Canadian Journal of Emergency Nursing (CJEN)
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Inpatient supervised consumption services: A nursing perspective
Full text linkHarm reduction reduces the risk of negative effects of health behaviours. Supervised consumption services (SCS) provide clean, safe and supervised locations for substance use. They are one strategy to reduce unintentional overdose and spread of infectious disease. The first in-hospital SCS in Edmonton, Alberta continues to offer services to inpatients. Nurses provide supervision of substance use, health promotion and education to clients. SCS staff also provide education to hospital nursing staff who refer clients for SCS. Despite existing community and hospital SCS, nursing frameworks for SCS and federal and provincial policies that support SCS, implementation of SCS in hospitals is uncommon. Nurses should be informed about SCS and their potential for further implementation. Existing programs can be useful templates for future implementation in hospitals. Nurses can be advocates for harm reduction strategies in their workplace that include SCS
Examen de la fragilité et de la multimorbidité dans la recherche en soins infirmiers chez les patients âgés des services d\u27urgence
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Comparison Of Non-clinical Tourniquet Research for Appliance Superiority & Tolerance (CONTRAST): a systematic review and meta-analysis of commercial and improvised tourniquet devices for arterial occlusion, application speed, and tolerance
Full text linkBACKGROUND:
Tourniquets are effective tools to manage life-threatening extremity hemorrhage. Commercial devices are recommended over improvised ones; however, mass casualty incidents and austere environments may prevent access to commercial devices. The aim of this review is to systematically search and meta-analyze commercial and improvised tourniquets: arterial occlusion, application speed, and patient tolerance.
METHODS:
We searched MEDLINE, Embase, CINAHL, Cochrane Library, SPORTDiscus, and ProQuest Dissertations & Theses Global using controlled terms; without date limits. Manikin, animal, and operative studies were excluded. Tourniquet devices were pooled by design and compared. Data regarding provider training and experience, recipient anthropometrics, application site, ease of application, speed, tolerance, and device efficacy were examined.
RESULTS:
5169 studies were screened. The 36 included studies were prospective trials on healthy volunteers and published between 2000 and 2021. There were 8205 unique tourniquet applications to 1921 subjects using 23 unique commercial and improvised devices. Median sample size of included studies was 20 (IQR 26) participants, ranging from 1 to 773 participants; and 102 (IQR=152) applications ranging from 20 individual applications to 1546 unique applications. The most commonly assessed outcomes were: effectiveness (n=30), pain (n=18), speed of application (n=13), and amount of mechanical advantage (ex. Windlass turns) required (n=13). Male participants outnumbered females 1,414 to 169, mean age ranged from 21 to 45 years of age. Devices were pooled into 5 categories according to mechanical advantage mechanism: elastic, friction, mechanical, pneumatic, and windlass. Initial hemostasis was achieved in 95% of upper extremity placements (CI=0.89-0.98, p= 0.02), and 88% of mid-thigh applications (CI=0.78-0.94, p>0.01), in both groups pneumatic and mechanical tourniquet devices had the highest rates of success, with friction and elastic devices having the lowest rates of success. Meta-analysis showed that mechanical and pneumatic advantage systems had superior rates of hemostasis, ease of use, and pain tolerance scores. Due to study heterogeneity, we could not determine which devices were the fastest to apply. The overall risk of bias assessment for included studies found the certainty of studies ranged from moderate to critical.
CONCLUSION:
In pre-clinical studies mechanical and pneumatic advantage systems appear to be the superior tourniquet design. Due to the low certainty of evidence and non-randomizable nature of traumatic injury, pre-clinical tourniquet devices will likely continue to be tested on well volunteers. Adoption of a minimum data set, agreed upon definitions for testable metrics, and a standardized experimental design could improve the comparability and quality of future tourniquet device studies
Research Review: Emergency Nurse Perceptions of Pain and Opioids in the Emergency Department
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Emergency Nursing: A Staff-Led Mentorship Program in a Tertiary Adult and Pediatric Emergency Department
Full text linkBackground: Emergency Department (ED) nurses are familiar with high levels of turnover and staff burnout. All EDs have faced unprecedented stressors related to the global COVID-19 pandemic including higher patient acuity, senior staff attrition, and increased numbers of less-experienced new hires. In one combined pediatric and adult tertiary ED, senior nursing staff identified a need for integrating formalized mentorship for new staff in the current nursing orientation. Three senior, experienced, Registered Nurses (Mentor Leads) developed and implemented a volunteer-based, staff-led mentorship initiative piloted throughout 2021.
Implementation: Mentor Leads conducted stakeholder consultation with recent new hires and senior staff prior to proposing the mentorship program model to management and the education team in November 2020. Support obtained allocated Mentor Leads two hours of classroom department orientation to conduct virtual presentations with new hires (Mentees). The presentation was structured as a nursing assignment simulation with opportunities for open discussion; it reviewed emergency case scenarios, prioritization/time management, department flow, multidisciplinary communication, and staff roles and resources. Then groups of two to four nursing Mentors, with at least one year of experience in the department, provided sequential in-person and email check-ins throughout the first six-months of the Mentees’ employment. Electronic materials, including mentorship expectations and resources, were disseminated to the Mentors to support them during their mentorship term.
Evaluation Methods: Qualitative feedback was sought from Mentors and Mentees at the end of their mentorship term. Both were asked to describe any personal benefit gained from participation in the program, any challenges they recognized, and if/how the program impacted their future employment in the department. In addition, Mentees were asked to provide survey feedback following the orientation presentation.
Results: The mentorship program was applied to all nine orientation groups hired in 2021. A total of 70 new hires participated as Mentees. Twenty-one volunteer Mentors were utilized to lead the orientation groups. Initial qualitative feedback for the orientation presentation and the six-month follow-up was universally positive. Qualitative themes included enhanced preparedness concerning department realities, feeling welcomed by staff, and improved understanding of department flow and avenues of assistance. One Mentee shared that, without the program they would have considered seeking new opportunities outside of the emergency department setting shortly after orientation.
Mentors expressed a crucial need for the program and shared that their responsibilities and expectations were manageable. Mentors felt the email communication structure was less effective than the in-person check-ins. An incidental benefit of the program’s implementation was its positive effect on staff participating as Mentors. They reported that their experience with the program provided them with purpose, decreased levels of burnout, and strengthened their teaching and leadership skills. Qualitative feedback from Mentor Leads and experienced staff report that department mentorship culture as a whole has been enhanced by the program.
Advice and Lessons Learned:
Strong partnership with key stakeholders, including management and the nursing education team, was vital to implementing a successful mentorship program in the department. Concerns voiced by Mentors regarding Mentee overall performance and potential practice challenges were escalated to department Clinical Nurse Educators in order to provide targeted educational support for the success of staff.
The role of strong and determined Mentor Leads were key to conduct the necessary building, implementation, and preservation of the program. A significant amount of invested time was required to ensure program success. Consideration should be given to fiscal resources to incentivize staff-led grassroots mentorship programs.
Future program evaluation hopes to include detailed evaluation of objective data comparing levels of nurse turnover and vacancy rates pre- and post-implementation of the program, and an economic evaluation.
Future opportunities for this program are to expand mentorship to staff new to resuscitation, triage, and charge nurse roles within the department, as well as replicate the work to other local and provincial EDs
Research Review - Nursing staff factors influencing pain management in the emergency department: Both quantity and quality matter.
Full text linkNo abstract with this research review
Scale and spread of quality improvement initiatives for bronchiolitis management in Alberta emergency departments
Full text linkBackground: Acute viral bronchiolitis is among the most common illnesses seen in the emergency department (ED) and is the leading cause of infant hospitalization in Canada. Practice guidelines do not recommend routine use of certain diagnostic tests and medications in managing bronchiolitis, yet prior studies suggest that low-value interventions are routinely administered to patients with bronchiolitis. Successful implementation of quality improvement at the Alberta Children’s Hospital suggested that low-value interventions and tests can be improved. Yet, practice variation and potential opportunities to improve bronchiolitis management are likely present in EDs in urban and rural settings.
Implementation: The project is a collaboration between the Maternal Newborn Child and Youth Strategic Clinical Network (MNCY SCN), the Improving Health Outcomes Together Team (IHOT), and Physician Learning Program (PLP) under the umbrella of the AHS Ernst & Young Clinical Appropriateness Theme recommendations to expand and scale initiatives to reduce unnecessary tests to improve patient safety. A provincial Bronchiolitis Steering Committee, led by two Physician Initiative Leads, was formed to guide the project and implementation at 16 facilities across Alberta.
Site implementation includes two key aspects:
Audit & Feedback (A&F) – review practice data, facilitated discussion with clinicians, and identify enablers and barriers to practice change
Site Specific Implementation Plan – options for sites include use of posters, tools, resources; utilization of ConnectCare (order sets); and staff and physician education
Qualitative interviews with site-champions will provide perspectives and feedback on enablers and barriers to change. Discussions from the A&F sessions, in addition to the qualitative interviews will be coded and analyzed based on the Consolidated Framework for Implementation Research and Theoretical Domains Framework.
Resources required included clinical leads, project management, data/dashboards, educational posters, updated order sets, and a central location for staff and physician to access bronchiolitis materials (via SharePoint).
Evaluation Methods: The primary objective of the study is a reduction of chest x-ray utilization. Chest x-rays utilization can be readily obtained from administrative data at all sites in the project. Secondary measures include medications (PIN) and respiratory viral testing. There is strong evidence to support that medications and respiratory viral testing do not impact bronchiolitis management. The project addresses patient safety and outcomes by reducing the use of low-value interventions and tests in the ED and enables resources to be directed towards evidence-based care. As ConnectCare is phased into all facilities across Alberta, additional metrics will be incorporated into reports and updates to participating sites.
Results: The first phase of the project took place from September to November 2021, with rollout to six facilities (four EDs and two inpatient units). A total of 151 physicians attended the audit and group feedback sessions. Site-specific planning sessions and qualitative interviews with site-champions are planned, and the next phase of the project will continue with spread and scale to regional EDs (n=5), urban (n=2) and rural (n=4) locations in fall 2022.
Advice and Lessons Learned:
The partnership with MNCY SCN, PLP, IHOT, and two Clinician Leads has been beneficial for establishing a team-based multi-disciplinary approach to address needs as they arise and the ability to work together with site champions.
Identifying and collaborating with site champions is necessary for establishing relationships and trust prior to conducting audit and feedback sessions and addressing practice change. Site champions understand the contextual factors of their facility and how to best utilize enablers or address barriers for practice change. Initiation of these working relationships need to take place months before implementation and ideally develop through existing networks.
Timing and flexibility are crucial for successful implementation. Rescheduling launch dates, adjusting session time, validating data, and adjusting to external factors such as delays in ConnectCare rollouts and pressures on the healthcare system brought on by the COVID-19 pandemic were experienced in the planning and initiating phases of the project. These lessons will be carried forward as we plan for the second part of spread and scale in Fall 2022.Contexte : La bronchiolite virale aiguë est l\u27une des maladies les plus courantes observées aux urgences (SU) et la principale cause d\u27hospitalisation des nourrissons au Canada. Les directives de pratique ne recommandent pas l\u27utilisation systématique de certains tests diagnostiques et de certains médicaments dans la prise en charge de la bronchiolite, mais des études antérieures suggèrent que des interventions de faible valeur sont systématiquement administrées aux patients atteints de bronchiolite. La mise en œuvre réussie de l\u27amélioration de la qualité à l\u27hôpital pour enfants de l\u27Alberta suggère que les interventions et les tests de faible valeur peuvent être améliorés. Pourtant, la variation des pratiques et les opportunités potentielles d\u27amélioration de la prise en charge de la bronchiolite sont probablement présentes dans les services d\u27urgence en milieu urbain et rural.Mise en œuvre : Le projet est une collaboration entre le Maternal Newborn Child and Youth Strategic Clinical Network (MNCY SCN), l\u27équipe Improving Health Outcomes Together (IHOT) et le Physician Learning Program (PLP) sous l\u27égide de l\u27AHS Ernst & Young Clinical Appropriateness Recommandations thématiques pour étendre et intensifier les initiatives visant à réduire les tests inutiles afin d\u27améliorer la sécurité des patients. Un comité directeur provincial sur la bronchiolite, dirigé par deux médecins responsables de l\u27initiative, a été formé pour guider le projet et sa mise en œuvre dans 16 établissements de l\u27Alberta.La mise en œuvre du site comprend deux aspects clés :1. Audit & Feedback (A&F) - examiner les données de pratique, faciliter la discussion avec les cliniciens et identifier les catalyseurs et les obstacles au changement de pratique2. Plan de mise en œuvre spécifique au site – les options pour les sites incluent l\u27utilisation d\u27affiches, d\u27outils, de ressources ; utilisation de ConnectCare (ensembles de commandes) ; et la formation du personnel et des médecinsDes entretiens qualitatifs avec des champions de site fourniront des perspectives et des commentaires sur les catalyseurs et les obstacles au changement. Les discussions des sessions A&F, en plus des entretiens qualitatifs, seront codées et analysées sur la base du cadre consolidé pour la recherche sur la mise en œuvre et du cadre des domaines théoriques.Les ressources nécessaires comprenaient des responsables cliniques, la gestion de projet, des données/tableaux de bord, des affiches éducatives, des ensembles d\u27ordonnances mis à jour et un emplacement central permettant au personnel et aux médecins d\u27accéder aux documents sur la bronchiolite (via SharePoint).Méthodes d\u27évaluation : L\u27objectif principal de l\u27étude est une réduction de l\u27utilisation des radiographies pulmonaires. L\u27utilisation des radiographies pulmonaires peut être facilement obtenue à partir des données administratives de tous les sites du projet. Les mesures secondaires comprennent les médicaments (PIN) et les tests viraux respiratoires. Il existe des preuves solides pour soutenir que les médicaments et les tests viraux respiratoires n\u27ont pas d\u27impact sur la gestion de la bronchiolite. Le projet aborde la sécurité des patients et les résultats en réduisant l\u27utilisation d\u27interventions et de tests de faible valeur au service des urgences et permet d\u27orienter les ressources vers des soins fondés sur des données probantes. Au fur et à mesure que ConnectCare sera mis en place dans tous les établissements de l\u27Alberta, des mesures supplémentaires seront intégrées aux rapports et aux mises à jour des sites participants.Résultats : La première phase du projet s\u27est déroulée de septembre à novembre 2021, avec un déploiement dans six établissements (quatre urgences et deux unités d\u27hospitalisation). Au total, 151 médecins ont assisté aux séances d\u27audit et de rétroaction de groupe. Des sessions de planification spécifiques au site et des entretiens qualitatifs avec des champions de site sont prévus, et la prochaine phase du projet se poursuivra avec une propagation et une échelle aux ED régionaux (n = 5), urbains (n = 2) et ruraux (n = 4) emplacements à l\u27automne 2022.Conseils et leçons apprises :1. Le partenariat avec MNCY SCN, PLP, IHOT et deux responsables cliniciens a été bénéfique pour établir une approche multidisciplinaire en équipe pour répondre aux besoins à mesure qu\u27ils surviennent et la capacité de travailler avec les champions du site.2. L\u27identification et la collaboration avec les champions du site sont nécessaires pour établir des relations et la confiance avant de mener des sessions d\u27audit et de rétroaction et d\u27aborder le changement de pratique. Les champions de site comprennent les facteurs contextuels de leur établissement et comment utiliser au mieux les catalyseurs ou surmonter les obstacles au changement de pratique. L\u27initiation de ces relations de travail doit avoir lieu des mois avant la mise en œuvre et idéalement se développer à travers les réseaux existants.3. Le calendrier et la flexibilité sont cruciaux pour une mise en œuvre réussie. La reprogrammation des dates de lancement, l\u27ajustement du temps de session, la validation des données et l\u27ajustement aux facteurs externes tels que les retards dans les déploiements de ConnectCare et les pressions sur le système de santé provoquées par la pandémie de COVID-19 ont été expérimentés dans les phases de planification et de lancement du projet. Ces leçons seront reportées alors que nous prévoyons la deuxième partie de la diffusion et de l\u27échelle à l\u27automne 2022
Pediatric Emergency Resident – Nurse Teaching: a Survey of an Innovative Method
Full text linkBackground: Triage is one of the most important steps in the emergency department (ED), as it helps to recognize the urgency among patients. A proper triage system identifies the most critical patients regardless of the time of presentation. Triage nurses rarely can follow up on their triaged patients to verify the accuracy of their decision.
Methods: A teaching session on male genitalia triage by a Pediatric Emergency Medicine (PEM) resident was given to triage nurses and a survey was sent afterwards to all participants to evaluate the confidence in their triage accuracy before and after the session.
Results: The results showed a statistically significant increase in the confidence of nurses in avoiding both undertriage and overtriage accuracy. Also, all the nurses recommended attending similar talks given by a PEM resident. This study has helped in ameliorating interprofessional relationship between the nurses and residents especially with the increased use of masks. However, the number of nurses is too small to be representative and a bigger quality improvement study is needed.
Conclusion: PEM resident-nurses teaching is an innovative method to improve the accuracy and quality of triage and to help establish good interpersonal relationship skills in the pediatric ED. More studies are needed in the future to validate this technique so that it can be implemented for all presentations.Contexte : Le triage est l’une des étapes les plus importantes du service des urgences, car il permet de discerner l’urgence des patients. Un système de triage adéquat permet d’identifier les patients les plus critiques, peu importe le moment où ils se présentent. Le personnel infirmier de triage peut rarement assurer le suivi des patients triés pour en vérifier l’exactitude de leur décision.
Méthodes : Une séance d’enseignement sur le triage des organes génitaux masculins par un résident en médecine d’urgence pédiatrique (MUP) a été donnée au personnel infirmier de triage et une enquête a été envoyée par la suite à tous les participants pour évaluer leur degré de confiance dans la précision de leur triage avant et après la séance. Les données ont été collectées via Google Forms® et analysées à l’aide d’un test t d’échantillons appariés pour vérifier l’importance.
Résultats : Les résultats ont révélé une augmentation statistiquement significative de la confiance du personnel infirmier dans la capacité à éviter le sous-triage et le surtriage. En outre, tous les participants infirmiers ont recommandé d’assister à des conférences similaires données par un résident en MUP.
Conclusion : L’enseignement du personnel infirmier par les résidents en MUP est une méthode innovante pour améliorer la précision et la qualité du triage et pour aider à établir de bonnes compétences en matière de relations interpersonnelles dans les urgences pédiatriques. À l’avenir, il faudra mener d’autres études pour valider cette technique afin qu’elle puisse être mise en œuvre pour toutes les présentations