March 2, 2021

Emergency

COVID-19 leads to “startling” change in ED presentations 

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Emergency Departments have a drastic change in the number and acuity of patients being admitted through the COVID-19 pandemic. 

In a study published in the Medical Journal of Australia, emergency health workers in New South Wales and Victoria have seen a sizeable drop in presentations in 2020 compared to 2019. Despite this, EDs are seeing more complex patients, resulting in no reduction in workload. 

For example, ED presentation numbers from Western Sydney Local Health District from March 29 to 31 May 2019 and 2020 show a 25% drop in admissions. However, there was a 14% increase in category 1 presentations (resuscitation). 

“I think we will find people’s conditions have been brewing in the community and we will see some presentations of more serious conditions as the pandemic eases,” said Dr Andrew Kam, an emergency doctor at Westmead Hospital and of the study’s authors. 

It’s a concern shared by Dr Shyaman Menon from Peninsula Health in Victoria.  

“EDs will see the downstream effect of some conditions like uncontrolled hypertension, uncontrolled sugar, uncontrolled chronic kidney and lung disease,” Dr Menon said. 

There is concern that patients are not presenting to emergency for important diseases such as gastroentiritis, bronchilitis and influenza, as well as mental health issues. 

“We want people who need to be in emergency departments to be there”, the authors said.  

The NSW Nurses and Midwives’ Association is the professional association for emergency nurses. To join, visit their website today.

Better ratios mean improved outcomes in paediatric EDs

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Increased nurse staffing has a marked effect upon patient outcomes in paediatric emergency departments, a recent study has shown.

The study, published in the Journal of Clinical Nursing, analysed administrative data of 21,956 patients gathered from a university hospital’s paediatric emergency department in the first half of 2019.

It found that increases of nursing numbers reduced the average stay of patients in the emergency department by 2% per additional nursing staff member.

Further, the study found that a decline in nurse-to-patient ratios correlated with an increase of patients leaving before treatment completion.

It concluded that nurse-to-patient ratios did in fact affect patient outcomes and quality of care in the scenario studied.

While studies on the effects of nurse-to-patient ratios on patient outcomes have been commonplace over the past few decades, the study is the first to focus on a paediatric emergency department.

The study was conducted by a Finish team, led by nursing academic Katja Janhunen.

Support the NSW Nurses and Midwives’ Association‘s campaign for nurse-to-patient ratios across the state by signing this ePetition today.

The frontline: Nurse Ashleigh’s story.

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Nurse Ashleigh Woods will never forget the first time she had to help a doctor insert an endotracheal tube into a patient’s lungs, so they could breathe.

“It’s pretty intense. We got through it, and I was finishing at 9.30, I stepped outside and just burst into tears because I was so overwhelmed,” she said.

“You have to concentrate the whole time and you’re in the zone and you block all of your feelings, and then you walk out and go ‘oh my god that was so intense’. That’s why debriefing is so important.”

These days it’s all par for the course for the 25-year-old Southern Cross University Graduate who is now a Registered Nurse and Midwife at The Tweed Hospital.

Accredited in Advanced Life Support, Ashleigh has just begun working in an Airway role in the resuscitation room in the Emergency Department. The resuscitation teams include a doctor, nurse, someone dedicated to the patient’s airway, someone looking after their circulation and a team leader.

“It’s my responsibility to make sure the person’s breathing is maintained and if they need oxygen to administer it, to make sure they don’t have any blockages, then monitor their breathing,” she said.

“We all work in Emergency and we all love trauma care, you kind of have to be into that to be able to cope. It’s not that scary because that’s what we enjoy doing, we enjoy helping.”

Ashleigh is just one of the many nurses and other staff now braving the frontline of the Covid-19 pandemic.

The hospital is testing many patients each day. They have a fever clinic and an isolation room for patients awaiting test results.

During shifts in the fever clinic the nurses, including Ashleigh, wear multiple pieces of personal protective equipment.

“When taking the Personal Protective Equipment off you have to wash your hands continuously. You have to wash your hands between each piece of PPE you remove,” said Ashleigh.

As there is no current cure for the virus itself, patients are treated for individual symptoms. The majority of people with COVID-19 will have mild symptoms and will recover without needing hospital care.

Unfortunately, though, some patients will be significantly unwell and will need to be cared for in an Intensive Care Unit.

“Not all nurses can work in critical care or in ICU,” Ashleigh said.

“I can ventilate someone as an Emergency Nurse but not in the long term, I don’t have that training.”

“We’re all on the spot now. You just become flexible, you adapt and do what you need to do and overcome it.”

When asked what she liked most about nursing, Ashleigh reminisces about a past patient at St Vincent’s Hospital in Lismore whom she managed to win over, despite the fact that he took a strong dislike to every other staff member and nurse.

“Nursing is so different to being a doctor, as a nurse you’re really the one providing that compassionate care to patients, and you’re there for them. You’re there for them when they want to talk.”

More nurses for Blacktown ED

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Staff and union pressure achieved three extra nurses per shift for Blacktown Hospital’s emergency department.

Western Sydney Local Health District agreed to roster three extra nurses per shift at Blacktown Hospital’s ED for six months while a staffing review takes place.

The NSWNMA led a push for more staff after the ED moved to a new, expanded area in August 2019.

Nurses found that the larger workspace added to existing workloads pressures.

Blacktown emergency present-ations have increased by almost 15,000 since 2012, when the ED had its last significant staffing increase.

NSWNMA representatives put a case for three extra nurses per shift to management, but the LHD said no.

Blacktown Hospital branch then resolved to impose an overtime ban unless management agreed to a formal staffing review.

Management agreed to a review and members backed by the union pressed NSW Health Minister Brad Hazzard for further action.

More than 100 nurses and other ED staffers signed an open letter to Mr Hazzard.

The letter warned the ED was “dangerously understaffed” and said understaffing had already “led to catastrophic outcomes for patients under our care”.

Three extra staff won

After the letter appeared, LHD CEO Graeme Loy and other senior executives met with representatives from the NSWNMA and other hospital unions.

Following the meeting, Mr Loy agreed to an additional three nurses, 24 hours per day, for six months starting in November 2019.

The LHD expects to finish the staffing review by March.

ED nurses have welcomed improvements resulting from the additional staffing.

“The extra staffing has made a huge difference, particularly in ‘resus’”, said NSWNMA member Quennie Douglas.

“Having that extra nurse to cover meal breaks and give support during times when patients deteriorate is a massive load off our backs.

“Patients are better cared for as well. They are neat and comfortable because we have the extra hands to attend to their basic needs.”

NSWNMA member Erwin Alfonso said: “The extra hands at front of house have made caring for patients in the waiting room safer and more efficient.

“There is also room for us to be able to implement a more structured approach to deliver care in the waiting room as a result of appropriate staffing.”

Wyong ED campaigns for more staff

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Nurses are campaigning for more staff at Wyong Hospital’s emergency department, where waiting times are among the worst in the state.

 In the past six months, NSWNMA members have held two lunchtime rallies outside Wyong Hospital to highlight inadequate staff levels in the emergency department.

The rallies have received support from Central Coast Labor MPs and favourable coverage in local media.

The NSWNMA is calling for three extra nurses to be rostered on each shift in ED, and an urgent staffing review.

More than one third of Wyong ED patients wait more than four hours to receive treatment, according to the Bureau of Health Information.

The NSWNMA’s Wyong branch has been reporting unreasonable workloads in the ED since 2016.

Branch assistant secretary Jacinda Farrell said members received union training in how to document workloads during 2019.

“We hope management will come forward with a solution because nurses are overwhelmed and genuinely concerned about not being able to provide adequate care to their patients,” she said.

“It’s incredibly stressful not to be able to give your patients the care they deserve.”

Jacinda said excessive workloads left senior staff with little time to mentor junior nurses in the ED.

NSWNMA General Secretary Brett Holmes said members were distressed by the lack of support from the Central Coast Local Health District.

“Our members know firsthand that staffing levels are inadequate to meet the local growth in population, which is putting patient safety constantly at risk,” Brett said.

“ED presentations have continued to rise and the patients presenting are very unwell. The hospital’s own data shows this, and management knows this, yet they continue to expect their nursing staff to do more with less.

“Our members are reporting increased levels of overtime, sick leave not being replaced, senior nurses being unable to fully support their junior counterparts, as well as high levels of exhaustion and fatigue due to understaffing.”

Brett said patient aggression towards nurses was a major issue and long waiting times were a contributing factor.

ED presentations break records

Presentations to NSW public hospital emergency departments hit an all-time high last winter, vindicating calls by the NSWNMA for urgent extra nursing staff.

According to the Bureau of Health Information (BHI), emergency presentations rose in all 15 Local Health Districts during July to September.

There were more than 760,000 ED presentations across the state – an increase of 6.6 per cent compared with the same quarter in 2018.

The timeliness of care provided in EDs was down across key measures in July to September.

For instance, 31.9 per cent of patients spent more than four hours in ED – an increase of 3.3 percentage points.

Central Coast hospitals were high on the list of the percentage of patients waiting more than four hours.

Gosford was among the worst five in the state, with 42.9 per cent and Wyong registered 35.1 per cent.

Data obtained by the NSWNMA shows that presentations to Wyong hospital ED increased by 10,102 patients between 2014 and 2018.

That represents an average increase of 28 patients per day.

Coronavirus: Updated Department Advice

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The Federal Department of Health has released new advice regarding the recent outbreak of novel coronavirus (2019-nCoV) detected in Wuhan, China. This update is most relevant to Primary and Community Health nurses, as well as those working in Emergency Departments.

The fact sheet for Primary and Community Health workers can be found here.

The fact sheet for Emergency Department workers can be found here.

Additional resources can be found on the Department of Health’s website, including posters that can be used in health facilities and factsheets that can be provided to patients.

Resources will continue to be updated in coming days and weeks as the situation evolves.

Nurses and midwives should be across this updated information, to ensure that we can limit the spread of this virus.