Abstract: With the intention of decreasing emergency department demand, there has been a focus on determining those patients who do not require the services of the emergency department so they can be redirected away to an alternative health care provider or facility. Co-locating an after-hours primary health care facility near to the emergency department is a model under consideration in some district health boards. This model suggests that a substantial proportion of the patients currently managed in the emergency department can be assessed and managed in a general practice setting. It is envisaged that by redirecting the lower acuity patients away from the emergency department, overcrowding will be relieved. This is despite evidence demonstrating that low acuity patients are not the cause of emergency department overcrowding. Moreover, being treated at the emergency department is the only safety net for many people in the community who cannot afford alternative care. This research report discusses the literature regarding the practice of referring or redirecting patients away from the emergency department and the issues associated with this model. In doing this, it looks at the Australasian Triage Scale, the system used to ensure patients are seen in order of clinical urgency, because it has been suggested that this system could be used as a tool to refer patients away from the emergency department. The author concludes that even though some people could be seen by another health care provider, the triage system is not an appropriate tool for achieving this. While it is tempting to believe that patients in the lower triage categories are prime candidates for being referred away, there is evidence from hospital statistics that patients in these categories have a high number of hospital admissions and in-hospital death rates. Additionally, to complicate matters, there is no universal definition of what constitutes an 'appropriate' emergemcy department presentation and no consensus of opinion amongst health professionals in deciding patients' 'appropriateness'. For these reasons it is unethical to expect nurses who administer the triage system to use it for the purpose of referring people away from the emergency department.

Abstract: This study used a non-experimental correlational design to research the relationship between the experience of the nurse, with the application of continuous positive airway pressure therapy (CPAP) to patients presenting to a metropolitan emergency department with cardiogenic pulmonary oedema (CPO), and to establish what difference, if any, CPAP made to outcomes. A retrospective audit of records was used to extract data on all 54 patients that received CPAP over a 12-month period. The primary outcome measures were off CPAP within two hours, transfer to intensive care unit or cardiac care unit, and secondary outcome measures were length of hospital stay and death. There was a trend towards more experienced nurses attending patients who required immediate treatment or treatment within 10 minutes. These patients were more likely to be recognised at triage as requiring CPAP therapy. The early application of CPAP reduced hospital mortality, length of stay, and the need for intubation and ventilation. Attention needs to be given on how best to educate nurses so that more patients presenting with acute respiratory failure can benefit from nurses' decision-making regarding the commencement of CPAP.

Abstract: Family violence is common and there are significant long-term negative health effects from victimisation. Health professionals are now recognised as key providers of family violence intervention. The Hawke's Bay District Health Board HBDHB) launched a Family Violence Intervention Programme in the emergency department in 2002, in accordance with national directives. The Family Violence Intervention Programme includes routine questioning for partner abuse within social history assessments for all women 16 years and over who seek healthcare services. Nurses assumed responsibility for implementing this programme into emergency department practice. Establishing partner abuse screening in practice requires an organisational and attitudinal change. Achieving and sustaining this change can be difficult. Evaluation was considered an essential aspect of the systems approach adopted within the HBDHB Family Violence Intervention Programme to support change. The aim of this study was to identify the enablers and barriers to routine questioning in the emergency department one year after the programme was launched and the strategies to address these barriers. The staff who have responsibility for routinely questioning women were considered well placed to provide this information. The methodology selected was evaluation research using semi-structured interviews. The design included member checking and triangulation of the findings. Eleven emergency department staff members participated in five (two group and three single) interviews. The interviews revealed that routine questioning for partner abuse is difficult in the emergency department setting. Barriers to questioning exist and enablers can eliminate or minimise these. Enablers such as policy and training support routine questioning. Barriers identified included the lack of privacy and time. Participants suggested strategies to overcome these. These barriers, enablers and solutions were either personal or organisational in origin and all had a common theme of safety. An outcome of the study was the development of a model of barriers and enablers to ensure safety when routinely questioning women for partner abuse. This evaluation has utility within the HBDHB as it informs programme progression. However, the evaluation has wider implications. The experiences of the emergency department staff led to the emergence of key themes that may inform the development of comparable programmes. Introducing routine questioning requires a practice change; a multifaceted approach focusing on safety can assist staff to achieve that change.

Abstract: The aim of this paper is to compare the Emergency Nurse Practitioner role in the UK, Australia and New Zealand. Whilst geographically distant, the role of the Emergency Nurse Practitioner within these three countries shares fundamental similarities, causing the researchers to question, is this a time to implement international standards for the role? The Emergency Nurse Practitioner role in all three countries is gradually establishing itself, yet there are shared concerns over how the role is regulated and deficits in standardisation of scope of practice and educational level. Together these issues generate confusion over what the role embodies. The authors suggest that one method of demystifying the Emergency Nurse Practitioner role would be to progress towards international standards for regulation, education and core components of practice.

Abstract: To find an effective approach to managing or reducing waiting times for lower triage category patients processed through one particular metropolitan emergency department, an extensive search of the literature revealed several different patient flow processes. These approaches are discussed, in relation to suitability for the particular emergency department. The history of triage, including how and why it evolved, plus the realities of triage today are explored. Included are case examples of two patients on a journey through the department the way it is presently, and how it could be if particular approaches are introduced. Extending nursing practice by introducing nurse-initiated x-rays at triage and the introduction of a separate stream for minor category patients in a dedicated ambulatory care area is one approach that could improve waiting times for these patients. There would be the added advantage of improving triage compliance figures for category three patients. The additional costs involved in such a process could be offset by improved efficiency in terms of waiting times, improved triage compliance figures, happier patients and clinical staff, and an emptier waiting room.

Abstract: The aim of this research was to describe what factors contribute to people re-presenting to the emergency department (ED) within one week of a previous visit for intentional self-harm. Objectives identified were to describe the people using demographic and clinical features; describe and evaluate ED management; and identify possible personal or system reasons as to why people re-present to ED within one week. A retrospective observational design was selected for a period of one year. The data was collected from electronic clinical case notes. The sample consisted of 48 people with 73 presentations and re-presentations. Missing data limited the number of inferential analyses. Outcome measures were divided into information regarding the person and the presentation. This study made several discoveries: many representations (55%) occurred within one day; the exact number of people who represented many times to ED is unknown, but is far higher than reported in other studies; fewer support people were present for the second presentation; the documentation of triage and assessments by ED staff was often minimal, though frequently portrayed immense distress of this population; cultural input for Maori was missing; physical health complaints and psychosis were found with some intentional self-harm presentations; challenging behaviours occurred in at least a quarter of presentations; and the medical and mental health inpatient admission rates were approximately 50% higher for second presentations. Recommendations in regard to the use of a triage assessment tool, the practice of reviewing peoples' past presentations and the need for a mental health consultation liaison nurse in ED are made. Staff education, collaboration between services with consumer involvement and further research of this group are required. This study supports the need for holistic and expert care for people who present at emergency departments with intentional self-harm.

Abstract: This thesis explores the theoretical notions of suffering and caring within the nurse patient relationship in the context of emergency nursing. It includes a small pilot study that aimed to assess the feasibliity of a major research project, by describing the impact of vicarious traumatisation in emergency nurses, specifically in relation to their self capacities. This pilot study utilised a descriptive, correlational design. Data was collected by using the Inner Experience Questionnaire (IEQ) a twenty four-item questionnaire developed by Dr Pearlman (1995), and a profile sheet which identified demographic details. Twenty-seven emergency nurses participated in this pilot study. The IEQ was assessed for internal reliability by applying the Cronbachs alpha and utilising a focus group to gain insight into the usability and relevance of the questions. The internal reliability of the IEQ suggests that it may be an appropriate tool to measure disruption of self capacities in the population of emergency nurses. Although the results are limited, and conclusions cannot be drawn, findings suggest a correlation between the variables of age, experience, nursing qualifications and a history of personal trauma and the IEQ. There is evidence that emergency nurses are affected psychologically when caring for the victims of trauma in emergency departments and the IEQ has the potential as a tool to be integrated into future emergency nursing studies. A multidimensional methodological approach is recommended to capture the many contours of the complex phenomena of vicarious traumatisation and the emergency nurse.