Journal of Emergency Nursing

Passion

JoAnn Lazarus — 2013-05-01

What runs your life? Is it the clock or compass?

What Are You Going to Do?

Reneé S. Holleran — 2013-05-01

And the seasons they go ’round and ’round

Withholding Cardiopulmonary Resuscitation—At the Crossroads of Compassion and Corporate Policy

Kathy Robinson — 2013-05-01

An 87-year-old woman collapsed in the dining room of Glenwood Gardens, a continuing care facility in Bakersfield, California, on February 26, 2013. Thousands of persons subsequently engaged in an international debate on the appropriateness of the actions of a staffer who dialed 911 but refused to provide cardiopulmonary resuscitation (CPR) to the victim, citing a facility policy regarding the provision of medical care. The staffer, functioning in the role of resident services director, reportedly identified herself as a “nurse” and is on voluntary leave after public condemnation fueled by the media, which repeatedly broadcast the verbal exchange between staff and the 911 dispatcher begging for “any human being” who would be willing to intervene until the ambulance arrived. According to news reports, the victim subsequently died at the hospital from a massive cerebral hemorrhage and, retrospectively, would likely not have benefitted from early CPR. The police and district attorney have determined that criminal charges were not warranted, and the local investigation has been closed. Yet, the ethical concerns—primarily that a licensed health care provider did not intervene with basic medical care while calling for help—remain unresolved.

Weigh Children in Kilograms Only!

Darlene Farek — 2013-05-01

I would like to express my thanks to Dr. Gail Lenehan for writing the article, “The Emergency Nurses Association (ENA) ‘Weighs In’ On Pediatric Medication Safety: ‘Weigh Children in Kilograms Only!’” because it reminds emergency nurses of this patient safety issue. As ED crowding continues and the world of the emergency nursing becomes more chaotic, it is imperative that we streamline equipment and processes to ensure that medication is based on the pediatric patient's weight in kilograms. ED personnel continue to weigh the pediatric patient in pounds as well as kilograms, thereby potentially increasing the chance of error when medicating pediatric patients. To ensure that weights are documented only in kilograms, scales that measure only in kilograms and electronic documentation that supports weight in kilograms only can be used to help decrease potential errors.

Response

Gail Lenehan — 2013-05-01

Thank you for your letter, which keeps the issue in the forefront, and thank you for your passion for keeping pediatric patients safe by weighing them in kilograms only. We are indebted to Elizabeth Stone Griffin, BS, RN, CPEN, who led the ENA Position Statement Committee in the writing of our position statement on this issue, available at ENA.org, and to Sue Hohenhaus, ENA Executive Director, who saw this, early on, as critical to the safety of our pediatric patients and is building bridges with regulators on the issue.

How Much Do ED Patients Know About Medication Prescribed for Them on Discharge? A Pilot Study in Turkey

Hulya Bulut, Gulay Tanrıkulu, Ümran Dal, Sevgisun Kapucu — 2009-05-14

Introduction: Hospital emergency departments provide health care to patients with various ailments and illnesses. If necessary, doctors write prescriptions for patients who visit emergency departments for their use after discharge from hospitals. It is important to inform patients about their prescribed medications because compliance with the prescription plays an important role in the success of the treatment. If a patient must use more than one medication, this might result in negative drug interactions. These undesirable developments may adversely affect the treatment process and cause many unplanned patient visits to emergency departments. This study was carried out to determine patient knowledge as related to the names, dosage, frequency, purpose and course of medications given on discharge from emergency departments.Methods: Study subjects were patients who came to the emergency department between the hours of 8 am and 8 pm during a period of 1 month. Data were collected through use of a questionnaire.Results: In this study, it was found that 37% of the patients (37 patients) had no knowledge at all about the prescribed medications; however, out of 63 patients, 61.9% had knowledge of when to take the medications, 57.1% knew the purpose of the particular medications, and 52.3% were aware of the appropriate dosage. Furthermore, 31.7% knew the name of the medications and 25.3% knew something about their prescribed course.Conclusion: Upon discharge from emergency departments, patients should be fully and properly informed about their prescribed medications through a written document. Providing patients with information concerning the correct use of their prescribed medications enables them to use the medications appropriately, thereby increasing not only their satisfaction but also their compliance with the treatment plan. As a result, this vital information may help to decrease rehospitalizations.

Advanced Nursing Interventions and Length of Stay in the Emergency Department

Mary A. Stauber — 2012-05-21

Introduction: Over the past 15 years, emergency departments have become overcrowded, with prolonged wait times and an extended length of stay (LOS). These factors cause delay in treatment, which reduces quality of care and increases the potential for adverse events. One suggestion to decrease LOS in the emergency department is to implement advanced nursing interventions (ANIs) at triage. The study purpose was to determine whether there was a difference in ED LOS between patients presenting with a chief complaint of abdominal pain who received ANIs at triage and patients who did not receive ANIs at triage.Methods: A retrospective chart review was performed to determine the ED LOS (mean time in department and mean time in room [TIR]). The convenience sample included ED patients who presented to a large Midwestern academic medical center's emergency department with a chief complaint of abdominal pain and Emergency Severity Index level 3. Independent-samples t tests were used to determine whether there was any statistical difference in LOS between the two groups. Cohen's d statistic was used to determine effect size.Results: Implementation of ANIs at triage for patients with low-acuity abdominal pain resulted in an increased time in department and a decreased TIR with a medium effect size.Conclusion: A reduction in TIR optimizes bed availability in the emergency department. Low-acuity patients spend less time occupying an ED bed, which preserves limited bed space for the sickest patients. Results of diagnostic tests are often available by the time the patient is placed in a room, facilitating early medical decision making and decreasing treatment time.

Emergency Nurse Responsibilities for Mechanical Ventilation: A National Survey

Louise Rose, Sharon Ramagnano — 2012-12-10

Introduction: Few data describe the role of registered nurses working in emergency departments in caring for ventilated patients, yet these patients may remain in the emergency department for prolonged durations because of the unavailability of intensive care unit beds. Our objective was to examine the exposure of emergency nurses to patients requiring mechanical ventilation, as well as their responsibilities and education on ventilation received.Methods: A cross-sectional mailed survey was sent to members of the National Emergency Nursing Association in Canada. Domains and items were refined from a survey of ventilation roles and responsibilities in intensive care.Results: The response rate was 247 of 526 (47%); 39% of respondents provided care to 10 ventilated patients or fewer over a period of 2 weeks, 32% up to 5 patients or fewer monthly, and 27% to 5 patients or fewer over a period of 6 months. A 1:1 nurse-patient ratio for ventilated patients was reported by 38% of respondents, whereas 45% managed 1 or 2 additional patients and 15% managed 3 or more additional patients. Most respondents (54%) reported that respiratory therapists (RTs) remained in the emergency department until patients’ condition stabilized, 28% reported that an RT was on call, 11% reported that an RT remained until patient transfer, and 7% reported that no RT was available. Few nurses reported primary responsibility for initial ventilator setting selection (7%) or titration of ventilation (6%); nurse responsibility was influenced by RT availability (P < .001). Primary responsibility for monitoring patient response to ventilation, alarm troubleshooting, and oxygenation management was reported by 44%, 36%, and 30% of respondents, respectively. Education was received by 51% of respondents before exposure to ventilated patients; most (57%) indicated that competency was never assessed.Discussion: Emergency nurses had variable exposure to ventilated patients. Responsibility for ventilator management was influenced by RT availability. Low nurse-patient ratios; inconsistent availability of education; lack of competency assessment; and infrequent use of guidelines, protocols, or pre-printed order sets pose potential concerns for patient safety while ventilated in the emergency department.

A Photo Essay of Complications of Fabric Thumb Immobilization

Magnus W. Arnander, Jennifer C. Lane, Simon Ball, Rupert Eckersley — 2013-02-27

We are part of a hand trauma unit that provides tertiary care of hand injuries referred from several district hospitals from North West Greater London. Patients are seen within a few days of their presentation to their local emergency departments, being triaged on the basis of telephone referrals.

Whether to Break Confidentiality: An Ethical Dilemma

Nancy Winters — 2012-05-25

When a threat of violence is made in a health care setting, it leaves those involved feeling scared and vulnerable. Even if the threat is not directed toward the nurse, the nurse still must deal with numerous emotions and decisions. One of these decisions is whether to break confidentiality.

A 48-Year-Old Woman With Chloride Gas Toxicity

Efrain Marrero — 2012-07-26

A 48-year-old woman who arrived at the emergency department by ambulance reported having nausea and shortness of breath, accompanied by chest discomfort. On the day of admission the woman's apartment had been sprayed for mold with a “bleach solution.” The patient stated that her symptoms developed when she reentered the apartment before the indicated time frame. Pertinent medical history included systemic lupus erythematosus and glaucoma, with no history of tobacco use or exposure.

The Participation of Emergency Nurses in the Development of the Basic Knowledge Assessment Tool (BKAT) for the Adult Emergency Department, the ED-BKAT2

Jean C. Toth — 2013-02-25

This article describes the participation of ED nurses in the development of the Basic Knowledge Assessment Tool (BKAT) for the adult emergency department (ED-BKAT2©), developed by Jean Toth and Kathleen Ritchey and copyrighted in 1980. The research covered the span of 7 years, from 2005 to 2012. Findings include research support/evidence for both validity and reliability of the tool. Uses for the ED-BKAT2 are found in the Figure and discussed in the text. Acknowledgements are made by name, of the 60 emergency nurses across the United States of America who participated in this university/multi-hospital setting collaborative work.

A Serious Threat to Patient Safety: The Unintended Misuse of FentaNYL Patches

Susan F. Paparella — 2013-03-27

FentaNYL transdermal patches (Duragesic and other generic brands) are a mainstay in the treatment of chronic pain, yet the US health care community and patients alike continue to face challenges regarding the safe use of this product. Despite numerous warnings from drug manufacturers, patient safety groups, and even the Food and Drug Administration (FDA), the Institute for Safe Medication Practices (ISMP) continues to receive serious event reports about FentaNYL patches to its national medication error reporting program. Unfortunately, a significant number of reports of FentaNYL patch misuse have resulted in patient harm and even death. Tragically, on further investigation, most of these events were found to be preventable. Such events are described herein.

Advocating for Registered Nurse Specialty Certification

C. Lynne Grief — 2013-04-08

Two years ago, the Board of Directors of the Board of Certification for Emergency Nursing (BCEN) embarked on a project to promote registered nurse (RN) specialty certification by advocating its acceptance to meet continuing education (CE) requirements for licensure, as well as for emerging competence initiatives.

Emergency Nursing Review Questions: May 2013 Online Only

Reneé S. Holleran — 2013-05-01

The review questions that are featured in each of the issues of the JEN are based upon the Emergency Nursing Core Curriculum and other pertinent resources to emergency nursing practice, pediatric and adult. These questions offer emergency nurses an opportunity to test their knowledge about their practice. These questions appear in each issue and are either online and in print, or online only.

Emergency Nursing Review Questions: May 2013

Kathleen Carlson — 2013-05-01

A Framework for Creating and Evaluating Competencies for Emergency Nurses

2012-11-12

Nurses have a duty to the public, their profession, and themselves to maintain and demonstrate competence throughout their career. Increasing numbers of patients access health care through the emergency department, placing increased importance on ED nurses to maintain competencies. However, a consensus definition and methodology to maintain clinical competence remains elusive. Competency is an intangible construct that is not a specific skill or task to be completed but rather is a necessary characteristic required to act effectively in a nursing setting. Individual nurses and health care agencies struggle to demonstrate and document competencies, often relying on skill checklists, return demonstrations, portfolios, and certifications. The purpose of this article is to discuss the development of competencies and provide examples of competencies for nurses to use in their quest to maintain and demonstrate clinical competence.

Experience Talks

Jeff Solheim, AnnMarie Papa, Cindy Lefton — 2013-03-27

DOES YOUR EMERGENCY DEPARTMENT HAVE A SHIFT “HUDDLE” OR SHIFT REPORT THAT INVOLVES ALL STAFF AT SHIFT CHANGE? IF SO, WHAT ARE THE ADVANTAGES YOU HAVE NOTED? WHAT TYPES OF THINGS ARE COVERED DURING THE HUDDLE?

Extended ED Stay of the Older Adult Results in Poor Patient Outcome

Nancy Stephens Donatelli, Jennifer Gregorowicz, Joan Somes — 2013-03-20

The literature is clear concerning poor patient outcomes in the older adult experiencing an extended stay in the emergency department. Both critically ill patients as well as trauma victims fall into this category. Unfortunately, there is scant information about what symptoms develop after these patients are admitted that increase their morbidity and mortality. However, there is strong evidence pointing to the longer the patient stays in the emergency department the longer their inpatient hospital length of stay (LOS). For example, “A prolonged emergency department stay for older admitted patients is associated with an increased risk of an in-hospital adverse event (AE).”

Family Violence Assessment Practices of Pediatric ED Nurses and Physicians

Donna M. O'Malley, Patricia J. Kelly, An-Lin Cheng — 2012-10-29

Background: Recommendations by the ENA and other professional organizations have not resulted in widespread adoption of routine assessment for family violence such as child abuse and intimate partner violence. The aim of this qualitative study was to use a theory-driven approach to explore the salient beliefs and attitudes of nurses and physicians related to routine assessment of child abuse and intimate partner violence in the pediatric emergency department.Methods: Nurse and physician participants from a large Midwestern pediatric trauma center responded to a series of open-ended questions designed to identify positive or negative attitudes toward family violence assessment, approving or disapproving beliefs about family violence assessment, and the perception of ease or difficulty in performing family violence assessment.Results: Respondents valued early identification and the associated health benefits of keeping pediatric patients safe, as well as linking at-risk families to community resources. They believe that victims, health care organizations, and some providers approve of routine family violence assessment but also believe that some providers and families who value privacy disapprove. Previously identified barriers and facilitators to family violence assessment were confirmed by participants. A finding unique to this study was that participants expressed the belief that routine family violence assessment offers more complete health care to children.Discussion: Participants viewed child abuse and intimate partner violence as an event in a child's life that affects the child's health. Participants valued the benefits of routine family violence assessment; however, translating these value beliefs into practice remains elusive. A theoretical framework may provide insight into yet unidentified aspects of known barriers and facilitators.

The Growing Business of Human Trafficking and the Power of Emergency Nurses to Stop It

Karen Peters — 2012-12-10

You may have thought that slavery was an atrocious crime of the past, but you had better think again. There are more slaves in the world right now than at any other time in history. Although exact numbers are difficult to determine, slavery is well known to be a global problem of significant magnitude. Modern-day slavery, known as human trafficking (HT), focuses on large profits and cheap lives. It is an unimaginable abuse of human rights that shatters victims both physically and psychologically, as it undermines the health and safety of all communities it touches. Although most of its victims have little or no access to health care, almost 30% will end up somewhere within the health care system seeking treatment for illnesses or injuries sustained while in captivity. Tragically, the majority of these individuals will not be recognized as victims of trafficking and therefore will not receive appropriate interventions to help them escape and reintegrate back into society. Emergency nurses are often the first health care professionals to interact with victims because the brutal nature of the business frequently leaves these victims with life-threatening injuries. As frontline caregivers, these nurses are also the link between victims and other service providers, making it necessary for the nurses to be skilled in identifying victims, providing appropriate interventions, and working collaboratively with other agencies to protect victims from further harm. The purpose of this article is to examine the role of emergency nurses when confronted with potential victims of HT. Although some people may find this article disturbing, the reality of this heinous business and its effects on humanity must be exposed if victims are to be saved.

Nurse-Driven Protocols for Febrile Pediatric Oncology Patients

2013-04-08

Introduction: Infection is a frequent complication experienced by many children with cancer, with potentially life-threatening consequences that may result in hospitalization, prolonged length of stay, and increased mortality. The need for prompt assessment and early intervention for infection is widely recognized by ED staff as best practice; however, the average length of time to antibiotic administration varies widely in published studies.Methods: An interdisciplinary quality improvement initiative including physician, nursing, and pharmacy leaders was created to streamline the identification and treatment for this high-risk population. Based on published evidence for best practice and national recognition of the need for rapid treatment, the goal was set for administration of antibiotic therapy to less than 60 minutes after ED arrival. This project was conducted at 2 emergency departments in a pediatric health care system with 520 beds and a level I and level II trauma designation. Approximately 154,000 patients are seen annually. In the emergency departments, 271 staff members, including registered nurses, paramedics, and patient care technicians, required education about using the newly designed process. Records from all patients with fever and a known history of pediatric cancer who presented to the emergency departments were included in the retrospective review, including patients with solid tumors, acute lymphoblastic leukemia, acute myeloid leukemia, and chronic myelogenous leukemia. Exclusion criteria included patients in known remission, those with prior antibiotic therapy at another facility, congenital neutropenia, or parental concern or objection to treatment. A retrospective medical record review of febrile oncology patients treated from September 2008 until May 2012 was conducted to evaluate the impact of this evidence-based practice change to streamline the “door to drug” process. The average length of time until antibiotic administration, nurses' compliance initiating the protocol, and ED length of stay were determined.Results: The review included 2758 medical records. During the study period from 2008 to 2012, one emergency department's average time for drug administration dropped from 103 to 44 minutes, and the second dropped from 141 to 61 minutes. Both campuses also improved their protocol compliance, with ED 1 increasing from 24% to 78% and ED 2 improving from 30% to 84%.Discussion: This quality initiative has direct application for all ED leaders who treat children with cancer. High-risk patients can benefit from a streamlined nurse-initiated process that decreases negative consequences of fever. Collaboration by interdisciplinary leadership within the health care facility, as well as key stakeholder buy-in, is imperative to achieve a process that may lead to decreased hospital stay and reduced systemic infection or mortality for these vulnerable patients.

Suspected Tricyclic Antidepressant Overdose Successfully Treated With Lipids

Michael N. Perza, Laura A. Schneider, Jamie M. Rosini — 2013-03-07

In recent years, the use of intravenous lipid emulsion (ILE) for the treatment of overdoses has become increasingly prevalent in the literature. The role of intravenous lipids in medication overdoses—also referred to as “lipid rescue” or “lipid resuscitation therapy”—is still being assessed because the majority of the available literature exists in the form of case reports and animal studies. The use of lipid formulations as an antidote originated from animal studies whereby administration substantially increased the lethal dose of bupivacaine, a lipophilic local anesthetic, needed to cause mortality in rats. Research progressed further until it was found that human patients having systemic cardiovascular toxicities with local anesthetics were able to be successfully treated with intravenous lipid administration as well. This ultimately culminated in the emergence of case reports using ILE therapy in the treatment of toxidromes associated with a number of lipophilic pharmacologic agents including β-adrenergic antagonists, calcium channel blockers, antipsychotics, antiepileptics, and tricyclic antidepressants (TCAs).

Developing Your Clinical Question: The Key to Successful Research

2013-04-01

You are concerned about something in your clinical practice; you are aware that the way a certain procedure is performed is, well, archaic. Or, perhaps a process for how patients navigate through the emergency department is so inefficient that it affects patient outcomes. You are sure that there must be a better way that can improve the quality of emergency care delivered to the patients in your institution or possibly one that can be disseminated for all your fellow emergency nurses to share. Any investigation into possible changes requires that you examine the available literature to identify possibilities and determine the strength of the evidence. The most critical piece to this process is determining exactly what it is that you want to know by developing a sound clinical question.

Managing Blunt Trauma in Patients Receiving Dabigatran Etexilate: Case Study and Review of the Literature

2013-04-01

Chronic oral anticoagulant therapy is currently indicated for the prevention of thromboembolism in patients with atrial fibrillation, mechanical heart valves, or acute myocardial infarction, as well as for the treatment of venous thromboembolism (VTE). Vitamin K antagonists, such as warfarin, have been a mainstay of anticoagulant therapy for over 60 years. The limitations of warfarin, including the need for frequent monitoring to ensure a therapeutic range, difficulty maintaining therapeutic levels in patients, and the abundance of drug-drug and drug-diet interactions, have resulted in the development of newer oral anticoagulant agents. The Food and Drug Administration (FDA) recently approved the direct thrombin inhibitor dabigatran etexilate (Pradaxa) for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation, representing a significant advance in chronic anticoagulation therapy (). However, with no currently known reversal strategy available and a paucity of evidence from human studies, the management of critical bleeding in patients receiving dabigatran etexilate therapy poses a new challenge. The objectives of this article are to present a case of life-threatening bleeding in a patient receiving dabigatran etexilate, followed by a review of the current literature and a suggested reversal guideline.

Enhancing ED Triage to Accommodate the Special Needs of Geriatric Patients

Gail Tucker, Nora K. Clark, Ivo Abraham — 2010-09-27

Seemingly normal vital signs in an elderly ED client, when combined with atypical pain or unexpected presentations for common disorders, can lead to under-triaging of time-sensitive conditions. Misdiagnosis, dangerous delays in treatment, altered disease trajectories, and dysfunctional ED dispositions are among the many risks faced by older adults presenting with common complaints such as abdominal pain, cardiovascular events, and sepsis.

Erratum

2013-05-01

There were errors in the guest editorial, “Is Your Emergency Department Ready to Care for Sick and Injured Children? A Joint Policy Statement, Checklist, the National Pediatric Readiness Assessment, and ENA Can Help,” by Sally K. Snow (2013;39[2]:114-115). The errors were not the fault of the author and the corrected version appears online at www.jenonline.org/.

Earn Up to 9.0 Contact Hours by Reading the Designated Articles and Taking These Post Tests

2013-05-01

Clinical Test Questions

2013-05-01

Research Test Questions

2013-05-01

CE Enrollment Form

2013-05-01

Editorial Board

2013-05-01

Information for Readers

2013-05-01

Journal of Emergency Nursing

Passion

What Are You Going to Do?

Withholding Cardiopulmonary Resuscitation—At the Crossroads of Compassion and Corporate Policy

Weigh Children in Kilograms Only!

Response

How Much Do ED Patients Know About Medication Prescribed for Them on Discharge? A Pilot Study in Turkey

Advanced Nursing Interventions and Length of Stay in the Emergency Department

Emergency Nurse Responsibilities for Mechanical Ventilation: A National Survey

A Photo Essay of Complications of Fabric Thumb Immobilization

Whether to Break Confidentiality: An Ethical Dilemma

A 48-Year-Old Woman With Chloride Gas Toxicity

The Participation of Emergency Nurses in the Development of the Basic Knowledge Assessment Tool (BKAT) for the Adult Emergency Department, the ED-BKAT2

A Serious Threat to Patient Safety: The Unintended Misuse of FentaNYL Patches

Advocating for Registered Nurse Specialty Certification

Emergency Nursing Review Questions: May 2013 Online Only

Emergency Nursing Review Questions: May 2013

A Framework for Creating and Evaluating Competencies for Emergency Nurses

Experience Talks

Extended ED Stay of the Older Adult Results in Poor Patient Outcome

Family Violence Assessment Practices of Pediatric ED Nurses and Physicians

The Growing Business of Human Trafficking and the Power of Emergency Nurses to Stop It

Nurse-Driven Protocols for Febrile Pediatric Oncology Patients

Suspected Tricyclic Antidepressant Overdose Successfully Treated With Lipids

Developing Your Clinical Question: The Key to Successful Research

Managing Blunt Trauma in Patients Receiving Dabigatran Etexilate: Case Study and Review of the Literature

Enhancing ED Triage to Accommodate the Special Needs of Geriatric Patients

Erratum

Earn Up to 9.0 Contact Hours by Reading the Designated Articles and Taking These Post Tests

Clinical Test Questions

Research Test Questions

CE Enrollment Form

Table of Contents

Editorial Board

Information for Readers