Cutting-edge discussion of management, policy and program issues in emergency care☆☆☆

Article Outline

• Nutritional assessment
  • How are other emergency departments meeting the requirement of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to do a nutritional assessment for every patient?
    • Answer 1:
    • Answer 2:
    • Answer 3:
• Checking medication orders
  • I am confused about how emergency departments are implementing the JCAHO requirement for verification of physician orders, including medications. We do not have a department-based pharmacist, and ED orders are often carried out on an emergent basis
    • Answer 1:
    • Answer 2:
• Night shift bonus
  • How do other emergency departments retain their night shift staff?
    • Answer:
• Experience/education compensation
  • Do any emergency departments compensate RNs for additional education and/or experience?
    • Answer:
• Unfolding case study instruction
  • I often feel like I am resorting to the same old lecture method in my department's in-service sessions. How can I get the nurses more involved?
    • Answer:
• Failure in standardized course
  • One of my staff nurses recently failed the national standardized Emergency Nursing Pediatric Course and blames the instructor for the failure. Should I approach the instructor and discuss the nurse's performance?
    • Answer:
• Staff participation in research
  • Should “participation in research” be an expectation of staff members in the emergency department?
    • Answer:
• Identifying managed care coverage
  • How can I tell if a patient's managed care coverage is current?
    • Answer:
• Promoting prevention
  • What are other emergency departments doing to promote prevention in the community?
    • Answer 1:
    • Answer 2:
• Staying current clinically
  • I fear I am not staying current clinically the longer I am in my management role. How do other managers deal with that concern?
    • Answer 1:
    • Answer 2:
• Managing friends
  • I am new in my management position, and some staff are good friends. How do I avoid the illusion of favoritism?
    • Answer:
• Applications plus resumes
  • I do not understand why the Human Resources Department always insists that candidates complete an application in addition to submitting their professional resume. It seems like an unnecessary burden
    • Answer:
• Promoting teamwork
  • What will help me promote teamwork in creating new solutions for our unit?
    • Answer:
• Patient confidentiality
  • Are there measures I should be taking to ensure patient confidentiality?
    • Answer 1:
    • Answer 2:
• Copyright

Back to Article Outline

Nutritional assessment 

How are other emergency departments meeting the requirement of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to do a nutritional assessment for every patient? 

The JCAHO standard PE1.2 states that “nutritional status is assessed when warranted by the patient's needs or condition.” We meet this requirement by giving a 1-page self-screening sheet to every discharged patient.

The sheet notes that the warning signs of poor nutritional health are often overlooked and provides a checklist for self-assessment. The list includes not having enough money to buy food, losing or gaining 10 pounds in the past 6 months, not understanding a prescribed special diet, or eating fewer than 2 meals a day.

The sheet then states that any “yes” answers could mean the patient is at risk for poor nutrition. Hospital and community resources the patient can contact are listed, along with phone numbers. A copy of the form can be located at the following Web site: http://enw.org/Solutions.htm .

We mark a check box on the nursing note after we give patients the form. Patients who are admitted or transferred are screened as inpatients.—Cynthia K. Russell, MSN, RN, Director, Emergency Department, Frederick Memorial Hospital, Frederick, Md; E-mail: Crussell@FMH.ORG

I believe the intention of the required ED nutritional screening is to plug patients into other resources when needed, rather than to perform an in-depth assessment and create a treatment plan in the emergency department. To accomplish this screening, our department asks only 2 questions:

We meet this requirement by asking every patient one standard question: “When was the last time you ate or drank?” This brief question actually provides a lot of information regarding procedures such as conscious sedation/surgery and opens the door for further questions in relation to a social work/dietary consultation. I find that asking this question is especially effective because then I am not put in the position of needing to make an assumption about someone based on their appearance or age.—Robert (Bob) Knies, Jr, RN, MSN, CEN, Director of Emergency Services, Stevens Hospital, Edmonds, Wash; E-mail: bknies@stevenshealthcare.org

Back to Article Outline

Checking medication orders 

I am confused about how emergency departments are implementing the JCAHO requirement for verification of physician orders, including medications. We do not have a department-based pharmacist, and ED orders are often carried out on an emergent basis 

Currently we are working on a policy that will exempt urgent medication orders that are carried out in the emergency department. However, the emergency department will fax all inpatient admission orders to the pharmacy. These routine orders will be reviewed prior to the ED implementation when an admitted patient is being held in the department while waiting for an available bed. —Cynthia K. Russell, MSN, RN, Director, Emergency Department, Frederick Memorial Hospital, Frederick, Md; E-mail: Crussell@fmh.org

Our JCAHO surveyor indicated that we meet the standards as long as the ED physician signs the ED sheet that has the medication order. The pharmacists, who are available 24 hours a day, check any admitted patients' medication orders before the orders are entered in the system.—Cindy Tibbett, RN, Staff Nurse, Emergency Department, St John's Medical Center, Anderson, Ind; E-mail: Cintibb@aol.com

Back to Article Outline

Night shift bonus 

How do other emergency departments retain their night shift staff? 

Our hospital has a 5% bonus for contracted night shift nursing employees (registered nurses [RNs], licensed practical nurses [LPNs], and aides) that is paid in addition to the 10% shift differential. The bonus is paid at the completion of the 6-month contract.

The contract includes very specific requirements about the number of allowed call-ins. A full-time employee is allowed only 4 absences during this period; part-time employees are allowed a prorated number of absences. If the employee has more absences than are allowed, the bonus is forfeited. A few employees choose not to sign the contract, but most “regular” night-shift staff request it and sign contract after contract.

The bonus has been used as a recruitment tool. Some nurses sign up for one 6-month contract to help with college tuition or a down payment on a house, and then they return to their regular shift. The hospital permits this because the shift is filled for that time without temporary agency help.

This program has been very successful throughout our facility since the 1980s. As a result, we have very little night staff turnover. In fact, for one 3-year period, our small rural emergency department had 0% turnover! In addition, sick-time pay is very low, which in turn helps fund the bonus program.—Sharon Lester, RN, Senior Manager, Outpatient Services, The Aroostook Medical Center, Presque Isle, Me; E-mail: Slester@TAMC.ORG and Daryl Boucher, RN, BSN, ED staff nurse and former ED Manager, The Aroostook Medical Center; Nursing faculty/EMS Coordinator, Northern Maine Technical College, Presque Isle, Me; E-mail: ndbouche@nmtc.net

Back to Article Outline

Experience/education compensation 

Do any emergency departments compensate RNs for additional education and/or experience? 

Our union contract negotiated compensation for both additional education and experience. RNs are rewarded increasing amounts for every 5 years of experience, in increments up to 21 years. For example, in addition to my hourly pay, I was receiving around $650 per 75-hour pay period for my 21+ years of service. Nurses with a BS receive additional compensation of $34.52 per pay period; those with an MS receive additional compensation of $77.11 per pay period.

This additional compensation is only given to staff up through the role of staff nurse, head nurse, and supervisor. It does not extend to management.—Mitzi Tullai, RN, BS, Assistant Director of Nursing, Kings County Hospital Center, Brooklyn, NY

Back to Article Outline

Unfolding case study instruction 

I often feel like I am resorting to the same old lecture method in my department's in-service sessions. How can I get the nurses more involved? 

I have found in my teaching experience that I cannot depend on learners to complete the assigned reading so we can have a meaningful group discussion. Instead, one successful method I use with students is the “unfolding case study.” It could also be used in department in-service sessions.

After dividing the learners into groups of 3 to 4, I present a case scenario. It might be a teenage female with lower abdominal pain or a patient with left upper quadrant pain (blood pressure of 100/70 and a heart rate of 100) who came to the emergency department. I then pose some focused questions, such as “What could be happening here?” “What data are missing?” or “What immediate actions need to be taken?”

Then, using cooperative learning strategies such as “think, pair, and share” or “round table,” groups process the questions. With the “think, pair, and share” strategy, pairs of students are given 1 minute of silent think time, followed by time to share their answers with each other. With the “round table” strategy, a pad of paper is passed as each group member records his or her ideas while saying them aloud to the group. A learner is allowed to pass but usually builds on the previous content.

I often then add further content, “unfolding” the scenario, and have the group process how the new information would modify their decisions. For instance, I might say, “You now learn that she fell 12 hours ago” or “The patient tells you he is taking warfarin (Coumadin).”

Individual groups then are called on to share their ideas with the entire class. The individual group processing is always followed by a total class discussion.

Both of these strategies actively involve all of the participants in the clarification and solution processes. People learn from each other in this nonthreatening environment and sometimes surprise themselves with the depth of their own problem-solving ability.

I also use more than 60 different written “unfolding” cases that span all of nursing's content areas. These cases allow individuals to work through the thought process at their own pace. ¹ —Deborah Ulrich, PhD, RN, Professor, Department of Nursing, Miami University, Oxford, Ohio; E-mail: ulrichdl@muohio.edu and Kellie Glendon, MSN, RNC, Associate Professor, Miami University, Oxford, Ohio; E-mail: glendonk@muohio.edu

Reference

1. Glendon K, Ulrich D. Unfolding cases: experiencing the realities of clinical nursing practice. Upper Saddle River (NJ): Prentice Hall; 2001.

Back to Article Outline

Failure in standardized course 

One of my staff nurses recently failed the national standardized Emergency Nursing Pediatric Course and blames the instructor for the failure. Should I approach the instructor and discuss the nurse's performance? 

It might be most informative to ask the staff member about his or her personal preparation strategy. Most courses will allow a “retake” of an examination or a skills station. Perhaps with a review of materials, the individual staff member will be able to succeed. ¹

The instructor has an obligation to prepare material, present it in an organized manner, and fairly evaluate the participant. Consideration can be made for participants who have learning disabilities or personal difficulties at a particular time. However, the instructor is not responsible for guaranteeing success for all participants.

It is the responsibility of the participant to come to the course prepared. Most national standardized courses provide a textbook and specific directions as to what must be done to be successful. This includes reading the textbook, studying areas where the information is new, and asking questions to clarify information.

In one course's instructor-given survey, 60% of respondents indicated they had read less than half of the material beforehand. Many nurses mistakenly assume they will be spoon-fed the test's answers.

There are ethical, if not legal, obligations to maintain confidentiality that should be considered before becoming involved. Direct the participant to discuss the performance with the nurse instructor if there is confusion about the reason for the failure. If the participant believes an objective third party is needed, perhaps someone not directly related with this staff member's ongoing performance and evaluation, such as the Director of the Education Department, can become involved.—Mary E. Fecht Gramley, PhD, RN, Assistant Professor, School of Nursing, Aurora University Aurora, Ill; former Outreach Director, Trauma Department, Advocate Good Samaritan Hospital, Downers Grove, Ill; E-mail: mary.gramley@advocatehealth.com

Reference

1. Gramley MEF. Ongoing staff education and professional development. In: Zimmermann PG, editor. Nursing management secrets. Philadelphia: Hanley & Belfus; 2002. p. 123.

Back to Article Outline

Staff participation in research 

Should “participation in research” be an expectation of staff members in the emergency department? 

Usually it is expected that clinical research will be conducted if the department is within an academic medical center. Staff nurses may be involved in research at varying levels. The positive benefits of any participation in research include advancing knowledge, enhancing critical thinking, challenging one to think beyond day-to-day activities, and promoting the institution's mission.

At a minimum, the nurses should be aware of any studies being conducted in the department and the implications for patient care. Many institutions require that the study protocol be available on the unit so nurses have access to it. They also usually require that a copy of the signed consent form be kept in a specific research file or in the patient's medical record.

Nurses may be expected to participate in data collection when doing so can be incorporated into routine nursing care. However, if collecting data will take away from patient care duties or add to the feeling of having an overwhelming workload, then it may be an unreasonable expectation. In addition, often there is no tangible reward for the nurses' involvement in someone else's research.

The nurse manager can negotiate with the principal investigator for some staff recognition. At a bare minimum, the staff nurses' efforts should be acknowledged in the research report and any publications. ¹ —Teresa A. Savage, PhD, RN, Research Assistant Professor, University of Illinois at Chicago, College of Nursing, Department of Maternal-Child Nursing, Chicago, Ill; E-mail: tsavag2@tigger.cc.uic.edu and Laura Anne Leigh, MBA, MSN, RN, CCRN, Vice President, Patient Care Services and Chief Nurse Executive, Rehabilitation Institute of Chicago, Chicago, Ill; E-mail: lleigh@rehabchicago.org

Reference

1. Savage TA, Leigh LA. Applying research in practice. In: Zimmermann PG, editor. Nursing management secrets. Philadelphia: Hanley & Belfus; 2002. p. 204-5.

Back to Article Outline

Identifying managed care coverage 

How can I tell if a patient's managed care coverage is current? 

From my years of experience working with and in managed care systems, I know that ascertaining whether a patient's managed care coverage is current can be a problem. My experience shows that few people (including me) truly understand any of their insurance coverage even when they need it. Health insurance is no exception. In many cases policy language is simpler now than it was 10 years ago. However, often a gap still exists between the enrollee's hope for universal coverage and the reality of the low-cost plan they purchased.

Some people may not recall that they changed managed care plans since their last visit to your emergency department. In fact, people can change their levels of coverage, deductibles, provider networks, and the need for preauthorization even if they stay with the same plan. Managed care plans complicate the situation when they change the appearance of membership cards and send them to members who have had no change in any coverage.

Few persons understand that a small change in health insurance can totally change the way their care is delivered. I recall contacting a managed care plan listed on a patient's card to arrange air evacuation from a remote clinic in a national park. We made arrangements with a receiving physician, booked a fixed-wing aircraft, gave report to the receiving ED physician, and loaded the patient into the ambulance. As the ambulance doors were about to shut, the patient's wife produced another membership card to a different health plan. He had dual coverage, but the new plan rated primary coverage. Each of the previous arrangements for transfer had to be changed. It was exasperating!

A related side issue is when a patient's managed care plan insurance has expired. For whatever reason, some people collect expired health insurance membership cards instead of destroying them.

The point is to routinely ask patients, including “known” patients, about changes in health insurance whenever they are being seen. It is a good idea to ask about changes before you need to make a pivotal decision about referral, testing, or hospitalization.

You should be aware of the existence of a loophole that may allow the insurance company to not pay you. If an employer neglected to let the health care plan know that this member was no longer covered (eg, because of being fired), the managed care plan will not be responsible to cover this patient even though the coverage was confirmed during your call. However, overall, your chances of being paid are better with the call.

Be aware that many companies now offer benefits to domestic partners of employees. Patients may hand you a card with a same-sex partner as a primary policyholder. In addition, after your institution joins a new managed care plan, I recommend that you post a sign alerting patients about your participation in the plan.¹—Robert D. Herr, MD, MBA, CMCE, Medical Director, Utilization Management, Group Health Cooperative of Puget Sound, Seattle, Wash; E-mail: herr.rd@GHC.org

Reference

1. Herr RD. Managed care concerns. In: Zimmermann PG, editor. Nursing management secrets. Philadelphia: Hanley & Belfus; 2002. p. 72-3.

Back to Article Outline

Promoting prevention 

What are other emergency departments doing to promote prevention in the community? 

The local emergency department, safe communities, and college nursing students jointly sponsor a 2-hour program on safe driving for local high school students. They perform a skit with a mock motor vehicle crash that results in a spinal cord injury, a death, and one student walking away riddled with guilt. The story line portrays the long-term effects of being reckless or drinking while driving. The high school welcomes having the program as a supplement to its driver's education.—Phyllis A. Fletcher, RN, MN, CCRN, Assistant Professor, School of Nursing, Wichita State University, Wichita, Kan; E-mail: fletcher@chp.twsu.edu

Every month I give a 45-minute slide presentation to drivers at the local courthouse. The presentation covers prevention of driving accidents and includes many graphic pictures. The judge requires attendance from those appearing in court before they can receive their driver's license. Our intrastate hospital system donates the time to make this presentation in each of our jurisdictions because it provides an effective, sobering message for responsible driving.—Connie Cantor, RNC, BS, Director, Acute Care Nursing, Wellmont Lonesome Pine Hospital, Big Stone Gap, Va

Back to Article Outline

Staying current clinically 

I fear I am not staying current clinically the longer I am in my management role. How do other managers deal with that concern? 

I think nursing has different tracks. If you want to be a clinical “top dog,” a management role is probably not your best choice. I remember when I finally realized I could not be both on the clinical cutting edge and be an effective manager: it was a sad day. However, it is part of accepting the reality that you cannot excel in everything.

Nonetheless, it is important to be familiar with advances in clinical concepts, such as the use of thrombolytics for strokes. I gain this knowledge by focusing on the clinical component at ENA's Scientific Assembly every few years. I attend clinical sessions and purchase tapes of those I cannot attend. That way I have current knowledge and can provide the needed response from management, even though I may not be practicing direct patient care. —Camilla “Cami” Jones, RN, Director, Emergency and Transfer Services, Columbia Lewis-Gale Medical Center, Salem, Va; E-mail: ERslave@aol.com

Being too busy seems to be a universal experience. The key is to do something . Some useful ideas include the following:

—Jo Manion, RN, MA, CNAA, FAAN, Consultant and author, Oviedo, Fla; E-mail: jomanion@sprintmail.com

References

1. Manion J. Managing your career. In: Zimmermann PG, editor. Nursing management secrets. Philadelphia: Hanley & Belfus; 2002. p. 214-5.

2. Marion J. From management to leadership: interpersonal skills for success in health care. Chicago: AHA Press; 1998.

Back to Article Outline

Managing friends 

I am new in my management position, and some staff are good friends. How do I avoid the illusion of favoritism? 

It is very important that the manager treat each person with fairness, no matter what the personal relationship. One way to treat each person fairly is to use the concept of hats. When you need to counsel or discipline a friend, tell the person up front, “I have my serious manager hat on.” This comment provides a signal that the interaction will be strictly between a manager and an employee. Outside of work, the manager hat can come off.

Do not participate in unit gossip outside of the facility and never betray personnel issues, even though there are times when it is tempting to share stories. By following these guidelines, many managers have successfully maintained personal friendships with staff members. ¹ —Vicki Cadwell, RN, MS, CEN, CCRN, Emergency Department Educator, St Jude Medical Center, Fullerton, Calif; E-mail: VCADWELL@sjf.stjoe.org

Reference

1. Cadwell V. Management and leadership styles. In: Zimmermann PG, editor. Nursing management secrets. Philadelphia: Hanley & Belfus; 2002. p. 10-1.

Back to Article Outline

Applications plus resumes 

I do not understand why the Human Resources Department always insists that candidates complete an application in addition to submitting their professional resume. It seems like an unnecessary burden 

Most organizations have all candidates complete and sign an application because it includes a standard signed statement to the effect that all information is accurate. A resume's content can be a misrepresentation and a candidate never signs to verify its truth. Having this signed statement could prove legally useful should the actual facts change upon further investigation. ¹ —John Vicik, SMIR, SPHR, Director, Human Resources, Mather LifeWays, Evanston, Ill; E-mail: jvicik@matherlifeways.com

Reference

1. Vicik J. Staff hiring. In: Zimmermann PG, editor. Nursing management secrets. Philadelphia: Hanley & Belfus; 2002. p. 96.

Back to Article Outline

Promoting teamwork 

What will help me promote teamwork in creating new solutions for our unit? 

I like Fran Rees' book, Teamwork from Start to Finish. ¹ Her ideas include the following:

—Shelley Cohen, RN, BS, CEN, Consultant and Educator, Health Resources Unlimited, Springfield, Tenn; E-mail: educate@hru.net; www.hru.net

Reference

1. Rees F. Teamwork from start to finish. San Francisco: Jossey-Bass; 1997.

Back to Article Outline

Patient confidentiality 

Are there measures I should be taking to ensure patient confidentiality? 

We have 2 triage booths for our nonemergent patients. In our system, the hospital personnel do the moving, rather than the patient.

After the nurse has finished triage, a registrar comes in the booth to collect registration information from the patient. The triage nurse then moves to the other booth to triage the next patient. When the registration is finished, the patient is directed either to the main waiting area or to the treatment area by the triage nurse.

This system has been beneficial in maintaining patient flow during our busy times. Patients and families comment that they like not having to move from place to place; it is certainly easier for patients in wheelchairs.

Patient confidentiality has not been a problem because there is enough room between the areas to avoid inadvertent eavesdropping. Overall, I believe this system works very well, especially if both the triage nurse and registrar are proficient.—Cindy Wage, RN, BSN, Lead RN, Trinity Medical Center, Rock Island, Ill; E-mail: RCWAGE@cs.com

The Department of Health and Human Services' Health Insurance Portability and Accountability Act (HIPAA) has brought new awareness and regulations on the privacy of protected health information. However, I would like to raise consciousness about even simple daily activities that could weaken confidentiality and privacy for our patients or staff, beyond HIPAA. Managers should do the following:

We all have something in our personal lives that we do not want to become public knowledge. Practicing these simple measures is important. Unless there is complete confidentiality, there cannot be complete trust.—Bernard Heilicser, DO, MS, FACEP, Medical Director, South Cook County EMS System; Director of Medical Ethics Program, Ingalls Memorial Hospital, Harvey, Ill