Challenging the culture of Emergency Department violence and aggression.

AIMS: To examine reported levels of violence and aggression within a tertiary level emergency department in New Zealand, and to compare incident reporting within a dedicated yearly audit period to standard organisational reporting procedures. METHOD: A prospective, longitudinal cohort study involving repeated yearly audits of violence and aggression reported by emergency department staff from 2014-2020. RESULTS: Episodes of violence and aggression were reported at high levels during audit months compared to standard reporting, suggesting current systems do not accurately reflect the presence of violence and aggression. Levels of reported violence and aggression remained relatively static over a seven-year period, despite increasing emergency department attendances. Most events reported involved verbal abuse from patients, and occurred on weekend and night shifts. A number of potentially contributing factors were identified. CONCLUSIONS: Persistently higher levels of violence and aggression were reported during the targeted audit months, while reporting via the organisation's formal system during the intervening months remained at low levels. Further research is essential to monitor trends, assess the effectiveness of interventions to improve reporting, modify factors contributing to violence and aggression, and to address the impact on staff and bystanders affected in emergency departments.

Mental health presentations to Christchurch Hospital Emergency Department during COVID-19 lockdown.

OBJECTIVE: To describe mental health presentations to a tertiary ED in New Zealand during a national COVID-19 lockdown. METHODS: A retrospective, comparative cohort study in Christchurch Hospital, New Zealand. RESULTS: There was a 3510 (37%)-patient decrease in all presentations to Christchurch Hospital ED during the 5-week COVID-19 lockdown period from 26 March 2020 to 28 April 2020, compared to a 111 (1.2%)-patient decrease in the same time period in the previous year (P < 0.00001). There is usually a seasonal reduction in mental health attendances at this time of year compared to the weeks before. In 2019, there was a 49 (9.8%)-patient reduction in mental health presentations, whereas in 2020 there was a 193 (34%)-patient reduction (P < 0.001). In 2020, the proportion of mental health attendances compared to all ED attendances during the 5-week lockdown period was similar to the 5-week pre-lockdown period (564/9460 vs 371/5950, P = 0.48). The proportion of mental health patients presenting due to overdose increased by 6.5% (158/564 vs 128/371, P = 0.035); those due to self-harm increased by 3.5% (35/564 vs 36/371, P = 0.049). The proportion of mental health presentations due to anxiety, depression and other non-self-harm/overdose complaints decreased by 10% (371/564 vs 207/371, P = 0.002). The proportion of overdoses of paracetamol and ibuprofen increased by 13.4% during lockdown (22/158 vs 35/128, P = 0.005). CONCLUSIONS: During the COVID-19 lockdown, both overall ED presentations as well as mental health-related presentations decreased. There was a relative increase in overdoses and self-harm, particularly involving paracetamol and ibuprofen.

Management of the aggressive emergency department patient: non-pharmacological perspectives and evidence base.

INTRODUCTION: Aggression in the Emergency Department (ED) remains an ongoing issue, described as reaching epidemic proportions, with an impact on staff recruitment, retention, and ability to provide quality care. Most literature has focused on the definition (or lack of) core concepts, efforts to quantify the phenomenon or provide an epidemiological profile. Relatively little offers evidence-based interventions or evaluations of the same. AIM: To identify the range of suggested practices and the evidence base for currently recommended actions relating to the management of the aggressive Emergency Department patient. METHODS: A meta-synthesis of existing reviews of violence and aggression in the acute health-care setting, including management of the aggressive patient, was undertaken. This provided the context for critical consideration of the management of this patient group in the ED and implications for clinical practice. RESULTS: An initial outline of issues was followed by a systematic search and 15 reviews were further assessed. Commonly identified interventions are grouped around educational, interpersonal, environmental, and physical responses. These actions can be focused in terms of overall responses to the wider issues of violence and aggression, targeted at the pre-event, event, or post-event phase in terms of strategies; however, there is a very limited evidence base to show the effectiveness of strategies suggested. CLINICAL IMPLICATIONS: The lack of evidence-based intervention strategies leaves clinicians in a difficult situation, often enacting practices based on anecdote rather than evidence. Local solutions to local problems are occurring in a pragmatic manner, but there needs to be clarification and integration of workable processes for evaluating and disseminating best practice. CONCLUSION: There is limited evidence reporting on interventional studies, in addition to identification of the need for high quality longitudinal and evaluation studies to determine the efficacy of those responses that have been identified.

Violence and aggression in the emergency department is under-reported and under-appreciated.

AIM: To examine levels of reporting of violence and aggression within a tertiary level emergency department in New Zealand, and to explore staff attitudes to violence and reporting. METHOD: A one-month intensive, prospective audit of the emergency department's violence and aggression reporting was undertaken and compared with previously reported data. RESULTS: There was a significant mismatch between the number of events identified during the campaign month and previously reported instances of violence and aggression. The findings identified that failure to report acts of violence was common. CONCLUSIONS: Reports of violence and aggression in the emergency department underestimate the true incidence. Failure to report has potential impacts on organisational recognition of risk and the ability to develop appropriate policy responses.

The initial health-system response to the earthquake in Christchurch, New Zealand, in February, 2011.

At 1251 h on Feb 22, 2011, an earthquake struck Christchurch, New Zealand, causing widespread destruction. The only regional acute hospital was compromised but was able to continue to provide care, supported by other hospitals and primary care facilities in the city. 6659 people were injured and 182 died in the initial 24 h. The massive peak ground accelerations, the time of the day, and the collapse of major buildings contributed to injuries, but the proximity of the hospital to the central business district, which was the most affected, and the provision of good medical care based on careful preparation helped reduce mortality and the burden of injury. Lessons learned from the health response to this earthquake include the need for emergency departments to prepare for: patients arriving by unusual means without prehospital care, manual registration and tracking of patients, patient reluctance to come into hospital buildings, complete loss of electrical power, management of the many willing helpers, alternative communication methods, control of the media, and teamwork with clear leadership. Additionally, atypical providers of acute injury care need to be integrated into response plans.

Emergency department overcrowding: the Emergency Department Cardiac Analogy Model (EDCAM).

Increasing patient numbers, changing demographics and altered patient expectations have all contributed to the current problem with 'overcrowding' in emergency departments (EDs). The problem has reached crisis level in a number of countries, with significant implications for patient safety, quality of care, staff 'burnout' and patient and staff satisfaction. There is no single, clear definition of the cause of overcrowding, nor a simple means of addressing the problem. For some hospitals, the option of ambulance diversion has become a necessity, as overcrowded waiting rooms and 'bed-block' force emergency staff to turn patients away. But what are the options when ambulance diversion is not possible? Christchurch Hospital, New Zealand is a tertiary level facility with an emergency department that sees on average 65,000 patients per year. There are no other EDs to whom patients can be diverted, and so despite admission rates from the ED of up to 48%, other options need to be examined. In order to develop a series of unified responses, which acknowledge the multifactorial nature of the problem, the Emergency Department Cardiac Analogy model of ED flow, was developed. This model highlights the need to intervene at each of three key points, in order to address the issue of overcrowding and its associated problems.