysed using Braun and Clarkes
Africa. A Pan Africa Strategic Action Plan was created to operationa- (2004) thematic analysis framework. Analysis and results: Three
lise the emergency nursing framework. This paper summarises dia- core themes emerged – ED staff perceptions and attitudes towards
logue between emergency nurses and outlines project targets. intoxicated patients, the impact of limited resources on the manage-
ment of alcohol misusers in the ED and the specific educational
References requirements of staff. Key findings from the study suggest that ED
staff have a negative attitude towards this group of patients and feel
Institute for Health Metrics and Evaluation, 2010. Global they draw heavily on staff time and department resources. Nursing
burden of diseases, injuries, and risk factors study 2010. staff appeared to consider the impact of alcohol misusers in the ED
Available at: http://www.healthmetricsandevaluation.org/ to be of a greater concern than their medical colleagues. There was
gbd/publications/policy-report/global-burden-disease-sub- concern expressed with regard to the care these clients receive in
saharan-africa. an ED setting and participants believed that a more holistic and evi-
dence–based approach was required. They proposed the use of
Screening and Brief Intervention (SBI) tools, the introduction of alco-
hol nurse specialists or alcohol liaison nurses, and specialist educa-
O10.2 tional and training programmes for staff.
Challenges in pre-hospital care: a maritime perspective
N. Oakley O11.2
Carnival UK, UK Innovations in the care of vulnerable adults
Introduction: A man collapses and begins fitting uncontrollably.

S.E. Charters
A pregnant woman with pre-eclampsia goes into premature labour.
University Hospitals Southampton NHS Foundation Trust, UK
A man presents with an ischaemic right leg. A young woman is diag-
nosed with a likely ectopic pregnancy. A previously healthy man pre- Introduction: Emerging from a range of sub-specialities within
sents in acute renal failure and requires dialysis. These are complex emergency nursing is that of vulnerable adult care. Every day, emer-
conditions seen on a daily basis in hospitals all over the world, but gency nurses are required to manage the complexity of issues expe-
they become infinitely more challenging when they present at sea, rienced by patients who present with one or more adult
sometimes when a ship is more than a day away from the nearest vulnerabilities, including: mental health crises, homelessness, sub-
port. Purpose: This presentation outlines some of the medical, prac- stance misuse, domestic abuse, harmful traditional practices, sexual
tical and logistical challenges of treating the seriously ill patient at violence, learning disability, and dementia. Trying to navigate
sea and discusses the decision making around emergency disembar- around legal and professional responsibility, issues of capacity and
kation versus managing the patient onboard. The second part of the consent, requirement for adult and child safeguarding, and access
presentation examines the detail of the real cases above, and uses a to a multitude of community services, can be a daunting challenge.
structured approach to explain the treatment options and resources Purpose: In a UK-based University Teaching Hospital, an innovative
available to the ship’s medical team and the rationale for the man- programme of service development for vulnerable adult care has
agement decision made in each case. Conclusions: There is currently been on-going for two years. Led by the Consultant Nurse Emergency
little research available on best practice for management of seriously Care (Vulnerable Adults), this diverse programme includes the
ill patients in the maritime environment, but a focus on lessons development of guidelines and protocols, referral pathways, web-
learned from real life cases, such as the ones above is recognised based resources, training packages and multi-agency fora. Close
as being invaluable within the industry. The presentation concludes working partnerships have been built with a broad range of special-
with a summary of the lessons learned from these real life cases, ity and community services. To enhance face-to-face delivery of psy-
how these lessons have been shared with colleagues in the industry chosocial care, a Vulnerable Adult Support Team (VAST) has been
and how this has changed our practice. introduced to work alongside clinicians, bringing expertise in the
unique management of this often, disadvantaged group.
Drawing on approaches advocated within motivational inter-
O11.1 viewing, the team come alongside patients to provide interventions
‘‘Alcohol misusers and the emergency department- views of that are congruent with the patient’s own beliefs, values and con-
nursing and medical staff’’ cerns. Using a brief intervention model, members of VAST support
screening and identification, risk assessment, information giving,
E. Ni Neachtain, Y. Conway referral to appropriate services and safeguarding. With over a hun-
National University of Ireland Galway, Ireland dred patient contacts each month, during the working hours of
1400–2200 hrs 7/7, the team is able to provide a comprehensive
Introduction: It is suggested that between 20% and 50% of all and personalised intervention to each patient.
presentations to Irish Emergency Departments (ED) are alcohol The multi-faceted programme has resulted in enhanced patient
related, with the figure rising to over 80% at peak weekend periods. experience of emergency care and, through addressing psychosocial
need, has promoted the health, safety, and wellbeing of vulnerable O12.1
patients. Personality profile of emergency nurses
B. Kennedy 1,2, K. Curtis 1,2, D. Waters 1,2

1
2
O11.3 St George Hospital, Australia
Project helping to save: empowering a vulnerable neighbourhood
to deal with emergency situations Introduction: With the ever increasing demands on emergency
services and the difficulties in recruitment of suitably qualified staff
(Australian Health Workforce Advisory Committee, 2006), it is nec-
T. Leal, C. Durao
essary to consider how to enhance the recruitment and retention
ESEL, Portugal
of emergency nurses in public hospitals. Personality influences occu-
Introduction: Vulnerable neighbourhoods are a common con- pational choice (Holland, 1985; Osipow, 1973; Ozer and Benet-Mar-
cern for health professionals. They are not integrated in the commu- tinez, 2006), yet there is a lack of research exploring the personality
nity and lack the basic resources to face even minor emergencies, of emergency nurses. Methods: A standardised personality test
often related to a high prevalence of accidents, crime, and substance instrument, the NEO™-PI-3 was used in a survey design inclusive
and alcohol abuse (Mechanic and Tanner, 2007). Empowering these of demographic questions to measure personality characteristics.
groups encompasses the European social innovation strategies Data were collected from 72 emergency nurses working at an Aus-
(European Community, 2011). Nursing educators must be aware of tralian Emergency Department between July and October 2012.
political and social tendencies and meet the challenge of providing The scores of the emergency nurses were compared against general
specific community experiences to undergraduate students (Gaines population norms in each of the five personality domains and their
et al., 2005; Narsavage et al., 2003; Niederhauser et al., 2012). 30 associated facets. Results: The sample of emergency nurses in
Purpose: In 2008, Lisbon School of Nursing began a project of this study scored higher than the population norm in the domains
empowering residents of a vulnerable neighbourhood, because they of extraversion (P < .001), openness to experience (P < .001) and
had great difficulties in getting help in emergency situations, as well agreeableness (P = .001). Results were significant in twelve domain
as to provide first-aid. With faculty guidance and in partnership with facets, such as higher scores for excitement-seeking (P < .001) and
the community leaders, students prepared sessions of education and competence (P = .003); and lower scores for vulnerability (P < .001).
training for small groups identified by the population as key Conclusion: The personality profile of this sample of emergency
resources. Topics like contents of a first-aid kit and dealing with nurses is different from the established population norms. Assess-
wounds (how to stop bleeding, cleaning and covering the wound) ment of personality and knowledge of its influence on specialty
and BLS were evaluated by the participants as very helpful for the selection may assist in improving retention and recruitment in
community, with practical application on everyday life. To students emergency nursing.
as well as to faculty, this particular learning environment had a great
impact since it provided the opportunity to integrate theory with References
practice and to develop nursing knowledge and skills (communica-
tion, education, problem-based learning), and increased their moti- Australian Health Workforce Advisory Committee, 2006.
vation and sense of being nurses. The project has promoted strong Health Workforce Planning and Emergency Care Model of
relations with the community and positive perceptions of nursing, Care. Australian Health Workforce Advisory Committee
and nursing education, as community leaders were able to observe Report, Sydney.
nursing students working with them to meet their needs. This edu- Holland, J.L., 1985. Making Vocational Choices: A Theory of
cational project brought positive outcomes for the faculty, for nurs- Vocational Personalities & Work Environments, Prentice-
ing students and for the neighbourhood. Hall, Englewood Cliffs, New Jersey.
Osipow, S.H., 1973. Theories of Career Development,
Prentice-Hall Inc, Englewood Cliffs, New Jersey.
References Ozer, D.J., Benet-Martinez, V., 2006. Personality and the
prediction of consequential outcomes. Annual Review of
European Community, 2011. Empowering people, driving Psychology. 57, 401–421.
change: social innovation in the European Union. Luxem-
bourg. doi:10.2796/13155.
Gaines, C., Jenkins, S., Ashe, W., 2005. Empowering nursing
faculty and students for community service. The Journal O12.2
of Nursing Education. 44, 522–525. Nurses’ experiences of caring for the older adult in the
Mechanic, D., Tanner, J., 2007. Vulnerable people, groups, and emergency department
populations: societal view. Health Affairs. 26, 1220–1230.
doi:10.1377/hlthaff.26.5.1220. B.J. Taylor, K. Rush, C. Robinson
Narsavage, G.L., Batchelor, H., Lindell, D., Chen, Y., 2003. University of British Columbia – Canada
Developing personal and community learning in graduate
nursing education through community engagement. Nurs- Introduction: Compared to other age cohorts the older adult
ing Education Perspectives. 24, 300–305. spends more time in the emergency department (ED), requires more
Niederhauser, V., Schoessler, M., Gubrud-Howe, P.M., diagnostic tests, and is more often admitted and then held in the ED
Magnussen, L., Codier, E., 2012. Creating innovative models until an inpatient bed becomes available (Hodgins et al., 2010; Low-
of clinical nursing education. The Journal of Nursing Educa- thian et al., 2012). ED nurses must care for both boarded and incom-
tion. 51, 603–608. doi:10.3928/01484834-20121011-02. ing older adult patients but little is known about their experiences of
caring for the older adult in this unique venue. Therefore the purpose
of this study was to explore nurses’ experiences of caring for the
older adult within the ED. Methods: This focused ethnography used
a combination of semi-structured interviews and non-participant Results: Data collection is still taking place. Data analysis, discus-
observation. Seven registered nurses participated in the interview sion and conclusion will be available by conference date.
process, detailing their experiences of caring for the older adult in By the end of the presentation, delegates will be able to:
the ED; this was supplemented with 12 hours of observation. Data
were transcribed verbatim and analyzed thematically. Results: 1. Understand the issues facing the nurse in charge of an emer-
Three themes emerged: the culture of the ED which focused on pri- gency department.
ority setting and throughput of patients; lack of fit between the older 2. Explore the challenges of the nurse in charge role in their hos-
adult and the ED; and, managing lack of fit. Nurses relied on a default pital setting.
orientation of priority setting but recognized this put older adults at 3. Contemplate areas of improvement for the role of the nurse in
risk for substandard care, lengthened hospital stays, and increased charge.
mortality and morbidity. Lack of fit was accentuated by the need
to ‘hree themes eme the atypical presentations of many older adults.
Nurses found small ways to manage the lack of fit that depended on References
ideal patient and ED conditions that often did not reflect the norm.
Conclusions: This study has implications for nursing practice, edu- Fry, M., 2008. Overview of emergency nursing in Australasia.
cation, and research. ED nurses need to be aware of the influence International Emergency Nursing. 16 (4), 280–286.
of the ED culture on care quality of the older adult. Ways of navigat- Lincoln, Y. S., Guba, E. G., 1985. Naturalistic Inquiry.
ing the tensions between the culture of the ED and meeting the Sage Publications, Newbury Park, CA.
needs of older adults will be discussed. Areas for further research Nugus, P.T., Braithwaite, J., 2008. Report on a Sociological
will be addressed. Study of the Work of Emergency Department Clinicians
in New South Wales, Centre for Clinical Governance
References Research in Health, Faculty of Medicine, University of
New South Wales, Sydney, p. 24.
Hodgins, M.J., Moore, N., Legere, L., 2010. Who is sleeping in
our beds? Factors predicting the ED boarding of admitted
patients for more than 2 hours. Journal of Emergency
Nursing. doi:10.1016/j.jen.2010.02.020. O13.1
Lowthian, J., Curtis, A., Stoelwinder, J., McNeil, J., Cameron, P., Grand designs. Resuscitation room rebuild; using simulation to
2012. Emergency demand and repeat attendances by older design an ergonomic work space
adults. Internal Medicine Journal. doi:10.1111/imj.12061.
M. Rudd 1, S. Morton 2
1
United Lincolnshire Hospitals NHS Trust, UK
2
University of Lincoln, UK
O12.3
The lived experience of a nurse in charge of an emergency The principles of ergonomics and human factors are increasingly
department being applied to the design of healthcare environments particularly
operating rooms. Our resuscitation room was overstocked and cha-
otic with equipment added over time by various speciality teams
S. Kukec 1,2
1 with no overall consideration of how it all fitted together and how
King’s College London, UK
2 this affected the ability to work efficiently in this environment.
Imperial College Healthcare Trust, UK
When the opportunity to redesign the room arose, the challenge
Introduction: In the last 35 years, accident and emergency nurs- was to create an environment that is easy and safe to work in, and
ing has evolved into a specialty practice delivering care to a broad enable the clinicians to focus on the patient. Collaborative discussion
and diversified population. This population is experiencing abrupt, between a HEI and NHS Trust led to the development of the concept
potentially life threatening or psychosocial conditions (Fry, 2008). of redesigning the resus room through inter-professional simulation.
The crucial feature of the clinical-organisational role of a nurse in Resuscitation and trauma simulations were run starting in an empty
charge of an emergency department (ED) lies in the connection of room and building the equipment around the ED and specialist
the day to day work to external reporting mechanisms by which teams as they worked. The location of equipment was further tested
the ED is held accountable (Nugus and Braithwaite, 2008). Purpose: to optimise accessibility and the flow of the team. The resulting
The aim of this study is to explore and retrieve the feelings, beliefs design is a resuscitation room that will be easy and intuitive to work
and emotions experienced by the nurse in charge running an emer- in, so greater attention can be paid to the patient and the safe func-
gency department. Furthermore, this study will open a discussion on tioning of the team. There is a paucity of information or research in
how the role a nurse in charge of such department is defined and redesigning resuscitation rooms using simulated clinical experi-
how it can be improved. Method: A qualitative method of interpre- ences, so this is a unique presentation on simulation designed envi-
tative phenomenological analysis (IPA) was used. The research ques- ronments with a focus upon safety and ergonomics.
tion ‘‘What is the lived experience of the nurse in charge of an
emergency department?’’ was answered through:
Semi-structured O13.2
Face to face, audiotaped interviews Enhancing major trauma team performance by using paediatric
10 nurses in charge of an ED were interviewed medical simulation
Data analysis will follow the criteria presented by Lincoln and
Guba (1985) ensuring: credibility, transferability, dependabil- J. Thistlethwaite, K. Sykes, K. Grant
ity, and confirmability. University Hospital Southampton, UK
In April 2012, NHS trauma services were restructured leading to feedback processes. Conclusion: In these populations knowledge
the creation of Major Trauma Centres (MTC). Prior to the launch of and skills are low however the First2Act programme does have an
the MTC in my region, trauma simulations were run to test the impact on knowledge and clinical skills. These findings and the e
new SOPs in the regional trauma manual and to develop roles within web based training programme will be presented.
the trauma team. Following the simulation training we noted a Web link – http://first2actweb.com/
reduction in the time taken to intubate a trauma patient from 57
to 9 minutes, post admission to the MTC. In April 2013, funding References
was secured to expand the paediatric trauma training. A multi-disci-
plinary education team arranged monthly paediatric trauma simula- Cooper, S., McConnell-Henry, T., Cant, R., Porter, J., Missen, K.,
tion events within the emergency department (ED). Initially, these Kinsman, L., et al., 2011. Managing deteriorating patients:
simulations concentrated on trauma scenarios with the aim of registered nurses’ performance in a simulated setting. The
ensuring treatments such as intubation and transfer to CT scan were Open Nursing Journal. 5, 120–126. doi:10.2174/
provided within national target times. We also wished to review 18744346011050100120.
clinical skill sets, role identification, policy development, standardi-
sation and use of equipment. These training events allowed the
teams to explore the challenging human factors identified in team
working, promoted collaborative working with child health and O14.1
facilitated critical incident reporting, leading to improved gover- Specialities in emergency nursing: nurse led mental health care
nance within the service. A 6 month review of progress demon- pathway
strated significant service improvement. However, a review of one
year’s paediatric resuscitation room admission data revealed that S. McCullough, L. Craig
only 11% of admissions related to major trauma. It was decided to N.H.S.C.T., UK
extend and enhance simulation training by constructing cases that
might present to the medical team but have an unrecognised trauma Effectively caring for patients with complex mental health needs
origin, for example, status epilepticus as a result of non-accidental has been a long-standing challenge for emergency nurses. This inno-
injury. By adding paediatric medical simulation to major trauma it vative pathway is designed to identify the holistic needs of the
was anticipated greater benefits would accrue to the MDT and patient from initial presentation to the Emergency Department.
patient care in the ED. In conclusion, a broad based, regular, point There are two distinct sections.
of care team based simulation programme has improved care of crit- Section 1: Triage of the Mental Health Presentations to the Emer-
ically ill and injured children in the ED. gency Department. In accordance with guidelines from the national
governing body the pathway permits the triage nurse to initiate
treatment for both physical and psychological needs according to
O13.3 priority (NICE, 2011). This parallel assessment is achieved through
Managing patient deterioration: introducing the First2ActWeb e- amalgamating the Manchester Triage System with the Australian
simulation learning package Mental Health Triage System into a corresponding colour-coded
pathway with additional prompts for social circumstance such as
safeguarding issues (Manchester Triage Group, 2013; Smart et al.,
J. Porter 1, S. Cooper 2
1 1999). Through this early holistic assessment a complete plan of care
Federation University Australia, Australia
2 can be identified and tailored for each individual. The benefits of this
are twofold. The assessment provides a common language by which
Purpose: This paper will introduce the First2ActWeb on-line sim- the emergency nurse and the mental health crisis response team can
ulation package which was developed to enhance the management communicate effectively. The pathway also promotes early referral
of deteriorating patients. Introduction: There are international con- to mental health services from triage as led by an experienced triage
cerns regarding the management of deteriorating patients with nurse and facilitates efficient management of the patient’s needs.
issues around the failure to recognise deterioration. The primary Section 2: Psychosocial Assessment in the Emergency Depart-
response to these issues has been the development of medical emer- ment. This section primarily relates to qualifying risk when the
gency teams with little focus on the education of primary first patient is in the Emergency Department. It is designed for patients
responders and recognition of deteriorating (Cooper et al., 2011). who may be eligible for nurse led discharge or alternatively if the
Methods: Following a series of face to face studies that identified nurse has concerns the patient is not suitable for discharge and
deficits in nurses’ ability to manage deteriorating patients we devel- may be at risk of absconding. Within each part of this assessment
oped a feasible web based learning package that includes a range of the nurse is alerted to factors of which may place the patient at
material and pre-post intervention assessment tests. This includes greater risk of self-harm (Broadbent et al., 2002). It promotes a tai-
scenarios where we filmed patient actors deteriorating and recorded lored action plan of which is robust and promotes patient safety
a range of interactive clinical tasks that appear as pop up videos (e.g. and effective care within the department.
taking a BP and ECG). Performance scores are provided and evalua-
tion data collected. Results: In a primary evaluation a total of 367 References
final year nursing students from three Australian universities and
one college completed the programme. Knowledge increased signif- Broadbent, M., Jarman, H., Berk, M., 2002. Improving
icantly following the intervention (69% to 79%; P < 0.001). Clinical competence in emergency mental health triage. Accident
performance also improved (by 15%) between the first and subse- and Emergency Nursing. 10, 155–162.
quent scenarios (P < 0.001). Self-ratings of knowledge improved sig- Manchester Triage Group, 2013. Emergency Triage. Advanced
nificantly after the intervention (P < 0.001), as did the students’ Life Support Group, third ed. Wiley-Blackwell, Oxford.
perceived confidence and competence. Multiple components of the NICE, 2011. NICE pathways. Self-harm. Available at
programme were reported to assist skills development with positive http://www.pathways.nice.org.uk/pathways/self-harm
rating for the form of programme delivery, the clinical focus and the (accessed 13.12.18).
Smart, D., Pollard, C., Walpole, B., 1999. Mental health triage in Introduction: The Emergency Care Innovation & Research (EIR)
emergency medicine. The Australian and New Zealand Group, Cork is the first emergency care research group in Ireland,
Journal of Psychiatry. 33 (1), 57–66. incorporating adult and paediatric emergency care, from roadside
to bedside. We are a multidisciplinary group of doctors, nurses, allied
health and paramedical professionals whose expertise spans prehos-
pital and in-hospital emergency care of patients from all age groups
O14.2 with acute traumatic, surgical, medical and mental health needs. Our
Compromising care – a grounded theory study of moral distress goal is to promote and improve all aspects of care of emergency
in emergency departments patients to ensure the best outcomes following injury, sudden acute
illness or acute deterioration in health status. Objectives: To identify
G. White key research areas pertinent to our group and emergency care in Ire-
National University of Ireland Galway, Ireland land. Methods: The EIR Group has been conducting strategy meet-
ings on a bimonthly basis since its inception in early 2013. The
Introduction: Modern emergency departments place conflicting aim of these meetings is to encourage and develop a supportive
demands on nurses with increased workloads, diminishing resources research community within the Emergency Department (ED) of Ire-
and staff shortages. When a conflict arises between nurses’ moral land’s largest university hospital. Our goal was to develop a research
codes and the clinical situation, they may experience moral distress agenda for EIR. We distributed an invitation to all EIR members to
(Jameton, 1984) which can lead to job dissatisfaction, burnout, take part in a Research Away Day. The away day was an opportunity
increased turnover and lower staff retention (Corley et al., 2001). for practitioners to remove themselves from the demands of their
However, no studies examining moral distress have been conducted clinical workload and participate in the development of the future
in emergency departments. Purpose: This study sought to discover research agenda for EIR. The meeting was audio recorded, tran-
the main concern of Emergency Nurses experiencing moral distress. scribed and transcripts were subsequently sent to all attendees for
Methods: Classical Grounded Theory was used for the analysis of member validation. Results: A total of 39/60 EIR members attended
qualitative data including 40 interviews and several episodes of clin- the away day. Preliminary analysis of the transcriptions reveals nine
ical observation. Recruitment was initially performed using purpo- research categories relevant to emergency care in Ireland today such
sive sampling followed by theoretical sampling. Data collection as; Sedation & Analgesia, Sepsis, Prehospital Management and
and analysis have been conducted concurrently incorporating a pro- Observation Medicine. Within each category a number of potential
cess of constant comparison and theory generation. Data have been specific research studies were identified. Conclusion: EIR’s next step
analysed using a system of open coding, selective coding and theo- is to convene a core group of clinical researchers and perform further
retical coding (Glaser, 1978). Results: The main concern of Emer- transcription analysis, assessing the feasibility of the proposed stud-
gency Nurses was balancing competing demands. Coding revealed ies. Once studies have been defined we will charge champions
the core category of compromising care. Compromising care consists within EIR to develop study protocols.
of a process of funneling down care to core caring when emergency
department overcrowding reaches critical levels. Additional catego-
ries include Rationing Care, Covering Patients and Making a Differ- O15.2
ence. Conclusion: This study describes a substantive theory of Early warnings of an emergency? Analysing staff perceptions and
moral distress among Emergency Nurses. Nurses use a number of predicting hospital admissions using a mixed methods approach
strategies to manage overcrowding, competing patient demands
and staffing issues to ensure the provision of core caring in difficult
C.M. Dutton
care environments. Discussion: This study adds to the existing the-
University Hospital of South Manchester, UK
ory of moral distress by explaining this process in the context of
Emergency Care. Furthermore, the emergent theory of compromis- Emergency Departments (ED) operate in a dynamic climate, with
ing care reveals the relationship between balancing competing increasing demands and tighter resource constraints. This research
demands, core caring and moral distress. study questioned whether a robust clinical tool, such as the Modified
Early Warning Score (MEWS), inserted into this dynamic climate
could accurately detect an un-well patient and expedite the decision
References to admit (DTA). The MEWS has been validated to identify unwell in-
patients but has not been validated for use in the ED. Perceived clin-
Corley, M.C., Elswick, R.K., Gorman, M., Clor, T., 2001. ical usefulness of the MEWS amongst ED staff, and its ability to pre-
Development and evaluation of a moral distress scale. dict hospital admission in an undifferentiated sample of patients
Journal of Advanced Nursing. 33, 250–256. presenting to a busy inner-city ED had not previously been mea-
Glaser, B.G., 1978. Theoretical Sensitivity – Advances in the sured. A prospective questionnaire cohort methodology measured
Methodology of Grounded Theory, Sociology Press, Mill the change in perceived clinical usefulness of the MEWS amongst
Valley. ED nurses and doctors (n = 56) using a pre- and post-implementation
Jameton, A., 1984. Nursing Practice: The Ethical Issues, questionnaire; the primary outcome was the change in staff percep-
Prentice Hall, London. tion using a mixed quantitative (descriptive analysis & Student t
test) and qualitative (Framework approach) analysis of the paired
questionnaires. Retrospective analysis of the implemented MEWS
documentation from an undifferentiated consecutive sample of
O15.1 patients presenting to the ED (n = 1014) was used to measure the
First steps for the Emergency Care Innovation & Research (EIR) secondary outcomes which were: the discriminatory ability of
Group – developing an emergency research agenda MEWS to predict hospital admission (Receiver Operating Character-
istic (ROC) curve) and correlation between MEWS and the level of
S.C. McCoy, P. Cotter, R.G. O’Sullivan inpatient care required (Spearman’s correlation coefficient). The
Cork University Hospital, Ireland study concluded that when used, MEWS was perceived to be a useful
clinical tool in the ED. MEWS’s ability to predict hospital admission O16.1
(AUROC = 0.613 [95% CI 0.576–0.649; P < 0.001]) and detect level of The development of HIRAID: an evidence-based emergency
inpatient care required (Spearman correlation coefficient +0.259) nursing assessment framework and education package
in an undifferentiated sample is statistically significant, but is weak
and is best two hours after a patient’s presentation. The ED is an B. Munroe 1,2, K. Curtis 1,3, M. Murphy 1,4, L. Strachan 5, M.J. Lewis 1,
inherently difficult clinical environment to undertake research, how- T. Buckley 1
ever nurses on the shop floor are crucial to innovating emergency 1
care through simple research. 2
The Wollongong Hospital, Australia
3
St George Hospital Trauma Service, Australia
4
Westmead Hospital, Australia
5
O15.3 Blacktown Hospital, Australia
Momentary fitting in a fluid environment: a grounded theory of
emergency triage nurse decision making Introduction: When reviewing the curriculum of an emergency
nursing post graduate course a team of academics at Sydney Nursing
School, University of Sydney was unable to locate an evidenced-
G. Reay, J.A. Rankin
based systematic approach to emergency nursing assessment. An
University of Calgary, Canada
integrative review of the literature confirmed the paucity of evi-
Introduction: Emergency departments (EDs) are fluid environ- dence surrounding the emergency nursing assessment process
ments where conditions are constantly changing (Noon, 2014). Triage (Munroe et al., 2013). Purpose: To describe the development of an
nurses control access to the ED and make decisions about patient acu- evidenced-based framework and education package to teach emer-
ity, placement, and priority to be examined by a physician. Under- gency nurses how to perform a systematic initial patient assessment.
standing the processes and strategies that triage nurses use in Methods: A team of doctoral trained academics, experienced emer-
decision making is therefore vital for patient safety and operation of gency nurses and an educational expert was formed. An emergency
the ED (Hodge et al., 2013). Purpose: The investigators aimed to gen- nursing assessment framework was devised (Curtis et al., 2009) and
erate a substantive grounded theory (GT) of emergency triage regis- revised using available evidence for each of the framework’s seven
tered nurse (RN) decision making. Methods: We conducted the components. The framework was titled ‘HIRAID’. The HIRAID compo-
study using classical GT (Glaser, 1978; Glaser and Strauss, 1967), nents are: collecting a patient history; identifying red flags; perform-
which aims to discover the main concern of participants and how they ing a physical assessment; interventions; diagnostics; reassessment
resolve this concern. Twelve individual interviews were conducted and communication. These steps may be undertaken singularly or
with RNs who had five or more years of triage experience from three simultaneously as emergency clinicians are often required to per-
hospitals in a large urban centre in Canada. The triage environment form multiple tasks at the same time both individually and as part
was also observed on seven occasions. Data were analysed using clas- of a team (Laxmisan et al., 2007). Implementation: A four hour edu-
sical GT. Results: Preliminary results reveal that the main concern of cation workshop was developed to teach the application of HIRAID.
triage RNs was to achieve the best possible fit between patients and The education program integrated the adult learning principles of
the ED as a whole, given the circumstances for each moment in time. experiential and transformative learning theories. The education
The main concern was conceptualized as momentary fitting in a fluid program underwent peer review, was piloted by 38 early career
environment. Best possible fit was not synonymous with optimal fit. emergency nurses in a simulated setting and has now been incorpo-
Decision making occurred in a context where each decision changed rated into clinical practice at the study sites. Conclusion: HIRAID is
the conditions for subsequent decisions. Momentary fitting consists an evidence-based structured emergency nursing assessment frame-
of the partially interrelated categories determining acuity, anticipat- work which provides emergency nurses a systematic approach to
ing needs, managing space, and creating space. At certain critical junc- initial patient assessment. Evaluation of the effectiveness of HIRAID
tures, RNs decided to create space by pushing boundaries and, at on the content and quality of clinical documentation, accuracy and
times, temporarily crossing boundaries. Discussion: The investigators completeness of emergency nursing initial patient assessment, and
stress the importance of enabling triage RNs to quickly form a picture anxiety, perceptions of control and self-efficacy levels related to
of what is transpiring in the ED. Moreover, the findings point to the assessment performance is underway.
need for structuring triage environments to facilitate mechanisms
that allow quick communication between co-workers.
References
References
Curtis, K., Murphy, M., Hoy, S., Lewis, M.J., 2009. The
Glaser, B.G., 1978. Theoretical Sensitivity, Sociology Press, emergency nursing assessment process – a structured
Mill Valley. framework for a systematic approach. Australasian Emer-
Glaser, B.G., Strauss, A.L., 1967. The Discovery of Grounded gency Nursing Journal. 12, 130–136.
Theory: Strategies for Qualitative Research, Aldine, Chi- Laxmisan, A., Hakimzada, F., Sayan, O.R., Green, R.A., Zhang, J.,
cago, IL. Patel, V.L., 2007. The multitasking clinician: decision-mak-
Hodge, A., Hugman, A., Varndell, A., Kylie, H., 2013. A review of ing and cognitive demand during and after team handoffs
the quality assurance processes for the Australasian triage in emergency care. International Journal of Medical Infor-
scale (ATS) and implications for future practice. Austral- matics. 76, 801–811.
asian Emergency Nursing Journal. 58 (1), 21–29. Munroe, B., Curtis, K., Considine, J., Buckley, T., 2013. The
Noon, A., 2014. The cognitive processes underpinning clinical impact structured patient assessment frameworks have
decision in triage assessment: a theoretical conundrum? on patient care: an integrative review. Journal of Clinical
International Emergency Nursing. 22 (2), 40–46. Nursing. 22, 2991–3005.
O16.2 reported moderate levels of clinical autonomy and nurse/physician

Transition to specialty practice programs in emergency nursing collaboration. No relationships were found between sample charac-
teristics and clinical autonomy and nurse/physician collaboration
J. Morphet 1,2, J. Considine 1,3, V. Plummer 2,4, B. Kent 1,5 among emergency nurses. Relationships were found between levels
1
Deakin University, Australia of clinical autonomy and nurse/physician collaboration (r = 0.395,
2
Monash University, Australia n = 100, P < 0.001), and organisational influence on nursing
3
Eastern Health – Deakin University Nursing and Midwifery (r = 0.455, P < 0.001) and also between nurse/physician collaboration
Research Centre, Australia and organisational influence on nursing (r = 0.413, P < 0.001). Dis-
4
Peninsula Health, Australia cussion: Clinical autonomy of nurses has been linked with quality
5
University of Plymouth, UK outcomes in healthcare. The quest for quality in modern healthcare
in a challenging environment should acknowledge that strategies
Introduction: Transition to Specialty Practice Programs (TSPPs) need to focus beyond education and skills provision and include
have been introduced nationally and internationally since the late essential elements such as nurse/physician collaboration and the
90s, to ensure the provision of safe and effective patient care, and organisational influence on nursing to ensure the greater involve-
improve recruitment, preparation and retention of emergency ment of nurses in patient care.
nurses. TSPPs have developed in a ‘home grown’ manner, and as a
result there is variability in the characteristics and duration of these
programs. Aims: The aim of this study was to examine the breadth O17.1
and scope of TSPPs in Australian emergency departments (EDs), The development of a paediatric trauma system in an Australian
and to identify a framework for the future development of ED TSPPs. context
Methods: An explanatory sequential design was used to examine the
breadth, function, and structure of TSPPs in Australian EDs. Data in
T.C. Gillen
this phase of the study were collected by survey of Nurse Unit Man-
Royal Children’s Hospital, Australia
agers and Nurse Educators (n = 118 EDs). Results: TSPPs were offered
in more than half of the EDs sampled (n = 78, 66.1%). The median Introduction: The Australian environment presents many chal-
duration for TSPPs was 12 months (IQR 5–12 months). Most TSPPs lenges to the implementation of a trauma service predominantly
offered clinical preparation including orientation days, study days, due to distance. The Paediatric Trauma Service was established in
supernumerary and clinical support shifts (Mdn = 18 days, IQR 9– 2008 and is responsible for the management of all paediatric trauma
27 days). EDs with TSPPs had a lower nursing turnover rate than patients from throughout Queensland and northern New South
EDs without TSPPs. TSPPs which were 6 months duration had better Wales (an area of over 1,700,000 km2). Purpose: To develop a reli-
professional development outcomes. Conclusion: While the aims of able and sustainable Paediatric Trauma Service capable of meeting
TSPPs were similar, there was variability in the structure and fea- the needs of severely injured children in Queensland. Method: This
tures of TSPPs in Australian EDs, and subsequently in TSPP outcomes. presentation will provide an overview of the innovative Paediatric
The identification of a national framework to support TSPP develop- Trauma Service in Brisbane, the challenges and the opportunities.
ment should provide consistency and quality in the delivery of ED It will address six priority areas that have enhanced acute trauma
TSPPs and preparation of novice ED nurses. care to paediatric patients in Queensland, namely;
Injury prevention
O16.3 Clinical services
Clinical autonomy and nurse/physician collaboration in Education
emergency nurses Research and data collection
Quality activities
P.T. Cotter 1,2, G. McCarthy 1 Networking and administration.
1
Catherine McAuley School of Nursing and Midwifery, University
College Cork, Ireland Discussion: The Paediatric Trauma Service was established as a
2
Cork University Hospital, Ireland matter of urgency in 2008. The Paediatric Trauma Service provides
a consultancy service for all paediatric trauma patients admitted
Purpose: To investigate clinical autonomy and nurse/physician for more than 24 hours and their families, and provides a liaison ser-
collaboration among emergency nurses in Ireland. Introduction: A vice between the multidisciplinary teams and the allied health pro-
number of reports identify nurses as having a significant role in fessionals. It coordinates the care of approximately 1000 trauma
addressing the challenges of providing modern healthcare. Emer- admissions (of greater than 24 hours) each year from the two major
gency nurses have reported competence in a wide range of emer- paediatric hospitals in Queensland. The Paediatric Trauma Service
gency care skills. However, Emergency Department (ED) nurses takes a leadership role in trauma prevention, education, data collec-
appear to have lower levels of clinical autonomy than other nurses. tion and research.
A number of influences have been identified in the literature includ-
ing levels of collaboration with physicians and the organisations in
which nurses work. Methods: A descriptive correlational study using O17.2
a survey design with a purposive convenience sample of 141 ED staff Comparison of two outcome measures in assessing paediatric
nurses (response 70.9%) from 3 EDs in Ireland. Data were collected trauma team activation appropriateness
using the Dempster Practice Behaviours Scale (DPBS), the Nurse/Phy-
sician Collaboration Scale (NPCS) and the newly developed Organisa-
H.E. Jowett, S. Bressan, K. Franklin, S. King, E. Oakley, C.S. Palmer
tional Influences on Nursing Scale. Demographic information was
The Royal Children’s Hospital, Australia
also sought from participants. Results: Participants were predomi-
nantly female (87%), relatively young (mean age 35.57, SD = 7.83) Introduction: Trauma Team Activation (TTA) criteria are
and educated to degree level (48%) or higher (31%) with 40% possess- assessed based on their ability to accurately identify patients who
ing specialist emergency nursing qualifications. Participants will benefit from a trauma team response. Ideal criteria provide
the best balance between over- and undertriage. This study aimed to were analysed by content analysis. Results: The results showed a
assess the appropriateness of TTA criteria at a paediatric centre using high degree of job satisfaction (88%). Triage as a method, the inter-
two different outcome measures: retrospective major trauma (MT) esting nature of the work, and a certain freedom in connection with
classification as defined within our state, and the use of Emergency the triage tasks contributed to job satisfaction (R2 = 0.40). The nurses
Department high-level resources (Falcone interventions; FI). MT may found their work interesting and stimulating, although some
not necessarily reflect acute patient requirements, while FI focus on reported job dissatisfaction due to a heavy workload and lack of
the acute resuscitation care that the trauma team is assembled for. competence. Most of the nurses thought that Manchester Triage Sys-
Methods: Trauma registry data and patients’ charts between Feb- tem (MTS) was a clear and straightforward method but in need of
ruary 2011 and June 2013 were reviewed. Over- and undertriage development. One result from the content analysis was difficulties
rates for TTA were calculated using either MT or FI as outcome in decision-making during the assessment of patients with multiple
measures. diseases. Since this patient group had increased in number, greater
Results: In total, 280 patients received TTA, 244 met MT defini- demands were placed on the nurses’ competence. Conclusions:
tion and 132 received one or more FI. The rates of overtriage and The rational modelling structure by which the triage method is con-
undertriage for our TTA criteria were 39.6% (95%CI, 35.9–44.4%) structed is unable to distinguish all the parameters that an experi-
and 30.7% (95%CI, 26.4–35.4%) when the MT definition was used as enced nurse takes into account. When the model is allowed to
the outcome measure, and 60.1% (95%CI, 54.8–65.3%) and 15.4% take precedence over experience, it can be of hindrance and contrib-
(95%CI, 11.9–19.7%) when FI was used. Patients receiving TTA had ute to certain estimates not corresponding with the patient’s needs.
an increased likelihood of requiring FI (OR 2.3; 95%CI 1.5–3.4), while The participants requested regular exercises solving and discussing
TTA was not associated with an increased likelihood of MT classifica- patient scenarios, which can contribute to develop the instrument.
tion (OR 1.3; 95%CI 0.9–1.8). Assessment of TTA appropriateness
based on evaluation of FI resulted in lower undertriage rates com-
pared to MT classification. FI may be preferable in evaluating TTA.
O19.1
Symposium with papers O19.2 and O19.3
O17.3 Staffing & Skill Mix – the BEST way! (Baseline Emergency Staffing
Head injury in nursery rhymes: an educational tool for Tool (BEST))
paediatrics
J. Windle, J. Youd, G. Jones
L. Ballasty, C. Mahon, S. Egan Salford University, UK
UCD, Ireland
This paper presents BEST. It will include the development of the
Introduction: Nursery rhymes have been used since the 18th tool and the purpose of using BEST within the emergency depart-
century as a development tool for children, with ample research to ment. The paper demonstrates how linking the JDT, FEN competen-
support their merit as a means of developing language and cognitive cies and patient attendance numbers into one tool can provide
skills in young children. It is our aim to use the auspices of the nurs- appropriate nurse staffing and skill mix within the emergency
ery rhyme to teach the basics of head injury care in a fun, interactive department.
way. Historically nursing establishments have been calculated using
Purpose: attendance figures and very little if any account has been taken of
the dependency these patients have for nursing care. BEST brings
1. To identify those nursery rhymes that feature head injury together a method of measuring patient numbers, patient depen-
among their main themes. dency and linking this to staffing numbers and skill mix based on
2. To construct a new nursery rhyme, using the original well FEN competency levels. BEST is a workforce planning tool for use
known characters, which will serve as an educational tool at local level in the emergency department (ED) to allow any dispar-
to young children in the event that they, or those around ity between nursing workload and staffing to be highlighted. The
them sustain a head injury. tool allows you to:
Discussion: Some of the most well known and loved nursery analyse the volume and pattern of nursing workload in your
rhymes, for example, ‘Humpty Dumpty’, ‘Jack and Jill’ and ‘Rock-a- ED
bye Baby’ involve the main characters sustaining a head injury of track this against your rostered staffing level
some description. However, no medical intervention is mentioned calculate the whole time equivalent workforce and skill mix
in any of the rhymes and, for the most part, the serious potential which would be required to provide the nursing care needed
implications of head injury are trivialised. in the department during the audit period.
The BEST calculation requires data to be collected and input for a

O18.1 seven-day period on an hour-by-hour basis. The calculations work
Working with Manchester triage – job satisfaction in nursing by using nurse-to-patient ratios in the various dependency catego-
ries. The ratios used by BEST are:
S. Forsgren, B. Forsman, E. Carlstrom
University West, Sweden total dependency – 2 nurses to 1 patient
high dependency – 1 nurse to 1 patient
Introduction: This study covers nurses’ job satisfaction during moderate dependency – 1 nurse to 2 patients
triage at emergency departments in Western Sweden. Method: Data low dependency – 1 nurse to 3.5 patients
were collected from 74 triage nurses using a questionnaire contain-
ing 37 short form open questions. The answers were analysed The hourly data sets used by BEST are:
descriptively and by measuring the covariance. Two open questions
patient dependency volume in the department using the Jones symposium to show how it can be linked with the Faculty of Emer-
Dependency Tool gency Nursing competencies and patient attendance numbers to
the total number of staff rostered to be clinical on shift in the form the Baseline Emergency Staffing Tool.
department. The JDT was developed in the late 1980’s to provide a means of iden-
tifying the patient dependency for nursing care. Since then it has been
used in a number of ways to improve care including the following:
O19.2
Symposium with papers O19.1 and O19.3 Individual patients can be allocated the most appropriately
Staffing & Skill Mix – the BEST way! (Faculty of Emergency skilled nurse to provide their care (competency).
Nursing (FEN) Competencies) Individual component headings can be used to identify spe-
cific risks to the patient
J. Windle, J. Youd, G. Jones The use of the JDT to review patient allocation to specific areas
Salford University, UK of the department
A clear picture of the workload at any given time can be
This paper presents the FEN competencies. It will include the his- obtained and this can be used to trigger actions to reduce
tory of their development, the purpose of using the competencies the workload when it reaches an agreed threshold
and linking two other papers in this symposium to show how it Planning nursing and other staffing establishments and skill mix
can be linked with the Jones Dependency Tool and patient atten-
dance numbers to form the Baseline Emergency Staffing Tool. Research demonstrated that the JDT is a valid and transferable
The Faculty of Emergency Nursing (FEN) is a body of nurses com- tool. The research also found a highly significant correlation between
mitted to ensuring patients who require emergency care receive the the JDT dependency scores and the nurse’s subjective rating of
highest standards of service. This is achieved through advancing patient dependency.
nursing practice, developing standards of care, advising and guiding The JDT comprises six key component headings (with relevant
emergency service. Key to achieving high standards is the FEN statements to guide the user); each one has three ratings. On arrival
competencies. and subsequently throughout the stay in the emergency department
FEN competencies are identified under eight key practice head- this provides the overall ratings that determine which of four depen-
ings: emergency care of the adult, prehospital care, major incident dency levels the patient falls into. Once the dependency level has
planning, care of the patient with psychological needs, major trauma been determined appropriate nursing intervention can take place
management, emergency care of the person with minor injury/ill- linking the competency of the nurse with the dependency level.
ness, emergency care of the child or younger person, and emergency
care of the older person. Competencies under each key practice O20.1
heading are sub-divided into core and specific competencies. When to put acute HIV infection in the differential diagnosis in
Each practice heading has three levels of competency – associate, the emergency room
member and fellow.
R.M. Grimes 1, D.E. Grimes 2, D.S. DeGarmo 2
1
University of Texas Health Science Center at Houston Medical School,
Level Definition
USA
Associate Competent emergency nurse who delivers evidence 2
Health Science Center at Houston School of Nursing, USA
based practice to patients presenting with
complaints, working under the direct guidance of a Purpose: 75–90% of HIV infected persons experience a condition
proficient emergency nurse known as acute HIV infection (AHI) within a few weeks of being
Member Proficient emergency nurse who delivers evidence infected. The purpose of this presentation is to assure that advanced
based care under minimal guidance with peer practice nurses (APNs) and other emergency nurses: (a) are aware of
support the likelihood of AHI appearing in the ER; (b) understand the impor-
Fellow Expert emergency nurse who draws on a large tance of early detection of HIV; (c) recognize the presenting signs
knowledge base and contributes to the development and symptoms; (d) know the new HIV detection tests for use in
of new evidence base of emergency practice, working the emergency room (ER); and (e) engage in the appropriate coun-
without supervision in any care setting. selling of these patients. Methods: We will present information
on: (a) frequency of acute HIV infection (AHI) appearing in the emer-
By linking the JDT with the FEN competencies an improved level of
gency room – 1–2% of febrile patients (1); (b) the highly infectious
patient care could be achieved.
nature of persons with recent infection – 8–26 times more likely
to infect others (2,3); (c) frequency of the most common signs and
symptoms with pictures where appropriate. We will show how the
common signs and symptoms of AHI (fever, rash, lymphadenopathy,
mucosal ulcers, anorexia, pharyngitis, myalgia, gastrointestinal
O19.3
symptoms) can be used to include AHI in the differential diagnosis
Symposium with papers O19.1 and O19.2
of febrile patients; (d) the fourth generation HIV test which can be
Staffing & Skill Mix – the BEST way! (Jones Dependency Tool)
used in the ER and which detects the presence of HIV within a week
of infection; (e) approaches to educating patients about their HIV
J. Windle, J. Youd, G. Jones status; and (f) mechanisms for referral. Results: The expected out-
Salford University, UK come is that APNs and other nurses will be more sensitive to the
This paper presents the Jones Dependency Tool (JDT). It will potential for AHI appearing in the ER, will be better able recognize
include the history of its development, purpose of using such a tool AHI, and have the skills to deal with the aftermath of discovering
in the emergency department, the research that has shown it to be a new HIV infection in a patient.
valid and transferable tool and linking it to two other papers in this
O20.2
Toxidromes: keys to clinical puzzles and guides for treatment of II. Spheres of Influence
poisoned patients A. Patient
B. Nurse
A.J. Tomassoni C. System
Yale University School of Medicine, USA D. CNS Interventions within the Spheres
The ability to recognize toxidromes is a powerful tool for emer- III. Barriers to Role Implementation
gency care. Toxidromes offer keys to the many puzzles that chal- A. Financial
lenge emergency care providers in the context of the patient B. Multidisciplinary Challenges
presenting with suspected poisoning, unexplained altered mental
status, unknown HazMat or chemical weapons exposure, or the IV. Strategies for Success
unknown overdose. The concept is especially important and applica- A. Job Description
ble in austere, alternative and disaster care settings where advanced B. Reporting Relationships
diagnostic tools are unavailable. To illustrate: arsenic poisoning is C. Personal Qualities
often only diagnosed post-mortem. Using the toxidrome concept, a D. Starting Out on the Right Foot
rural covert mass-poisoning with arsenic was solved well in advance E. Justifying Your Worth
of laboratory detection, allowing rapid deployment of life-saving
antidotes. The ability to recognize toxidromes and understand the V. Creating a Foundation for Professional Practice in the ED
physiology and pharmacology that causes them empowers providers A. Shared Governance Model
to evaluate and treat patients without unnecessary delays for labo- B. Evidence Based Practice
ratory tests that may not be available or may not provide necessary C. Standards
diagnostic data in real time. Toxidrome recognition may reduce our D. Competency
time to delivery of specific antidote therapy and improve selection of E. Implementing New Practices
supportive care practices tailored to the etiologic agent, improving
the quality of care for patients. Selected toxidromes that may be VI. Too Much of a Good Thing: Managing Success
caused by pharmaceuticals, common street drugs, over-the-counter A. Time Management
medications, selected herbs, selected hazardous materials and chem- B. Growth in the CNS Role
ical agents are presented. The focus is on toxidrome recognition
based on presenting vital signs, mental status and autonomic signs
and symptoms. Where specific antidotes for toxidromes exist, the
antidote(s) and their mechanism of action will be outlined. For those
toxidromes where special supportive measures are indicated these O21.2
too will be presented. Learners will be able to discuss how toxidrome There’s a RAT in the ED: an evaluation of a multidisciplinary
recognition can improve care delivery, cite the types of clinical approach to rapid assessment and treatment
observations needed to identify many toxidromes, list several toxi-
dromes and some agents that may cause them, and identify some
R.E. Pinate
antidotes and supportive care measures targeted to these toxi-
King’s College Hospital NHS Foundation Trust, UK
dromes.
King’s College Hospital is currently in the process of establishing
Rapid Assessment and Treatment + (RAT+) for Majors patients having
taken a multidisciplinary approach to its development. In particular
O21.1 we are in the process of establishing an Advanced Assessment Prac-
Actualizing the clinical nurse specialist role in the emergency titioner (AAP) role which will form part of the RAT+ team. The role is
department innovative in that it, in effect, creates a career pathway towards the
development of full Advanced Clinical Practitioners (ACPs) in EDs.
J.A. Proehl 1–3 Many departments are struggling to find ways in which they can
1
Proehl PRN, LLC, USA effectively develop their staff as full ACPs, this is one way in which
2 a training and development structure could be developed.
Dartmouth-Hitchcock Medical Center, USA
3
Gifford Medical Center, USA This work has been part of Health Education England’s, Better
Training, Better Care pilot work stream which has been supporting
This presentation will review the implementation and actualiza- this project since 2012. A key focus has been the measurement of
tion of the CNS (consultant practitioner) role in the ED. Barriers and the impact of RAT+. We have now completed 5 pilot phases and
strategies to overcome them will be addressed along with informa- we intend to roll this out full time in the coming months. After five
tion on creating an evidence-based practice environment, promoting pilots we have data reflecting the impact of the RAT+ team, key high-
standards of care, ensuring competency, working within a Shared lights are:
Governance model, implementing new practices, and time
management. ‘Time to treatment’:
RAT+ consistently achieved the 60 minute Quality Indica-
I. Roles tor (DH, 2010) for Majors patients (median = 53 minutes).
A. Educator The data support the hypothesis that the RAT+ model
B. Expert Clinician would reduce the time taken to being seen by a decision
C. Researcher making clinician with an 18.3 minute (24.3%) reduction
D. Consultant in mean ‘time to treatment’ when compared to the non-
E. Leader RAT control group. This is statistically significant,
F. The Unspoken "Subroles" P 0.0001.
‘Time to referral’ gap in senior clinical staff where it is most needed in the Emergency
The data support the hypothesis that the RAT+ model Department.
would reduce the time to referral to in-patient teams from
arrival with an 83.1 minute (43.6%) reduction in mean time
when compared to the non-RAT control group. This is sta- O22.2
tistically significant, P 0.0001. Benefits of having a pharmacist as part of the healthcare team in
‘Total time’ emergency medicine
RAT+ reduces the mean total time in the ED when com-
pared to the non-RAT control group by 23.7 minutes F. Colen, C. Peters, A. Burke, D. Schilling, R. Wadas, D. Abernethy
(10%). This is statistically significant, P = 0.013. UPMC, USA
This session/poster seeks to share our experiences in not
only establishing a developmental pathway for future ACPs Purpose: Emergency departments (ED) are fast paced work envi-
but also how a multidisciplinary approach to the care of ronments prone to medication errors and adverse drug events (ADE).
patients in the Majors area can have a real, measurable, Design: One year quality assurance pilot project. Setting: Urban ED,
impact. 56,000 annual visits Participants/subjects: Nurses, physicians, and
pharmacists. Methods: Pharmacy services were piloted through a
grant from a healthcare foundation. Interventions documented by
the pharmacist include: obtaining medication and allergy histories,
O22.1 drug information consults, dose adjustments/recommendations,
The use of paramedics in the emergency department ADE prevention, antibiotic recommendations, medication reconcilia-
resuscitation room tion, renal dose adjustments, code participations, high acuity patient
management, recommending discharge medications, patient educa-
tion, pharmacokinetic consult, and education to staff. A satisfaction
S. Davey
survey was distributed prior to pharmacist implementation with fol-
Croydon University Hospital, UK
low up surveys every three months. Staff surveys include evaluation
Croydon University Hospital Emergency Department (ED) has of: frequency of pharmacy consult, value of pharmacist in assisting
employed a team of senior nurses and paramedics to provide clinical with medication selection, value of a pharmacist as a patient educa-
excellence and patient safety in the resuscitation room. The use of tor and teaching resource, availability of pharmacist based in the ED,
paramedics in the hospital setting is a new and exciting way of value of pharmacist present during medical resuscitation, value of
bringing advanced assessment skills and expertise from the roadside pharmacist improving quality of care, value of the pharmacist as
to the bedside. The specialist team consists of an integral member of the ED team, time spent looking for medica-
tions, availability of medications, response to medication requests,
1 band 7 paramedic team leader and satisfaction of the pharmacy services. Results: The pharmacist
3 band 6 paramedics documented 1825 interventions, a cost savings of $523,353. Survey
3 experienced band 6 nurses results include: 56% increase in perception that the pharmacist is
Support of band 8a Matron/Lead for education an integral member of the ED team, 47% increase in perception that
1 member of the specialist team is allocated to work in the resus- the pharmacist improves quality of care, and 50% increase in percep-
citation room working alongside a nurse from the general Emer- tion that the pharmacist is valuable in assisting with selection of
gency Department team. This close team working aids in the appropriate medications, identification and management of drug
support and professional development of all staff with regard to interactions, and medication decisions in special situations. Implica-
maintaining high standards in resuscitation and emergency care. tions: The pharmacist is an integral member of the team in the ED.
The team primarily works in the resuscitation room to provide, Pharmacists are able to prevent ADEs, assist with delivery of patient
develop and co-ordinate high quality nursing care to patients care, and improve outcomes with significant cost savings. The results
attending with emergency care needs whilst maintaining a safe of this project allowed for expansion of pharmacy services to the ED.
and efficient resuscitation room.
A novel education and training programme, along with a newly
designed portfolio, has been devised to support educational needs O22.3
and to equip the team with the knowledge and skills required to Seeing beyond the image: developing the role of the radiographer
undertake this advanced role. The training has included advanced in the emergency department
adult and paediatric life support and advanced trauma life support.
These courses have been augmented with locally provided training S. Knight, N. Whistler, P. Morris
in ordering appropriate diagnostic investigations, performing and Ipswich Hospital NHS Trust, UK
interpreting arterial blood gases and difficult access techniques
including use of intraosseous methods. As well as these advanced Introduction: Health care professionals are constantly expanding
skills the paramedics required some basic areas of nursing care to their scope of practice as a proactive response to delivering effective,
be taught and assessed. These skills are not included in the paramed- efficient care. The Ipswich Hospital ED has an established Emergency
ics training but were required in the hospital setting. Nurse Practitioner service that sees minor injury and illness in adults
Each team member is supported by a band 7 mentor and a regis- and paediatrics, equating to about 25,000 attendances per year in
trar who will work alongside them and help support personal and 2013. The ED has implemented a number of changes in practice to
professional development and ensure portfolio development and improve flow of patients, reduced journey times, improved care,
competencies are completed. met patient expectations and government targets, while maintaining
This innovation will ensure that the sickest patients in the ED are high clinical standards. One idea initially explored with a reporting
cared for by a specialist team with advanced skills and expertise Advanced Practice Radiographer (APR), was the possibility of radiog-
whilst ensuring that all ED staff are developed to also be able to pro- rapher led discharge for groups of patients, but there was concern
vide safe and efficient care to level 1 and level 2 patients. We believe that there would be insufficient benefit for the patient and the ED.
that this novel way of working provides expertise and a solution to a The APR had already been contributing to the Minor Injuries course
run by the ED and had an excellent working relationship with the uncontrolled workload and high information intensity doing simul-
ENP/consultant team. Further discussion explored whether the APR taneous management of multiple tasks. In complex environments,
could undertake the role of seeing, treating and discharging patients such as the emergency department, this puts extra demands on
independently and the potential benefits for patients and the ED. the staff. Efficiency is highly regarded as important for the workflow,
Method: Discussions were held with the APR, radiography depart- however, quality and safety aspects should be more addressed. Pur-
ment, ENP Module leader, ED Educator and ED consultants about pose: To explore how registered nurses perceive working in an envi-
the possibility of the APR undertaking the Minor Injury Module ronment prone to multitasking and interruptions, and how it relates
and subsequently working in the ED seeing, treating and discharging to their everyday practice in the emergency department. Method:
patients alongside ENPs. Results: This collaborative working has The settings were two Swedish emergency departments. All regis-
resulted in the APR successfully completing the Minor Injury Mod- tered nurses were invited to participate. Participants varied in age
ule. The feedback throughout the supervised practice element of between 30 and 57 years and had ED working experiences varying
the course has been extremely positive and there has been no obser- between 5 and 27 years. Nine individual interviews were carried
vable differences in outcomes between the APR and trainee ENPs. out following an interview guide with open-ended questions. Tran-
The presence of a reporting APR working alongside ENPs has led to scripts were analyzed using Schilling’s five-level model for content
increased confidence and accuracy in X-ray interpretation. Discus- analysis. Results: The findings showed registered nurses’ percep-
sions are in place to use the APR on the ENP rota and to develop tions regarding their work, where multitasking was seen as an
the role and service further. attractive prerequisite, implying efficiency and not stressful. They
didn’t perceive multitasking as related to an increase risk of error.
However, the participants expressed their worries about new inex-
O23.1 perienced colleagues and other colleagues not managing stressful
Right clinician, right place, right time multitasking situations. Discussion: Findings show that registered
nurses working in the emergency department perceive multitasking
J. Windle and interruptions as characteristic in their everyday practice. The
Salford Royal NHS Foundation Trust, UK complex context and uncontrolled workload may not allow space
to further reflections on nursing practice and multitasking relating
Urgent or unplanned care arises when patients feel the need to to an increase risk of error. Clinical implications: These findings
access care quickly but health expenditure on these services remains add value to the discourse on multitasking and patient safety in
above sustainable levels nationally. One Trust has adopted an innova- the emergency departments, as few studies go beyond examining
tion to identify safe and efficient methods of deflecting patients away the quantitative aspects of this. However, more studies with larger
from urgent care services, with presentations that could and should be samples are needed. Reflective practice is encouraged to ensure safe
dealt with in primary care or elsewhere. The Manchester Triage Sys- high quality nursing practice.
tem 2005 (2nd Edition) Presentation Priority Matrix (PPM) was used
in a joint venture between the Emergency Department (ED) and the
local Primary Care Trust. The PPM was personalised by reviewing
the 50 presentations, across five priorities against a list of pre-deter- O23.3
mined dispositions where the patient could be best managed. The Assessing and improving the quality of pre-alert telephone calls
resulting protocol details those patients who can be safely deflected from the ambulance service to the emergency department
to primary or self-care, and those that should remain in the ED.
Patients deflected to their own GP in hours or self-care require a short
M.B. Holbrook 1,2, R.B. Way 3
consultation by trained practitioners, known locally as deflectors, 1
Health Education Wessex/Thames Valley, UK
ENPs and ECPs fulfil this role, where the conversation is equally as 2
South Central Ambulance Service NHS Foundation Trust, UK
important as the action. Deflections commenced in May 2011. In the 3
Oxford University Hospitals NHS Trust, UK
first year 6663 patients were deflected (7.8% total annual atten-
dances). The PPM has to date been revised three times and the current Introduction: Information loss at the point of handover is well
deflection rate remains around 12%. Half of all deflections are aged 18– known both anecdotally and documented in literature (Carter
35 years (50.1%). 73% of all deflections occur within 30 minutes of arri- et al., 2009; Talbot and Bleetman, 2007). National Confidential
val; 86% of deflected patients were identified as requiring urgent GP Enquiry into Patient Outcome and Death (2007) found only 50.1%
appointments, both in and out of hours. Deflection practitioners are of patients arriving in Emergency Departments (ED) had been pre-
empowered to use the process for direct patient benefit, demonstrat- alerted by the ambulance crew. Purpose: To assess the quality of
ing safe, reliable and reproducible decisions for increasing numbers of pre-alert telephone calls from the Ambulance Service to the ED
patients. In addition to deflecting patients to the right clinician, in the and strategies for improvement developed and tested. Methods: A
right place at the right time we are making the best use of both human retrospective audit of pre-alert telephone calls was conducted over
and physical resources across the primary/secondary interface. a period of one week. This was done by collecting copies of the
pre-alert handover forms in the ED. These were then assessed for
completeness of information. The recorded telephone calls were
O23.2 accessed via a web interface and in conjunction with the ED pre-alert
Multitasking in the emergency department: does it affect the handover forms the information was checked for correlation and
registered nurses’ perceptions of their everyday practice? against the ATMIST structure. Results: 90 calls were documented
as being received by the ED. 58 calls were recorded, of which 48
H. Forsberg Hvitfeldt 3, A. Muntlin Athlin 1,2, U. von Thiele Schwarz 3 recordings were directly comparable against the pre-alert forms.
1
Uppsala University, Sweden Information provision and documentation was >91% for Age, Mech-
2
University of Adelaide, Australia anism/Medical problem, Vital Signs and ETA. Injuries/exam findings
3
Karolinska Institutet, Sweden were provided 93.9% but only documented 81.3% of the time. Time of
injury/onset and treatment given were provided or documented in
Introduction: Multitasking is a well-known phenomenon in the <57% of cases. The ATMIST provided and documented in correct
emergency care context. This is often related to an unpredictable, order 52% and 54% respectively. Conclusion: Despite the use of a
mnemonic the structure and information provided are poor in some recorded using hand held electronic devises with VitalPacÒ software,
areas. Testing of alternative methods is currently under way. which calculated the EWS and produced an electronic observation
chart. All data collection has been completed. Results: We have ana-
References lysed results based on data completeness and accuracy of calculating
EWS. Block 1: 61.1% of attendances had a full set of vital-signs doc-
Carter, A.J.E., Davis, K.A., Evans, L.V., Cone, D.C., 2009. umented at any time during their stay in ED, and 52.7% (76.7% of
Information loss in emergency medical services handover those with charts) had an EWS completed. Block 2: 80.6% of atten-
of trauma patients. Prehospital Emergency Care. 13 (3), dances had a full set of vital-signs at any time during their stay in
280–285. ED, and 92% (99.3% of those enrolled through the App ) had an
National Confidential Enquiry into Patient Outcome and EWS completed. A greater proportion of vital-signs sets (10%) had
Death, 2602 2007. Trauma: Who Cares?, NCEPOD, London. an EWS score above 0. Further analysis is being completed and will
Talbot, R., Bleetman, A., 2007. Retention of information by be reported within the presentation. Conclusions: Electronic record-
emergency department staff at ambulance handover: do ing of vital-signs and automatic calculation of EWS improve the
standardised approaches work? Emergency Medicine accuracy and completeness of vital-sign documentation for patients
Journal. 24 (8), 539–542. in our ED. When analysing daily patterns, we observed that nursing
staff did more observations on the more unwell patients, when
guided by the electronic system.
O24.1
SMS picture text messaging as an adjunct in emergency medicine References
training of doctors and nurses – pilot project on feasibility in an
Irish health care setting National Institute of Clinical Excellence, 2007. Acutely Ill
Patients in Hospital: Recognition of and Response to Acute
L. Balleasty, S. Egan, R.M. Lynch, Y. McCague Illness in Adults in Hospital. Clinical Guideline 50, National
Midland Regional Hospital, Ireland Institute of Clinical Excellence. London, UK.
Smith, A.F., Oakley, R.J., 2006. Incidence and significance of
Introduction: Advances in mobile phone technology have aided errors in patient track and trigger system during an epi-
the development of new methods of instantaneous communication, demic of Legionnaires’ disease: retrospective case note
such as SMS picture messaging. Purpose: To assess the feasibility of analysis. Anaesthesia. 61, 222–228.
SMS picture messaging as an adjunct in Emergency Medicine (EM) Wilson, S.J., Wong, D., Clifton, D., Flemming, S., Way, R.,
training for doctors and nurses and identify factors which might Pullinger, R., et al., 2013. Track and trigger in an emergency
impact on it. Methods: Pilot project involving fifteen doctors and department: an observational evaluation study. Emergency
10 nurses in an Irish Emergency Department. SMS picture messages, Medicine Journal. 30 (3), 186–191.
with predetermined learning points, were sent to all participants on
Mondays, Wednesdays and Fridays over an eight week period. All
participants were asked to submit an answer to each question.
Reminders were sent after 24 hours to all non-responders. Discus- O24.3
sion: Overall satisfaction among participants was very high. The Revolutionising patient management in the ED. Developing and
response rate among doctors (70%) exceeded that for nurses (40%). implementing the paperless ED
Conclusion: This pilot project proved very popular with participants
and trainers. Technical issues proved frustrating at times and may
P. Bennett 1,2
pose difficulties for its use in EM training. 1
Stockport NHS Foundation Trust, UK
2
University of Manchester, UK
O24.2 The aim of this paper is to share the experiences of developing

Paper and electronic early warning scoring systems: review of and implementing an electronic patient tracking system together
6000 patients in the emergency department with an electronic patient record (EPR) in an Emergency Depart-
ment. Emergency Department EPRs are common in the US, Canada
R. Way 1, K. Warnes 1, S. Yousefi 1, S. Beer 1, M. Santos 2, D. Wong 2, and Australia but less so in the UK. Those that are in place are usually
S. Wilson 3, R. Pullinger 1, L. Tarassenko 2 commercial systems and can create as many problems as they solve
1
Oxford University Hospitals NHS Trust, UK (Bates et al., 2003). At Stockport a patient tracking and EPR was
2
University of Oxford, UK developed in-house as apposed to purchasing a commercial solution.
3
Heatherwood and Wexham Park Hospitals NHS Foundation Trust, UK AdvantisED was developed over a 6 month period by a team of IT
developers and ED clinicians. Launched in June 2013 it has solved
Introduction: UK ‘‘track and trigger’’ scoring systems use Early a multitude of previous data collection, workflow and coding prob-
Warning Scores (EWS) to assess patients’ illness severity (National lems. Staff enter and review all clinical data via desktop PCs or iPads.
Institute of Clinical Excellence, 2007) and at certain threshold values The bedside use of iPads by nursing and medical staff has increased
trigger certain additional actions. Accuracy and completeness of the mobility of staff, reduced delays and improved workload man-
chart based systems to generate such scores is variable (Smith and agement (Hulme et al., 2013) AdvantisED has improved clinical doc-
Oakley, 2006; Wilson et al., 2013). This study forms part of our umentation, clinical coding and electronically tracks each stage and
research into detecting deterioration in the Emergency Department clinical decision during the ED episode. A recent audit of ED clinical
(REC no. 08/H1307/56). Purpose: To evaluate the recording of documentation based on General Medical Council (2013) and Nurs-
patient observations on paper charts and electronic devices in the ing and Midwifery Council (2009) standards demonstrated 100%
ED. Methods: 3000 patients from ‘majors’ were recruited into each adherence in all areas. AdvantisED has direct links to clinical guide-
block, each over a 7 week period. In block 1, vital signs were recorded lines and with that the potential to ensure care and treatment is con-
onto paper observation charts with EWS. In block 2, vital signs were sistently based on the best evidence in a way not seen before.
References General Medical Council, 2013. Good Medical Practice,

GMC, London.
Bates, D.W., Kuperman, G.J., Wang, S., Gandhi, T., Kittler, A., Hulme, P., Bennett, P., Curr, I., Morriss, H., 2013. iPad use in the
Volk, L., et al., 2003. Ten commandments for effective clin- ED. A poster presentation. Quality and Innovation in
ical decision support: making the practice of evidence- Healthcare Conference.
based medicine a reality. Journal of the American Medical Nursing and Midwifery Council, 2009. Recording Keeping.
Informatics Association. 10 (6), 523–530. http:// Guidance for Nurses and Midwives, NMC, London.
dx.doi.org/10.1197/jamia.M1370.

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International Emergency Nursing 22 (2014) 237–260

Contents lists available at ScienceDirect

International Emergency Nursing

Oral abstracts – 1st Global Conference on Emergency Nursing

promptly; and (iii) communication (information, explanation). O2.2

Purpose: The primary objective in healthcare, at its most basic, is

References E.J. Baker 1,2, G. Lee 1

Introduction: Emergency department (ED) crowding and pro-

Introduction: The incorrect identiﬁcation of patients was out- O5.2

O7.2 C. Deiana, A. Bagnasco, L. Sasso

computerized component and a verbal component, and meet conﬁ- O8.2

Introduction: A man collapses and begins ﬁtting uncontrollably.

B. Kennedy 1,2, K. Curtis 1,2, D. Waters 1,2

O16.2 reported moderate levels of clinical autonomy and nurse/physician

The BEST calculation requires data to be collected and input for a

O24.2 The aim of this paper is to share the experiences of developing

References General Medical Council, 2013. Good Medical Practice,

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