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NHS emergency services, including ambulance services and emergency departments (EDs), are under considerable pressure due, in part, to the lack of availability of alternative healthcare services. People with mental health issues often contact ambulance 999 services when they cannot access the care they require from other sources. Welsh Ambulance Services NHS Trust (WAST) employs mental health professionals in its 999 call centres to provide remote mental health triage and support. While this has been effective in reducing ambulance conveyance to EDs, many patients still require a face-to-face assessment. To address this, WAST explored the option of providing a mental health response vehicle (MHRV) service, which has been shown to be effective in some ambulance trusts in England. This article gives an overview of a pilot MHRV service that was delivered by WAST across the Aneurin Bevan University Health Board locality in south-east Wales in between January and March 2024. Results suggest that the MHRV service can reduce ED conveyance rates and potentially provide cost savings for WAST and the wider NHS in Wales., Competing Interests: None declared, (© 2024 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Ambulance handover delays arise when emergency departments become overcrowded as patients waiting prolonged periods for admission occupy clinical cubicles designed to facilitate the assessment and treatment of emergency arrivals. In response, many organisations become reliant on temporarily lodging acutely unwell patients awaiting admission in undesignated areas for care such as corridors, to provide additional space. This results in a significant risk of avoidable harm, indignity and psychological trauma for patients and has a negative effect on the well-being of healthcare professionals, since unacceptable standards of care become normalised. A two-phase strategic quality improvement project was implemented at the authors' acute trust. Ambulance handover data from between 2 November 2020 and 26 July 2021 provided a benchmark for the project. The first phase was implemented between 2 November 2021 and 26 July 2022 and aimed to reduce 60-minute ambulance handover delays. The second phase was implemented between 2 November 2022 and 26 July 2023 and aimed to eradicate 60-minute ambulance handover delays and improve overall performance. Phase one resulted in a 32% reduction in 60-minute ambulance handover delays. Phase two resulted in a 97% reduction in 60-minute ambulance handover delays. Over the course of the project there was a 24% increase in handovers completed within 15 minutes. This project demonstrates how strategic planning and collaboration between healthcare teams can reduce the potential for avoidable patient harm, while simultaneously promoting workforce well-being and retention., Competing Interests: None declared, (© 2024 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Demand for ambulances has increased significantly in recent years due, for example, to ongoing public health issues and lack of availability of alternative healthcare services. However, as demand increases, so too do ambulance waiting times, partly due to significant pressures on emergency departments (EDs) resulting in handover delays. People experiencing mental health distress who cannot access the care they need often contact ambulance services or present to the ED. Ambulance trusts across the UK are attempting to address this by employing mental health professionals (MHPs) in various capacities. In this article, the authors explore some of the issues related to mental health-related calls to 999 services. The authors then describe a service improvement initiative in Wales which involves MHPs working in 999 call centre clinical support desk services to improve the quality of care delivered to people with mental health issues and reduce demand on ambulance and ED services., Competing Interests: None declared, (© 2024 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Nitrous oxide (N 2 O) has become one of the most popular recreational drugs in Europe. While N 2 O is often used in medical settings as an analgesic and anaesthetic agent, its recreational use was documented many years before its introduction into clinical practice. The desired effects from inhaling N 2 O for recreational purposes include rapid feelings of relaxation, calmness and euphoria, which can be accompanied by giddiness and laughter. There are various adverse effects associated with N 2 O use, including headache, nausea, vomiting, drowsiness and the development of permanent neurological damage. Furthermore, its use is associated with cold burns and road accidents. This article details the case of a patient who sustained an N 2 O tank burn to his forearm from recreational use. It also discusses the prevalence, legal status and adverse effects of N 2 O use as well as the pathophysiology and management of cold burn injuries., Competing Interests: None declared, (© 2024 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Background: Emergency departments (EDs) afford 'teachable moments' for health behaviour change, but staff may not see themselves as public health practitioners and it can be challenging to undertake health promotion activities in emergency care settings. Furthermore, the evidence on health promotion in these settings is limited., Aim: To investigate the views and experiences of emergency nurses and ambulance service paramedics regarding health promotion in emergency care settings., Method: A convenience sample of emergency nurses (n=3) and ambulance service paramedics (n=3) was recruited. An inductive and descriptive qualitative study design using semi-structured interviews and thematic analysis was employed., Findings: The participants understood health promotion and were willing to have conversations about it with patients. However, they cited several barriers to health promotion, including understaffing, a lack of understanding of the relevance of health promotion among staff, a lack of training and information, and the sensitivity of topics such as body weight and sexual health. Lack of time was not cited as a barrier., Conclusion: There are opportunities for developing the health promotion aspect of practice in emergency care settings, where staff and patients would benefit from a more structured, system-wide approach to health promotion., Competing Interests: None declared, (© 2023 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

It is estimated that between 58% and 82% of children and young people who present to paediatric emergency department (PEDs) have a non-urgent condition. This systematic review of the literature explores why parents of children with non-urgent conditions present to the PED rather than to community healthcare services. Five databases were searched for studies on children and young people's presentations to the PED for the treatment of a non-urgent condition, as identified by a low priority triage code. This article describes and discusses the findings of the 18 included studies., Competing Interests: None declared, (© 2023 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

The use of conducted energy devices - better known under the brand name Taser - by police officers is subject to scrutiny. Consequently, the clinical assessment and management of people who have been exposed to Taser discharge is also subject to scrutiny. In 2021 the Conducted Energy Device Joint Working Group published a new guideline on assessment in police custody after Taser discharge. The guideline enables any appropriately trained and competent healthcare professional, including nurses, to undertake post-Taser assessments and determine the person's fitness to be detained in police custody. This would be done in the first instance by nurses working in police custody suites, but emergency department (ED) nurses may also be involved, as people who have been 'tasered' may need referral to the ED. This article explains how Tasers work, their physiological effects and potential complications, and the required approaches to clinical assessment and management as outlined in the new guideline., Competing Interests: The authors are members of the Conducted Energy Device Joint Working Group and have co-authored the ‘Healthcare Assessment in Police Custody after Conducted Energy Device (CED) Discharge’ guideline on which this article is based, (© 2022 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Regional trauma networks enable the rapid and safe management and transfer of patients with traumatic injury between designated trauma units and one of 27 major trauma centres throughout the UK. Multispecialty trauma teams are available 24 hours a day, seven days a week, and are activated immediately upon receipt of a patient presenting with major trauma. With most serious trauma patients going direct to major trauma centres rather than a less specialised hospital-based trauma unit, it can be challenging for hospital-based trauma unit staff to gain experience and skill in this area, leading to potential inconsistencies in the process of activating the trauma team. The aim of this service evaluation was to identify factors influencing the decision to activate the trauma team in emergency department (ED) staff working within a 700-bed trauma unit. A questionnaire was sent to 107 staff and 70 completed it, a response rate of 65%. Results indicated that shortfalls in trauma-specific training, lack of clinical experience, undefined roles and responsibilities, department culture, ambulance handover, knowledge of clinical guidelines and previous experience of trauma team activation all affected the decision to activate the trauma team. Trauma-specific training and the support of senior staff could enhance confidence and appropriate trauma team activation rates., Competing Interests: None declared, (© 2022 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Mental health issues have increased significantly over the past decade in the US and emergency departments (EDs) often serve as a safety net to protect and support patients with mental health issues. However, many EDs in the US are not equipped to provide the level of advanced care that patients experiencing a mental health crisis require. This article describes a quality improvement project conducted in an ED in Colorado, US, to identify and address deficiencies in the care provided to patients with mental health issues. The care of patients with mental health issues in the ED can be enhanced through measures such as implementing a validated suicide risk assessment tool, reducing ligature risks, improving the physical environment and training staff in de-escalation techniques., Competing Interests: None declared, (© 2021 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

In the UK, the use of antiemetics in children with gastroenteritis is not standardised. The antiemetic ondansetron is often administered, in clinical practice, to children presenting with gastroenteritis. However, it is not listed in the British National Formulary for Children for use in gastroenteritis and it is not included in the National Institute for Health and Care Excellence algorithm for the management of gastroenteritis in children under 5 years. This article discusses the findings of a literature review of the outcomes of ondansetron use in children with gastroenteritis in the emergency department. The article concludes that ondansetron appears to be a beneficial and useful adjunct to the treatment of gastroenteritis in children., Competing Interests: None declared, (© 2021 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Suicide is a major public health concern, with data suggesting that suicide rates may be increasing. Ambulance services receive thousands of calls each year related to mental health issues, with responding to suicide a common element of the job. This article uses a service evaluation to explore the data collected by the North West Ambulance Service (NWAS) NHS Trust in relation to deaths by suicide and discuss how this can be used to improve pre-hospital and emergency department practice. The service evaluation used a retrospective patient cohort comprising calls made to NWAS over a six-month period from 1 January to 28 June 2019 inclusive. Of the 46,869 calls made to NWAS, 124 resulted in a death by suicide, with an average age of 43.6 years. The majority of deaths by suicide were by hanging. Investigation of the clinical notes for each case revealed that many of the individuals had mental health issues recorded in their documentation, and almost one fifth had previous contact with the ambulance service. Preventive interventions are important in supporting those bereaved by suicide who may be at increased risk of death by suicide., Competing Interests: None declared, (©2021 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Homelessness is on the rise in the UK and, over the past few years, there has been a significant increase in the number of emergency department (ED) attendances and admissions by homeless people. Those attending the ED will often have multiple unmet health, housing and social care needs. While it is not possible to meet all these needs in the ED, emergency nurses should be equipped with the knowledge and skills required to communicate with, refer and signpost patients who are homeless. Under the Homelessness Reduction Act 2017, ED staff have a duty to refer homeless people, with their consent, to local authorities for assistance. This article details the barriers that homeless people may experience when accessing healthcare services and explains how these can be addressed. It also outlines the actions that emergency nurses can take to improve the care of homeless people in the ED at an individual and a systems level., Competing Interests: None declared, (©2020 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

There is a high prevalence of exposure to traumatic events in childhood among people who have mental health issues. Presentation to the emergency department (ED) can be challenging for these patients because the environment and their experience of care can trigger traumatic memories. Trauma-informed care is an approach to practice that is guided by knowledge of how trauma affects people's lives and their healthcare needs. Despite the increasing prevalence of mental health care delivery in EDs, the level of translation of trauma-informed care into nursing practice in this setting is largely unknown. Therefore, the authors undertook a narrative literature review, the aim of which was to gather evidence relevant to trauma-informed care in the ED and provide guidance on this practice for emergency nurses. Several databases were searched, and the relevant articles found were thematically analysed. Three emergent themes were identified from the literature: an access point for mental health care; staff attitudes; and the ED experience. Emergency nurses need to be aware of the effects of childhood trauma on people presenting with mental health issues and plan their approach to care to avoid potentially re-traumatising patients., Competing Interests: None declared, (© 2020 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

The phrase 'cut the Gordian knot' describes a bold and direct solution to a complicated problem. Nursing presence has been defined as nurses' ability to pay attention to patients and make them feel that their needs have been considered. In the emergency department (ED), nursing presence can be adversely affected by factors such as fatigue, workplace bullying, moral distress and inadequate staffing levels, which could lead to suboptimal patient outcomes and compromise the goals of nursing. Nursing presence is also important for nurses' job satisfaction and therefore for staff retention. This article explores the combined effects of fatigue, workplace bullying, moral distress and inadequate staffing levels on emergency nurses. To cut the Gordian knot it also provides recommendations for mitigating these issues in EDs through safe staffing decisions that consider patient acuity and skill mix., Competing Interests: None declared, (© 2019 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Decompression sickness (DCS) is commonly associated with diving or occupational exposure to compressed air, and is a life-threatening condition if left untreated. This article provides an overview of the pathophysiology and types of DCS. It also explains the principles of care for people presenting to the emergency department with DCS that emergency nurses must be familiar with, including the recognition of its signs and symptoms and the initial management required. It is important that emergency nurses are aware of the optimal treatment protocol for DCS, which involves its early recognition, prompt administration of high-flow oxygen and referral to the nearest hyperbaric chamber for recompression., Competing Interests: None declared, (© 2019 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Aim: The aim of the study was to explore the reasons why people do not always wait to receive treatment after registering in emergency departments (EDs)., Method: Patients who attended the ED at a general hospital in the south of England and left without being seen (LWBS) were recorded between 1 June and 31 August 2016 and 597 patient records were analysed. Six patients participated in semi-structured interviews. Data were manually coded., Findings: The most common presenting complaint for people who LWBS was limb problems, however some had potentially more serious conditions such as chest pain. The six interviewees accessed the ED because of a perceived urgent need, and reasons for leaving before being seen included long waiting time, other commitments, non-availability of specialty services, perceiving their problem as less urgent, resolution of condition and discomfort in the waiting area., Conclusion: People who LWBS may not have trivial health problems, which is a risk for them and hospital trusts. Although many of the people who LWBS did so because of the lengthy waiting time, there may be other factors involved some of which could be prevented., Competing Interests: None declared, (© 2018 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Following critical events many people experience a period of emotional and cognitive disturbance before re-establishing well-being without the need for formal psychological support. Those working in emergency care have frequent and repeated exposure to such incidents and are therefore at increased risk of psychological distress. This article discusses the psychological sequalae of the author's witnessing and involvement in the immediate on-scene care of those injured in the Shoreham, England air show crash in August 2015. Using narrative reflection, the author describes, with reference to the literature, his psychological journey drawing particularly on the conservation of resources theory. Within this is the recognition that unduly early and misinformed emphasis on psychological disorder and post-traumatic stress disorder are not only unhelpful but may deliver the person into greater distress and long-term mental health problems., Competing Interests: None declared, (©2019 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

The release of chemical agents can cause loss of life and result in major incidents. Chemical agent-related major incidents require a modified response by emergency services due to the chemicals' transmissibility, lethality, latency and persistence. In general, modifications to casualty flow, triage and treatment are made to reduce transmissibility, and lethality of chemical hazards. This article, the second of a two-part series on nerve agents, describes the adapted response and explains how emergency nurses must be familiar with principles of care including incident and casualty management., Competing Interests: None declared, (©2019 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Recent incidents in the UK and the alleged chemical attacks in Syria by the Bashar al-Assad regime have brought the subject of chemical weapons back into the public domain. To date these types of event have been relatively rare because terrorist plans to harm large numbers of people have mostly been thwarted. This is the first part of a two-part article on nerve agents. Part one gives an overview of these agents, their historical background and manufacture, and how the agents affect physiology. Part two, which will appear in the next issue, considers the pre-hospital response to the use of nerve agents, including effective triage and decontamination, and in-hospital treatment., Competing Interests: None declared, (©2019 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Out-of-hospital cardiac arrest (OHCA) is a common occurrence in the UK, with 60,000 cases reported annually. To improve outcomes among these patients it is necessary to improve links in the cardiac arrest chain of survival. Cardiopulmonary resuscitation (CPR) is one of the main elements of this chain because it reduces further ischaemic insult in the brain and heart by contributing to blood flow. However, even the best manual CPR provides only 20%-30% of the normal cardiac output. Despite the emphasis on timely CPR at the correct rate and depth, delivery of compressions is suboptimal for many patients and mechanical devices may improve outcomes. This article critically appraises two important papers on the use of mechanical CPR for OHCA. It also suggests potential uses for this treatment option and areas for future research., Competing Interests: None declared, (© 2018 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Equipment and training for nurses in Africa are scarce but, as this article explains, if aid were targeted at local suppliers of cheap but vital equipment, such as resuscitation manikins, nursing practice would be enhanced and patient outcomes may improve.

Overcrowding due to poor patient flow increases risk for more than 500,000 patients a year ( College of Emergency Medicine (CEM) 2014 ) and is linked to increased mortality ( Geelhoed and de Klerk 2012 ). CEM ( 2014 ) has called for urgent action to address 'exit block' in UK emergency departments (EDs). In October last year, Croydon Health Services NHS Trust designed and implemented a site practitioner early warning system (SPEWS) to alert staff to capacity and flow pressures in the ED, and to initiate escalation to a nurse-led, protocol-driven response. Under pressurised and time-critical conditions, SPEWS ensures rigour and conformity in exchanges between clinical emergency care staff and managers. The result is closer collaboration between clinicians and managers, optimised patient flow and mitigated risk from exit block.