Multi-site study exploring the experiences of security staff responding to mental health, drug health and behavioural challenges in the emergency department.

OBJECTIVE: This multi-site study aimed to give voice to the views and experiences of security staff in assisting with the response to the growing number of people with mental health, drug health and behavioural problems attending EDs. METHODS: Explorative qualitative research design, using semi-structured interviews were conducted with security staff (n = 26) working in three different emergency settings across New South Wales, Australia. The data were analysed thematically. RESULTS: Participants recognised that long waiting times in the ED 'guarding' patients frequently accounted for escalating behaviour and increased the likelihood of restrictive interventions. Security staff expressed concerns about safety and were uncomfortable with a sense of uncertainty regarding their legal position. They voiced frustration over limited communication and lack of information provided by clinical staff on patient background, and the coordination of incidents and ongoing patient care. There was a perception that security staff are not treated with respect and their input was not valued. CONCLUSION: Expecting non-clinicians to undertake a clinical role (often under stressful circumstances involving close patient contact) places security staff and patients in a precarious position. Greater clarity regarding the role of security staff and information that allows them to adequately and safely undertake their work is required. If security staff are expected to participate in patient care then access to relevant information and the ability to document their activities and patient interactions should be provided. The vital support role that security staff perform needs to be valued and respected.

Documenting the pre-implementation phase for a multi-site translational research project to test a new model Emergency Department-based mental health nursing care.

BACKGROUND: Presentation rates to Emergency Departments (ED) for people with mental health, drug health and behavioural problems are increasing. This necessitates a reorientation of health services and resources to meet this change in demand. AIMS: This multi-site translation research project aims to implement and evaluate an innovative model of mental health nursing care in three EDs across New South Wales (NSW) Australia. METHODS: Three EDs (one city, regional, and rural site) were selected to participate in the project. A qualitative mixed methods approach was used in the pre-implementation phase comprising clinician focus groups (n = 3) and face-to-face interviews with senior staff (n = 15). A planning day and site visits were conducted involving consultation with key clinical, management and executive staff. FINDINGS: Timeliness of consultations, lengthy assessment and documentation processes and delays in decisions regarding patient disposition were the main frustrations expressed by ED staff and hospital executives. A designated team of mental health nurses based in the ED to see patients from the point of triage was viewed favourably for supporting the therapeutic care of people with mental health, drug health and behavioural problems. However, several psychiatrists raised objections over the clinical governance of the team culminating in one site leaving the project. CONCLUSION: Implementing new models of care that require a change in thinking and practice can challenge power relations which subsequently impact on individual willingness to support proposed change. Therefore, even with demonstrated effectiveness, extensive consultation and high level support the cooperation of key local stakeholders is not always assured.

Triage, damned triage and statistics: Sorting out redundancy and duplication within an Emergency Department Presenting Problem Code Set to enhance research capacity.

BACKGROUND: Having a robust Emergency Department Presenting Problem Code Set (EDPPCS) is important for collecting and analysing data around Emergency Department (ED) activity, funding, bio-surveillance and research. This paper analyses the clinical utilisation of the current EDPPCS using two years worth of ED data collected as part of the larger state-wide Demand for Emergency Services Trends in Years 2010-2014 (DESTINY) project. This project proposes potential improvements in the current EDPPCS including a reduction in duplication and redundant clinical terms. METHODS: ED presenting problem fields were abstracted from the Emergency Department Data Collection (EDCC) Registry as entered by trained triage nurses. Frequencies of presenting problems were calculated and cross referenced with the EDPPCS. These were then categorised into clinically meaningful groups. RESULTS: There were 1,746,635million eligible ED presentations during January 2013 and December 2014 to 23 level 5 or 6 EDs. Of these, there were 64,849 unique presenting problem entries with 450 terms being used more than 100 times during the study period. Of those 450 terms, only 177 (39.3%) matched the current EDPPCS. CONCLUSION: Future iterations of the EDPPCS should be based on the evidence presented making it shorter, more comprehensive and systematic leading to improved triage performance, usefulness in research and bio-surveillance.

Randomised control trial of humidified high flow nasal cannulae versus standard oxygen in the emergency department.

OBJECTIVES: The aim of the study was to determine if oxygen delivered through humidified high flow nasal cannulae (HHFNC) reduced the need for escalation in ventilation management and work of breathing in the ED patients presenting with acute undifferentiated shortness of breath compared with standard oxygen therapy. METHODS: This was an unblinded randomised control trial conducted at two hospital EDs in Sydney, Australia. Eligible patients presenting with shortness of breath were randomised to HHFNC or standard oxygen therapy. Primary outcomes were the need to escalate ventilation therapy or a reduction in respiratory rate of 20% or more within 2 h of commencement. RESULTS: One hundred patients were enrolled in the trial. The intervention group receiving HHFNC was associated with a higher proportion of patients with a reduced respiratory rate at 2 h (66.7% vs 38.5%, P = 0.005) and a lower proportion of patients requiring escalation in ventilation therapy (4.2% vs 19%, P = 0.02) compared with standard oxygen therapy. CONCLUSIONS: The use of high flow nasal cannula oxygenation was associated with improved respiratory state in selected patients presenting to the ED with acute undifferentiated shortness of breath.