Maintaining Best Practice in Rural Emergency Departments; tips, tricks and pitfalls

Gwenhyfar Ferguson1,

1 Country Health SA, SA, 5690, camelgwen@yahoo.com.au

Maintaining a skilled workforce in a rural emergency department presents a specific set of challenges. Barriers to training arise from internal and external issues. External issues include geographical isolation, training course cost and inflexible training delivery. Internal issues include limited or lack of nurse educators, deficient progression planning, limited support and paucity of senior staff and mentors. Due to the identified constraints, training for rural ED nurses is often inappropriate, insufficient and irrelevant.
The rural nurse role of the specialist-generalist has limited exposure to emergency nursing care due to infrequency of presentations. Consequently with high acuity emergency patients the rural nurse may lack confidence and proficiency to manage safe patient care. Meeting these challenges requires innovative solutions.
Developing skills and building a sustainable model of training delivery requires effort from nurses and management. There are transition and skill development tools available. The difficulty is to disband old assumptions about training strategies, now identified as ineffective and build systems on identified staff needs.

“An exploration of the experiences of emergency nurses’ workplace stressors and their coping strategies”

Miss Oluwadunsin Adesina1, Dr Anita De Bellis2, Dr Katrina Breaden3

1 Miss Oluwadunsin Adesina, Faculty of Medicine, Nursing & Health Sciences, Flinders University, GPO BOX 2100, ADELAIDE  SA  5001, Australia, ades0007@flinders.edu.au
2 Dr Anita De Bellis, Faculty of Medicine, Nursing & Health Sciences, Flinders University, GPO BOX 2100, ADELAIDE  SA  5001, Australia
3 Katrina Breaden, Faculty of Medicine, Nursing & Health Sciences, Flinders University, GPO BOX 2100, ADELAIDE  SA  5001

Australia

The challenges and stressors that nurses face in their workplaces can differ from one nursing specialty to another depending on the context of their work. A considerable amount of research has examined stress and coping in general; however, little of this has focused on emergency nurses, who are continually exposed to a wide range of workplace stressors in their daily nursing practice. Failure on the part of emergency nurses to adequately cope with and resolve these stressors can lead to compassion fatigue, burnout, post-traumatic stress disorder (PTSD) and a high attrition rate among emergency nurses.

The aim of the study was to explore emergency nurses’ experiences of stress in their workplace and the coping strategies they use to manage these stresses. Based on the review of the literature, Interpretive Description (ID) was adopted and used for the purposes of answering the research question. The study was conducted on willing emergency nurses who were members of the College of Emergency Nurses Australasia (CENA), with data collected through audiotaped semi-structured interviews via telephone. Ten participants answered questions about their experiences of stress, how they were affected by stress and the coping strategies they used to cope with stress. Five themes emerged with a number of associated subthemes.

The findings showed that emergency nurses enjoyed emergency nursing because of patient presentation, the team work, providing and delivering patient care and the satisfaction they derived from being an emergency nurse. Regarding the causes of stress for emergency nurses, these were found to include work conditions, violence and aggression, death and dying and interpersonal relationships. The third theme revealed the physiological and physical effects of stress in association with the effects of workplace stress on emergency nurses’ professional and personal life.

To cope with their workplace stresses, emergency nurses used debriefing as an important strategy and their perceived level of support from their organisation contributed to how they coped with stress. Emergency nurses also relied on their personal coping mechanisms.  The last theme revealed that emergency nurses’ personalities and use of a cognitive approach made a substantial difference to how they were affected by and coped with workplace stress.

The discussion interpreted the findings in relation to the research question. The discussion centred around the contemporary stresses of emergency nurses,  compassion fatigue being a result of workplace stress, the importance of coping with stress, and resilience as an attribute of coping. Finally, the implications of the findings for emergency nurses, practice and management were outlined and recommendations were made for education and further research.

Biography

My Name is Oluwadunsin (Dunsin) Adesina. I graduated from Flinders University Adelaide and I am a registered nurses that works at the Royal Adelaide Hospital I have been an emergency nurse for six years. I decided to pursue an Honours Degree after my graduation from Flinders University and my research question was based on my interest in knowing what emergency nurses found stressful and their coping strategies for these stressors.I have a graduate diploma in emergency nursing and I have been involved in the resuscitation team of the Royal Adelaide Hospital.  i have also had the opportunity to be a leadership position at work and being a member of a very multi-disciplinary team.

Is there a doctor on-board? A personal account of a mid-flight emergency

Karen Thompson1

Emergency Department North West Regional Hospital, Burnie, TAS, 7320 | RN Grad Dip (Emergency Nursing) Grad Cert (CritCare, Rural and Remote Health)  Certified Instructor (Non-violent Crisis Intervention) BN

Historically, international travel was the privilege of the wealthy, but the advent of discounted airfares in recent times has brought overseas travel within the reach of the average Australian. Although intrinsically remote with great distances between localities, our country is also extrinsically remote in its isolation from other countries. Consequently, a nurse may find his/herself practising in challenging and/or remote situations, with scant support. The following talk is a personal account of my experience of practicing in a very confronting environment during a mid-flight emergency. The presentation is underpinned by research on remote nursing and obstetric emergencies and summarised with my reflections, experiential learning and recommendations.

Halfway home from a family holiday to Fiji I had just put my book down and closed my eyes, when a man in the opposite row called for help. His wife – Sophie*- was lying awkwardly across the seats and floor in the clonic phase of a seizure. Given her obvious state of pregnancy, I immediately suspected eclampsia, an obstetric emergency.  Practising my DRABC I noted she was in imminent danger from surrounding fixed structures and at risk of positional asphyxia, so her husband assisted me to re-position her as the call went out for a “doctor on board”.

Her unresponsive post-ictal state indicated a GCS of 5 at best (E1V3M1) causing me further concern over the patency of her airway, so I enlisted the help of two men, who identified themselves an obstetrician and a urologist, to carry Sophie to the galley.  I turned to resume my seat, but when they discovered I was a remote emergency nurse, I was asked to stay, primarily because neither had cannulated for over ten years!

While conducting Sophie’s secondary survey, we discovered that she had many risk factors for pre-eclampsia, including having the condition in a previous pregnancy and hypertension during this pregnancy. At this point, my talk will detail Sophie’s management, including intravenous drug therapy, fluid resuscitation and airway management.

Most emergency nurses will find ourselves, at some point, practicing in challenging and/or remote situations.  However, I confess being 30000ft above the Pacific Ocean with a severely hypertensive post-ictal woman and limited medical supplies the most isolated and challenging situation of my career. Not to mention the almost surreal experience of sitting on the galley floor, managing the patient’s airway while the plane landed!

Upon reflection, I learned much from this unusual experience. Firstly, I was reassured that I was equipped to deal with a highly challenging situation. Secondly, it reminded me of how resourceful one becomes when working in remote areas and the intestinal fortitude one develops. It also made me realise that a good nurse is never off duty; we can leave the problems behind at the end of a shift, but we never leave the caring shut up in our locker. Finally, it reinforced my personal belief that all nursing students should experience remote placement time as part of the Bachelor of Nursing degree.

References

Australian Resuscitation Council http://resus.org.au/guidelines/flowcharts-3/  accessed 14/7/16
Central Australian Rural Practitioners Association, 2009, CARPA Stamdard Treatment Manual 5th Ed,  Alice Springs, Central Australian Rural Practitioners Association
Curtis, K & Ramsden, C 2015, Emergency and trauma care : For nurses and paramedics, Chatswood, NSW : Elsevier Australia, 2016. 2e Australia and New Zealand edition.
Duley, Lelia. “Pre-eclampsia and the hypertensive disorders of pregnancy.” British Medical Bulletin 67.1 (2003): 161-176
Duckitt, K. and Harrington, D., 2005. Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies. Bmj, 330(7491), p.565.
Smith, JD 2007, Australia’s rural and remote health : A social justice perspective, Croydon, Vic. : Tertiary Press, 2007. 2nd ed.

Biography

Karen has a varied background over the past 35 years, beginning her nursing career as a mental health nurse under the “old system” in the early 1980s. She returned to study at the University of Canberra in 2000, to complete a Bachelor of Nursing. She has worked in the emergency department for over seven years after extended stints in remote health and ICU nursing. She has also practised in women’s health, general practice and drug and alcohol programs. Karen has recently diversified into teaching as a certified instructor in non-violent crisis intervention and works as a sessional teacher of the Diploma of Nursing at TasTAFE. Her other qualifications include Grad Certs in both Critical Care and Rural and Remote Health, as well as a Grad Dip in Emergency Nursing and expects to complete her Masters of Clinical Nursing degree in October 2016. Karen’s clinical interests are education, crisis intervention and an intense fascination with the pathophysiology of trauma, particularly brain injury. Her personal interests include a passion for travel and study of languages, animal welfare, playing netball, volleyball and softball, loud rock music and maintaining an organic mini-farm. Not least, she enjoys spending time with her family and spoiling her four grandchildren, and her greatest supporter through all her academic achievements is her husband David.

Workplace violence in the Emergency Department in the Kingdom of Saudi Arabia

Waleed Alshehri1, Virginia Plummer2, Paul Jennings3

1 Monash University, School of Nursing and Midwifery (waleed.alshehri@monash.edu)
2 Monash University, School of Nursing and Midwifery (virginia.plummer@monash.edu)
3 Monash University, Department of Community Emergency Health and Paramedic Practice (paul.jennings@monash.edu)

Background: Workplace violence (WPV) occurs in any industry or occupation, but the health industry is at high risk. Healthcare professionals are at increased risk of WPV because they are working with the public, sometimes work with unstable or volatile persons, handling prescription drugs, and working late hours at night. Workplace violence occurs in every healthcare setting, but there are some areas at higher risk of WPV such as mental health units, and the Emergency Department (ED). Health care workers in the ED are at risk for WPV and are routinely exposed to WPV from patients and their families/friends.

Aim of the study: The aim of this study is to explore the WPV among the ED nurses and doctors in the Kingdom of Saudi Arabia (KSA).

Method: A correlational quantitative cross sectional design was used to collect data from six public hospitals in the KSA by utilizing an anonymous self-administered questionnaire.

Result: A total of 288 ED nurses and doctors participated ,73 (25.7%) participants were subjected to physical assault, 76 (27.2%) to physical threat, 196 (69.8%) to verbal abuse, and 47 (17.3%) to sexual harassment. Patients’ families/friends were the main source of WPV. Male patients or patients’ families/friends were the most common source of WPV for physical assault, physical threat and sexual harassment, except for verbal abuse were both genders were involved equally. Most of the participants (n=220; 78.9%) agreed they are vulnerable to WPV and 198 (69.7%) agreed that WPV affects their professional performance.  Furthermore, most of the participants (n=117; 41.5%) indicated that they are not sure if they could manage WPV and 230 (82.7%) have indicated that they need training/more training in dealing with WPV. Participants reported that an increase in the number and the quality of the security staff, improving the patient admission process, and educating the public about when to use the ED would reduce the WPV in the ED. In addition, there was a significant relationship between the prevalence of physical assault and the absence of WPV prevention training (p=0.040). Furthermore, there was a significant difference in the perception of participants regarding the acceptance of WPV as a part of the job and the job of the participants. Nurses were found to be more accepting of WPV more than doctors (p=0.019).

Conclusion: Workplace violence is prevalent among the ED nurses and doctors in the KSA especially verbal abuse. The findings are congruent with the existing literature however the recommendations for policy practice education and research need to be consistent with Saudi Culture and cognisant of the multicultural workforce. The utilisation of the findings for development of a WPV prevention policy in ED is recommended for further research.

Biography

I am a PhD candidate studying at Monash university. Right now, I am doing my PhD in Nursing as full time and fully sponsored by the Saudi government. I worked in the emergency department of two tertiary hospitals in the Kingdom of Saudi Arabia for more than 8 years. Furthermore, I worked in different areas in the ED. since I started doing my master, I focused on the management issues that prevent the ED nurses from providing their optimal care in the proper manner such as occupational stress and workplace violence. I believe that there is a chance for us as nurses to change the current situation by disseminating our research findings and that hope will change the current situation for a better one.

Understanding reasons for Emergency Department (ED) attendance in a metropolitan hospital

Jo-Anne McShane1, Andrew Maclean1, Julie Considine2

1 Emergency Department, Box Hill Hospital, Eastern Health, Victoria, Australia
2 Eastern Health – Deakin University Nursing and Midwifery Research Centre

Background
Our Emergency Department (ED) is located in a health service with three acute care sites and three ED’s. Following an above expected rise in presentations to one specific ED within the health service (16% in 12 months), we decided to look at why patients chose to present to our ED and the decision making process around their presentation.
Methods
This was a single-site cross-sectional study of patients (n=200) who were triaged to the main waiting room and fast-track waiting room (ATS 3-5) over a six week period from October- December 2015.
Patients were asked about:
• Their perception of the seriousness of their condition before ED arrival and while they were waiting (1=not serious at all to 10=serious).
• Their perception of the urgency of their condition before ED arrival and while they were waiting (1=not urgent at all to 10= serious).
• Factors considered prior to attending the ED.
• General perceptions and attitudes towards ED services.

Results
When making the decision to come to hospital patients rated their perception of the seriousness of their condition, with 52% rating themselves moderate to high (score 4-7), slightly increasing to 57.5% after arriving in the ED. A majority of patients (62%) rated themselves with the same level of seriousness pre and post presentation.

The perceived level of urgency at the time of making the decision to come to ED was 45%, (score 4-7) increasing to 51.5% after arriving in the ED. A majority of patients (68%) rated themselves the same level of urgency pre and post presentation.

There were many factors patients considered when presenting to the ED. Patients strongly felt that the hospital provided better care for their condition (59%), found it convenient to have all services in one place (55%), with the hospital being close by to where they live (58%). When deciding to attend the ED a majority of patients did not take into consideration the financial impact (68%) or issues around privacy (98.5%).
Patients had strong feelings in regards to general perceptions and attitudes towards ED services. Patients believed that people should only come to hospital if their illness is urgent or life threating (63%), with a majority of people saying that coming to the hospital for non-urgent illnesses was a misuse of the system (68%). Most patients felt that hospitals had the convenience of all facilities in one place (92%) and were willing to wait even if the ED was crowded (52.5%). They believed that hospital doctors and nurses are better specialised (63%) and even if they presented to a GP they would be referred to the hospital anyway (59.5%).
Conclusion
Patients present to the ED because they believe their condition is serious and urgent enough to warrant emergency care.

Biography

Jo-Anne is a Research Nurse and Clinical Nurse Specialist with over 16yrs experience in various Emergency Departments in Australia and overseas.

Under the radar or beyond the horizon? Aeromedical retrieval in Central Australia

David Carpenter1

1 David Carpenter BNurs, GradDip Nurs (Emerg), GradDip Mid.

Royal Flying Doctor Service (Central Operations), PO Box 2210  Alice Springs NT 0871 david.carpenter@flyingdoctor.net

The Royal Flying Doctor Service of Australia (RFDS) is one of the largest and most comprehensive aeromedical organisations in the world. Staff at the Alice Springs base provide emergency medical evacuations for people who live, work and travel in remote Central Australia, many of whom have a heavy chronic disease burden.  The vast distances, climatic extremes, cultural diversity and wide spectrum of clinical presentations combine to provide a unique practice setting with a birds-eye view.

This presentation outlines the influence that each of these factors has on aeromedical operations in the region, before exploring the development of innovative solutions that support the provision of safe and efficient aeromedical transport across a region the size of Western Europe. These include partnerships with the Alice Springs Hospital Retrieval Service and Central Australian Remote Health, along with a unique 7-tier priority coding system for tasks. The presentation will also incorporate the use of interactive technology to poll the audience for their answers to scenario-based questions in real time.

Biography

David Carpenter is Tasmanian born and bred, and worked as an Emergency Nurse in Launceston for a number of years. After a short period as a locum Remote Area Nurse in 2008, David qualified as a Midwife and swapped temperate island life for the vast deserts of Central Australia. He has worked as an Alice Springs-based Flight Nurse/Midwife with the RFDS since 2011.

Transplanting emergency nursing: Can lessons from Australian emergency nursing make a difference in Indonesia?

Putu Budiarsana1

1 Rumah Sakit Umum Pusat Sanglah, Jalan Diponogoro Denpasar, Bali, Indonesia, budiarsana79@gmail.com

Emergency departments around the world face similar challenges in such as increasing acuity and overcrowding due to bed block. Emergency departments in developing countries face additional challenges such as limited resources and problems associated with professional status and the development of collaborative working relationships.

Indonesia has recently introduced universal health coverage which has resulted in unprecedented pressure on public hospitals. As a major teaching and referral hospital Sanglah Hospital in Bali has been particularly affected by these changes, with up to sixty admitted patients at one time waiting in the emergency department for transfer to wards.

This paper describes a collaborative improvement project conducted jointly between nurses from Darwin and nurses in Bali to assist in improving patient flow. Using the Practice Change Framework for International Development (Brown, 2011) this paper describes the process for designing and implementing patient flow ideas from Australia to improve the quality of emergency care at Sanglah Hospital. The challenges and results of implementing reforms in such a challenging environment are explored.

Biography

Pak Budi is the Nurse Coordinator for the Emergency Department at Sanlgah Hospital, Bali, Indonesia. He has also nursed in Australia and completed postgraduate studies in Adelaide.

The Case Reflection Emergency Master Class

Melissa Hanson1, Kerralyn Buckman2, Judy Townsend3

1 Dubbo Base Hospital, Myall Street, Dubbo, N.S.W., 2830, Melissa.Hanson@health.nsw.gov.au
2 Dubbo Base Hospital, Myall Street, Dubbo, N.S.W., 2830, Kerralyn75@gmail.com
3 Dubbo Base Hospital, Myall Street, Dubbo, N.S.W., 2830, Judytownsend_60@hotmail.com

Reflection is an important facet of nursing, because it helps us as nursing professionals to analyse and evaluate our practice. It helps us to recognise those elements of excellent service provision, as well as areas for improvement. It provides for a wider scope of learning from these experiences. It is through this reflection that we as Emergency Nurses aim to continually improve the professional standards of nursing in our Australian Emergency Departments (ED).

The Case Reflection Emergency Master Class was developed for the Dubbo Base Hospital ED nursing employees in response to the need for reflection and education opportunities. It was designed to provide additional education and service improvement prospects within the Dubbo rural area, and further aims to expand these prospects to Dubbo’s outlying rural and remote peripheral services – the Western New South Wales Local Health District (WNSWLHD) – in view of its continuing success. The Case Reflection Emergency Master Class is an innovative model of education designed to maintain and enhance nursing knowledge and skills.

As nursing employees within the WNSWLHD, we know it can be difficult to access and participate in education and simulation-based learning opportunities due to a myriad of multi-faceted issues. Distance and isolation are all too real; resources are limited; and being able to get time off in order to attend education is often difficult due to a lack of staff in the first place. Most of the education and travelling involved are undertaken in nurses’ own time, and at their own expense.

That is where the Case Reflection Emergency Master Class steps in. Dubbed “Master Class” for short, it is Dubbo Base Hospital ED’s analysis session focussed on education and reflection. It involves the discussion of important cases that we see in our department – we talk about what we did well; what we can learn from; the background and patho-physiology of the case, and more. Think along the lines of a Morbidity and Mortality Meeting, only less formal, less confronting for nursing staff, and more targeted to nursing knowledge and performance.

The main aims of the Master Class are to:

  • Identify areas of strength, as well as areas of need;
  • Enable additional ED skill acquisition;
  • Improve clinical competency and confidence amongst ED nursing staff, and therefore as a result;
  • Improve health-based outcomes for all our patients.

The added benefit of this form of education is that we can review and learn about presentations that are classified as infrequent in nature. These types of presentations, for example, a major trauma or a paediatric cardiac arrest, require advanced skills and knowledge that may not be fully utilised regularly by nursing staff in rural and remote areas. The Master Class gives ED nurses the opportunity to learn and develop these skills, and practice them in a simulation-based environment without having to travel great distances, pay a great deal of money, and take significant time off work.

Biography

Melissa Hanson is an Advanced Clinical Nurse and the acting Clinical Nurse Educator in the Emergency Department of Dubbo Base Hospital. She has 5 years of experience in Emergency Departments within metropolitan and rural New South Wales. When she is not living and breathing emergency nursing, you’ll find her being a mum to her 3 babies aged 4 and under, baby-wearing one of her babies, or out on the family farm trying her hand at country life!

Team work through trauma

Greg Brown1, Mel Brown2 , Mark Tyler3, Donna Kennedy4

1 Manager – Medical Education and Training, CareFlight, 4 Barden St, Northmead, NSW, 2152, Australia. Greg.Brown@careflight.org
2 Clinical Nurse Consultant – Medical Education, CareFlight, 4 Barden St, Northmead, NSW, 2152, Australia. Melanie.Brown@careflight.org
3 Deputy Director Of Nursing, Macksville Health Campus, MNCLHD. Boundary St, Macksville, 2447, NSW, Australia. Mark.Tyler@ncahs.health.nsw.gov.au
4 Clinical Nurse Educator, Macksville Health Campus, MNCLHD. Boundary St, Macksville, 2447, NSW, Australia. Donna.Kennedy@ncahs.health.gov.au

Teamwork is not just about how well you look after the patient but also how well you look after your team. A strong team working well together can provide care for patients well above the sum of each individual team members skills. The “soft” skills can really make a difference in assuring that patients have the best possible outcome.

“Team Training Through Trauma” which occurred in Macksville on Friday, 13th May 2016, had  a total of 67 participants attended CareFlight’s training over the four sessions with each session lasting 120 minutes. Presenting the sessions were a FACEM, a Clinical Nurse Consultant, an Intensive Care Paramedic and a Technical Rescue Instructor.

The main thrust of each session was the application of the seven non-technical team skills with focus on leadership, teamwork and communication. Each session contained a range of activities including baseline theory on the afore mentioned topics, skill stations to facilitate practicing of these non-technical team skills and an outdoor scenario designed to bring all previous aspects together in an unfamiliar yet realistic and enjoyable environment.

The training was delivered to an impressive cross-section of health sector employees including medical, nursing (registered, enrolled and assistant), midwifery, allied health, administrative and pre-hospital staff from the Mid North Coast Local Health District, general practice, numerous aged care facilities and New South Wales Ambulance. From the 65 feedback forms collected, the self appraised results were impress with staff recognizing a 155% increase in knowledge of the “7 Non Technical Team Skills”. Not to mention that 100% of the participants assessed themselves as having fun whilst learning.

Biography

Donna currently works as a CNE at Macksville Hospital on the MNCLHD. She works across both the inpatient ward  and theatre environment.

Profiling wound management in the emergency department: A descriptive analysis

Rachel Cross1,2,Natasha Jennings2, William McGuiness1, Charne Miller1

1La Trobe University, Alfred Clinical School, 99 Commercial Road Melbourne, Victoria, 3004, Australia. r.cross@latrobe.edu.au
2The Alfred Hospital, Emergency and Trauma Centre, 99 Commercial Road Melbourne, Victoria, 3004, Australia.

Background: In Australia, wound and skin conditions are among the top 10 patient presentations to emergency departments. Yet the service profile of wound, skin and ulcer presentations to emergency departments is an area that lacks an existing published commentary. Knowledge of these presentations would inform the allocation of resources, staff training, and, in turn, patient outcomes.

Aim: The aim of this study was to describe the frequency of wound, skin and ulcer patient presentations to one ED, to profile the most common types of wounds seen, and to appraise the discharge and referral status of this patient population. This study was conducted in one Australian emergency department.

Methods: A retrospective descriptive review was conducted of all emergency presentations including discharge and referral statuses for skin, wound and ulcer related conditions from 1st January 2014 until 31st December 2014.

Results: A total of 4231 patients presented to the emergency department for a wound, skin or ulcer complaint. Management for these conditions accounted for 7% of the total emergency presentations. Wound conditions were the most prevalent (n=3658; 86%), followed by skin (n=539; 12.7%) and decubitus ulcer and pressure area (n=34; 0.8%). Males were more likely to present for all three conditions. For all conditions, discharge to home was the most common destination. Following discharge to home, over half all patients were referred to the local medical officer.

Conclusions: The current workload for the management of wound, skin and ulcer presentations to the emergency department would suggest that these patients contribute a significant financial burden to the ED. The implications for appropriate wound management in the ED are, therefore, significant. Nursing workforce models, education and training needs to reflect the skill set required to respond to wound, skin and ulcer conditions to ensure that high quality skin and wound care continues outside of the emergency department.

Biography

Rachel Cross is a Lecturer in the School of Nursing and Midwifery for La Trobe University, Victoria, Australia. Rachel also works in a clinical capacity in one large emergency and trauma centre in Victoria. Rachel has worked in clinical and educational roles in both local and international emergency and acute care settings. Rachel’s research area of interest is patient safety at the point of emergency department discharge and the influence for the transition of patient care. Rachel is currently undertaking her PhD examining handover and clinical deterioration in emergency care transitions.

12