Canadian Journal of Emergency Nursing (CJEN)
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Editorial: Wellness and resilience: Beyond buzzwords and BS
Full text linkA friend recently quit after 25 years working in healthcare. His parting words were memorable and chilling: “When I started this job I was given a bag for cash and a bag for crap; both bags are now full, so I’m outta here.” This ICU doctor did not know whether to cheer or cringe, but I understood where he was coming from. Hopefully you cannot relate, but I suspect many can. If so, then it’s time for a proper chat. I’ll share a few dark secrets, in the hopes that you feel safe doing the same
Emergency Nurses’ Perceptions of Leadership Strategies and Intention to Leave: A scoping review of the literature
Full text linkBackgroundRetention of registered nurses in emergency departments (EDs) is as a critical issue, further exacerbated by the COVID pandemic. Leaders influence work life and working environment, but it is unclear what strategies leaders use to address nurse staffing issues in the ED. The purpose of this scoping review is to understand if leadership strategies used in EDs have links to nursing retention and turnover.
MethodologyThis scoping review was completed with a comprehensive search within Cumulative Index to Nursing and Allied Health Literature, EMCARE, EMBASE. Two authors developed inclusion and exclusion criteria, did title and abstract screening, and full text screening using review software. Data extracted from included studies was analyzed to determine leadership strategies and relationships to intent to stay, retention, intent to leave, or turnover.
ResultsOf the 553 records identified, nine met inclusion criteria. Leadership strategies identified in the studies included support from supervisor, engagement by the leader, organizational culture assessment, and a cultural change toolkit. No leadership strategy influenced nurse intention to stay, retention, intention to leave or turnover.
ConclusionEmergency nurse retention and the prevention of turnover is a multidimensional issue stemming from various factors that may not be controllable due to the nature of the setting. However, leaders can implement strategies and provide support to staff to enhance quality of work life and the work environment. More information is needed to understand how leaders can influence the current and future supply of emergency nurses to produce quality patient care outcomes
Impacts de la COVID-19 sur le système cardiovasculaire
Full text linkSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an infectious disease where symptoms can be mild, requiring no treatment or severe, requiring hospital admission for hemodynamic support and mechanical ventilation. Given the affinity of SARS-CoV-2 to angiotensin-converting enzyme 2 (ACE2) receptors, the heart is a highly susceptible target to its associated damages. Knowledge about SARS-CoV-2 modes of transmission and their impact on the cardiovascular system is paramount for emergency department (ED) nurses to protect themselves and competently care for their patients. The authors of this manuscript aim to provide a clinical overview of the impact of SARS-CoV-2 on the cardiovascular system based on the latest scientific evidence. A profound understanding of SARS-CoV-2 and its related consequences has the potential to minimize its associated mortality and morbidity.
 
The Impact of Standardized Interprofessional Rounds on Critically Ill Patients in the Emergency Department: A Quality Improvement Initiative
Full text linkBackground & Local Problem
ED boarded ICU patients are generally not included in interprofessional ICU rounds. The project objective was to implement interprofessional rounds in the ED on boarded ICU patients.
Methods & Interventions
ICU patients in the ED were followed for two months from admission to transfer. The primary outcome was feasibility of ED ICU rounds, measured as the proportion of days on which rounds occurred. Secondary outcomes included communication quality, time to oral intake, and DVT prophylaxis documentation.
Results
A total of 92 patients were included in this project. Rounds occurred on 33 of 36 possible days. Following rounds, nurses and physicians reported improved communication. New DVT prophylaxis orders were written for 42% of cases, and 61 near miss events were corrected. Time from patient ED presentation to first oral intake decreased from 28 to 17 hours.
Conclusions
Interprofessional rounds in the ED are feasible, improve patient care, and enhance communication among team members.
 
Use of rational subgrouping to identify areas for improving time to ultrasound performance
Full text linkBackground: Safe, high-quality care within emergency departments includes the provision of efficient diagnostic and testing. At the Alberta Children’s Hospital, emergency department (ED) and radiology staff have anecdotally noted delays for some patients in the completion of abdominal and pelvic ultrasounds. Rational subgrouping is an approach that stratifies data into multiple groups for display in control charts to minimize in-group variability and maximize between-group variability. The aim of this project was to identify subgroups based on demographic factors, shift type, and disposition status that experience longer time to completion, in order to identify targeted areas for improvement.
Methods: A working group of interprofessional stakeholders was formed, including emergency physicians, an emergency QI nurse, a radiologist and a sonographer. Existing protocols were reviewed. These included recent changes that had been implemented but not yet systemically evaluated, including specifying ultrasound indications that require bladder filling, revising bladder filling protocols, specifying requirements for radiologist approval, and clarifying flow and communication processes.
Abdominal and pelvic ultrasounds conducted in the Alberta Children’s Hospital ED from May 2019 to April 2021 were included. This range encapsulated data points both before and after the declaration of the COVID-19 pandemic on Mar 11, 2020, which notably reduced ED volumes. Time stamps were obtained from the electronic health record for the time of physician assessment, time of study request and the time of study result. Data was subdivided based on rational subgroups for (1) sex, (2) age (3) shift time availability, and (4) disposition status. Cases with excessive delay were identified and a chart review was conducted to confirm time stamp validity and to identify unique circumstances contributing to delay. An exemption for ethics board review was obtained from the Conjoint Health Research Ethics Board at the University of Calgary due to the primary purpose of the project being quality improvement.
Evaluation Methods: Statistical process control charts (X-bar and S-chart) were used to establish mean and variation in time from ultrasound order to study result in the total population and each subgroup, measured in minutes. Scrotal ultrasounds were analyzed as a comparator to understand the most efficient time expected from ultrasound order to completion, given that they are typically highly prioritized. Rules to detect special causes were applied, including: (1) Single point outside control limits, defined as 3-sigma (2) Eight or more points above or below the centre line (mean) (3) Six consecutive points that are increasing (trend up) or decreasing (trend down) (4) Two out of three consecutive points near the outer third of a control limit (5) 15 consecutive points in the inner third nearest the centre line (mean).
Results: The mean time from ordering an abdominal/pelvic ultrasound to having reported findings was 203 minutes, compared to 103 minutes for scrotal ultrasounds. The mean time from physician assessment to having a reported study was 279 minutes, compared to 135 minutes for scrotal ultrasounds. Using subgrouping by sex for abdominal/pelvic ultrasounds, females had an mean order to result time of 226 minutes, versus 178 minutes for males. For the 0 to 3 year age group, the mean order to result time was 167 minutes, which increased for ages 4 to 11 to 193 minutes and for children greater than 12 years old, it was 223 minutes. By shift type, day shifts had a mean order to result time of 157 minutes, evening shifts 142 minutes and night shifts 317 minutes. Using rational subgrouping for disposition status, the order to result time for admitted patients was shorter at 190 minutes compared to discharged patients, which was 214 minutes.
Advice and Lessons Learned:
1) This initiative highlights the benefits of using rational subgrouping for emergency department quality improvement projects. By separating our data based on sex, age, time of care, and disposition status, considerable variability was revealed between subgroups that would have otherwise been hidden.
2) Groups more likely to experience longer wait times for abdominal or pelvic ultrasounds included females, patients arriving at night, and adolescents.
3) Rational subgrouping with baseline data enables a targeted approach when designing plan-do-study-act cycles
Impact of Calgary’s supervised consumption site on opioid-related emergency health care usage
Full text linkBackground: Opioid overdoses have been an increasing public health problem in North America for several years. Supervised consumption sites (SCSs) – hygienic and medically supervised spaces to use illicit substances – are one harm reduction strategy intended to decrease morbidity and mortality, with literature suggesting they reduce emergency department (ED) visits, overdoses, and deaths. Calgary’s sole SCS opened in 2017 and received over 6000 monthly visits prior to the COVID-19 pandemic, but recent provincial policy has jeopardized its longevity. To our knowledge, there has not been an evaluation of its effectiveness, so we sought to investigate its impact on opioid-related ED visits.
Methods: Calgary’s SCS was not implemented in our institution specifically. It was implemented for the Calgary region by Safeworks, an outreach program under the Alberta Health Services (AHS) umbrella, after obtaining a Health Canada exemption and funding from the provincial government. Implementation also required close collaboration with public services (e.g., Calgary Police Services) and the municipal government.
The Safeworks SCS opened on October 30, 2017 and remains the only supervised consumption facility in the Calgary region. It is currently located in the Sheldon Chumir Health Centre in downtown Calgary. In addition to supervised consumption, the SCS also offers all clients harm reduction supplies (e.g., naloxone kits), health services (e.g., testing and counselling for sexually transmitted infections, referral to Calgary Opioid Dependency Program), education (e.g., vein care), and access to social services (e.g., housing supports).
Evaluation Methods: This was a retrospective observational study examining the impact of the SCS on two markers of opioid related morbidity (EMS responses and ED visits). Calgary EMS responses, wherein the opioid overdose protocol was activated or naloxone was administered, were queried from the Alberta Health Services (AHS) information management database. ED visits due to opioid toxicity were queried from AHS using ICD-10 codes T40.0-T40.4 and T40.6. Data was collected from January 2014 to February 2020. The impact of Calgary’s SCS was analyzed with an interrupted time series using ordinary least squares regression with Newey-West standard errors.
Results: Our data query yielded 9208 EMS responses and 8442 ED visits related to opioid use over the 74-month period. There were no months with missing data. Prior to the opening of Calgary’s SCS, monthly EMS responses and ED visits increased significantly by 3.69 [3.08, 4.30] and 7.09 [5.92, 8.26] visits/month, respectively (p<0.001). After the SCS’ opening, the trends in EMS responses and ED visits declined significantly, relative to the pre-intervention trends, by 7.14 [5.72, 8.56] (p<0.001) and 15.34 [12.21, 18.48] (p<0.001) visits/month, respectively. After the intervention, EMS responses declined at a rate of 3.45 visits per month (p <0.001) and ED visits declined at a rate of 8.25 visits per month (p< 0.001).
Our interrupted time series suggest that Calgary’s SCS led to a significant change (and in fact, a reversal) in the trends of opioid-related EMS responses and ED visits. This evidence suggests that ongoing access to Calgary’s SCS has a favourable impact.
Advice and Lessons Learned:
1) Similar studies in the future should consider partnering with their local SCSs (e.g., Safeworks) to conduct a multi-faceted program evaluation, including organization-driven outcomes. This could also facilitate respectful and ethical patient engagement.
2) Evaluating mortality data or other more direct markers of morbidity in addition to ED visits may be high yield in future research as it provides greater insight into the breadth of medical outcomes and further informs advocacy efforts.
3) Our study did not consider the impacts of other opioid-related interventions in Calgary/Alberta. This was a deliberate choice, however it is ultimately difficult to estimate the impact of an isolated intervention. One option would be to evaluate all relevant interventions as a group of interventions, given that substance misuse and associated harms is a multifaceted problem that requires a multidisciplinary approac
Intimate Partner Violence in COVID-19: A Literature Review
No full textAbstract
The silent pandemic that rages simultaneously behind the scenes of the COVID-19 is intimate partner violence (IPV). Intimate partner violence occurs when one partner uses abusive behavior to control or harm the other partner in the relationship. Due to public health orders including the stay-at-home initiated in response to the pandemic from March 2020 IPV incidents have increased. Purpose: The purpose of this study is to review the current literature that evaluates the impact that the COVID-19 public health orders have had on the IPV victims during the pandemic. Research Question:How have IPV victims been impacted by the COVID-19 pandemic? Method: A targeted literature review using PICO format (population, intervention, comparison, and outcomes) examines how IPV victims have been impacted by the COVID-19 pandemic and factors associated with the increased rates of IPV. Results: Comparisons of pre-COVID-19 IPV rates to the rates of IPV during the pandemic reveal outcomes an elevated number of IPV numbers during the pandemic, particularly with the abuse that is more severe. Risk factors for the increased rate of IPV included financial factors, care giver burnout, stress and other factors are discussed. Implications: Health care professionals have a key role to play in helping IPV victims to access resources
Key words: COVID-19, novel corona virus, intimate partner violence, domestic violence, nursin
The Implications of Simulation and Real-Life Learning for Novice Emergency Nurses in COVID-19: Real-life versus Simulation for ED Nurses
No full textAbstract
In recent decades, technological influences have propelled the advancement of nursing education, both in practical and theoretical andragogy. Simulation technology has become an integral component of many nursing programs and clinical practice settings. The introduction of simulation challenges current mentorship and practice-based real-life learning, alluding to the question: Is the use of simulation to educate nurses within the clinical environment a sufficient replacement for real-life learning? The recent severe acute respiratory syndrome coronavirus 2 disease (SARS-CoV-2 or COVID-19) pandemic has caused emergency departments (EDs) to re-examine educational practices, potentially replacing real-life learning with simulation technology to support novice nurses as they care for acutely ill COVID-19 patients. Many experienced ED nurses have left the profession during the COVID-19 pandemic, and novice ED nurses with minimal ED experience have been hired in their places. While their enthusiasm, skill, and knowledge are highly valued, novice ED nurses face many challenges in the complex ED environment, particularly in the rapidly changing COVID-19 pandemic. This article provides an overview of simulation learning and real-life learning and how both of these models, along with their educational strategies, may be implemented by ED nurse educators in assisting novice ED nurses transitioning to independent practice.
Keywords: simulation, real-life learning, novice nurse education, emergency department, COVID-1
Impact of COVID19-related non-pharmacologic interventions on healthcare utilization for other virally-triggered respiratory illnesses
Full text linkBackground: Acute and chronic respiratory illnesses are a leading cause of morbidity and mortality in Canada. While non-pharmacological interventions (NPIs) such as masking and physical distancing have effectively stemmed the spread of COVID19, the efficacy of NPIs in preventing other virally-triggered respiratory illnesses (VRIs) is less well understood. As the world moves into what may be the endemic phase of the COVID19 pandemic, better evidence is needed to inform rapidly-evolving public policy recommendations on the role of NPIs in infection control.
Methods: This study assessed the impact of NPI implementation on VRI-related healthcare utilization during the COVID19 pandemic. Following ethics approval from the Conjoined Health Research Ethics Board of Alberta (CHREB), long-term retrospective tableau data was extracted from the Alberta Health Services (AHS) data analytics enterprise data warehouse. International classification of disease (ICD-10) codes were used to identify patients who presented to an acute care facility in Alberta during the pandemic (Mar 2020-2021) and pre-pandemic (Feb 2015-2020) periods with a primary complaint of asthma, community-acquired pneumonia, influenza, or chronic obstructive pulmonary disease (COPD). Heart failure (HF) and acute appendicitis (AA) served as controls. The study team consisted of a medical student, an undergraduate student, a principal investigator from the Department of Emergency Medicine at the University of Calgary, members of the AHS provincial research data services team, and collaborating faculty members.
Evaluation Methods: The final study dataset comprised 585,809 ED visits and 175,456 hospitalizations. The primary outcome of interest was the change in ED visits and hospitalizations between the pandemic and pre-pandemic period for VRIs and controls. This was evaluated using quasi-experimental interrupted time-series analyses. A secondary outcome of interest was the cost-reduction associated with NPI implementation, for which multivariable regression models were constructed. These evaluation methods aimed to identify whether NPI implementation can (i) improve patient outcomes by preventing VRI-related ED visits and hospitalizations (ii) alleviate the strain on an already-constrained healthcare system by reducing VRI-associated healthcare spending.
Results: Triage acuity and comorbidity index scores were similar between the two periods. While a substantial decrease in healthcare utilization was observed in the early months of the pandemic for both VRIs and controls, a rapid rebound towards pre-pandemic caseloads was observed only for controls, while VRI-related health utilization remained consistently low. Overall, there was a 43-62% and 41-84% decrease in weekly ED visits and hospitalizations for individual VRIs during the pandemic period (all P<0.001). ED visits and hospitalizations for HF declined by a small magnitude of 6% (P=0.002) and 8% (P<0.001), respectively. In contrast, an 11% increase in ED visits (P<0.001) and 3% increase in hospitalizations (P=0.046) was observed for AA. The decrease in VRI-related healthcare utilization resulted in $121 million in cost reduction. Surprisingly, even after accounting for COVID19, there was a significant decrease of 19,391 ED visits and 1,524 hospitalizations for respiratory illnesses during the pandemic period (P<0.001).
Advice and Lessons Learned:
NPI implementation was followed by a substantial decrease in healthcare utilization for VRIs. This resulted in substantial decrease in healthcare utilization costs and likely prevented significant patient morbidity and mortality.
The greater magnitude decrease for VRIs than controls as well as the fact that acuity/comorbidity scores did not increase indicates that the observed decrease I healthcare utilization was primary driven by NPI implementation rather than an avoidance of healthcare settings due to fears of nosocomial COVID19 acquisition.
NPIs appear to be an effective method of reducing the perennial burden of common respiratory illnesses. These findings provide a strong foundation for public policy recommendations on NPI use and establish the rationale for randomized studies on NPI use for preventing VRIs
Le coin du clinicien : Maîtriser le règle d’Ottawa concernant la radiographie de la cheville : Qu’est-ce que c’est ?
Full text linkThe Ottawa Ankle Rule (OAR) is a clinical decision-making tool to help guide clinicians’ decision to obtain an ankle radiograph (x-ray) to rule out a clinically significant ankle or foot fracture among patients who have suffered a blunt, traumatic injury (Stiell et al., 1992). The Ottawa Ankle Rule (OAR) carries a 100% sensitivity for ankle or foot fractures (Stiell et al., 1992) and has been validated for use in multiple studies (Sperry et al., 1999; Stiell et al., 1993). Subsequent studies have found that the OAR can be applied to children aged 2–16 years presenting to the emergency department (ED) with similarly high sensitivity (Plint et al., 1999).La règle d’Ottawa pour la cheville est un outil clinique décisionnel destiné à guider les cliniciens dans leur décision d’effectuer une radiographie (rayon X) de la cheville pour exclure une importante fracture de la cheville ou du pied chez les patients ayant subi une blessure traumatique contondante. (Stiell et coll., 1992). La règle d’Ottawa pour la cheville a une sensibilité de 100 % pour les fractures de la cheville ou du pied (Stiell et coll., 1992) et son utilisation a été approuvée dans de nombreuses études (Sperry et coll., 1999 ; Stiell et coll., 1993). Des études menées par la suite ont constaté que la règle peut être appliquée aux enfants âgés de 2 à 16 ans se présentant aux urgences avec une sensibilité tout aussi élevée (Plint et coll., 1999)