The effect of transition to specialty practice programs on Australian emergency nurses' professional development, recruitment and retention

BACKGROUND: To date, emergency nursing Transition to Specialty Practice Program (TSPP) evaluations have been single-site observational studies. The aim of this paper was to examine the professional development, recruitment and retention outcomes of Australian emergency nursing TSPPs. METHODS: An explanatory sequential design was used. Data were collected via online surveys and interviews of emergency Nurse Unit Managers and Nurse Educators. Survey data from EDs with TSPPs and EDs without TSPPs were compared. Qualitative data were analysed using content analysis. RESULTS: Data were collected from 118 EDs, and 13 interviews. TSPPs were offered in 72.1% of EDs. EDs with TSPPs had higher proportions of nurses with postgraduate qualifications (Mdn 28.3% vs. 22.1%, p=0.45) and Clinical Specialists (Mdn 16.4% vs. 6.3%, p=0.04). The median proportion of currently rostered nurses with TSPP completion was 34.2% in EDs with TSPPs introduced in 2000-2005 indicating ED high levels of retention. CONCLUSION: Emergency nursing TSPPs have had a positive effect on nursing professional development, recruitment and retention. To ensure consistency in outcomes and optimise reliability of emergency nursing skills and knowledge, a national emergency nursing TSPP framework is needed.

Early protection in sheep against intratypic heterologous challenge with serotype O foot-and-mouth disease virus using high-potency, emergency vaccine

In 2009-2011, spread of a serotype O foot-and-mouth disease virus (FMDV) belonging to the South East Asia topotype led to the culling of over 3.5 million cattle and pigs in Japan and Korea. The O1 Manisa vaccine (belonging to the Middle East-South Asian topotype) was used at high potency in Korea to limit the expansion of the outbreak. However, no data are available on the spread of this virus or the efficacy of the O1 Manisa vaccine against this virus in sheep. In this study, the early protection afforded with a high potency (>6 PD50) FMD O1 Manisa vaccine against challenge with the O/SKR/2010 virus was tested in sheep. Sheep (n=8) were vaccinated 4 days prior to continuous direct-contact challenge with donor sheep. Donor sheep were infected with FMDV O/SKR/2010 by coronary band inoculation 24h prior to contact with the vaccinated animals, or unvaccinated controls (n=4). Three of the four control sheep became infected, two clinically. All eight O1 Manisa vaccinated sheep were protected from clinical disease. None had detectable antibodies to FMDV non-structural proteins (3ABC), no virus was isolated from nasal swabs, saliva or oro-pharyngeal fluid and none became carriers. Using this model of challenge, sheep were protected against infection as early as 4 days post vaccination.

Hormonal and metabolic responses to repeated cycling sprints under different hypoxic conditions

OBJECTIVE: Sprint exercise and hypoxic stimulus during exercise are potent factors affecting hormonal and metabolic responses. However, the effects of different hypoxic levels on hormonal and metabolic responses during sprint exercise are not known. Here, we examined the effect of different hypoxic conditions on hormonal and metabolic responses during sprint exercise. DESIGN: Seven male subjects participated in three experimental trials: 1) sprint exercise under normoxia (NSE); 2) sprint exercise under moderate normobaric hypoxia (16.4% oxygen) (HSE 16.4); and 3) sprint exercise under severe normobaric hypoxia (13.6% oxygen) (HSE 13.6). The sprint exercise consisted of four 30s all-out cycling bouts with 4-min rest between bouts. Glucose, free fatty acids (FFA), blood lactate, growth hormone (GH), epinephrine (E), norepinephrine (NE), and insulin concentrations in the HSE trials were measured before exposure to hypoxia (pre 1), 15 min after exposure to hypoxia (pre 2), and at 0, 15, 30, 60, 120, and 180 min after the exercise performed in hypoxia. The blood samples in the NSE trial were obtained in normoxia at the same time points as the HSE trials. RESULTS: Circulating levels of glucose, FFA, lactate, GH, E, NE, and insulin significantly increased after all three exercise trials (P < 0.05). The area under the curve (AUC) for GH was significantly higher in the HSE 13.6 trial than in the NSE and HSE 16.4 trials (P < 0.05). A maximal increase in FFA concentration was observed at 180 min after exercise and was not different between trials. CONCLUSION: These findings suggest that severe hypoxia may be an important factor for the enhancement of GH response to all-out sprint exercise.

Clinical review criteria and medical emergency teams: evaluating a two-tier rapid response system

OBJECTIVES: To assess the prevalence of patients fulfilling clinical review criteria (CRC), to determine activation rates for CRC assessments, to compare baseline characteristics and outcomes of patients who fulfilled CRC with patients who did not, and to identify the documented nursing actions in response to CRC values. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional study using a retrospective medical record audit, in a universityaffiliated, tertiary referral hospital with a two-tier rapid response system in Melbourne, Australia. We used a convenience sample of hospital inpatients on general medical, surgical and specialist service wards admitted during a 24-hour period in 2013. MAIN OUTCOME MEASURES: Medical emergency team (MET) or code blue activation, unplanned intensive care unit admissions, hospital length of stay and inhospital mortality. For patients who fulfilled CRC or MET criteria during the 24- hour period, the specific criteria fulfilled, escalation treatments and outcomes were collected. RESULTS: Of the sample (N = 422), 81 patients (19%) fulfilled CRC on 109 occasions. From 109 CRC events, 66 patients (81%) had at least one observation fulfilling CRC, and 15 patients (18%) met CRC on multiple occasions. The documented escalation rate was 58 of 109 events (53%). The number of patients who fulfilled CRC and subsequent MET call activation criteria within 24 hours was significantly greater than the number who did not meet CRC (P < 0.001). CONCLUSIONS: About one in five patients reached CRC during the study period; these patients were about four times more likely to also fulfil MET call criteria. Contrary to hospital policy, escalation was not documented for about half the patients meeting CRC values. Despite the clarity of escalation procedures on the graphic observation chart, escalation remains an ongoing problem. Further research is needed on the impact on patient outcomes over time and to understand factors influencing staff response.

The emergency powers in Bangladesh: means for subversion of the rule of law?

The Constitution of Bangladesh empowers the President to proclaim an emergency on the actual or imminent ground of war or external aggression or internal disturbance. However, the insertion of ‘internal disturbance’ in the Constitution as a ground for invoking emergency has provided the executive with the opportunity to proclaim all the five emergencies in Bangladesh on this vague ground for purposes other than that of securing the life of the nation. Furthermore, in the absence of any effective constitutional mechanisms for scrutinising the exercise of emergency powers and a time limit on the continuation of a state of emergency, some of the proclamations of emergency continued even after the alleged threat posed to the life of the nation was over to perpetuate the survival of the party in power by repressing any political threat to the regime. This Article, therefore, recommends for insertion in the Constitution of Bangladesh detailed norms providing for legal limits on the wide power of the executive concerning the proclamation, administration and termination of emergency with a view to ensure that emergencies can no longer be resorted to as the effective means of discarding the rule of law.

Impact of automated dispensing cabinets on medication selection and preparation error rates in an emergency department: a prospective and direct observational before-and-after study

RATIONALE, AIMS AND OBJECTIVES: The implementation of automated dispensing cabinets (ADCs) in healthcare facilities appears to be increasing, in particular within Australian hospital emergency departments (EDs). While the investment in ADCs is on the increase, no studies have specifically investigated the impacts of ADCs on medication selection and preparation error rates in EDs. Our aim was to assess the impact of ADCs on medication selection and preparation error rates in an ED of a tertiary teaching hospital. METHODS: Pre intervention and post intervention study involving direct observations of nurses completing medication selection and preparation activities before and after the implementation of ADCs in the original and new emergency departments within a 377-bed tertiary teaching hospital in Australia. Medication selection and preparation error rates were calculated and compared between these two periods. Secondary end points included the impact on medication error type and severity. RESULTS: A total of 2087 medication selection and preparations were observed among 808 patients pre and post intervention. Implementation of ADCs in the new ED resulted in a 64.7% (1.96% versus 0.69%, respectively, P = 0.017) reduction in medication selection and preparation errors. All medication error types were reduced in the post intervention study period. There was an insignificant impact on medication error severity as all errors detected were categorised as minor. CONCLUSION: The implementation of ADCs could reduce medication selection and preparation errors and improve medication safety in an ED setting.

Spinal immobilisaton in pre-hospital and emergency care: A systematic review of the literature

Background: Spinal immobilisation has been a mainstay of trauma care for decades and is based on the premise that immobilisation will prevent further neurological compromise in patients with a spinal column injury. The aim of this systematic review was to examine the evidence related to spinal immobilisation in pre-hospital and emergency care settings. Methods: In February 2015, we performed a systematic literature review of English language publications from 1966 to January 2015 indexed in MEDLINE and Cochrane library using the following search terms: 'spinal injuries' OR 'spinal cord injuries' AND 'emergency treatment' OR 'emergency care' OR 'first aid' AND immobilisation. EMBASE was searched for keywords 'spinal injury OR 'spinal cord injury' OR 'spine fracture AND 'emergency care' OR 'prehospital care'. Results: There were 47 studies meeting inclusion criteria for further review. Ten studies were case series (level of evidence IV) and there were 37 studies from which data were extrapolated from healthy volunteers, cadavers or multiple trauma patients. There were 15 studies that were supportive, 13 studies that were neutral, and 19 studies opposing spinal immobilisation. Conclusion: There are no published high-level studies that assess the efficacy of spinal immobilisation in pre-hospital and emergency care settings. Almost all of the current evidence is related to spinal immobilisation is extrapolated data, mostly from healthy volunteers.

The effect of a staged, emergency department specific rapid response system on reporting of clinical deterioration

BACKGROUND: Despite emerging evidence regarding clinical deterioration in emergency department (ED) patients, the widespread uptake of rapid response systems (RRS) in EDs has been limited. AIMS: To evaluate the effect of an ED RRS on reporting of clinical deterioration and determine if there were differences between patients who did, and did not, deteriorate during ED care. METHODS: A retrospective cross sectional design was used to conduct this single site study in Melbourne, Australia. Stratified random sampling identified 50 patients with shortness of breath, chest pain or abdominal pain per each year studied (2009-2012) giving a total of 600 patients. The intervention was an ED RRS implemented in stages. RESULTS: The frequency of clinical deterioration was 14.8% (318 episodes/89 patients). Unreported deterioration decreased each year (86.7%; 68.8%; 55.3%; 54.0%, p=0.141). Patients who deteriorated during ED care had a longer median ED length of stay (2.8h; p<0.001), were 31.9% more likely to need hospital admission (p<0.001) and 4.9% more likely to die in hospital (p=0.044). CONCLUSIONS: A staged ED specific RRS decreased the frequency of unreported clinical deterioration. Controlled multi-site studies of ED specific RRSs are needed to examine the effect of formal ED RRSs on patient outcomes.

States of emergency

 Dark legacies combined with ‘moral panic’ and ‘extraordinary measures’ have slowly shaped attitudes in Australia and Italy towards asylum-seekers into something increasingly dangerous.

Dual-axis hormonal covariation in adolescence and the moderating influence of prior trauma and aversive maternal parenting

Adversity early in life can disrupt the functioning of the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal axes and increase risk for negative health outcomes. The interplay between these axes and the environment is complex, and understanding needs to be advanced by the investigation of the multiple hormonal relationships underlying these processes. The current study examined basal hormonal associations between morning levels of cortisol, testosterone, and dehydroepiandrosterone in a cohort of adolescents (mean age 15.56 years). The moderating influence of childhood adversity was also examined, as indexed by self-reported trauma (at mean age 14.91), and observed maternal aggressive parenting (at mean age 12.41). Between-person regressions revealed significant associations between hormones that were moderated by both measures of adversity. In females, all hormones positively covaried, but also interacted with adversity, such that positive covariation was typically only present when levels of trauma and/or aggressive parenting were low. In males, hormonal associations and interactions were less evident; however, interactions were detected for cortisol-testosterone - positively covarying at high levels of aggressive parenting but negatively covarying at low levels - and DHEA-cortisol - similarly positively covarying at high levels of parental aggression. These results demonstrate associations between adrenal and gonadal hormones and the moderating role of adversity, which is likely driven by feedback mechanisms, or cross-talk, between the axes. These findings suggest that hormonal changes may be the pathway through which early life adversity alters physiology and increases health risks, but does so differentially in the sexes; however further study is necessary to establish causation.

Physiological status during emergency department care : relationship with inhospital death after clinical deterioration

OBJECTIVE: To examine the relationship between patient physiological status in the emergency department (ED) and inhospital mortality after rapid response team (RRT) or cardiac arrest team (CAT) activations within 72 hours of emergency admission to medical or surgical wards. DESIGN, SETTING AND PARTICIPANTS: A multisite, retrospective, cohort study of 660 randomly selected (220 patients per site) adult medical or surgical patients who were admitted from the ED during 2012 and who had had an RRT or CAT activation within 72 hours of admission, at three hospitals in Melbourne, Australia. MAIN OUTCOME MEASURE: Inhospital mortality. RESULTS: There were 825 RRT activations (for 634 patients) and 42 CAT activations (for 35 patients). The median time to the first RRT or CAT activation was 18.8 hours and was significantly shorter in patients who died in hospital (14.6 v 20.6 hours, P=0.036). Compared with survivors, patients who died were more likely to have at least one observation meeting RRT criteria during their ED stay (45.9% v 34.8%; P=0.029): tachypnoea (21.1% v 13.4%, P=0.039), hypotension (20.2% v 11.8%, P=0.018), hypoxaemia (8.3% v 3.1%, P=0.001) and altered conscious state (6.2% v 1.3%, P=0.001) were more common in patients who died. The risk-adjusted odds ratio (OR) for inhospital death was highest for patients with an altered conscious state during their ED stay (OR, 4.633; 95% CI, 1.365-15.728; P=0.014). CONCLUSIONS: In patients who needed an RRT or CAT activation within the first 72 hours of emergency admission to medical or surgical wards, there was a strong association between physiological derangement during ED care and inhospital death.

Cancer diagnosed in the emergency department of a regional health service

OBJECTIVE: Patients diagnosed with cancer in the Emergency Department (ED) have more advanced disease at diagnosis and poorer outcomes. High rates of initial presentation to ED suggest potential problems with access to care. The aim of this project was to interpret findings in regional/rural Victoria and explore implications for practice.

DESIGN: Cross-sectional study linking two independent data sets.

SETTING: Regional city of Geelong and surrounding rural areas in south-west Victoria.

PARTICIPANTS: All newly diagnosed cancer patients in 2009.

MAIN OUTCOME MEASURES: Number of cancer patients diagnosed in the ED.

RESULTS: One in five newly diagnosed cancer patients present to ED 6 months prior to cancer diagnosis. One in 10 is diagnosed as a result of their ED visit. Patients presenting to ED were older, more often men and from disadvantaged areas. Symptoms on presentation included chest complaints, bowel obstruction, abdominal pain, anaemia and generalised weakness. Cancer diagnosed in the ED is associated with advanced stage and shorter survival.

CONCLUSION: Reasons for presentation to ED would be multifactorial and include complex cases with coexisting symptoms making diagnosis difficult. The general public appear to have a low level of awareness of alternative primary care services or difficulty accessing such information. Some of the changes towards reducing the number of patients presenting to ED will include patient education.

Prediciton of emergency events: a multi-task multi-label learning approach

Prediction of patient outcomes is critical to plan resources in an hospital emergency department. We present a method to exploit longitudinal data from Electronic Medical Records (EMR), whilst exploiting multiple patient outcomes. We divide the EMR data into segments where each segment is a task, and all tasks are associated with multiple patient outcomes over a 3, 6 and 12 month period. We propose a model that learns a prediction function for each task-label pair, interacting through two subspaces: the first subspace is used to impose sharing across all tasks for a given label. The second subspace captures the task-specific variations and is shared across all the labels for a given task. The proposed model is formulated as an iterative optimization problems and solved using a scalable and efficient Block co-ordinate descent (BCD) method. We apply the proposed model on two hospital cohorts - Cancer and Acute Myocardial Infarction (AMI) patients collected over a two year period from a large hospital emergency department. We show that the predictive performance of our proposed models is significantly better than those of several state-of-the-art multi-task and multi-label learning methods.