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August | 2019 EMERGENCY NURSE NEW ZEALAND The Journal of the College of Emergency Nurses New Zealand (NZNO) ISSN 1176-2691
EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019
In this issue
Features
Moving beyond Pillows and Pills Minor Scald Burns in kids
06 14
Workplace Wellbeing Snippets Winter 2019
11 36
in Emergency Departments
Worksafe NZ: Consultation, Draft Treatment of moderate to
13 39
Good Practice Guidelines on severe cellulitis in the home
Violence in Healthcare
CENNZ Social Media Update
42
Regulars
A Word from Regional Reports
03 15
the Editor
Chairperson’s NEW FEATURES
05 30-35
Report College Activities
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A Word from the Editor
Matt Comeskey
Editor | Emergency Nurse NZ
mcomeskey@adhb.govt.nz
Letters to the Editor are welcome. Letters of explosive, odourless, methane gas Mental Health and Addiction Inquiry. It
should be no more than 500 words, with were to build up. EDs are a bit like remains to be seen if any of this funding
no more than 5 references and no tables those canaries – whatever is going on will be allocated to EDs. The allocation
or figures. in our local community is played out will be followed closely by ACEM, the
in our workplace. We are amongst the CENNZ National Committee and the
first to see the direct result of social and NZNO Mental Health Nurses Section. A
economic change - for better or for worse. report on the symposium is featured in
this edition.
The change we are seeing is evident
This edition of the journal reflects a and ongoing. The rate of mental health Finally - speaking of wellness… please
healthy level of activity in CENNZ. It presentations to our EDs is growing at don’t fall off your perch this winter. Be
is exciting to see the formation of the a rate greater than the corresponding kind to yourself and others. Don’t be
ED Nurse Educators Group and the increase in community and inpatient a canary in a coal mine – escape your
ongoing activity of the Clinical Nurse mental health services. Consequently, cage for a bit and spread your wings
Managers Group. Their efforts to share our resource stressed EDs are placed in somewhere warm and sunny.
resources and ideas will no doubt benefit the position of providing acute mental
our colleagues and patients. Together we health care to meet the shortfall. On Correction
are stronger. 7 June ACEM (Australasian College of
In the last edition the featured Conference
Emergency Medicine) convened a one-
One of the problems we face is the Report: ConnectED 2018, was incorrectly
day symposium to discuss this issue.
growing burden of acute mental health attributed. The report was written by
Our College Chair, Jo King, represented
presentations in our EDs. In the previous Sandra Richardson, Senior Lecturer,
CENNZ.
Journal, Jo King likened EDs as the School of Health Sciences, University of
canary-in-the-coal-mine. An explanation One week before the symposium being Canterbury, Canterbury Westland CENNZ
may be required. In the bad old days, convened, the Government announced rep. My apologies.
canaries were taken underground in the allocation of $1.9 billion in the most
cages by coal miners as an improvised recent budget to address wellness. This
early warning system. The canary would allocation is in part a response to the
fall off its perch and die if lethal levels findings of He Ara Oranga Report into Matt
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EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019
Editorial Info
Subscription: Journal Coordinator/Editor: Dr. Sandra Richardson: Dr Sandra
Richardson : PhD Senior Lecturer,
Matt Comeskey:
School of Health Sciences, University
Subscription to this journal is through a Nurse Practitioner, ADHB
of Canterbury.
membership levy of the College of Emergency Email: mcomeskey@adhb.govt.nz
Deborah Somerville: MN. Senior
Nurses New Zealand - NZNO (CENNZ).
The journal is published 3 times per year Peer Review Coordinator: Lecturer. Faculty of Medical and Health
Matt Comeskey: Sciences, University of Auckland.
and circulated to paid Full and Associated
Nurse Practitioner, ADHB
members of CENNZ and other interested
subscribers, libraries and institutions.
Email: mcomeskey@adhb.govt.nz Submission of articles for
publication in Emergency
Copyright: This publication is copyright in its Peer Review Committee: Nurse New Zealand.
entirety. Material may not be printed without
Margaret Colligan: MHsc. Nurse All articles submitted for publication should
the prior permission of CENNZ.
Practitioner. Auckland City Hospital be presented electronically in Microsoft
Website: www.cennz.co.nz Emergency Department, ADHB Word, and e-mailed to mcomeskey@adhb.
Lucien Cronin: MN. Nurse Practitioner. govt.nz. Guidelines for the submission
Auckland City Hospital Emergency of articles to Emergency Nurse New
Department, ADHB Zealand were published in the March
2007 issue of the journal, or are available
Editorial Committee Prof. Brian Dolan: FRSA, MSc(Oxon),
from the Journal Editor Matt Comeskey
MSc(Lond), RMN, RGN. Director
at: mcomeskey@adhb.govt.nz Articles
of Service Improvement.Canterbury
Emergency Nurse N.Z. is the official journal are peer reviewed, and we aim to advise
District Health Board.
of the College of Emergency Nurses of New authors of the outcome of the peer review
Zealand (CENNZ) / New Zealand Nurses Nikki Fair: MN. Clinical Nurse process within six weeks of our receipt of the
Organisation (NZNO). The views expressed Specialist. Middlemore Hospital article. CENNZ NZNO Membership:
in this publication are not necessarily those Paediatric Emergency Care, CMDHB Membership is $25.00 and due annually
of either organisation. All clinical practice Paula Grainger: RN, MN (Clin), in April. For membership enquiries
articles are reviewed by a peer review Nurse Coordinator Clinical Projects, please contact: Kathryn Wadsworth
committee. When necessary further expert Emergency Department, Christchurch Email: cennzmembership@gmail.com
advice may be sought external Hospital.
to this group. Design / Production / Distribution:
Libby Haskell: MN. Nurse Practitioner.
All articles published in this journal remain Children’s Emergency Department Sean McGarry
the property of Emergency Nurse NZ and Starship Children’s Health, ADHB. Phone: 029 381 8724
may be reprinted in other publications if Email: seanrmcgarry@gmail.com
Sharon Payne: MN. Nurse Practitioner.
prior permission is sought and is credited to
Hawkes Bay Emergency Department,
Emergency Nurse NZ. Emergency Nurse NZ
HBDHB.
has been published under a variety of names
since 1992.
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EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019
Chairperson’s
Report
On behalf of the National CENNZ committee, greetings to all our
nursing colleagues.
Reports from around the country initiative to ensure we all talk the same
identify similar themes in the world of language. In the emergency department
emergency nursing. They are increased we have some key objective indicators
demand, high acuity and complexity of that represent significant clinical risk.
presentations, bed block, overcrowding, Furthermore they highlight immediately
pressure on ICU beds, inadequate staffing that there is a capacity versus demand
and limited variance response. And of mismatch. These are breaches, patients
course high rates of influenza continue to who are placed in un-resourced or virtual
add to the mix. beds, patients outside triage times and
large numbers in our waiting rooms
There are two urgent needs. One is to
adding to the workload of triage nurses.
identify a robust and validated model
These factors are unique to emergency
to calculate what is accurate base
departments and are often not
staffing for New Zealand emergency
acknowledged as representing variance.
departments. The second is to ensure
It is important they are understood in
variance response scoring has nationally
discussion around capacity / demand
standardised indicators that reflect
mismatch.
clinical risk that is specific to emergency
nursing. While I talk of challenges and gaps
in practice to calculating staffing
Finding a tool to accurately calculate
and variance, it also creates a unique
base staffing, that has research validation
opportunity to get this right. If we can
and is nationally acceptable to employers
work collaboratively across NZ to identify
has been a challenge for some time.
standardised staffing models and ED
There is even a lack of evidence in the
specific variance indicators we may be in
international setting to help solve this
a much stronger position to achieve safe
problem. The College has done work
staffing and mitigate clinical risk.
on this for many years without much
traction. I believe we must prioritise this Jo.
and be able to work with Safe Staffing
Healthy Workplaces (SSHW) and the
CCDM programme to move this forward.
The Variance Indicator Scoring (VIS) Jo King
is aimed at providing an early warning
Chairperson
of the mismatch between capacity
College of Emergency Nurses New Zealand
and demand. The work to standardise
the scoring nationally is an excellent Contact: cennzchair@gmail.com
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Author: Matt Comeskey. NP Adult Emergency Department, Auckland City Hospital.
Moving beyond Pillows and Pills - How do we
respond to the increasing number of people
presenting to Emergency Departments in a
state of mental crisis?
Everyone has the right to timely access to appropriate
mental health care. Data collected in emergency
departments across Australia and New Zealand,
confirms that people in crisis are routinely experiencing
unacceptable delays in access to mental health care in “Change can’t
our emergency departments (1). happen without the
perspective of others”
This finding is confirmed through the lived experiences of
those treated and the professionals delivering treatment. The Clare Skinner. Director of
associated outcomes are negative and well known. Our ability Emergency Medicine. Hornsby
to minimise harm has been compromised by the demand on Ku-ring-gai Hospital. Australia.
our services, from not only the increasing burden of mental
un-wellness in the community but the resource constraint
that emergency departments, mental health services and first
responders are currently operating under.
In June this year, ACEM (Australasian College of Emergency
Medicine) convened a one-day symposium to address this
issue. Invited parties were drawn from psychiatry, mental health
nursing, ED nursing, ED physicians and consumer advocate Three key issues were addressed in the programme.
groups. The symposium met the week after the Government
What is the Size of the problem?
announced a significant budget allocation to ‘Wellbeing’. This
allocation came in the wake of the recently released findings of Speakers presented data from their DHBs that suggested several
the Government Inquiry into Mental Health and Addiction, He themes in presentations. Broadly described these include:
Ara Oranga (2).
1. An increasing number of mental health presentations
The inquiry was wide-ranging in its breadth and number over and above population growth. The number of people
of respondents. The report identified significant gaps and presenting to New Zealand EDs for mental health related
inequities in the provision of mental health services – including reasons, increased significantly between the 2017 and 2018,
the management of crisis in the Emergency Department. 3.7% of all presentations in 2017 to 7.4% in 2018 (1.).
During the course of the day, a common and recurring theme 2. There has been a significant increase in overnight and
of presentations was ‘lived experience’ – that being the sharp prolonged stays in EDs. People experiencing mental health
end of mental health service delivery as spoken by those with crises experienced a significant increase in ED waiting times
real-world experience of what it is to be in a state of crisis. between December 2017 and October 2018. The proportion
of mental health presentations who had an ED length of stay
of eight or more hours while waiting for an inpatient bed
increased between the 2017 and 2018 study periods, from
4.5% to 27.5% (1.).
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EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019
Moving beyond Pillows and Pills - How do we
respond to the increasing number of people
presenting to Emergency Departments in a
state of mental crisis? cont.
3. A disproportionate number of Maori present in a state of
mental health crisis. Māori are over represented in the
population of those accessing mental health and addiction “With current resourcing we have
services at 27.7%, compared with their proportion in the
run out of ‘white rabbits to pull out
general population, at 15.4% (1.).
of hats. We are failing in our duty
4. There is continuing inequity of service and barriers to the
provision of community mental health services experienced
of care to maintain patient safety
by Maori and the wider population particularly in rural and provide best practice that is
areas. culturally appropriate.”
5. There is an increasing predominance of drug and alcohol-
Jo King. Chair, College of Emergency Nurse New
related presentations associated with crisis. There has been Zealand (CENNZ). NP Intern. Nelson Emergency
a steady annual increase in the number of people accessing Department.
mental health and addiction specialist services across New
Zealand.
6. There is difficulty in distinguishing between behavioural
disturbance and psychological distress and consequently
neither treatment path may be well managed.
7. There is a predominance of young adults and children Several speakers gave examples of sentinel events in EDs
presenting in crisis. related to delays to psych assessment and delays to transfer
to inpatient treatment. Additionally, barriers to timely care
The information presented suggested we need better data to and assessment are additionally problematic in provincial
guide practice. It is worth considering that ED presentations and rural ED settings. Regardless of location, in any ED, the
are the tip of the iceberg that is the burden of mental unwellness clinical environment is a significant contributor to further
in our communities. Without comprehensive data, we do not distress. Noise, 24-hour lighting, a lack of peer support and the
have the information required to ensure changes signalled in alienation experienced with seclusion and security watches -
the Wellbeing Budget are targeted to the right people or if they are all significant contributing factors exacerbating distress.
have been useful. Additionally, without robust data we cannot
hold ourselves and the Government to account for progress.
Mental Health and the Emergency Department Experience:
Using and Working in the System.
Mental crisis has always been a core ED presentation, and this “Often what we need is
will not change. The challenge, however, is in maintaining what you don’t have - time.”
quality of care in the face of an increasing number of
presentations and already stretched resources. Additionally, Caro Swanson. Principal Advisor, Mental
we need to ensure the ‘carers’ – nurses, doctors, watches and Health and service user lead. Te Pou o te
security staff, amongst others, are not over-burdened and face Whakaaro Nui (Te Pou). Mental Health
Consumer.
their own professional or personal crisis.
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EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019
Moving beyond Pillows and Pills - How do we
respond to the increasing number of people
presenting to Emergency Departments in a
state of mental crisis? cont.
A police representative described the current experience from We heard from consumer advocates and users of mental health
his point of view. He described people in crisis in the police services in the ED. One of whom related their experience of the
cells – as the “bad old days when bad things happened”. He care received in addressing the pain associated with a cardiac
acknowledged that while the ED environment is safer than arrest as opposed to the pain of a mental crisis – the difference
that of a police cell, it is better that acute assessment is done between the two separate experiences was stark and disturbing.
in the community. Police involvement often escalates crisis (6).
Police involvement in effect risks criminalizing a health issue. System Reform: What are the Government’s Next Steps?
He described the frustration police experience in being used At this time, it is unclear how the Government plans to allocate
as a default responder in crisis because of limited community spending under the Wellbeing Budget. The Government has
mental health services. Police often find themselves as sole identified mental health and community wellbeing as a priority.
responders or at best, co-responding with a paramedic and Exactly what this entails remains to be seen.
usually without community mental health support. This
Collectively, presenters identified significant gaps and
impression was backed-up by the assistant medical director
challenges in mental health services.
from St John.
We heard about significant delays to psych assessment and
transfer to inpatient beds for those medically cleared from
ED. Delay to assessment and treatment is a problem across “We forget the chronically, mentally
the District Health Boards. Delay increases the likelihood of
a cycle of agitation - sedation - observation - agitation and
unwell, are often chronically
re-sedation. Consequently, there is an additional delay to physically unwell too.”
transfer or discharge, adding significant distress and placing
Taimi Allan. CEO, Changing Minds.
extra demand on limited ED resources. In short, delays to
assessment and treatment are contributing significant further
harm. In any other medical or surgical service, these delays
would be deemed to be utterly unacceptable.
Broadly, these include:
1. The need for an appropriately trained workforce.
2. Timely assessment.
“We cannot allow systems 3. 24/7 community services of crisis care.
failure to become business 4. Safe spaces in ED.
as usual.”
5. Mental Health staff placed in EDs.
Scott Orman. Emergency Medicine
In response to these challenges, presenters shared experiences
Specialist. ADHB.
of effective models of care, innovations in service delivery and
structures that addressed the core elements needed to improve
emergency care for people in a state of mental health crisis.
There was a discussion about the appropriateness and safety
of ED clinicians undertaking mental health assessments in
some cases to expedite discharge from ED – thereby freeing up
psych services to focus on more complex cases. There was a
discussion about risk management in this context.
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Moving beyond Pillows and Pills - How do we
respond to the increasing number of people
presenting to Emergency Departments in a
state of mental crisis? cont.
reforms (3.) In the next six months, ACEM undertakes to
develop a Consensus Statement that captures commitments
and provide a mandate for systemic actions by the Government.
CENNZ will continue to be engaged in this discussion and will
“Whose risk are we continue to advocate for service improvement. Engagement
managing? Our own will be an ongoing work that cuts across other projects the
College is involved in – such as safe staffing, shorter stays in
or our patient’s?” ED, and addressing violence and aggression in our workplaces.
Alain Marcuse. Consultant
The systemic challenges identified in the symposium may
Psychiatrist. Crisis Resolution
lie beyond us to address, - out there on the floor, day after
Services. CCDHB.
day, doing our best an often messy, chaotic and demanding
environment. This symposium is a starting point. Broader
conversations need to be had that address the systemic failure
to deliver consistent, quality care to people in crisis in EDs and
the wider community. However, there are a few simple things
that each of us can do to improve the care we give to people
presenting in crisis.
Discussion followed on what is an acceptable time for a person Let’s change our vernacular. We need to stop referring to people
medically cleared, to wait in an ED for psych assessment and as “Frequent Fliers”, “Attention Seekers”, “Cutters” or any of
transfer to an inpatient service. Also, what does appropriate those other terms we use to minimize the suffering people are
follow up by community mental health services look like? experiencing in any moment. Our conversation travels in our
Innovations discussed included remote telemedicine psych departments. We know curtains are not soundproof, but we
assessments of people in remote or rural locations. These may treat them like they should be. People are hurt overhearing
diminish travel time and reduce delay to assessment. More unprofessional talk. Ruth Large, an ED SMO from Thames,
extensive use of peer group supporters and mental health gave a moving presentation that you can watch here.
advocates in ED may go some way towards de-escalating
https://vimeo.com/340605232/20d607547e
agitation and bridging understanding between people in crisis
and the professionals caring for them. Dedicated areas in EDs
for mental health assessments may go some way to addressing
the immediate shortfall in community services – but are
unlikely to be a long term solution. The ED will remain a “It should be Okay to NOT be Okay”.
less than favourable environment, even if there are physical
modifications to meet specific needs, for managing crisis. Ruth Large. Emergency Physician, Rural Hospitalist,
Clinical Director, Information Services and Virtual Health
What now? Care.
This symposium is the first step in the process of engagement
and advocacy. The day concluded with a communique that
included immediate priorities for policy, funding and workforce
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EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019
Moving beyond Pillows and Pills - How do we
respond to the increasing number of people
presenting to Emergency Departments in a
state of mental crisis? cont.
Let’s stop judging suicidality, or the seriousness of an attempt,
by the degree of toxicity in an overdose or the mechanism of
self-harm. Let’s accept that someone presenting in crisis is just
that - a person in crisis, regardless of the potential lethality or
our preconceived notion of the ‘seriousness’ of their suicide
attempt. Let’s resolve not to distinguish between the depth
of emotional and physical pain and the urgency in which we
should address either - pain is pain. Let’s recognize that we are
failing Maori and resolve to be open to being guided by Maori
in how to do better - even if it challenges us professionally and
challenges our world view. Let’s re-engage with the compassion
that is at the core of nursing by recognising that people in
crisis are simply that - people in a crisis. Any one of us or our
colleagues could be that person experiencing similar distress.
References:
1. Mental Health Service Use. A New Zealand Context. Report. May 2019. ACEM. https://acem.org.au/ 4. https://acem.org.au/News/May-2019/Mental-Health-in-the-Emergency-Department-Summit-C
getmedia/dc683d35-116a-4a4d-8481-733e9f49aad7/ACEM-Report-2019-Mental-Health-Ser-
5. https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12234598
vice-Use-A-New-Zealand-Contextv2
6. https://www.stuff.co.nz/national/health/99735922/a-growing-emergency-why-are-cops-look-
2. https://mentalhealth.inquiry.govt.nz/inquiry-report/he-ara-oranga/
ing-after-mental-health-patients-in-crisis
3. https://acem.org.au/getmedia/155a3761-26a8-4b03-82e9-8a39d2e9fb25/ACEM-Draft-Com-
munique-on-Letterhead-7-June-2019-1
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Author: Dr Mike Nicholls , Auckland Adult Emergency Department, FACEM
Workplace Wellbeing in Emergency
Departments
Results of a Wellbeing Survey Undertaken at Auckland City The HWG has adopted a quality improvement approach to
Hospital Emergency Department address some of the survey findings. Initiatives include a nurse
mentoring program, an information technology improvement
“He who has a why (to live for) can bear almost any how.” Friedrich
program, a mindfulness meditation program, and a “hot”
Nietzsche.
debrief project.
The importance of the wellbeing of emergency department
While we can’t do everything, there are things we can attempt
staff is obvious to all who have worked in emergency
to improve that may make a small but important difference.
departments. Experiential understanding is supported by a
recent metanalyses which demonstrates that as well as being Rather than trying to improve everything, a key principle
important for ourselves, our patients probably receive improved of quality improvement is identifying what is potentially
care from those who are not burnt out. (Pangioti, JAMA, 2018) controllable and focus on what is potentially doable. Another
We clearly have a “why”. important principle is measuring the effects of interventions,
something the research group is attempting.
But what can be done to address workforce wellbeing? What
factors are most important, what interventions may make a I would encourage all nurses and ED staff to get involved in
difference, what is actually doable and can these be measured? their workplace wellbeing and staff support programs. Thinking
“How” can we improve our wellbeing for ourselves, our patients and acting locally with a multidisciplinary team makes sense.
and the health system overall?
Researchers, with support from the multidisciplinary Healthy Figure 1. Reciprocal Domains of Staff Wellbeing
Workplace Group (HWG) at Auckland City Hospital Adult
Emergency Department, sought to identify baseline measures
of wellbeing (the extent of the “why”) as well as identify what
measures may improve wellbeing in their department (the
potential “how”) for all workgroups. (read the EMA article
online) Wellbeing was conceptualised as being influenced
by personal resilience, culture of wellness, and workplace
efficiency domains. (see figure, adapted from Bohman, NEJM
catalyst, August 7 2017)
Personal Resilience Culture of wellness
Despite personal burnout (measured using the Copenhagen Staff Wellbeing
Burnout Inventory) reaching 51% among nurses (30% for
doctors, and 0% for cleaners), most staff found their work
meaningful (81%), felt they had a good work-life balance (74%),
and agreed their department was “an excellent place to work”
(72%).
Efficiency of practice
What matters most to staff is providing safe, high-quality care
for their patients, and team work. Barriers to these included
high workload, being understaffed and lack of support within
teams and from management.
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Author: Jo King | Chairperson | National Committee of the College Of Emergency Nurses, NZ (CENNZ)
Worksafe NZ: Consultation, Draft Good
Practice Guidelines on Violence in Healthcare
I am submitting this feedback on behalf of the national significant consequences that have been reported using
committee of the College of Emergency Nurses New Zealand official processes. This is supported by evidence and data.
(CENNZ). There is current research in the New Zealand setting
(Richardson et al, 2018). There are escalating numbers
We acknowledge that the draft guidelines outline many
of reportable and sentinel events submitted through
recommendations which constitute best practice in reducing
DHB reporting processes. There is ACC data relating
violence and aggression in the workplace; however, as the
to workplace injuries sustained through violence and
voice of emergency nursing in New Zealand, we would like to
aggression and significant media coverage of this issue.
register our disappointment and concerns regarding this draft
There has been no adequate response.
document.
• The document discusses valuing a violence-free
We do not consider the guidelines are an adequate response to
workplace (4.2) and the provision of adequately trained
the escalating violence and aggression that is experienced by
staffing. Many emergency departments in NZ do not have
emergency nurses in their daily practice.
dedicated security personnel or only a paucity of security
Furthermore, we do not see these guidelines making any that is not 24 hours a day. Emergency department Charge
immediate impact on the safety of nurses in their current Nurse Managers are spending large amounts of time
workplaces. advocating for security and writing business cases to
DHB executive for adequate security. All emergency
The draft document ‘Violence in the Healthcare Industry:
departments in NZ report using significant police
guidance for PCBUS’ is a guideline with recommendations.
resources to maintain safety. This situation is untenable.
What is urgently required is not guidance and recommendations
but mandated regulations. The document states that “Work • The document recommends significant changes to
safe New Zealand is the work health and safety regulator” workplace environments (4.3) such as dual exit points
(2.1). As such, we see a critical responsibility to ensure in interview rooms, appropriate consult rooms for high
regulation, mandated safety standards, mandated reporting, risk patients, reduction of noise, staff car parks close
accountability of employers and robust investigation processes to work exits, comfortable waiting areas, appropriate
with enforceable outcomes. staff rest areas, metal detectors, treatment rooms away
from public areas, closed circuit TV (4.3). These are
• The document discusses – the likelihood of hazards and
all very ideal recommendations which would require
risks (2.5), identifying potential for violence (3.1) and
significant rebuilding and restructuring of NZ emergency
assessing risks (3.2). The risks in emergency departments
departments and considerable financial investment.
have been identified and well documented for a long
They therefore do not represent the reality of the world
time. They are multifactorial and relate to overcrowding,
of emergency nursing at the coal face of acute care in
patients and families under stress, mental health
NZ. These recommendations, while ideal are unlikely to
presentations, alcohol and drug intoxication, concealed
contribute to making the workplace of emergency nurses
weapons and organic illness. There has been no adequate
safer in the immediate future.
response.
• The document discusses client assessment (4.6).
• The document discusses looking at previous violent
Emergency nurses have robust and validated frameworks,
incidents in an organization and asking about workers’
such as the New Zealand Mental Health Triage Tool’
experiences (3.1) to identify risk. These are daily
(CENNZ, 2018), to identify patients who may pose risks
occurrences in our emergency departments, some with
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Worksafe NZ: Consultation, Draft Good
Practice Guidelines on Violence in Healthcare
cont.
of violence and aggression. Furthermore, we understand • Mandatory reporting by ACC to Work safe NZ of all
the level of security and observation required. However, injuries sustained by emergency staff.
emergency nurses do not have adequate access to
• Mandated requirements for security staff in emergency
resources to meet best practice guidelines. This has been
departments.
highlighted for some time, such as on DHB risk registers
and reportable/sentinel event reporting. Service gaps • Mandatory, fully funded training for all emergency
include inadequate staffing, inadequate security and the nurses such as the’ Management of Actual or Potential
inability to provide dedicated mental health observation Aggression’ course (MAPA).
in appropriate emergency department spaces. There has
• Mandatory personnel duress alarms for emergency
been no adequate response.
nurses.
The College of Emergency Nurses Zealand considers an urgent
• Organizational support and assistance for emergency
response to the escalating issues of violence and aggression is
nurses to pursue criminal charges for incidents of assault.
critical.
• Government funded national advertising campaign on
We consider that Work Safe NZ, as the regulator of work health
violence and aggression in emergency departments.
and safety, has a responsibility to ensure safety in emergency
The intent to stimulate both individual and community
departments is immediately actioned as a priority.
reflection on this issue to change behaviours.
We consider best practice initiatives must be actionable,
• Funded research to understand social and community
mandated by the regulatory body, they must be enforceable,
behaviours which suggest a societal normalization of
and there must be organizational accountability with processes
behaving badly in emergency departments.
that ensure investigation and remedial actions must be taken.
Guidelines and recommendations are an inadequate response The College of Emergency Nurses New Zealand is a key
unless they are underpinned by accountability and authority. stakeholder and a leading authority on violence and aggression
in emergency departments. We are very willing to collaborate
Recommendations on initiatives to mitigate the risks to the health and safety of
• Mandatory reporting by emergency staff of all incidents emergency nurses in their workplaces.
of violence and aggression.
• Mandatory reporting by DHBs of all incidents where
staff sustain injuries through violence and aggression in E References
the workplace. CENNZ (2018). New Zealand Mental Health Triage Tool.
Richardson. S., et al. (2018). Violence and aggression in the emergency department is under-reported
and under-reported. New Zealand Medical Journal. June, Volume 131 Number 1476.
P 13EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019 Minor Scald Burns in kids Burn injuries are a common paediatric emergency department (ED) presentation. In the paediatric population most are small (
EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019 Regional Reports Northland/Te Taitokerau | Auckland Midland | Hawkes Bay/Tarawhiti Mid Central | Wellington | Top of the South Canterbury/Westland | Southern P 15
EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019
Northland/Te Taitokerau Region
increased while planned renovations initiated hospital-wide. The aim
to create a small isolation cubicle is that data feeding from EDaAG
were brought forward. Most recently can be communicated to flag ED
there is a portable cabin in the car reaching the threshold for levels of
park nearby for stable presentations. overload automatically.
We are awaiting feedback from the The newly refreshed hospital
ACEM symposium on mental health integrated op centre is working on
in ED. Safety for staff and all patients ward- to-ward transfers so that stable
remains the priority. transfers do not come to ED.
Methamphetamine use in the region The Friends of ED volunteer service
is reflected in the number of meth- has started in April – 2 shifts from
related ED presentations. A more noon till 8 pm. This has been much
Sue Stebbings positive aspects are the outcomes appreciated by patients and staff.
Nurse Practitioner coming out of the ED Alcohol
and other Drugs screening and Rawene
Emergency Department brief intervention programme in Staff recruitment continues due to
Whangarei Hospital Whangarei – both with patient and people leaving to work overseas.
whanau engagement in community There are plans to send new staff
Contact: Chrisl_t@Yahoo.com support programmes. to triage course when rosters and
Staffing resources are low in both funding can be arranged.
the nursing and medical rosters,
exacerbated by winter illnesses. Kaitaia
We are grateful for bureau staff They are exploring options for
and locum cover. Several staff are overnight care/admission for people
on leave growing their families or with mental health presentations
travelling. Submissions to increase as the general ward or ED is not
staffing levels are underway. If appropriate. Subacute services are
approved, recruitment will be the often full. Overnight there are 3
Kia Ora. next step to return to adequately nurses on shift – 1 in ED and 2 on
covered shifts. the ward. Security staff are available
I am writing this on a cold wintry day
The Trendcare ED module is on the 24 hrs a day with improved police
with thunder, lightning and power
horizon, with discussions continuing access to the hospital after a critical
cuts – winter weather has arrived to
as the HL7 interface is introduced. incident overnight.
match the calendar. Winter illnesses
arrived quite a few weeks ago. The aim is to retrieve as much data Access to tele-education via mobile
as possible from EDaAG whiteboard health services has been a helpful
In Whangarei, our lack of rather than unnecessary duplication strategy for staff professional
appropriate isolation space to assess and data entry. development that avoids travel out
possible measles presentations
There is a review of the triggers of the area.
has been challenging. The process
has changed frequently over the and factors leading to ED overload
and the actions/processes that are
Sue
last couple of weeks as numbers
P 16EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019
Auckland Region
As anticipated, patient presentation reporting where these arise. This
volumes at Auckland Emergency process is helping to formally identify
Department continue to rise. the impact of key staffing factors
Within a setting of high patient- - such as sick calls and skill mix,
care workload, our hard-working and key workload factors – including
teams continue to support staff patient acuity, public holidays
professional development, undertake and major events. Emergency
research and implement numerous departments must deal with a
initiatives, quality improvements certain amount of unpredictability,
and risk reductions. and there is no easy-fix for system-
wide issues. However, nurses have
Winter seasonal presentations
a critical role advocating for patient
have already proven plentiful, and
safety and need to raise awareness
Natalie Anderson systems are in place to quickly
where unsafe staffing occurs.
identify and safely care for patients
Registered Nurse
presenting with symptoms of
Natalie
Doctoral Candidate influenza or measles.
& Professional Teaching Fellow SNOMED, with its uniform AED, CED and Middlemore ED
triage categorisation, has been
Adult Emergency Department, High winter volumes are impacting
implemented and staff have overall Hospital and ED capacity.
Auckland City Hospital worked to overcome the cognitive Patients are being seen in the corridors
Contact: na.anderson@auckland. and administrative challenges, and other spaces.
ac.nz associated with a new system.
Auckland Adult ED and Middlemore
An important programme of facilities are continuing to see high volumes
refreshment continues across in mental health presentations that
Level 2 at Auckland City Hospital, is putting a huge impact on resources
with careful planning, hoardings
and signage ensuring minimal Both areas have initiated pastoral care
interruption to clinical work, even as programmes with EAP to support the
sections of our department become staff with an increase in aggression
construction sites. that is being seen.
Auckland District Health Board is Auckland AED and CED, along
developing a team of specialised with Middlemore ED, have been
health security staff. Readily doing some work on nursing staffing
identified by their distinctive models and looking to make this more
bright green uniforms, they will regional.
have training and support for the Anna-Marie is working on using the
Anna-Marie Grace unique demands of working with staffing discussion outcomes for a
Nurse Unit Manager clinicians, patients and families in national statement on nursing staff
an emergency department. for the College of Emergency Nurses
Children’s Emergency
Our charge nurse group have been New Zealand (CENNZ).
Department
working hard to raise awareness of
Starship Children’s Health staffing challenges and ensure clear
Anna-Marie
Auckland City Hospital
Contact: annamarieg@adhb.govt.nz
P 17EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019
Midland Region
It has been a steady few months There has also been a large number
throughout the Midland region with of new staff come and join our team
numbers on the increase as we head which has lead to the increased need
into the cooler months. Recently of support from our professional
the ACEM (Australasian College development unit in regards to
of Emergency Medicine) Winter education support particularly in the
Symposium was held in Rotorua, pediatric area.
this was a very successful conference
Waikato ED have welcomed Kirsty
with large attendances and the
Greaves into a 6 month secondment
content was enlightening, ranging
in ED as our pediatric nurse educator
from pre hospital care, pediatrics and
at 0.7 FTE working alongside our
a presentation from Christchurch
existing nurse educator Helen Gavin
ED on the management of mass
Kaidee Hesford and they have just announced a 0.3
casualties.
FTE clinical mentor in the pediatric
Nurse Manager unit along with 7 day a week cover
Taupo
Lakes District Health Board of clinical mentors throughout the
The new helicopter service in department who will cross cover the
Emergency Department, Taupo has already been used pediatric unit outside of the 0.3 FTE
Rotorua Hospital several times with great success pediatric mentor to support the staff
since now having an Intensive care on the floor.
Contact: kaidee.hesford@
paramedic permanently rostered to
lakesdhb.govt.nz Waikato are continuing to work with
the helicopter. This has helped with
mental health around patients who
transfers out of the department and
present with mental health crisis in
will be developed further as more
ED to ensure they have a streamlined
training is given.
journey through the department,
Security remains an issue due to they are also working closely with
having no security on site. Staff security and the New Zealand Police
continue to complete datix forms around staff safety and continue to
and this is added to the database ensure our staff are well supported
regarding unsafe work conditions. with the fantastic peer support
group which was developed in house
Waikato and has representatives from the
Over the past 5 months the Waikato MDT in ED.
Emergency Department has been Waikato are prepping to host the 2019
reviewing their Model of Care, this CENNZ conference in September,
includes looking at processes and which their staff have been working
models in ED and how they can tirelessly on and hope to see you all
make changes to promote positive there.
ways of working such as a triage pull
model and looking at increased FTE Fingers crossed winter is nice to us
staffing numbers for both nursing this year and all the winter planning
and medical (they are awaiting the pays off.
outcome of this at present).
Kaidee
P 18EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019
Hawkes Bay / Tarawhiti Region
Hi everyone from a cold but sunny Extra nursing staff are now rostered
Hawkes Bay. onto the Nightshift, and a further
nurse will be rostered to the front of
Winter is certainly hitting us hard
house which continues to be a high-
here this year. As usual each winter,
risk area.
the hospital is at capacity, with
high acuity patients, and staffing However, the department has lost
and resources are struggling to meet an RN off the afternoon shift to
the demand. cover the night shift, the dedicated
orderly which it had in the afternoon
This is especially true for the
and evening time, as well as the
Emergency Department, which has
Dedicated Care Associate that was
yet again become the holding area
employed for Fast Track and Front
for patients needing admission and
Paula Draper of House.
complex care. As always, the staff
Registered Nurse of ED work hard and selflessly to Sadly, staff are also reporting that
meet the needs of patients. However, there has been an increase in violent
Emergency Department this is not without a cost to staff. incidents. Staff no longer have faith
Hawkes Bay Regional Hospital Staff are physically and emotionally in the powers that be who have
impacted by the ongoing stress of promised improvements. These
Contact: pjdraper@xtra.co.nz trying to meet the demands of caring promises have been made before but
in an environment that is under- not fulfilled. Recent media reports
resourced for the volume and acuity also highlight similar concerns of
of patients. the senior medical staff at the DHB
of under-resourcing to meet the
Many staff are leaving for a variety of
health demands of Hawkes Bay.
reasons. Many of those leaving have
stated they can no longer work in a I am sure these issues are not unique
department that is having a negative to Hawkes Bay, and many of you are
impact on their health, well being, facing the same issues.
and their families.
Balancing the books is, unfortunately,
Although recruitment is actively a necessity, but at what price?
pursued to fill vacant positions,
Stay safe and well everyone.
there is inevitably a delay, which
again adds further pressure on staff Paula
to cover roster gaps.
P 19EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019
Mid Central Region
Palmerston North Emergency her Registrar years with us, and it
Department is great to welcome her back to the
team.
So as winter has only just begun, we
have hit our capacity on more than We have continued presence within
one occasion, and the trend begun the dept of our NZDF Nursing
long before we hit the winter season. colleagues, and welcome them
The high acuity presentations, large conducting regular clinical shifts.
volumes and an often full hospital
After the recent renovations to ED,
continue to place pressure on the
and the redevelopment of our sub-
ED. We are seeing very high numbers
acute area and waiting room, we
of patients, and have recently set
have seen large numbers streamed
new record high numbers for the
through this area, and processes
Katie Smith dept. A greater VRM response to
ED overload has been asked for
being streamlined for maximum
Nurse Practitioner patient care and safety. The RN/
and initiatives to assist with surge
CNS/SMO team is working well, and
(Knowledge & Skills Framework capacity are being considered.
the colour coded system at triage to
& Website/Social Media) Hopefully this will provide some
identify appropriate patients for care
relief with the ongoing pressures of
NZDF in this area is proving successful.
winter, and we will be able to review
Palmerston North Hospital the data as we continue over the next This winter has already proved to
Emergency Department couple of months. provide high acuity patient load
and large volumes of presentation
There are several changes in the
Contact: katie.smith@nzdf.mil.nz numbers into the dept. Staff
Associate Charge Nurse space, as
continue to work extremely hard,
we say goodbye to Margot, who is
and have often worked over time
off to join the Duty Nurse Manager
and extra duties to cover roster
team. We wish you all the best, and
gaps and a busy dept. This was
can’t wait to see the great value you
recently acknowledged in the local
add to the DNM team. We are sure
newspaper, with one of PN EDs
to see you around ED in your new
busiest weekends. This is a timely
role. Several new ACNs have been
reminder for everyone to look after
appointed into permanent and
themselves and each other, and take
temporary roles, and we wish the
some time out if you need it.
new ACNs all the very best in their
new roles. Katie
As always, staffing numbers
continue to alter, with staff leaving Taranaki DHB Emergency Dept
and new staff being appointed, or We have been utilising clinical
returning. Welcome to all the new coaches recently to support our new
members of staff, you’re all valuable staff, especially with our skill mix
team members, and we are very being a challenge. This has been
lucky to have you all. well received, and although is only
A warm welcome back to our new short term while we had vacant Fte,
SMO Oni Alias – who comes back it is a concept we are hoping to
to us in her new capacity as a continue to better support our new
FACEM SMO – Oni spent some of staff in ED.
P 20EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019
Mid Central Region
We will be trialling a medical stages, but very exciting to be able to We are also having some staff
assessment unit from 20th May for start planning our model of care for turnover and delays in recruitment
about 8 weeks, and hoping if this is the new build and getting an idea of that are making some roster
successful it may be ongoing, and what the new ED might look like. challenges. Winter has definitely
will help with our ED bed block arrived!
We have a working group including
and capacity issues. For the trial
ED admin, clinical co-ordinator,
the medical assessment unit will Therese Manning – Charge Nurse
and senior staff nurses, as well as
be on the medical ward and stable Manager, ED / TDHB
ED doctors who are working with
GP medical referrals will be triaged,
the architects and planners for the Whanganui DHB
have lines, bloods and x-rays if
new build.
needed and go directly to the medical NIL report available.
assessment area on the ward. We are seeing record numbers
coming through the door, and high Carla O’Keeffe
We are planning the new build for
acuity patient presentations.
our ED, which is still in the design
Contributions for Publication.
We are always open to receiving submissions
for publication. Submissions in the form of case
studies, research posters and practice guidelines are
welcome. There is a modest contribution for featured
articles.
You can find guidelines for publication here: https://www.nzno.org.nz/groups/colleges_sections/colleges/
college_of_emergency_nurses/journal
Alternatively, email and enquire: mcomeskey@adhb.govt.nz
P 21EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019
Wellington Region
Practitioner in their Emergency reports significant security issues
Department. Wellington has also with ongoing discussions on how to
secured 2.0 FTE for the Nurse best address these.
Practitioner role. Both of these
The Wairarapa ED continues to
departments have battled tirelessly
struggle with the effects of inadequate
to achieve these advanced nursing
GP coverage and the results of
roles and they are excited about
this impinging on the Emergency
showing the value and proving the
Departments wait time’s which
benefit this will add to departments
now far exceed reasonable limits.
under pressure coupled with
Unfortunately it is the lower triage
improved patient management.
group who is fairing the worst with
Staff shortages, sickness, injury this. Like many other departments
Kathryn Wadsworth and turnover are something that in the country this exacerbates
all three Emergency Departments frustrations resulting in aggression,
Clinical Nurse Manager
in this region are battling. It is complaints and poor patient flow
Acute Services fair to say this goes beyond the but this seems the reality of our
Emergency Department and into environments currently. Increasing
Wairarapa District Health Board
the wider hospital. Volunteers are population is now being felt and will
Contact: Kathryn.wadsworth@ now pivotal to the smooth running only worsen over time with huge
wairarapa.dhb.org.nz of our departments and in Hutt their housing developments happening
roles are being expanded to move throughout the Wellington region.
into MAPU, this can only support
The annual mass casualty exercise
how valuable this resource is to our
in the Wairarapa happened in May
services. This group work tirelessly
with good interest from our wider
to support our departments for very
support networks like Police, Fire and
little recognition but very quickly
Regional Emergency Management.
A busy start to the year with some have become part of the wider team
Due to our isolation it is vital we
reprieve felt during the RMO in our ED’s.
have a collaborative approach and
strike week here in the Wairarapa Following the December event in this has been a challenge to achieve,
although the all or nothing feel was Hutt’s Emergency Department however some ground is being made
very apparent. The ED was either where multiple staff were assaulted both externally and internally of
frantic or empty with very little and many off work for a significant the Wairarapa DHB. A previously
in between. The messaging from time period a review was undertaken. identified weak point in the mass
Hutt Emergency Department is This review is yet to be released but casualty plan was the front door
that their winter has arrived early when published it will have short triage area and this was made a
with significantly unwell patients and long term recommendations focus for this exercise with promising
and associated challenges filling that will undoubtedly have wider improvements made. Another
their department. The same theme hospital ramifications. It is hoped significant project that has had huge
comes out of Wellington Emergency that the learning from this terrible success is the training programme
Department with them recording event is spread beyond the isolation developed by our educator aimed
their highest presentations over a 24 of one hospital and shared amongst at the care of the ventilated patient
hour period on the 5th March 2019. all Emergency Departments who are within the department. This has
Hutt are very excited to have 1.0 equally at risk of this scenario and captured the nursing group that
FTE approved for the first Nurse battle the same issues. Wellington often are nervous and unsure of this
P 22EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019
Wellington Region Cont.
task and has provided them with the benefits they offer to a challenging train and mentor those coming in
skills to manage this patient group environment. but is a crucial aspect of emergency
with some confidence. nursing again supporting advancing
The pressures of winter are nearly
nursing roles within our teams.
Wellington Emergency Department upon us and many are suggesting
has secured a fixed term position that what used to be easily identified Fingers crossed for the next round
for a research nurse funded through as changing pressures as colder of flu season that is upon us.
MRINZ that is great news for that weather came our way is not as Knowing that every department
department. Many nurses continue clearly defined now. This leaves essentially faces the same battles
on their pathway of post graduate our departments with minimal there is some solace in the sharing
education and with this the benefits down time. The need to nurture our of the challenges, frustrations and
are very clear within the department new nurses and support our more concerns.
with initiatives being undertaken to experienced ones is an ongoing
improve patient safety, management challenge for us all. Our teams Kathryn
and flow. It is wonderful to see this turn over quickly which results in
advancing nursing workforce and the additional pressure to continuously
If you would like to submit an advertisement
or article for the next issue of the journal
please contact the editor matt comeskey
for more information!
email Matt at: mcomeskey@adhb.govt.nz
P 23EMERGENCY NURSE NEW ZEALAND COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO AUGUST 2019
Top of the South Region
Greetings from the Top of the 6 month period, it has had a major
South. Winter has arrived and so impact on evening workloads and a
has influenza which is placing reduction in the need for afternoon
considerable strain on a service staff to do overtime. Loosing these 8
already under pressure. hours of nursing per day is certainly
a cause for concern. Over the last
Nelson Emergency Department 2 winters, the department also
There are many challenges currently had a CNS service working Friday
facing emergency nursing in this – Monday. This has also ceased
part of the country. The themes are - as it was funded from additional
relentless demand, high complexity money resulting from the Kaikoura
and acuity, overcrowding, bed block earthquake. Loosing these resources
and inadequate staffing resources at a time of high winter demand
Jo King to respond to variance. At times it adds to the challenges at the coal
Nurse Practitioner Intern feels like the only tool navigating us face. However, the establishment
(CENNZ Chairperson) through this are the attributes of a of a 7 day a week, 1-9.30pm, HCA
very cohesive and resilient team. position has been welcomed.
Emergency Department,
Data continues to support the Improving the care of mental
Nelson Hospital health patients in the emergency
increasing workload of the
department is high on the ‘To do’
Contact: jo.king@nmhs.govt.nz department. Presentations are
up per year, patient minutes in list. It is recognised the clinical risk
the department continue to rise, that is created when we are unable to
deterioration in the 6hr LOS and meet the National MOH standards
increasing admission rates. VRM for observation. Work is ongoing
data also demonstrates increasing across the region on a triage initiated
periods spent in red. In June this year mental health pathway. The aim is
Nelson recorded a 262% increase in to ensure the correct observation is
Triage 1 patients compared to June implemented and documented for
2018. This equated to ED nurses triage code and the risk identified.
providing 80 hours of 1:1 nursing Barriers to implementing this
care while waiting for ICCU beds. pathway remain the lack of adequate
The impact of this on ED staffing staffing resource, such as health care
resources is significant. If there assistants, to provide observation.
is an upside, it has been all the The recent Australasian College
opportunities for revising, coaching of Emergency Medicine (ACEM)
and development of ventilator and summit which was held in
critical care skills. Wellington was a great first step in
moving this discussion forward.
A 10-bed Medical Assessment and
Planning Unit (MAPU) officially I would like to congratulate Diane
opened in early July. This should Varey, one of our senior staff nurses,
provide some assistance to ED flow. who has been appointed as a
However, at the same time, we have National Triage Instructor. As well
lost our 1745- 0215 nursing shift, 7 as this Di is our Health & Safety
days a week. This shift was added representative and her work in this
to our roster as a result of the Meca area should be acknowledged. She
/ CCDM staffing initiatives. While has been tireless in advocating for
it was introduced for a temporary staffing resource and for strategies to
P 24You can also read
