emergency – Nursing Review

Nursing hero in blue on and off duty

Wed, 01 Nov 2017 20:56:16 +0000

With nasty weather and heavy rain, registered nurse Carol Rogers prepared for what she thought was going to be a standard drive from the King Country to work at Waikato Hospital.

Living on a large section of forest, Carol put her “very rural” weatherproof jacket on over her Waikato DHB uniform for the journey.

Traffic was busier with school holidays, and just north of Te Kuiti traffic started to slow to a halt. A fatal accident had occurred and they needed Carol’s help.

As she approached the accident site, she’d removed her jacket by this stage and said “I’m a registered nurse at Waikato Hospital on my way to work, do you need my help?” Carol will never forget the look of relief on peoples’ faces when they saw her uniform.

“The accident was horrific” said Carol. “It was pouring with rain; there was no hospital emergency bell, other medical staff or equipment – clinically, I was it.”

Carol naturally became the leader of this heartbreaking scene. She was very apprehensive at first but once she focused on what was there that all disappeared completely. She utilised her nursing experience, especially from trauma and ED, and skills developed from previous roles that included time in the Royal New Zealand Nursing Corps covering Army, Air force and Navy, and as a prison nurse in the Department of Corrections, where she was often first responder to incidents.

“There were pieces of car all over the road, I had to step over an exhaust system and work my way around broken glass that was everywhere,” she said.

“After ensuring 111 had been called and delegating people to divert traffic, I first went to a vehicle with a casualty laying outside of it; described to me as having a sore foot, the injury was a horrendous fracture.

“The car had the windscreens smashed, and inside was another poor casualty looking absolutely shocked. I climbed inside the car and triaged her and conducted a primary survey to assess injuries where I found a large dent in her chest. The person was surrounded by a mess of broken glass and deployed airbags.

“We realised the car was a fire risk, but being electric we could not turn the engine off, so I had to back her out of the car, being conscious of a possible chest fracture.”

To access the second vehicle involved, Carol had to climb down because it was stuck in a drain.

“It only took one look to see it was too late for them,” she said sadly, having known the occupants from her hometown.

“I also took responsibility for the scene coordination and risk management as I didn’t want others to see what had happened to this couple and informed other people it was now a scene for the coroner that could not be disturbed.

“Although few people seemed to know this, they were amazingly cooperative, and when I went back to check on the other casualties an off-duty paramedic had turned up, which allowed us each to care for the two remaining injured.”

Carol says everything may have been different if she hadn’t been in her Waikato DHB uniform. “I may have had problems getting people to listen to my advice and wouldn’t naturally have become their leader in a way. As a nurse, in our uniforms this is what we do every day on the job – lead, care and comfort people.

“At all times I was very conscious of the fact I was a registered nurse and an employee of the DHB and I had to work within my scope of practice.

“It was a relief when the medical, police and fire crew arrived. They also saw my uniform and at times thought I’d brought my medical equipment, with some asking if I had a stethoscope and a cannula,” she smiled.

“When the scene started to clear and I was left alone to provide my statements with a police officer, I noticed I’d lost my glasses, I was cold, I was thirsty, I was also in a bit of shock. I’ve seen lots of accidents and odd events on these roads but nothing like this.

“Maybe because I was in my uniform I didn’t get victim support offered straight away either, and I didn’t have my work colleagues to debrief with, which was quite hard,” she said.

Carol’s advice to anyone in a first-response situation is that as you can’t prepare for what will happen next, work well with what you know and do it well. Don’t make decisions that you don’t think you have the experience or training to do, unless you absolutely have to. Delegate just one task at a time and request immediate feedback when it is completed, stay calm and always thank everyone for their help and input.

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Hospitals shifted patients to meet ED targets, reports study

Tue, 03 Oct 2017 20:55:20 +0000

Wait times dropped after emergency department time targets were introduced but a report has found some hospitals shuffled patients around just to meet the target.

A University of Auckland-led study published in BioMed Central Health Services Research studied emergency department (ED) waiting times at four New Zealand hospitals between 2006 and 2012.

With hospitals under pressure, a target measure was introduced in an effort to minimise crowding, which left some patients in hospital corridors.

Official DHB reports found most EDs met the 95 per cent target to be seen, treated or discharged within six hours. However, the introduction of “short-stay units” in the last 10-years has seen researchers question those reports.

Hospitals record the length of stay in EDs, but shifting patients into the short-stay units isn’t counted in reported ED figures.

The reported and total ED length of stay figures showed a reduction in the first 18 months of the target introduction from 2009. Reported ED length of stay continued to improve after 2010, but total ED length of stay figures remained static.

The findings suggested hospitals were moving patients into the short-stay units in part just to meet target performance.

Associate Professor of the University of Auckland’s School of Population Health Dr Tim Tenbensel said moving patients to the short-stay units was reasonable in most cases.

However, their interviews confirmed there were other instances in which patients were moved solely to meet the target requirement.

“Having patients in these short-stay units is certainly preferable to having them wait in hospital corridors, as was common before 2009.

“However, we know from our interviews that there were some instances where the only reason patients were transferred to short-stay was to avoid breaching the target.”

While the introduction of the ED target was initially successful, Tenbensel said the official DBH reports did not accurately represent patient stay times.

“The increasing use of short-stay units means that time spent waiting in ED is becoming less useful as a way of measuring hospitals’ responses to demand for acute services,” he said.

“Without including short-stay unit waiting times, we don’t get the full picture. Our analysis questions the value of ED targets as a long-term approach. To the extent that ED targets work in improving timeliness of care, it is in the form of a short, sharp shock.

“Given that ED demand continues to increase at rates above population growth rates and increases in health sector funding, additional policy and organisational strategies will be required in order to meet the challenges of increasing acute demand.”

Two of the four studied hospitals were in larger urban areas, while the other two were in a regional centre and in a provincial city.

The study found streamlining ED waiting times was most effective. A 3-2-1 approach, which sees a three-hour ED assessment phase, followed by a two-hour inpatient assessment phase and a one-hour transfer ward phase worked well.

Moving patients to the short-stay units allowed movement of other patients within the hospital. All four hospitals reworked their medical rosters to cope with the increased patient demand.

Further initiatives like increasing staff resources only began in 2010, so were not found to reduce total length of stay.

“It appears that the effectiveness of the target in reducing patient time in EDs was confined to the period from mid-2009 to late 2010.

“From 2011 onwards, improved target performance was achieved by increasing use of short-stay units as a tool for managing acute hospital demand.

“This means that the continued improvement of DHBs in official ED target performance after 2010 does not give the full picture.”

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Elective surgeries cancelled as Waikato Hospital hit capacity

Tue, 12 Sep 2017 19:08:44 +0000

Waikato Hospital reached capacity yesterday and was warning people to only go to its Emergency Department if it was a “real emergency”.

Elective surgeries other than cancer or other emergency type surgeries were also cancelled as the hospital dealt with the overflow of patients. Patients slept on beds in the corridors of the ED on Monday night as there were no beds left in the wards.

Waikato Hospital is not the only hospital feeling the pressure. Last month Middlemore Hospital put up a sign on the door of its ED telling patients the hospital was full and to expect delays of up to eight hours to be seen in the emergency department.

North Shore, Waitakere, Auckland City, Palmerston North and Hawke’s Bay Hospitals have also been at capacity at least once this winter.

The Waikato DHB posted a video on its Facebook page at Tuesday lunchtime telling patients to check with their GPs or call Healthline first and only go to the emergency department it was a “real emergency” or be prepared for a long wait.

“Today our Emergency Department at Waikato Hospital is in overload and Waikato Hospital is full,” the message said.

Waikato Hospital Services executive director Brett Paradine said by Tuesday afternoon the ED was back to running at normal capacities and all patients had beds. However its message that the ED should only be used for emergencies still stood.

Paradine said the overload was due to a higher number of presentations than normal in the morning and fewer discharges than expected. Although patients slept in corridors they were “all cared for”.

The hospital has been at capacity several times this winter and Paradine put it down to an increase in a whole range of presentations, especially respiratory illness.

“The number of people coming to Waikato Hospital has increased 20 per cent over the last five years. Patients are also often sicker and consequently spending longer in the hospital, which is putting more pressure on hospital beds,” Paradine said.

The first new ward in five years, aimed at geriatric and rehab patients, opened last week and it was hoped the additional 27 beds would ease the pressure.

Waikato DHB had also enhanced theatre usage improved patient flow to deal with the influx.

Association of Salaried Medical Specialists executive director Ian Powell said an overflow of patients meant senior doctors and other health professionals would be severely overworked and under considerable pressure.

“They will be working in a very difficult environment that is also stressful.”

Powell said the larger hospitals appeared to be increasingly reaching capacity and while the Waikato DHB had opened a new ward it would only cater for a sub-set of the patients needing care.

Labour spokesman for Health David Clark said hospitals were reaching capacity too often. “Obviously when that happens if there’s a major disaster or epidemic the hospital won’t have any capacity to cope.”

Hospitals were also often under staffed which meant patients weren’t being processed as quickly, he said. Clark also believed cheaper GP visits would encourage people to get treated early and prevent them even having to visit the ED.

NZ First Hamilton East candidate Pita Paraone said it was scary that the hospital was full as it should never get to that point.

Paraone knew of one elderly patient who spent 24 hours in ED before being admitted to a ward.

“As the demand for health services grow, the insufficiency of all that (being told to go to the GP or call Healthline) is heightened and I think the New Zealand public deserves better.”

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Internal email confirms “hospital is full” sign

Tue, 05 Sep 2017 03:22:49 +0000

An internal email has emerged showing Middlemore Hospital bursting at the seams around the time staff erected a “hospital full” sign urging patients to go elsewhere.

The email reveals “ground zero” pressures on the South Auckland hospital and details strategies for staff to clear beds and get patients out.

It has brought a concession from management at Counties Manukau District Health Board that staff are under pressure and have raised concerns about “staffing and capacity”.

Despite this, Health Minister Jonathan Coleman said in a statement: “This isn’t unusual for this time of year, and the reality is that the hospital can cope.”

The pressure at Middlemore Hospital was revealed last month when it emerged staff had created a sign urging patients to go elsewhere or face waiting eight hours in the Emergency Department.

While the sign was removed after management learned of it, the NZ Herald has since found it had been used on a number of occasions for at least eight weeks.

The internal email – provided to Labour’s Mangere MP Aupito Su’a William Sio – showed the extent of the pressure placed on the South Auckland hospital, and how those issues existed beyond the Emergency Department.

The memo told staff the total hospital occupancy was at 104 per cent and stated: “The hospital is full.”

Other areas of the hospital were stretched even further, with medicine and surgical areas at 116 per cent capacity.

The memo detailed coping strategies, telling staff to get people into the “discharge lounge as soon as possible” to help move patients from the Emergency Department.

It stated that there had been 355 patients through the Emergency Department the previous day and there were still 119 patients there.

The Emergency Care section had 45 patients waiting for a hospital bed while the 12 operating theatres had 50 people waiting for surgery.

Staff were told: “We need a total of 58 beds before today’s patients arrive.”

Sio told the NZ Herald he believed the pressures on the Emergency Department were – in part – a reflection of the scarcity of money for doctor’s visits among families in South Auckland.

He said those in Middlemore Hospital’s area were “working class” people who had little to spare after rent, power and food.

“They won’t go to the doctors because there’s a charge so go to the A&E because it’s free. That hospital just isn’t coping.”

Sio said doctor’s fees of $20 or more was a “big chunk” out of a family’s budget. “And it’s not just the doctor’s fee, it’s the medicine.”

Sio’s own family experienced a lengthy delay at the Emergency Department in May when his father Aupito Pupu Lolesio, 79, waited 10 hours for an x-ray after suffering a cut to the face.

A spokeswoman for the health board said August had been “particularly busy” with illness among not only among the community but those working at the hospital, which had made staffing difficult.

“We encourage our staff to report their concerns so that we are able to respond where possible.

“Our staff have raised with us (through internal reporting and through their unions) concerns about staffing and capacity – particularly recently during winter.”

The spokeswoman said the health board’s planning for winter used data from the previous year to predict the numbers of patients. “This year an additional 40 beds were included for winter planning.”

The expected winter increase came early in mid-May meaning the extra beds were started early and kept available.

She said the “hospital full” memo was sent on “extremely busy days” when Middlemore Hospital started with “a full hospital, a full Emergency Department and patients already waiting for a bed before the next wave of patients arrive”.

It was sent out across the hospital “letting them know that everyone needs to help”.

Coleman said there had been a “sustained rise” in demand across the region which “isn’t unusual” for winter and the hospital could manage.

He said the current occupancy was 98.6 per cent and “there are pressures that hard-working staff are dealing with”.

Coleman said those with illnesses that could be managed by their family doctor should seek care there.

He said National had supported GP visits with free care for those aged under 13, a low-cost scheme and expansion of the Community Services Card capping doctor visits at $18 for 600,000 New Zealanders.

“These policies mean around half of all New Zealanders have either free or cheap doctor’s visits.”

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Asthma Foundation calls for ‘big picture’ approach to tackling respiratory health

Wed, 30 Aug 2017 06:07:52 +0000

The Asthma and Respiratory Foundation is calling for a government target to be set across health, housing and social portfolios to reduce emergency visits for acute respiratory illness.

The Foundation was responding to today’s New Zealand Herald report linking cold, damp and overcrowded homes with 30,000 children being hospitalised each year with housing-related diseases, including asthma, bronchiolitis and the third-world disease bronchiectasis that should be confined to people in their 80s.

Letitia O’Dwyer, Chief Executive of the Foundation, said currently reducing respiratory disease was not a Ministry of Health, district health board or “even a primary health organisation” target but the Foundation advocated that the next government should ensure a cross-portfolio target was set to help break down silos between health, housing, education and other related portfolios.

The cross-portfolio target it wanted acted on was: “Reduce emergency visits for acute respiratory illnesses by 20 per cent within the next five years”.

“It’s obvious that one organisation or agency cannot act alone to address poverty, unhealthy housing and inadequate basic health care,” said O’Dwyer. “There is a strong need for a government approach that ‘sees the bigger picture’ and works across all areas focusing on prevention.”

At present the Foundation was working with a healthcare provider in South Auckland to deliver respiratory health ‘action plans’ to schools in the area, with the aim of reducing the “disproportionate hospitalisation rates” of the people most at risk, said O’Dwyer.

The Foundation said its proposed national target should go across all of the following portfolios:

Health
Māori Development
Pacific Peoples
Social Housing
Education
Social Development
Social Investment
Whānau Ora

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ED nurses say ED targets nothing to celebrate

Wed, 23 Aug 2017 03:55:02 +0000

The College of Emergency Nurses are “outraged” at the Health Minister “claiming the emergency department health targets are a great success”.

The NZNO College of Emergency Nurses NZ (CENNZ) was responding to a press release yesterday from Health Minister Jonathan Coleman stating that the nationwide health targets – including the ‘shorter stays in ED‘ target – were making a real difference to the quality of care and saving lives. The latest target data shows that 93 per cent of patients were admitted, discharged or transferred from emergency departments (EDs) around the country within six hours. Coleman said that recent New Zealand research indicated that the ‘shorter stay’ target was saving lives, with an estimated “700 fewer deaths than predicted in 2012 if pre-target trends had continued”.

The College said their outrage at the minister claiming the target as a success was because nurses knew that meeting the ED target in “an underfunded health system” could “cost lives and careers”.

Hilary Graham-Smith, NZNO’s associate professional services manager, also pointed to the recent Health & Disability Commissioner’s report into the death of a Northland man who was moved out of ED specifically to meet the national target when he had a heart condition needing further assessment. She said “trumpeting the targets” just days after that news was “inappropriate”.

Chairperson of CENNZ, Rick Forster said members told him that ED occupancy rates were often well over 100 per cent and ED staff faced additional difficulties trying to admit patients to the wards because hospital beds were full.

“When ED’s full we can’t close the doors, so more patients are ending up in corridors,” said Forster. “There comes a tipping point where care is rationed and risk of harm increases.”

Graham-Smith said the ED targets needed to be re-examined and nurses consulted. She said the combined effect of a high-needs and ageing population, patients with complex needs and several particularly bad winters had resulted in ED staff feeling they were compromising the quality of care and patient safety. EDs were also facing a staff shortage crisis.

She backed Forster’s comments and said New Zealanders did not deserve to be left waiting for extended periods in ED waiting rooms, in ambulances or on trolleys in corridors.

“Nurses need to be able to provide safe and effective care that is of a high standard, and the time to do that should not be constrained by a national target,” said Graham-Smith. “The stress of care rationing on nurses is unacceptable to the nursing profession and NZNO.”

Coleman acknowledges ED nurses work

Coleman responded on August 24 to the College and NZNO comments saying he acknowledged the work of nurses across the health system “particularly among the pressures which do arise in any busy ED, especially in the middle of winter”.

He said the shorter stays target helped to address “formally unsafe and long ED waiting times which were known to put lives (and potentially careers) at risk”.

The minister said the Emergency specialist Mike Ardagh’s research cited in his initial press release indicated the target had lead to an overall reduction in hospital stays by an average of about seven hours, created capacity for more acute admissions and equated to 700 fewer deaths than expected if pre-target trends continued.

He said the health system wasn’t underfunded with health funding having kept ahead of demographic pressure and inflation over the past eight years. “Health has remained the Government’s number one funding priority,” said Coleman. “Budget 2017 delivers on that by investing an extra $3.9 billion in health over four years for new initiatives and to meet cost pressures and population growth.” He said the health budget would reach an record $16.8 billion in 2017/18.

Article updated 10am August 24

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Overloaded Christchurch Hospital treating ED patients in corridors

Tue, 22 Aug 2017 05:03:17 +0000

Christchurch Hospital’s emergency department is treating up to a dozen patients at a time in corridors because of an unprecedented number of admissions.

Clinical director Dr David Richards says the department normally has about 250 admissions a day at this time of year, but in the past three weeks it’s been more like 300.

He says the hospital has been at capacity, so on average they’re having to treat 10 or 12 patients in the ED corridors, which he says is “unacceptable”.

“It’s unpleasant for the patients and family members, it means staff have to navigate the trolleys, and it provides very little privacy,” he said.

]]> https://www.nursingreview.co.nz/overloaded-christchurch-hospital-treating-patients-in-ed-corridors-due-to-surge-in-numbers/feed/ 0 ED transfer targets and RN-ordered blood test results under spotlight in HDC decision https://www.nursingreview.co.nz/ed-transfer-targets-and-rn-ordered-blood-test-results-under-spotlight-in-hdc-decision/ https://www.nursingreview.co.nz/ed-transfer-targets-and-rn-ordered-blood-test-results-under-spotlight-in-hdc-decision/#respond Mon, 21 Aug 2017 21:50:40 +0000 https://www.nursingreview.co.nz/?p=2571

Bullying culture uncovered in Australasian emergency medical staff survey

Thu, 17 Aug 2017 00:26:06 +0000

The Australasian College for Emergency Medicine (ACEM) carried out a recent members survey that found 34 per cent of those who responded had been bullied at work, 21.7 per cent had experienced discrimination, 16.1 per cent had experienced harassment and 6.2 per cent had been sexually harassed.

President of the college Professor Tony Lawler said bullying, discrimination and sexual harassment were “distressingly common in the emergency care environment in Australia and New Zealand”.

The behaviour reported in the survey posed a risk to health, safety and professional well-being and also had a negative impact on the workplace, training environment and provision of care, he said.

“ACEM seeks to promote the highest possible professional standards for emergency physicians. These principles are explicit in college policy and standards for accreditation for training in emergency medicine. These findings are not consistent with whom we believe ourselves to be, and we must respond to that,” he said.

“We recognise that quality health care outcomes are dependent on high functioning teams across the hospital setting, and we are not doing the profession of emergency medicine or our patients any favours by conducting ourselves in this way.”

The survey carried out in April and May this year was part of a working group formed last year to explore the workplace and training culture in response to increased scrutiny of the medical workforce culture in 2015.

Lawler said the organisation would take immediate action to address the findings by consulting with members to prepare and publish an action plan by the end of November.

“The college is committed to its role of upholding the highest possible professional standards in emergency medicine. We have taken the initiative to understand the extent of these behaviours among members and trainee,” he said.

“We owe a duty to our members, fellows and trainees to do what we can to ensure emergency medicine is practised in a respectful and inclusive environment, and will use this experience to listen to and engage with our members to bring about meaningful cultural change and address the problems caused by some members of our profession.

“As healthcare workers on the front line and directly in the public eye, emergency physicians need to take a leadership position and champion and model the high standards of behaviour we expect of others.”

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Waikato DHB says taking action to meet high demand

Mon, 31 Jul 2017 04:27:30 +0000

Extra nursing staff, a new ward soon to open and extra emergency department seats are amongst initiatives announced by Waikato District Health Board to help cope with ED pressure.

The Waikato Times reported on Friday that ambulances were being turned away from city medical clinics because of long waiting times, so were putting further pressure on Waikato Hospital’s strained emergency department.

In December last year that DHB said it was to boost its ED doctor and nursing staffing in the New Year to help reduce ED waiting times. It said in a press release today that it was investing $4.4 million in recruiting five senior doctors, seven junior doctors and 12 nurses for its ED and several of these had already been recruited.

Executive Director of Waikato Hospital Services Brett Paradine said Waikato Hospital had 297 patients present at ED in one day in July – the most this year and 80 more than usual. Also that it had a 16 per cent increase in ED attendances in June compared to the previous year, which was the equivalent to more than 100 additional attendances.

The DHB said it was also increasing nursing staff for two general surgery wards at a cost of $844,000 and was currently recruiting doctors, nurses and other ward staff for a new 27 bed Older Persons and Rehabilitation ward due to open in early September.

Paradine said the number of people turning up to Waikato Hospital ED had increased 20 per cent over the last five years. “Patients are also spending longer in the hospital, which is putting more pressure on the available hospital beds.”

He said Waikato Hospital had already implemented an overflow bed policy which identified additional beds on 24 wards, in family rooms or treatment rooms, throughout the hospital. These were being used for patients who are waiting for discharge in times of high bed occupancy, when inpatients in the Emergency Department experience delays moving into a specialty ward bed. It had increased the size of the ED’s short stay area by five seats and increased the use of rural hospitals for relocating inpatients closer to home to free up beds in the base hospital.

Mr Paradine said: “While we are investing substantial sums in increasing the hospital’s capacity it is not going to completely solve the demand issue which is growing day by day and we need to work closely with our partners in primary care to help us manage this demand.

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