Virtual Reality or Virtual Dreaming - isolation is no barrier Cate Salter & Brenda Ainsworth

Identification of the problem Wentworth Area Health Service is the most western metropolitan health service within NSW and comprises the local government areas of the Blue Mountains, Hawkesbury and Penrith. It consists of four acute hospitals Blue Mountains District Hospital (BMDH) is the most distant from Nepean Hospital, the referral hospital for this area. It is 50 minutes driving time given traffic and weather conditions are optimal. At times the highway is blocked due to road accidents, bushfires and other incidents. There is only one road in and out of the area.

In this sense, care at BMDH is provided in the context of isolation with retrieval of critically ill patients being a challenge when transfer conditions are other than optimal. Retrieval or transport of patients is either by road or air. The medical support for the hospital is provided by a mixture of career medical officers, locum medical officers and visiting medical officers. There are no available on-site specialists in the management of critical care cases and no capability to keep these patients on site.

Over a number of years an analysis of trauma and critical care patients case records that were transferred from BMDH, have identified the sporadic ability to provide the clinical support to manage these patients. There are multiple factors contributing to this, including:

• lack of senior medical cover within the hospital, particularly at weekends

• decreased experienced of clinical staff in dealing with trauma and critically ill patients

• no on-site critical care staff (ie. emergency physicians, intensivists)

• gaps in anaesthetic cover.

The Solution in Concept The solution was envisaged to obtain emergency physician or intensivist support particularly at times when there was an inability to provide senior medical cover within the current staffing. Given the vacancy rate for specialists nationwide attempts to recruit were unsuccessful. It was seen as a time to start looking at alternative creative options.

The Concept to Solution/Pilot Project An opportunity arose for a collaborative approach to the problem between CSIRO and NSW Health through Wentworth Area Health Service. A proof of concept pilot project has been developed using the latest concepts in telecommunications and called the Virtual Critical Care Unit (ViCCU).

The Aim of the Pilot Project The clinical application of the ViCCU is to provide real-time clinical decision-making support to the clinical team at BMDH. A senior clinician at Nepean Hospital will provide the real time support. The target patient group is trauma and critical care patients at Blue Mountains District Hospital (BMDH) requiring transfer for tertiary critical care services.

Definition of the ViCCU The joint CSIRO and NSW Health Collaboration that is the ViCCU is a real-time audio visual link using broadband service provided by the SRA.

The purpose of the ViCCU is to provide real-time clinical decision-making support to the clinical staff at BMDH in the care of trauma and critically ill patients being prepared for transfer.

The Rewards The potential impact of the real-time clinician decision-making support provided by this project is immense. Isolation is no longer our enemy as we have a direct link to specialist clinicians. The prospect of fulfilling the dream of one department over two sites is now the reality that can be achieved. The potential for real time handovers between clinicians, the potential for increased collegiality between sites, the potential for area wide accepted protocols for all emergency department procedures from intubation to chest tube insertion, the potential for improved patient outcomes are the rewards offered.

26 Supplement to AENJ Volume 6 Number 2, College of Emergency Nursing Australasia Ltd.

The Challenges We now have the technology but...

Having the technology to achieve this concept is one thing but to engage clinicians in its use and to develop an environment of acceptance is another. Initially staff have expressed concerns with the use of such technology. From a Blue Mountains perspective these concerns have included issues of patient privacy, the 'Big Brother' impact, the feeling of clinicians' expertise being devalued, the fear of exposure of practice and the fear of ridicule.

From a Nepean perspective it has been the potential impact on workload for the emergency physicians and the 'buy in' to providing help to another facility. From an implementation point of view the issues supporting a cultural shift to one that embraces both a technological change and the change to the philosophy of one unit over two sites rather than stand alone emergency departments poses the biggest challenge. Many of the other perceived issues over both sites can be overcome with demonstrations and orientation to the new equipment and education. However, can we change the culture to accept a new philosophy? Only time will tell!

Where to From Here? The challenges and rewards identified also provide a template for further directions.

How will we capture improved patient outcome data? How will we identify the cost benefits of such technology? How will we roll out the technology to other isolated sites?

These are just a few of the questions that will need to be answered!

Nurse initiated narcotic analgesia is safe and reduces time to analgesia for patients with acute pain in the emergency department Caroline Barnes, Catherine Brumby & Anne-Maree Kelly

Objectives For patients presenting to the emergency department (ED) with acute pain and receiving nurse-initiated narcotic analgesia (NINA):

• to determine the safety of NINA when administered as per protocol.

For the subgroup with acute wrist fractures or renal or biliary colic:

• to determine the impact of NINA on time to first dose analgesia and time to pain control.

Methods Prospective, explicit medical record review conducted at a metropolitan teaching hospital in Melbourne which was piloting a protocol for NINA for patients in acute pain. For the safety study we included all patients receiving NINA. For the time substudy, the subjects were all adult patients with a suspected wrist fracture, or suspected renal or biliary colic. Patients were identified via the ED data management system. Data collected included demographics, condition, whether analgesia was nurse or doctor initiated, time from arrival to first dose of analgesia, time from arrival to pain control (defined as reporting a pain score < 3 on a 10-point verbal rating scale), and any adverse events.

Results For patients with wrist fractures and renal/biliary colic, there were 59 patients in the NINA group and 103 patients in the non-NINA group. The median time to first dose analgesia in the NINA group was 25 minutes compared with 64 minutes for the non-NINA group [effect size 39 mins, 95% CI 20-43 mins, p<0.0001]. The median time to pain score -< 3 was 103.5 mins in the NINA group compared with 130 rains in the non-NINA group [effect size 26.5 mins, 95% CI 1-68 mins, p = 0.04]. For the safety study there were 110 subjects. There were no cases of respiratory depression [0/110, 95% CI 0 to 4%] and two minor allergic reactions. Three patients had a fall in systolic blood pressure to between 80 and 90 mmHg. Two of these did not require intervention and one received IV fluids without adverse outcome.

Conclusion NINA administered according to protocol is safe and reduces time from arrival to first dose of analgesia and time to pain control.

ABSTRACTS 4th International Conference for Emergency Nurses, Sydney 2003 27