Measuring sustainable practice change of the sepsis guideline in one emergency department: A retrospective health care record audit.

AIMS AND OBJECTIVES: To explore the longitudinal impact of the New South Wales Sepsis guideline on time to antibiotics, triage assessment and emergency management before and four years after guideline implementation. BACKGROUND: Globally, sepsis continues to be a significant cause of mortality and morbidity within hospitals. To reduce avoidable adverse patient outcomes the corner stone has been to improve the early recognition and management of sepsis. The New South Wales government in Australia introduced sepsis guidelines into Emergency Departments. However, the longitudinal impact of the sepsis guideline, has never been conducted. METHODS: A 12-month retrospective randomised health care record audit of adult patients with a sepsis diagnosis was conducted 12-months before and four years after implementation of the sepsis guideline. RESULTS: This study demonstrated sustained improvement in allocation of urgent triage categories in the follow-up group (n = 43; 53.1%) and a reduction in the median time to antibiotics from 189 min to 102 min (p ≤ 0.001) after the implementation of the sepsis guideline. CONCLUSION: The study has demonstrated the sepsis guideline has improved a sustained change in early assessment, recognition and management of patients presenting with sepsis in one tertiary referral Emergency Department.

Recognition, response and outcomes of sepsis: A dual site retrospective observational study.

OBJECTIVES: To describe clinical recognition, response and outcomes of patients with sepsis. METHODS: A retrospective, observational study was undertaken at two hospitals. Inclusion criteria were: adult patients admitted via the Emergency Department (ED) between 1 January and 30 April 2014 allocated a primary ICD-10-AM discharge from hospital code related to sepsis. Recognition of sepsis was considered based on the presence of clinical documentation that reflects the Sepsis Kills criteria being met. Response to sepsis was considered based on the presence of clinical documentation where the patient received a response consistent with the 'Sepsis Six' strategies. Outcomes pertained to response to sepsis (e.g. time to antibiotics) and ED measures (e.g. time to be seen, ED length of stay). Sub-group analysis considered location where sepsis was recognised (ED/ward). RESULT: In total, 96 patients met the inclusion criteria; most were admitted under general medicine (37%) followed by intensive care (18%). Sepsis was recognised in the ED for most patients (n = 64), with a history of fevers/rigors the most common (60%) indication of infection. Regarding response and ED outcomes for this group, the median time from triage nurse assessment i) to being seen by the treating clinician was 19 min; ii) to sepsis recognition was 27 min; and iii) to antibiotics was 181 min; 35% received antibiotics within 60 min from recognition. Those recognised in the ED had a longer ED stay than those where sepsis was recognised on the ward (336 min vs. 225 min, p = 0.013). CONCLUSIONS: Sepsis can develop at various stages throughout the patient's journey. In this small sample, ED recognition was associated with longer ED stay, likely due to more interventions. Whilst guidelines recommend antibiotics be administered within 60 min of triage, this was not achieved for most patients. Given the dynamic nature of sepsis, future indicators may focus on time from recognition rather than time from triage.

The Emergency Department Response to Women Experiencing Intimate Partner Violence: Insights From Interviews With Clinicians in Australia.

BACKGROUND AND OBJECTIVES: Emergency departments (EDs) are essential providers of compassionate, immediate treatment and referral for women experiencing intimate partner violence (IPV). IPV, largely perpetrated by men against women, exerts a substantial burden on the health systems and economies of all nations. There is little known about how staff in Australian EDs respond to the challenges such violence generates. We therefore examined the clinical team response to women experiencing IPV in two large Australian metropolitan hospital EDs. METHODS: We undertook qualitative semistructured interviews and focus group discussions with 35 social workers, nurses, and doctors. Transcripts were recorded and transcribed verbatim. We analyzed the data thematically. We first undertook line-by-line coding and organized content into descriptive categories. Latent and manifest patterns were identified across the data and mapped to key themes in negotiation with all authors. RESULTS: Respondents emphasized challenges identifying IPV resulting from professional uncertainty or discomfort and women's fear of the ramifications of disclosure. Emergency clinicians routinely referred women to social workers after medical treatment and described effective collaboration across professions. Social workers outlined difficulties coordinating care with health and community agencies. Staff highlighted challenges maintaining nonjudgmental attitudes and managing their own feelings-especially clinicians who had personally experienced violence. CONCLUSIONS: Emergency departments can provide caring environments for women experiencing IPV. Effective interprofessional teamwork across nursing, medical, and social work professionals may mitigate the need for formal screening tools. Supportive workforce environments can improve staff understanding, reduce stigma, enhance appropriate treatment, and counsel health professionals experiencing violence. However, staff training and advocacy and referral relationships with local programs require strengthening. A connected multisystems-level response is required to coordinate and resource services for all affected by violence.

Transition support for new graduate nurses to rural and remote practice: A scoping review.

BACKGROUND: New graduate nurses undertaking transition to practice encounter enormous challenges in their first year, and this is expounded in rural and remote locations. In rural and remote settings where geographical isolation and inadequate resources impact health care delivery, there is a perceived shortage of support systems to assist new graduate nurses to transition smoothly, with reported negative effects for all staff and on recruitment and retention. OBJECTIVES: To investigate what transition support was reported for new graduate nurses to function effectively in rural and remote settings. DESIGN: A study protocol was developed using principles for scoping reviews that have been developed over the past fifteen years. DATA SOURCES: CINAHL, Medline, Proquest, Embase, Informit, PubMed, and Science Direct were systematically searched according to a predetermined search strategy. REVIEW METHODS: Search terms included New Graduate AND Rural OR Remote AND Education. Studies were selected according to an inclusion and exclusion criteria. Three reviewers were involved in independent screening of articles. The degree of agreement for an article to be included was based on a Kappa score calculation for inter-rater reliability. RESULTS: Of the 662 articles searched, 13 met the inclusion criteria and their findings synthesised to form this review. Three overarching themes (and a number of subthemes) were identified within the context of rural and remote nursing workforce development, and included: new graduates' support needs, multifaceted support strategies and recruitment and retention strategies. CONCLUSIONS: Challenges faced by new graduate nurses when transitioning to practice are exacerbated in most rural and remote settings due to resourcing, lack of structured support programs, lack of training for support staff to mentor and give feedback and this impacts on recruitment and retention as well. Structured, well supported transition programs that provide flexible support are urgently required in these settings.

The impact of evidence-based sepsis guidelines on emergency department clinical practice: a pre-post medical record audit.

AIMS AND OBJECTIVES: To explore the number of patients presenting with sepsis before and after guideline implementation; the impact of sepsis guidelines on triage assessment, emergency department management and time to antibiotics. BACKGROUND: Sepsis remains one of the leading causes of mortality and morbidity within hospitals. Globally, strategies have been implemented to reduce morbidity and mortality rates, which rely on the early recognition and management of sepsis. To improve patient outcomes, the New South Wales government in Australia introduced sepsis guidelines into emergency departments. However, the impact of the guidelines on clinical practice remains unclear. DESIGN/METHODS: A 12-month pre-post retrospective randomised medical record audit of adult patients with a sepsis diagnosis. Data were extracted from the emergency department database and paper medical record. Data included patient demographic (age, gender), clinical information (time of arrival, triage code, seen by time, disposition, time to antibiotic, pathology, time to intravenous fluids) and patient assessment data (heart rate, respiratory rate, blood pressure, temperature, oxygen saturations, medication). RESULTS: This study demonstrated a statistically significant 230-minute reduction in time to antibiotics post implementation of the guidelines. The post group (n = 165) received more urgent triage categories (n = 81; 49·1%), a 758-minute reduction in mean time to second litre of intravenous fluids and an improvement in collection of lactate (n = 112, 67·9%), also statistically significant. CONCLUSIONS: The findings highlight the impact the guidelines can have on clinician decision-making and behaviour that support best practice and positive patient outcomes. The sepsis guidelines improved the early assessment, recognition and management of patients presenting with sepsis in one tertiary referral emergency department. RELEVANCE TO CLINICAL PRACTICE: The use of evidenced-based guidelines can impact clinical decision-making and behaviour, resulting in the translation and support of best practice and improving patient care.

Utility of peripheral intravenous cannulae inserted in one tertiary referral emergency department: A medical record audit.

INTRODUCTION: Peripheral intravenous cannulation is a common intervention performed within the Emergency Department (ED). However, studies have shown that while patients may have a cannulae inserted they are often unused. Across Australia, it is unclear the frequency and use of peripheral intravenous cannulae (PIVC) within the emergency setting. METHOD: A one-month retrospective randomised medical record audit of adult patients was conducted. Data were retrieved from the ED electronic database and the paper medical record. Data included: patient demographic (age, gender) and clinical information (time of arrival, triage category, presenting problem, discharge diagnostic code, and disposition) and cannula usage (time of fluids, pharmacological agents, pathology, radiological investigations, other diagnostic uses). RESULTS: Of the 357 patients, 209 (58.5%) had a peripheral intravenous cannula inserted. Of the 209 patients a total of 233 cannulae were inserted. Of the patients with a cannulae 190 (90.9%) were used within 72 h. The majority of cannulae (68.9%; n=131) had more than one medical intervention. CONCLUSION: The majority of PIVCs inserted during the ED visit were used for medical treatment. The majority of devices were used for intravenous fluids medications and were accessed for multiple interventions. For future audit purposes improved documentation of this procedure is needed.