BACKGROUND:Patients who did not wait (DNW) for care in Emergency Departments (EDs) are individuals who present seeking treatment but leave before medical assessment. This cohort is an important focus for emergency research, as DNW events may reflect barriers to timely care, pose clinical and safety risks, and provide insight into broader system pressures within emergency services. METHODS:Retrospective study of DNW patients presenting to a metropolitan tertiary ED between January 1 and December 31, 2023. Descriptive statistics were generated for clinical and treatment variables, and multivariate logistic regression explored factors influencing 48-hour hospital representation. RESULTS:In total, 813 DNW patients were identified, representing approximately 1% of triaged patients. Most arrived by private transport and were allocated low-priority triage categories. Whilst 4% of cases had their presenting complaint completely managed by triage nursing staff, only 1.4% received nurse-initiated investigation or treatment. Overall, 9% represented to a local health district ED within 48 h. Multivariate logistic regression did not identify clinical factors significantly associated with subsequent hospital representation. CONCLUSION:DNW patients are common and frequently represent to other facilities to address healthcare needs. Earlier nurse-initiated treatments may accelerate patient care and potentially reduce DNW cases; however, this requires further research.
BACKGROUND:Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is increasingly used to control non-compressible torso hemorrhage in advanced trauma systems. However, its feasibility during active helicopter transport remains unclear. This study evaluated whether trained Helicopter Emergency Medical Services (HEMS) teams can perform REBOA in flight under realistic conditions. METHODS:A prospective high-fidelity simulation study was conducted with fourteen HEMS clinicians organized into seven physician-nurse teams. Standardized hemorrhagic shock scenarios were performed in full-motion helicopter simulators replicating AW109 and Bell 412 cabins. The primary outcome was successful in-flight REBOA deployment. Secondary outcomes included time to balloon inflation, first-attempt success, and procedural performance using the Objective Structured Assessment of Prehospital REBOA Application (OSAPRA). RESULTS:Successful deployment was achieved in all simulations (100%). Median time to balloon inflation was 7:32 min. First-attempt success occurred in 78.6% of cases. Higher OSAPRA scores were associated with shorter procedural times. Inflation times were shorter in the AW109 compared to the Bell 412, although overall success was similar. CONCLUSIONS:In-flight REBOA deployment is technically feasible in high-fidelity simulation. Operator competence and cabin configuration may influence performance, supporting further research prior to clinical implementation.
INTRODUCTION:Intimate partner violence (IPV) is a major contributor to poor health outcomes, particularly for women in rural areas. Geographical and social isolation can impede access to support networks and limited availability of specialised services can further compound vulnerability. Within this context, rural emergency departments have become key access points for IPV support; presenting an opportunity to explore how identification and response are approached in these rural settings. OBJECTIVE:This scoping review synthesises current research on clinician IPV identification and response practices in rural emergency departments (EDs) to inform future improvements in care and service delivery. DESIGN:This scoping review followed the Joanna Briggs methodology drawing on a search of four databases yielding ten peer-reviewed articles published between 2011 and 2025 that explored clinician IPV identification and response practices in rural EDs. FINDINGS:Five themes emerged: (1) Training and preparedness for IPV Practice, (2) Clinician Attitudes & Readiness, (3) Structural Barriers in Rural EDs, (4) Identification & Documentation Practices (5) Organisational and System Supports. CONCLUSION:Rural EDs face complex barriers to effectively identifying and responding to IPV, including workforce limitations, confidentiality concerns, and systemic under-resourcing. Enhancing emergency clinicians' IPV practices requires greater focus on trauma-informed organisational approaches, supported by workforce training that reflects the realities of rural healthcare and the communities it serves.
INTRODUCTION:Caller emotion influences the flow of emergency ambulance calls for out-of-hospital cardiac arrest (OHCA) however limited research has examined how call-takers manage emotion. We aimed to identify how and where emotion manifests in OHCA calls and how call-takers respond. METHODS:We analysed 107 consecutive OHCA calls to St John Western Australia (January-April 2021) containing emotion-related barriers to bystander cardiopulmonary resuscitation (B-CPR). Calls were ranked using the Emotional Content and Cooperation Score; 62 calls scoring 4 or 5 were included. We developed a schema of emotion displays, mapped their occurrence in calls, and transcribed call interactions. Conversation Analysis was used to examine interactional patterns. RESULTS:Callers displayed emotion through shouting, crying, "wobbly voice," and impatience (e.g., "just send the ambulance!"). Emotion was heightened at call onset, initial questioning, and when callers had to move the patient for B-CPR. Call-takers managed emotion using directness, boundary-setting, and empathy; sometimes emotion was not explicitly addressed to maintain call progression. CONCLUSIONS:Emotion is a disrupting factor in OHCA calls. Call-takers need a range of strategies to manage emotion according to the contexts in which they arise. Training using real-life call transcripts may enhance call-takers' skills, reducing delays in OHCA recognition and B-CPR.
BACKGROUND:Emergency medical service (EMS) providers play a critical role in delivering timely prehospital care and rely on a resilient workforce to respond effectively to emergencies. This study aimed to integrate frontline and decision-maker perspectives to identify key challenges and opportunities for strengthening EMS workforce resilience in Thailand. METHODS:Data were derived from a nationwide survey of 500 EMS personnel, including open-ended responses, and semi-structured interviews with six EMS decision-makers. Secondary content analysis was conducted to examine frontline perspectives, while primary thematic analysis of interviews was performed using NVivo. Findings were integrated to identify system-level priorities for strengthening EMS workforce resilience. RESULTS:Qualitative analyses identified challenges across five key domains: wellness, safety, competence, structure and resources, and policy and governance. Frontline providers reported high workload, mental health strain, and resource limitations. Decision-makers highlighted gaps in workforce planning, training, coordination, and governance. Integration of both perspectives identified system-level priorities for strengthening EMS workforce resilience. CONCLUSION:Strengthening EMS workforce resilience requires coordinated organizational and policy interventions that address workforce wellbeing, operational capacity, and governance simultaneously. The findings provide evidence to support workforce planning and health system resilience in Thailand.
BACKGROUND:Most of the available evidence regarding nursing leadership in emergency and critical care settings does not show how it is experienced in low-income healthcare systems. This study aimed to analyze the association between self-reported leadership behavior among emergency and critical care nurses and selected organizational outcomes. METHODS:An explanatory mixed-method design was conducted in a tertiary public hospital in Honduras. The quantitative phase included emergency and critical care nurses surveyed by using a validated questionnaire. Binary logistic regression was performed to identify factors associated with transformational leadership. The qualitative phase involved 17 nurses who participated in in-depth semi-structured interviews and analyzed using thematic analysis. RESULTS:Humanized care was a positive predictor (p = 0.042), while self-perceived clinical experience (p = 0.001) and teamwork incentive (p = 0.013) were negatively associated to transformational leadership. Qualitative findings revealed two main themes: (1) leadership conceptualized as guidance, adaptability, and transformational influence in high-pressure environments; and (2) structural barriers including workload, staffing shortages, limited supervision, and organizational culture constraints. CONCLUSION:These findings indicate that nursing leadership in emergency and critical care settings is shaped by both individual and systemic factors, highlighting the need for targeted educational and organizational investments in resource-limited contexts.
BACKGROUND:Topical Tranexamic Acid is increasingly used for epistaxis, but previous evidence syntheses have reported low certainty due to small sample sizes and high heterogeneity. We aimed to evaluate the efficacy of topical tranexamic acid in adult anterior epistaxis and identify clinical factors, specifically the method of administration, that influence treatment success. METHODS:We systematically searched PubMed, Embase, SCOPUS, and Web of Science for studies comparing topical tranexamic acid to standard care (nasal packing, vasoconstrictors, or placebo) for spontaneous anterior epistaxis. The primary outcome was bleeding cessation within 10 min. Secondary outcomes included emergency department length of stay and rebleeding rates (early and late). A subgroup analysis was conducted to compare the effects of different delivery methods on the success rate. RESULTS:Eighteen studies (16 RCTs, 2 prospective cohorts) involving 2760 patients were included. Topical tranexamic acid significantly reduced the mean time required to bleeding cessation, with a mean difference of -4.68 (95% CI -7.02; -2.34). Furthermore, it enhanced the probability of achieving bleeding cessation within 10 min (OR 2.54; 95% CI 1.22; 5.29) and reduced the risk of both early rebleeding (OR 0.42; 95% CI 0.29; 0.59) and late rebleeding (OR 0.45; 95% CI 0.24; 0.87). Patients treated with tranexamic acid were five times more likely to be discharged from the ED within two hours (OR 5.53). Subgroup analysis revealed that the method of administration was a critical moderator: tranexamic acid-saturated gauze provided a robust, consistent benefit (OR 2.98), whereas atomized delivery yielded inconsistent results (OR 0.29). Sensitivity analysis restricted to RCTs confirmed the stability of the primary effect (OR 2.50). CONCLUSION:Topical TXA could be superior to traditional management strategies for adult anterior epistaxis, offering faster hemostasis, reduced rebleeding, and shorter emergency department stays. However, efficacy is technique-dependent; saturated gauze/pledgets should be preferred over atomized delivery to ensure optimal and consistent treatment effect.
BACKGROUND:Peripheral intravenous catheters (PIVCs) are widely used in emergency departments to support treatment, yet their management is associated with preventable complications and variability in practice. METHODS:A descriptive observational study was conducted between June and September 2025 in an emergency department in (country). Direct, non-participant observation assessed PIVC insertion, maintenance, intravenous therapy administration, and removal using four structured checklists. Data were analyzed descriptively and organized according to the Irvine Nursing Framework. RESULTS:A total of 334 PIVC-related care episodes were observed: insertion (n = 129), maintenance (n = 33), intravenous therapy administration (n = 117), and removal (n = 55). Hand hygiene adherence was low before procedures (16.2%) and moderate after (51.2%). Deviations from guidelines were identified in catheter flushing (4.7%-10.3%), connector disinfection (11.1%), and use of sterile transparent dressings (9.3%). Maintenance practices were infrequent, and 22.7% of PIVCs were not used during the emergency department stay. CONCLUSIONS:Substantial discrepancies in PIVC management highlight the need for targeted quality improvement strategies to enhance adherence to evidence-based practices in emergency settings.
BACKGROUND:Paramedicine leadership is critical in high pressure emergencies that require rapid decision-making and effective team coordination. Strong leadership supports governance and improves patient outcomes, however, the specific attributes of leadership relevant to paramedicine remain under studied. This scoping review aims to improve an understanding of leadership and its key attributes within the paramedicine profession. METHODS:This scoping review followed Joanna Briggs Institute (JBI) methodology and PRISMA-ScR guidelines. Using the PCC framework, Ovid Medline, Ovid Emcare, Ovid Embase, CINAHL, and Scopus were searched from inception to 7 August 2025. Two reviewers independently screened records in Covidence and extracted data. Peer reviewed studies were thematically synthesised and appraised using JBI critical appraisal tools. Leadership patterns were identified through iterative content analysis and narrative contextualisation. RESULTS:Twenty studies (nine rated 'good', and eleven 'fair') from 11 countries were included. Four overarching leadership themes were identified: i) interpersonal skills, ii) professionalism, iii) personal attributes, and iv) learning and teaching capabilities. Transformational and situational leadership models highlighted adaptability, resilience, and ethical governance. The synthesis shows how dynamic interactions among these attributes enhance team effectiveness and crisis response in high-pressure medical settings. CONCLUSION:Effective paramedic leadership requires structured training in communication, adaptive decision making and ethical governance. This should be supported by system-level reforms that address resource gaps and cultural barriers in emergency care systems.
AIM:To describe the Continuous Quality Improvement (CQI) projects undertaken in Australian and New Zealand (ANZ) emergency ambulance services. BACKGROUND:Continuous Quality Improvement (CQI) is a structured approach to progressively improving processes within an organisation. CQI is well established in hospital settings but the extent of projects in emergency ambulance services is less well known. METHODS:Following the Joanna Briggs Institute (JBI) methodology for scoping reviews, a search of five databases, the websites of 10 ANZ emergency ambulance services and grey literature was undertaken. Papers describing CQI projects undertaken by emergency ambulance services were included. RESULTS:Seven papers were included, six of Australian origin. Results were mapped against National Safety and Quality Health Service (NSQHS) ambulance standards. All seven papers related to Standard One, Clinical Governance. Six related to Standard Eight, Recognising and Responding to Acute Deterioration. One related to Standard Two, Partnering with Consumers, and one to Standard Four, Medication Safety. Comments in reports on emergency ambulance service websites suggest CQI programmes exist; however, specific projects are not publicly listed. CONCLUSIONS:There is a paucity of publicly available evidence of CQI projects undertaken in the prehospital setting in ANZ. Emergency ambulance services should be encouraged to share information about CQI projects and results.
BACKGROUND:Acute wheeze is a common emergency department presentation among pre-school aged children. Innovative models of care that safely optimise treatment and streamline patient flow are needed. A nurse-led stretching of inhaled salbutamol pathway was introduced to enable nurses to independently manage bronchodilator weaning. This study evaluated its impact on length of stay within a children's short term treatment area. METHODS:A single-site controlled pre-post retrospective cohort study was conducted comparing children aged 1-5 years with wheeze admitted to the children's short term treatment area before and after the implementation of the nurse-led stretching of inhaled salbutamol pathway. A gastroenteritis cohort admitted during the same periods served as a non-equivalent control group to assess temporal confounding. The primary outcome was length of stay; secondary outcome included admission to the paediatric service. RESULTS:The wheeze cohort included 533 children. Median length of stay was similar pre- and post-implementation (420 vs 429 min; p = 0.48). However, escalation to a medical officer or nurse practitioner significantly declined post-implementation (from 70.9% to 49.8%; p < 0.001), while utilisation of criteria-led discharge increased (from 41.0% to 64.3%; p < 0.001). CONCLUSIONS:The nurse-led stretching of inhaled salbutamol pathway did not reduce length of stay but demonstrated comparable outcomes to conventional care. This model appears safe and may enhance workforce capacity and ED efficiency.
Background Situation awareness (SitAw) is increasingly recognized as a critical cognitive capability in emergency nursing; however, conceptual ambiguity persists regarding its defining attributes and conceptual boundaries, particularly in relation to decision-making in time-critical clinical environments. This concept analysis aimed to clarify the concept of SitAw and its defining attributes within the context of emergency nursing practice. Methods A concept analysis was conducted using the Walker and Avant framework. Thirty-six articles from multiple disciplines were reviewed to identify the defining attributes, antecedents, consequences, and empirical referents of SitAw relevant to emergency nursing practice. Results SitAw was consistently characterized by three core defining attributes: perception, comprehension, and projection, forming a dynamic cognitive process through which emergency nurses recognize relevant cues, interpret their significance, and anticipate future patient states. Decision-making did not emerge as a defining attribute but was identified as a decision-oriented readiness resulting from effective SitAw in time-critical settings. Key antecedents included clinical experience, assessment and monitoring skills, access to monitoring technologies, and supportive work environments, while consequences were reflected in patient safety and quality-of-care outcomes. Conclusion This analysis clarifies SitAw as a foundational cognitive process underpinning effective emergency nursing practice and provides a refined conceptual basis to support future research, education, and patient safety initiatives in emergency settings.
BACKGROUND:The adoption of key performance indicators (KPIs) in healthcare has transcended fiscal objectives, now seen as a symbol of commitment to high quality and safe patient care. Our objective was to describe and compare Australian Government state and territory-based Emergency Department (ED) KPIs. METHODS:Summative content analysis of all Australian Government state and territory health performance frameworks for 2024-2025 and supplementary documents describing ED KPIs. RESULTS:ED KPIs varied widely in number and categories across Australia. The proportion of patients seen on time was the only KPI used across all jurisdictions. All jurisdictions aside from Western Australia used ED length of stay as a KPI. Ambulance offload time was used in four jurisdictions. Only Tasmania measured 'did not wait' and only South Australia measured unplanned reattendance as a KPI. Both New South Wales and Tasmania used ED specific patient experience measures in their KPIs. KPIs measuring safety were reported across all jurisdictions but were not specific for ED. There were no KPIs measuring quality standards. CONCLUSIONS:Wide variability in ED KPIs and types of measures limit the ability to benchmark ED care nationally. This variability is shared internationally. It is important that policy makers, clinicians and the public also remain vigilant of the limitations of current KPIs and what they measure.
BACKGROUND:Child life therapists (CLT) use play and education to empower children and reduce their stress and anxiety in hospital. There is growing research on their effect on patient care; however, experiences of the multidisciplinary team (MDT) who work alongside them have not been explored. OBJECTIVES:To explore the MDT's perceptions on the role and impact of CLT in a children's emergency department (CED), during routine procedures such as cannulation, sedation and laceration repair. METHODS:A qualitative descriptive study was conducted using in person semi-structured interviews with 12 participants recruited through convenience sampling. Interviews were audio-recorded and manually transcribed verbatim, then subjected to inductive coding, primarily descriptive, and grouped into themes to identify patterns. RESULTS:Four key themes arose: (1) positive impact on family and wellbeing; (2) operational excellence and workflow enhancement; (3) professional impact and practice evolution; and (4) service demand and implementation challenges. Code frequency indicated that anxiety reduction, positive impact, resource availability, and improved workflow were the most prominent aspects identified. CONCLUSION:Introduction of CLT had a positive perceived impact on the MDT, contributing to enhanced patient-centred care. Findings reflected strong support for CLT integration within teams and recognised practical implementation considerations to inform future adoption in other departments.
BACKGROUND:Predicted nurse shortages internationally call for nurses to work at their full scope of practice. Nurse practitioners recommending computerised tomography imaging require medical signoff impacting emergency department flow. We aimed to develop a clinical guideline to support nurse practitioner-led requesting of computerised tomography scans for adults presenting to emergency department ambulatory care at a regional hospital. METHODS:We used a RAND/UCLA appropriateness method over two phases. Literature from a detailed review using a systematic process was extracted and synthesized into categories and shared via an online survey platform for phase one. Aggregated votes and comments were re-shared in summary before phase two, a face-to-face meeting of expert stakeholders. RESULTS:Five experts anonymously participated in phase one, and six contributed to the phase two meeting. Phase one agreement on appropriateness on the three literature generated topics ranged between 60 % and 80 %. Concerns about the need for emergency departments to be strategic with resources and fears of risk of increase in radiation exposure to patients were raised. In phase two, seven of the proposed eight items reached consensus (83 %-100 %). CONCLUSION:The agreed guideline supporting nurse practitioner ordering of computerised tomography scans provides a pathway to improve ambulatory care flow for patients with specific conditions.
AIM:To examine the effect of the HIRAID® emergency nursing framework on clinical handover. BACKGROUND:Clinical handover is very frequent in emergency departments and critical for patient safety. Inadequate handovers are associated with up to 80 % of adverse events. METHODS:This modified stepped-wedge cluster randomised control trial was conducted across 29 Australian rural, regional and metropolitan emergency departments between 2020 and 2024. HIRAID® was implemented using a behaviour change theory-informed strategy. Surveys were distributed to eligible staff. Quantitative data were analysed using a multiple regression approach; qualitative data using inductive content analysis. RESULTS:Surveys were completed by 1205 nurses (671 control, 534 intervention) and 328 medical staff (176 control, 152 intervention). Significant improvements were observed in satisfaction with nurse-to-nurse communication of patient history (t = 5.57, p < 0.001, 95 % C.I. = 0.33-0.69), physical assessment (t = 4.72, p < 0.001, 95 % C.I. = 0.28-0.68), recognition of clinical deterioration (t = 2.58, p = 0.01, 95 % C.I. = 0.06-0.43), information relevance (t = 3.29, p = 0.001, 95 % C.I. = 0.13-0.51) and completeness (t = 3.60, p < 0.001, 95 % C.I. = 0.17-0.56). Qualitative findings supported these results. CONCLUSIONS:Implementing a structured emergency nursing framework improved nurse-to-nurse clinical handover, supporting safer patient care.
BACKGROUND:Headache is a common emergency department (ED) presentation. We aimed to determine the proportion of patients undergoing Computerised Tomography (CT) for non-traumatic headache and identify factors influencing clinician decision-making. METHODS:We conducted a retrospective chart review of adult ED presentations at the Royal Melbourne Hospital from January to March 2024. Clinical features and CT data were extracted and mapped against SNOOP4 features. RESULTS:Among 223 patients, 124 (55.6 %) underwent CT, with abnormal findings in 15.3 % (19/124). No patient-reported symptoms increased the likelihood of CT ordering; photophobia was negatively associated (Odds Ratio (OR)= 0.41, 95 % Confidence Interval (CI):0.22-0.79). Examination abnormalities in peripheral sensation (OR=13.04, 95 %CI:1.69-100.59) and strength (OR= 3.62, 95 %CI:1.00-13.09) increased CT use. Patients with > 2 SNOOP4 features had markedly higher odds of receiving CT (OR= 13.5, 95 %CI:3.12-58.34) and of abnormal findings (OR= 5.75, 95 %CI:2.03-16.27). CONCLUSIONS:CT neuroimaging for non-traumatic headache was frequently performed, with a relatively low abnormal yield. While patient-reported symptoms did not influence CT ordering, examination findings and cumulative SNOOP4 features were associated with both imaging decisions and abnormal results. These findings support future studies into red-flag-based pathways to guide purposeful CT use.
Background To address increasing wait times and length of stay, many emergency departments (EDs) have implemented protocols focused on nurse-initiated care, enabling nurses to commence treatments, investigations or medications under standing orders or protocols. This study provides scientometric analysis and data visualisation of nurse-initiated care research. Methods A systematic search of the Web of Sciences Core Collection was conducted from inception to November 2025. Bibliometric and scientometric techniques examined publication trends, journals, authorship, co-citation patterns and keyword co-occurrence. Clinical coding was applied to classify problems, interventions and populations. Results A total 126 papers were identified, published between 1971 and 2025 across 64 journals and 23 countries. Publication activity was limited until 2000, until an increase and more marked growth from 2012. Nurse-initiated analgesia and x-rays were most frequently studied. Other studies examined nurse-initiated care for time-sensitive conditions such as pain, musculoskeletal injuries and trauma. Most protocols were for adult populations, though paediatric and older adult cohorts also featured. Keywords consistently included triage, analgesia and emergency care. Conclusions Nurse-initiated care in EDs is a growing field, with increasing evidence supporting its relevance to time-critical presentations.
Background Older adults with cognitive impairment frequently present to emergency departments and often experience poor pain management. Patients’ impaired self-reporting, limited clinician training, inconsistent use of behavioural tools, and environmental pressures have been reported challenges. This study examined emergency clinicians’ knowledge and practices in assessing pain for this population. Methods A descriptive cross-sectional survey was conducted across two emergency departments in Australia. An 86-item survey collected clinicians’ pain assessment knowledge and practices. Quantitative data were analysed using descriptive statistics, and qualitative responses were thematically analysed. Results 148 clinicians (110 nurses, 21 doctors, 17 allied health staff) responded to the survey (response rate =13.9 %). Whilst 80.9 % of respondents agreed observational tools were important, 44.6 % routinely used observational tools and perceived importance of these varied across clinical groups (p = 0.001). A self-report tool, the Numerical Rating Scale, was most used (78.3 %). The top barrier for pain assessment was patients’ inability to communicate and top enabler was viewing pain as a priority. Conclusions Clinicians recognised the importance of assessing pain in cognitively impaired older adults, yet practice was inconsistent and often relied on self-report and subjective observation. Targeted training, accessible observational assessment tools, and clear guidelines are needed to improve pain assessment and management.
BACKGROUND:First-line pharmacological management of acute renal colic pain may vary influenced by preference, structural and staffing issues with emergency departments. The aim of this study was to explore the variation in renal colic pain management and contributing factors within emergency departments in Australia METHODS: A specifically designed survey was sent to relevant national professional colleges and organisations for distribution. The survey presented respondents with four acute renal colic scenarios. Descriptive statistics summarised quantitative data, while free text responses were explored using content analysis. RESULTS:Responses from 180 nurses, paramedics and medical doctors were analysed. Opioids were the most commonly prescribed analgesia (4 scenarios) in combination with either paracetamol (3 scenarios) or rectal NSAIDs (1 scenario). Free text responses provided context to the preference of opioids and identified workload, clinician availability and scope of practice limitations to timely analgesia provision. Most respondents (91.2 %) would support research into non-pharmacological alternatives to opioids. CONCLUSION:Opioids remain the first line preference for many clinicians in managing acute renal colic pain despite current guideline recommendations for NSAIDs. Departmental and clinician capacity, and practice limitations contribute to delays in providing analgesia. Greater consistency and predictability in prescribing, review of limitations on nurse prescribing and exploring novel low risk first line non-pharmacological analgesics may improve management of acute renal colic.
