ED nurses’ Christmas Eve

'ED nursing is about critical thinking. It is never monotonous.'

'ED nursing is about critical thinking. It is never monotonous.'

ALL ACTION IN ED: Gisborne Emergency Department nurses, from left, Mandy Hughes, Mel Jones, Michelle Hunter and Karen MacDonald work on their “patient”, fellow ED nurse Jamie Phelps. Gisborne’s ED is a busy work place, seeing an average of between 45 and 65 patients each day. Most arrive from about 10.30am continuously through to about 9.30pm by which time most patients have been either admitted or discharged.

Picture by Rebecca Grunwell

EMERGENCY Department (ED) nurse Mel Jones remembers Christmas Eve, 2016. She was in bed when her phone rang.

“I was asked to come into work — I thought it was a joke.’’

It was no laughing matter. Mel quickly learned of the bus crash on the Whareratas, which resulted in three deaths, and multiple admissions to Gisborne Hospital’s ED. Fellow ED nurse Karen MacDonald remembers she rang another off-duty colleague to tell her she was urgently needed. The other nurse quickly left for the hospital, but not before telling Karen, “I haven’t wrapped my children’s Christmas presents”.

Last Christmas Eve was not typical, but the department did experience a “summer surge” of presentations, said Hauora Tairawhiti board chairman David Scott. In December and January presentations were up 32.5 percent from the previous summer. Official figures show 9611 ED patients in the six months to April 30. Chief executive Jim Green said March was a seven-year record for the number of ED presentations.

“This is doubly concerning when . . . there is a record in triage four and five (the least serious) presentations."

Mel said no one knew for sure why Gisborne’s ED was so busy.

“Gisborne has an ageing population and older people have more health problems,” she said. And Karen said the department was seeing more older people.

The stereotypical image of a busy ED is a Friday or Saturday night with many intoxicated patients. But Mel said that was not always the case. Sunday, Monday and lately Tuesdays are their busiest times. Some patients might want to avoid expensive weekend charges at their GP centre, although children still get free treatment. Others did not initially realise how seriously ill or injured they were.

But there are others who believe their injury or illness to be more serious than it is. Some patients think they will need x-rays, blood tests or a cast and decide to seek treatment “under the one roof”.

ED can be an emotional and stressful environment and not always for health reasons. Some patients can be impatient and are unaware of the triage process where patients are treated, not on a first-come, first-served basis, but based on the severity of their condition. Such assessments cannot always be made based on visual appearances. This process may confuse ED patients who are not trained in triage.

Karen said such situations could be challenging.

“Emotions can run high.’’

Some patients have been known to ring for an ambulance assuming it will get them priority treatment. But those patients still go through triage and are treated solely on that assessment. A small number of patients can become abusive and aggressive, but Hauora Tairawhiti practises a zero tolerance policy regarding violence. The police are sometimes called. But that can result in a Catch 22 situation where such people still require medical treatment.

The urgency and unpredictability of ED nursing is an attraction, said Mel.

“ED nursing is about critical thinking. It is never monotonous.’’

Karen said ED nurses were thinking on their feet constantly.

“No day is the same. You have to think quickly — and keep your mind active.”

ED was a collaborative work place, she said. There was no hierarchy.

“Doctors listen to us, they respect our opinions. ‘That could be partly because post-graduate study is now considered the norm and some nurses even have Masters degrees.”

Mel said more nurses were doing post-graduate study.

“That increases their knowledge and ability for critical thinking. That’s why we get on well with doctors.”

In addition to bedside nursing, senior nurses have other responsibilities in quality improvement matters such as health and safety, strategies to minimise risk of harm to patients and gaining efficiencies.

“We are always thinking of wastage,” said Karen, who has some responsibilities in purchasing. “Can we do things cheaper?’’

It was a different era from the generation of nurses her mother belonged to. They did their original three years of training to be a registered nurse.

“That was the total sum of their training. They had no other expectations.’’

Today continuing education was an important concept for nurses, Karen said.

EMERGENCY Department (ED) nurse Mel Jones remembers Christmas Eve, 2016. She was in bed when her phone rang.

“I was asked to come into work — I thought it was a joke.’’

It was no laughing matter. Mel quickly learned of the bus crash on the Whareratas, which resulted in three deaths, and multiple admissions to Gisborne Hospital’s ED. Fellow ED nurse Karen MacDonald remembers she rang another off-duty colleague to tell her she was urgently needed. The other nurse quickly left for the hospital, but not before telling Karen, “I haven’t wrapped my children’s Christmas presents”.

Last Christmas Eve was not typical, but the department did experience a “summer surge” of presentations, said Hauora Tairawhiti board chairman David Scott. In December and January presentations were up 32.5 percent from the previous summer. Official figures show 9611 ED patients in the six months to April 30. Chief executive Jim Green said March was a seven-year record for the number of ED presentations.

“This is doubly concerning when . . . there is a record in triage four and five (the least serious) presentations."

Mel said no one knew for sure why Gisborne’s ED was so busy.

“Gisborne has an ageing population and older people have more health problems,” she said. And Karen said the department was seeing more older people.

The stereotypical image of a busy ED is a Friday or Saturday night with many intoxicated patients. But Mel said that was not always the case. Sunday, Monday and lately Tuesdays are their busiest times. Some patients might want to avoid expensive weekend charges at their GP centre, although children still get free treatment. Others did not initially realise how seriously ill or injured they were.

But there are others who believe their injury or illness to be more serious than it is. Some patients think they will need x-rays, blood tests or a cast and decide to seek treatment “under the one roof”.

ED can be an emotional and stressful environment and not always for health reasons. Some patients can be impatient and are unaware of the triage process where patients are treated, not on a first-come, first-served basis, but based on the severity of their condition. Such assessments cannot always be made based on visual appearances. This process may confuse ED patients who are not trained in triage.

Karen said such situations could be challenging.

“Emotions can run high.’’

Some patients have been known to ring for an ambulance assuming it will get them priority treatment. But those patients still go through triage and are treated solely on that assessment. A small number of patients can become abusive and aggressive, but Hauora Tairawhiti practises a zero tolerance policy regarding violence. The police are sometimes called. But that can result in a Catch 22 situation where such people still require medical treatment.

The urgency and unpredictability of ED nursing is an attraction, said Mel.

“ED nursing is about critical thinking. It is never monotonous.’’

Karen said ED nurses were thinking on their feet constantly.

“No day is the same. You have to think quickly — and keep your mind active.”

ED was a collaborative work place, she said. There was no hierarchy.

“Doctors listen to us, they respect our opinions. ‘That could be partly because post-graduate study is now considered the norm and some nurses even have Masters degrees.”

Mel said more nurses were doing post-graduate study.

“That increases their knowledge and ability for critical thinking. That’s why we get on well with doctors.”

In addition to bedside nursing, senior nurses have other responsibilities in quality improvement matters such as health and safety, strategies to minimise risk of harm to patients and gaining efficiencies.

“We are always thinking of wastage,” said Karen, who has some responsibilities in purchasing. “Can we do things cheaper?’’

It was a different era from the generation of nurses her mother belonged to. They did their original three years of training to be a registered nurse.

“That was the total sum of their training. They had no other expectations.’’

Today continuing education was an important concept for nurses, Karen said.

Success in treating sepsis

GISBORNE Hospital’s Emergency Department (ED) has had great success in treating sepsis by emphasising the importance of the “golden hour’’ when fluids and antibiotics should be administered. ED nurse Karen MacDonald said an auditing process had identified that sepsis was not being recognised as well as it should be.

Several years ago two new graduate nurses developed a “sepsis board” which displays protocols and guidelines for identifying and managing sepsis. There was no official launch, but there was a ‘big education project’ featuring ED and St John staff. Since then the only changes made have been to name new antibiotics and doses, but the basis remains the same.

“It became a challenge," said Karen. “How quickly you could get it done.”

Karen said she and two colleagues hold the record for administering fluids and antibiotics the fastest — in nine minutes.

“It was at night and we knew the patient was coming, thanks to an early call from St John. But I am quite proud. We see a lot of patients with sepsis in Gisborne.”

The sepsis board gave nurses the ability to keep house surgeons and the many locums who come to Gisborne Hospital informed of the criteria on how ED manages sepsis. This allows for a pathway of care.

  • Sepsis is a potentially life-threatening complication of an infection.
  • Sepsis occurs when chemicals released into the bloodstream to fight the infection trigger inflammatory responses throughout the body.
  • This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail.
  • If sepsis progresses to septic shock, blood pressure drops dramatically, which may lead to death.
  • Anyone can develop sepsis, but it’s most common and most dangerous in older adults or those with weakened immune systems.
  • Early treatment of sepsis, usually with antibiotics and large amounts of intravenous fluids, improves chances for survival.
  • The sepsis board was developed as a part of a Quality Improvement project for ED at Tairawhiti Hauora.
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