EMERGENCY NURSE NEW ZEALAND - NZNO

 
EMERGENCY NURSE NEW ZEALAND - NZNO
August | 2019

EMERGENCY NURSE
NEW ZEALAND
The Journal of the College of Emergency Nurses New Zealand (NZNO)
ISSN 1176-2691
EMERGENCY NURSE NEW ZEALAND - NZNO
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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EMERGENCY NURSE NEW ZEALAND - NZNO
EMERGENCY NURSE NEW ZEALAND                   COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO                                     AUGUST 2019

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 - NZNO
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 - NZNO
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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EMERGENCY NURSE NEW ZEALAND - NZNO
EMERGENCY NURSE NEW ZEALAND                  COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO                                    AUGUST 2019

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 - NZNO
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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EMERGENCY NURSE NEW ZEALAND - NZNO
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.

                                                                        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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EMERGENCY NURSE NEW ZEALAND                   COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO                                                          AUGUST 2019

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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EMERGENCY NURSE NEW ZEALAND                    COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO                                   AUGUST 2019

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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EMERGENCY NURSE NEW ZEALAND                    COLLEGE OF EMERGENCY NURSES NEW ZEALAND - NZNO                                                                     AUGUST 2019

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 13
EMERGENCY 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 16
EMERGENCY 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 17
EMERGENCY 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 18
EMERGENCY 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 19
EMERGENCY 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 20
EMERGENCY 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 21
EMERGENCY 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 22
EMERGENCY 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!
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EMERGENCY 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

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