This document is a summarised version of OP-GC2-Comprehensive Care, OP-GC2-Preventing Patient Falls and Harm from Falls Procedure, OP-GC5-Advance Care Planning and End of Life Care, OG-GC2-Delirium Guidelines, OP-GC2-Pressure Injury Prevention and Management, The summary has been created to combine best practice information into one document specific to the Emergency Department, and has been endorsed by the ED Leadership Team. Staff should review the PPGs if they require further information.
This QRG aims to provide staff with an overview of risk screening within the Emergency Department. Risk screening in ED supports the Comprehensive Care Standard to identify patient needs and prevent harm. It includes actions related to falls, pressure injuries, mental health, cognitive impairment and end-of-life care.
This QRG applies to all presentations to the Emergency Department.
It is the responsibility of the Nurse Unit Managers and Directors of the Emergency Departments of each site to ensure the relevant staff are familiar with this QRG, that it is implemented according to the guidelines as outlined within, and that there is compliance by all staff members.
On arrival to the emergency department place patient in a hospital gown for assessment and complete the risk assessments in the Nursing Initial assessment section of FirstNet.
If the answer to any of the risk screening questions is yes – the appropriate strategies should be implemented as soon as practicable.
Figure 1: End of Life screening tool.
If answer is yes:
Figure 2: Mental Health screening tool
If answer is yes to any:
Risk for behaviours of concern (BOC) should be assessed at minimum:
Risk should be assessed against the BOC Management Matrix with appropriate interventions guided by the matrix as outlined in Figure 3.
Figure 3: Behaviours of Concern Observations and Management Matrix |
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Complete 4AT on EMR (Figure 5.1 & 5.2)
Figure 5.1 EMR Adult risk assessments |
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Figure 5.2 EMR 4AT |
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Skin Assessment and Preventing Pressure Injuries – Western Health Emergency Department (wh.org.au)
Complete the Alcohol and Other Drugs screening tool
If answer is yes to any:
ACE risk screening tool.
If answer is yes to any:
Risk Assessment: FirstNet Nursing Initial Assessment
Full skin check should be completed at initial presentation for patients under 3 years old and for patients assessed as at risk of pressure injury. This may need to be supported by the presence of a parent or guardian.
Specific consideration should be given to the securement of medical devices including IVC and NGT as these devices present a risk of pressure injuries developing.
Areas at risk of pressure injury should be checked minimum of hourly, and more frequently where deemed appropriate by clinical staff.
If pressure injury is found,
Falls Risk
Supporting Documents
| Title: | Risk Screening in the Emergency Departments | |
| Version: | 2.0 | |
| Date Published: | May, 2022 | |
| Date of scheduled review: | February 2024 | |
| Author: ED Leadership Team | Approved: ED Leadership Team | |
| Reviewed By: Ian Law | Date: February 2023 | |
