Journal of Emergency Nursing - Articles in Press

Using a Single-item Rating Scale as a Psychiatric Behavioral Management Triage Tool in the Emergency Department - Corrected Proof

2010-03-11

Introduction: Proper monitoring of patients' behavior is essential for effective treatment and efficient disposition of psychiatric cases in the adult emergency department. The goal of the current study was to examine an attempt to implement the Behavioral Activity Rating Scale, an existing single-item measure of behavioral activity, as part of a behavioral management triage strategy for psychiatric patients in an emergency department.Methods: For the period beginning approximately 2 months after use of the behavioral activity measure was initiated in the emergency department, charts from 284 consecutive patients who presented to the department with a chief complaint that was psychiatric in nature were reviewed.Results: Level of adoption of the measure by emergency nurses was lower than desired; only 46% of charts reviewed contained a behavioral activity rating. Ratings were less likely to be recorded during the night shift than during other shifts. As predicted, ratings indicative of elevated behavioral activity were associated with physician orders for formal behavioral management (ie, intramuscular, intravenous, or orally dissolving sedating medications or physical restraint).Discussion: The findings of this study suggest that a single-item behavioral activity measure may be an efficient, effective, and discreet way for emergency nursing staff to communicate with one another and with physicians about psychiatric patients in need of behavioral management in adult emergency departments. The findings also suggest that a broad implementation approach is needed to achieve desired levels of adoption by emergency nursing staff.

Patient Care Plans: An Innovative Approach to Superusers in the Emergency Department - Corrected Proof

Lorene Pugh, Lynne Duffy, Mary Stauss — 2010-03-10

Emergency nurses often are frustrated when caring for patients who have long-standing social, substance abuse, or behavioral issues. Many of these patients are frequent ED consumers and have learned demanding behaviors out of their dissatisfaction with the health care system and their perceived unmet needs. They absorb massive amounts of time and resources and frequently place emergency nurses in situations that pose ethical dilemmas and/or create moral distress.

Barriers to Screening and Intervention for ED Patients at Risk For Undiagnosed or Uncontrolled Hypertension - Corrected Proof

2010-03-08

Objectives: We describe clinician-reported knowledge of the Joint National Committee (JNC7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure definitions of Stage I hypertension; perceived causes of elevated blood pressure; barriers to blood pressure re-assessment; risk of adverse events associated with the elevated blood pressure.Methods: Health care providers from five emergency departments completed a questionnaire assessing knowledge of blood pressure criteria for hypertension, perceived causes of elevated blood pressures, barriers to re-assessment, and perceived risk of an adverse event at one year in a patient within three defined systolic and diastolic blood pressure ranges. Descriptive statistics were used to analyze the data.Results: Seventy-two percent (379/524) of providers (68 attending physicians, 87 residents, 209 nurses, and 15 nurse practitioners) completed questionnaires. One hundred and four providers (27%) correctly listed the systolic and diastolic criteria for Stage 1 hypertension. Nurses and physicians rated uncontrolled, known hypertension [mean (standard deviation)] [8.7 (2.1), 8.9 (1.9)] the highest and pain [8.3 (2.3), 8.3 (2.1)] as the second highest cause of elevated BP. Nurses and physicians rated the lack of time to perform a reassessment [5.2 (3.4), 4.7 (2.8)] and a lack of adequate staffing [4.7 (3.4), 4.6 (2.9)] the highest as barriers to re-assessment. Nurses' mean adverse risk assessment twice that of physicians.Discussion: Twenty seven percent of providers were aware of the JNC7 criteria and often attributed elevated blood pressures to chronic, uncontrolled hypertension, pain or anxiety. No single barrier to repeating elevated blood pressures was identified.

Drug Information Resources: Essential But May Be Error Prone - Corrected Proof

Susan Paparella — 2010-03-08

According to the landmark Harvard medical study by Leape et al, more than 30% of preventable medication errors occur because practitioners do not have timely access to drug information when prescribing, selecting, preparing, dispensing, and administering medications and monitoring patients. Drug information resources in the emergency department can take many forms and include but are not limited to text references, computerized drug information programs, protocols, guidelines, policies, order sets, paper and electronic health records, and knowledgeable pharmacy staff. Unfortunately, as patient volumes and acuity increase, new drugs become available, practice changes are added to our repertoire, and advanced technologies become commonplace, it is becoming increasingly difficult to safely manage the enormous amount of drug information available to guide practice. As a starting point, it is important to recognize that not all drug information that is published or available for use is accurate or safe to use in every organization. Many organizations are without a data management plan for the distribution and management of medication-related resources to the frontline staff, making it a free-for-all of sorts when it comes to the availability and use of drug references. Nursing staff tends to use whatever drug book is most familiar and close by, even if it is missing pages or extremely out of date. Nurses have also been known to handwrite preparation information or new drug concentration information in the margins of available protocols, post their own drug preparation guidelines, or use drug tables that are hanging in the medication area, even though they may not have been reviewed for more than a decade. This lack of readily accessible, appropriate reference material for frontline practitioners is a latent failure and can contribute to medication errors, as the following story illustrates.

“Stand Clear!” Tracing the Practice and Principles of Human Revival - Corrected Proof

Keith Stephens-Borg — 2010-03-08

In essence, people often stumble across discoveries of scientific significance during a caprice of Mother Nature, aided by our extraordinary drive forward in the quest for immortality. The moral fiber of human intuition impels us to preserve hopes and dreams by passing on the baton of knowledge gathered in our lifetime and by joining pieces of a jigsaw, assembling the means to continue our existence.

Family Presence During Resuscitation and/or Invasive Procedures in the Emergency Department: One Size Does Not Fit All - Corrected Proof

Renae L. Dougal, Jill H. Anderson, Kathy Reavy, Christine C. Shirazi — 2010-03-08

Family presence during resuscitation and/or invasive procedures is receiving more attention today because it speaks to the heart of patient- and family-centered care. Family members are the most important support for their loved ones during vulnerable times such as a life-threatening event. Although family presence during resuscitation and/or invasive procedures is becoming more accepted in hospital settings than in the past, only 5% of hospitals in the United States have unit policies guiding the practice of family presence in specialty settings. There is a need for family presence to be studied in non-academic hospitals and in other specialty settings such as emergency departments and adult intensive care units. These environments are unpredictable, and professionals have varying opinions regarding benefits of family presence during resuscitation and/or invasive procedures in adults. Currently, there is no hospital policy to guide practice of family presence at our 381-bed non-academic hospital in the Northwest. Acknowledging family presence as central to patient care inspired our Evidence-Based Practice (EBP) Committee to craft a hospital policy that provides guidance for the health care team in determining when it is appropriate to offer the option of family presence.

ED Services: The Impact of Caring Behaviors on Patient Loyalty - Corrected Proof

2010-02-24

Introduction: This article describes an observational study of caring behaviors in the emergency departments of 4 Ascension Health hospitals and the impact of these behaviors on patient loyalty to the associated hospital. These hospitals were diverse in size and geography, representing 3 large urban community hospitals in metropolitan areas and 1 in a midsized city.Methods: Research assistants from Purdue University (West Lafayette, IN) conducted observations at the first study site and validated survey instruments. The Purdue research assistants trained contracted observers at the subsequent study sites. The research assistants conducted observational studies of caregivers in the emergency departments at 4 study sites using convenience sampling of patients. Caring behaviors were rated from 0 (did not occur) to 5 (high intensity). The observation included additional information, for example, caregiver roles, timing, and type of visit. Observed and unobserved patients completed exit surveys that recorded patient responses to the likelihood-to-recommend (loyalty) questions, patient perceptions of care, and demographic information.Results: Common themes across all study sites emerged, including (1) the area that patients considered most important to an ED experience (prompt attention to their needs upon arrival to the emergency department); (2) the area that patients rated as least positive in their actual ED experience (prompt attention to their needs upon arrival to the emergency department); (3) caring behaviors that significantly affected patient loyalty (eg, making sure that the patient is aware of care-related details, working with a caring touch, and making the treatment procedure clearly understood by the patient); and (4) the impact of wait time to see a caregiver on patient loyalty. A number of correlations between caring behaviors and patient loyalty were statistically significant (P < .05) at all sites.Discussion: The study results raised considerations for ED caregivers, particularly with regard to those caring behaviors that are most closely linked to patient loyalty but that occurred least frequently. The study showed through factor analysis that some caring behaviors tended to occur together, suggesting an underlying, unifying dimension to that factor.

Interruptions Experienced by Registered Nurses Working in the Emergency Department - Corrected Proof

Lisa Kosits, Katherine Jones — 2010-02-22

Introduction: A descriptive, observational study was performed to determine (a) the frequency (number of interruptions per hour) that a typical ED nurse experiences interruptions, (b) the type of interruptions a typical ED nurse experiences, and (c) the percentage of interruptions that take place during medication related activities.Methods: A convenience sample of 30 nurses from 3 emergency departments of a major metropolitan academic medical center were each observed for 120 minutes to determine how many interruptions per hour the ED nurse experienced, the type of interruptions and what percentage of these interruptions took place during medication-related activities. A data collection tool was developed to record tasks performed by the nurses and the type of interruptions experienced. Interrater reliability was established with a Kappa of 0.825.Results: A total of 200 interruptions occurred during the 60 hours of observation, or 3.3 interruptions per hour per RN. Of the 20 possible types of interruptions that were identified a prior to the observation period, 11 different types of interruptions were actually observed. The majority of interruptions (95%) were related to face-to-face communications with others in the ED. The total number of interruptions related to medication activities was 55 (27.5% of the total number of interruptions).Discussion: The results of this study can serve as the basis for subsequent, larger studies that examine more closely the relationship between interruptions and errors in the ED, with the ultimate goal of developing interventions to reduce medication errors and other adverse events that occur due to nurse interruptions.

Train Versus Pedestrian Resulting in Traumatic Hemipelvectomy - Corrected Proof

Kathleen Whitney, Linda Haynes, David Craig Smith — 2010-02-22

A 36-year-old man who worked in a train yard calmly told the 911 operator, “I've been run over by a train, and I think it cut me in half.” He had sustained massive pelvic and lower-extremity trauma when he fell off a train car and was run over. When paramedics and fire rescue arrived on the scene, they found a challenging extrication. The patient lay on his left side with the lower half of his body pinned beneath the wheels of the railroad car. Multiple unsuccessful attempts were made to free his legs while he continued to hemorrhage at an alarming rate. Luckily, before an amputation team arrived, they were able to free him by using inflatable airbags to lift the railroad car upward, off of him (). The paramedics estimated that the patient lost 4 to 5 L of blood at the scene. After an extrication time of approximately 53 minutes, the patient was transported by air to the nearest level II trauma center.

Emergency Prevention: The Benefit of Chlamydia and Gonorrhea Screening in Urban Emergency Departments - Corrected Proof

Ashley N. Zampini — 2010-02-19

While emergency departments excel in the acute triage and management of a plethora of urgent complaints, they seldom have been highlighted for their expansive and growing attention to the chronic needs of underserved populations. Yet across the United States, urban emergency departments are embracing the role of prevention, specifically as it applies to the sexual health of young adults. The availability of a non-invasive, cost-effective screening tool has enabled emergency departments to quickly screen and treat chlamydia and gonorrhea infections in high-risk populations in whom these infections might not otherwise be detected. It is my belief that by detecting disease in young adults, the dramatic sequelae of these treatable illnesses can be halted.

Promoting the Use of Equestrian Helmets: Another Opportunity for Injury Prevention - Corrected Proof

Gordon H. Worley — 2010-02-19

There has been much attention paid to the use of bicycle helmets in reducing the rate of injury in children. Bicycle injury prevention programs exist in many communities, including “bicycle rodeos” and free bicycle helmet giveaways. Thirty-six states have some form of bicycle helmet laws, mostly for cyclists aged under 18 years. Another type of athletic activity that has received less attention and for which there is no legal mandate but where the promotion of helmet use can also have a significant beneficial effect in the prevention of head injuries is horseback riding.

A Study of the Workforce in Emergency Medicine: 2007 Research Summary - Corrected Proof

Vicki C. Patrick, JoAnn Lazarus — 2010-02-17

Introduction: This paper summarizes nurse-specific elements reported in a study of the emergency medicine workforce in 2007.Methods: In 2008, surveys were distributed to over 2600 emergency department (ED) medical directors and nurse managers in the United States.Results: The response rate was 21% from nurse managers. Registered nurses (RN) in staff positions are 37.9 years of age. The most common highest level of education is and associate degree (46%). The predominant workforce is RNs with a fixed assignment to the emergency department. Geographic relocation (46%) was the most common reason cited for resignations. Nurse practitioner positions continue to increase.Emergency department volumes continue to increase. Study respondents reported the largest increase in urgent care/fast track service areas. Throughput time from registration to discharge was reported as 158 minutes. Boarding patients in the emergency department is a common practice, and nurse managers reported boarding as an issue that impacts quality care 67% of the time.Conclusion: Emergency department volumes continue to increase significantly. Innovative nurse staffing and retention programs are required to meet future challenges of emergency patient care.

Assessing Emergency Nurses' Geriatric Knowledge and Perceptions of Their Geriatric Care - Corrected Proof

Courtney Roethler, Toby Adelman, Virgil Parsons — 2010-02-08

Introduction: Persons aged 65 years or older have up to a 45% increased functional dependence and a 10% mortality rate within the first 3 months after being discharged from the emergency department. It has been demonstrated that when elderly individuals are cared for by nurses with specialized training in geriatrics, their outcomes improve. However, few registered nurses have this specialized training. This study was designed to conduct a needs assessment of an emergency department concerning registered nurses' knowledge and self-assessment of geriatric emergency care.Methods: A quantitative, descriptive study utilizing a survey tool was conducted at a large, acute-care teaching hospital in northern California during a 2-week period. The questionnaire consisted of 2 separate sections, a knowledge section with 15 questions and 16 self-evaluated practice assessment questions utilizing a Likert scale.Results: Thirty-two emergency nurses participated in the study. The knowledge section scores ranged from 4 to 12. The mean score was 8.53 (SD ± 1.866). More than 80% of the participants rate themselves as either “very good” or “good” in the self-assessment section in 13 of the 16 categories. No participants rated themselves as “very poor” in any category.Discussion: The high ratings in the self-assessment section demonstrate a perception among the sample of being very capable in geriatric care. In contrast, the knowledge section revealed low scores throughout. This study revealed a clear lack of consistency between the nurses' knowledge about geriatric care and their perception of their ability to provide this care.

Initiation of a Stroke Alert in a Rural Emergency Department - Corrected Proof

Mary M. Pelton, Terri DeWees — 2010-02-01

Situated along the buckle of the stroke belt, Carteret County in eastern North Carolina has an estimated population of 63,195 according to a 2008 population estimate by the US Census Bureau. Carteret General Hospital is the only health care facility in a county whose land area totals 519.84 square miles. The geography of the county is such that it presents extensive EMS and private vehicle transport times. The county is approximately 7 miles wide and 100 miles long, surrounded by water from the Atlantic Ocean and its tributaries. The next closest health care facility is located a minimum of 45 minutes away. Classified as a comprehensive, rural hospital, Carteret General Hospital has a 13-bed emergency department, a 6-bed fast track area, and 5 overflow beds. Because of the work of the American Heart Association, community educators, and others, appropriate care of the patient presenting to the emergency department with signs and symptoms of stroke have come to the forefront as an expectation of the public. To ensure that the delivery of care provided to patients meets or exceeds standards and expectations, a team was developed to explore and improve the timeliness and appropriateness of the care-delivery process for stroke patients.

Anxiety is the Last Diagnosis on the List - Corrected Proof

Lisa Wolf — 2010-02-01

The triage nurse comes to you with a patient chart in her hand. “Thepatient complains of not feeling right,” she says, “but she's really vague. I can't really find anything to worry about—I think she's just anxious.” The patient, a woman in her 30s, walks to the treatment room and lies down on the bed. Within minutes you arecalled to the bedside; the patient is vomiting. She is pale and diaphoretic, and when you palpate her pulse, it is weak and impossibly slow. The cardiac monitor shows a bradycardia in the 30s.

Knowledge Assessment and Preparation for the Certified Emergency Nurses Examination - Corrected Proof

Kathleen Carlson — 2010-02-01

With the current emphasis on credentialing in nursing, many nurses have committed to taking the CEN examination. The following questions have been developed to assist in the emergency nursing knowledge assessment and in preparation for the CEN examination. Questions, rationale for the correct answers, and references are provided here for your self-evaluation. ENA has developed educational materials that can be used as further resources for CEN preparation: Emergency Nursing Core Curriculum and CEN Review Manual. For further information on educational review materials, please contact the ENA Association Services Team at (800) 243-8362.

A Twist on Aspirin Toxicity: When Symptoms and Levels Do Not Correlate - Corrected Proof

Alysha D. Behrman, Lisa Hawryschuk, Sarah Lamkin — 2010-02-01

Aspirin is a commonly known salicylate and is used as an anti-inflammatory, antipyretic, and a mild analgesic agent. Salicylates are found in numerous over-the-counter products such as topical muscle rubs (eg, methyl salicylate), stomach remedies (eg, bismuth subsalicylate), and wart removers (eg, salicylic acid), as well as in prescription medications.

Differential Diagnosis Cyanosis Versus Argyria: When Your Patient Remains Blue—A 48-Year-Old Trauma Patient With Persistent Cyanosis - Corrected Proof

Christina Travis — 2010-01-18

A 48-year-old man presented to the emergency department after a motorcycle-versus-car collision during which he was ejected from his bike. At the scene, the man was initially alert but had marked cyanosis; he then lost consciousness and exhibited generalized seizure activity. Paramedics attempted rapid-sequence induction intubation but could not place an endotracheal (ET) tube, so they resorted to Combitube (Tyco-Kendall, Mansfield, MA) insertion. Because breath sounds were decreased on the right side, needle decompression was performed to relieve a possible tension pneumothorax.

The Process of Acquiring Practical Knowledge By Emergency Nursing Professionals in Taiwan: A Phenomenological Study - Corrected Proof

Wen Chu, Li-Ling Hsu — 2010-01-15

Introduction: The emergency department is the front line in the hospital battlefield. Medical staff are frequently tested with highly complex and fast-changing clinical situations. Nurses must acquire practical knowledge in a fast-changing environment in order to provide the most appropriate form of nursing care. This study explores the process of the development of practical knowledge in emergency nurses.Method: This study uses a phenomenological approach and in-depth interviews and adopts Moustakas data analysis techniques. In 2007, the researcher interviewed 10 professional nurses with at least 3 years of ED experience and collected 13 interview transcripts.Results: Data analysis identified 4 major themes and 10 sub themes in the process of development of practical knowledge for ED nurses. The 4 major stages in the learning process are (1) matter-of-course apprenticeship, (2) stimulus-response learning, (3) work demand-oriented learning, and (4) self-reflective learning.Discussion: Upon entering the emergency department, nurses began learning by serving as apprentices to seniors. After this, they experienced the stimulus-response learning phase as they responded to stimuli in the form of pressure to grow and learn. As they gradually drifted away from the protection of seniors, they continued to learn in order to meet work demands, hold on to their jobs, and maintain a proper level of professional competence. A small number of participants entered the final stage of self-reflective learning, in which they examined their life experience by self-reflection and developed a proper nursing attitude and knowledge about holistic patient care.

Cardiovascular Emergencies Questions - Corrected Proof

Scott DeBoer, Michael Seaver — 2010-01-04

January of 2009 marked the start of the Certified Pediatric Emergency Nurse (CPEN) examination. In support of this new certification, three times a year JEN will feature this new column supplying questions similar to those in the CPEN examination to assist in preparation for the examination. This section appears in the January, May, and September issue of the Journal. Questions, rationale for the correct answers, and references are provided here for your self-evaluation.

Knowledge Assessment and Preparation for the Certified Pediatric Emergency Nurse Examination - Corrected Proof

Scott DeBoer, Michael Seaver — 2010-01-04

January of 2009 marked the start of the Certified Pediatric Emergency Nurse (CPEN) examination. In support of this new certification, 3 times a year, JEN will feature this new column, supplying questions similar to those in the CPEN examination to assist in preparation for the examination. Questions, rationale for the correct answers, and references are provided here for your self-evaluation.

Poison Control in the Emergency Department - Corrected Proof

Andrew D. Harding — 2009-12-31

There were 61 participating poison control centers in 2007 for the American Association of Poison Control Centers 2007 Annual Report of the National Poison Data System, with 2,482,041 human exposures reported. The health care setting calls to poison control throughout the United States accounted for over 15% of total call volume. Many of these calls were generated from the nation's emergency departments.

A 24-Year-Old Man With Subjective Fever and Syncope - Corrected Proof

Jeremy M. Johnson, Tiffany M. Thomas, Cindy M. Wilson, L. Kendall McKenzie — 2009-12-31

A 24-year-old man presented to the emergency department following a syncopal episode that occurred a couple of hours prior to ED presentation. The patient's girlfriend reported that the man fell forward and lost consciousness while sitting at home in front of his computer. She denied witnessing any seizure activity. He remained unconscious for an unknown period. On ED arrival, the patient's vital signs were as follows: blood pressure, 96/56 mm Hg; heart rate, 101 beats per minute; and oral temperature, 37.8°C (100°F). His physical examination was remarkable for pallor and lethargy, but he showed no signs of acute distress. His Glasgow Coma Scale score was 14 (mild confusion).

A “Back to Basics” Approach to Reduce ED Medication Errors - Corrected Proof

2009-12-28

Introduction: Medication error is the most frequently reported error in the emergency department. Nationally, 36% of medication errors occur in the administration phase. The purpose of this study is to reduce medication administration errors in the emergency department by reinforcing basic medication administration procedures.Methods: This study examined a 3-month educational intervention using a nonrandomized, single group comparing pre-post outcome variables. The educational intervention, titled “Preventing Medication and IV Administration Errors,” described current medication errors in the emergency department, and recommended practices for reducing medication administration errors. Of 127 nurses, 75% participated. Three measures used pre- and post-intervention were: a) knowledge of medication administration procedures assessed by tests; b) behaviors reflecting recommended medication practices assessed by surveys; and c) medication administration errors, identified via chart review and voluntary error reports.Results: In the post-test, 91% achieved perfect scores vs. 69% on the pre-test (P =. 0001). In the post-survey, the proportion responding that they follow recommended practice “all” or “most” of the time increased in 8 of the 10 survey questions, but the changes did not reach statistical significance (P = .98). Reviews of charts (299 pre-test and 295 post-test) revealed little change in total medication errors: 25% vs. 24% (P = .78). Voluntarily reported medication errors dropped from 1.28 to .99 errors/1000 patients.Discussion: This educational intervention successfully improved knowledge of recommended medication administration practices. However, improved knowledge did not translate to a significant change in practice. More research is needed to identify interventions that can modify behavior in clinical settings.

A 39-year-old Woman With New-onset Seizures - Corrected Proof

Andrew Storer — 2009-12-28

A 39-year-old woman presented to the emergency department via ambulance after 911 had been called. The patient's husband stated that the couple had been out to dinner and his wife drank 2 glasses of wine. Soon after returning home, the woman experienced involuntary, generalized tonic-clonic movements that lasted approximately 30 seconds. After the jerking stopped, the woman was unresponsive and had audible respirations. Upon ED arrival (20 minutes later), she was oriented but groggy, and her only complaint was general fatigue. Her medical history was negative except for occasional migraine headaches relieved by ibuprofen. The patient had not experienced any recent illnesses, had no personal or family history of seizures, and denied illicit drug use.

Injury Surveillance in a Central Hospital in Kigali, Rwanda - Corrected Proof

Etienne Nsereko, Petra Brysiewicz — 2009-12-25

Introduction: This paper will describe the injury profile of patients admitted over a 9-month period to the emergency department of the Central Hospital (CHUK) in Kigali, Rwanda.Methods: A quantitative, retrospective descriptive survey was conducted with the purpose of identifying the injury profile of the patients admitted to CHUK during the first 9 months of 2005. Haddon's Matrix was the conceptual framework used to guide this study. After consultation with the research supervisor, the doctors and nurses working in the emergency department at CHUK, the researcher developed a checklist which was used to collect information from the selected patients' files. This checklist comprised of 4 sections: demographic data, circumstance of injury, category of injury and outcome, and trauma score calculation.Results: This study found a high proportion of injury, especially in the urban setting that involved young males aged between 16-30 years. Blunt injury was the most common mechanism of injury, with the leading causes of injury being road traffic collisions. This study also highlighted the limitations in the record keeping of the patients admitted to the emergency department.Discussion: The researcher carried out this study in an attempt to compile an injury profile of patients admitted to CHUK ED in Kigali, Rwanda. The results illustrated that road traffic collisions are the major cause of injuries and young males are the most typical victim. This study also highlighted the limitations in the record keeping of the patients admitted to the emergency department and suggest important implications for the ED nurses working in Rwanda.

Emergency Nurses' Use of Psychosocial Nursing Interventions for Management of ED Patient Fear and Anxiety - Corrected Proof

Laural K. Wagley, Sarah E. Newton — 2009-12-25

Fear and anxiety are emotions felt by patients as they enter the health care arena through the emergency department. Management of ED patient fear and anxiety is important for emergency nurses because feelings of uneasiness and worry can produce altered levels of comfort and may be antecedents to violence. Use of psychosocial nursing interventions (eg, establishment of trust between the nurse and the patient, attendance to the family, provision of information, and emotional presence) by emergency nurses is endorsed by the ENA and has the potential to mitigate ED patient fear and anxiety. The purpose of this article is to provide an empirically based literature review related to the use of psychosocial nursing interventions by emergency nurses to manage ED patient fear and anxiety.

Assessing Cranial Nerves With a Stick of Gum - Corrected Proof

Jeff Strickler, Alberto Bonifacio — 2009-12-25

Most nurses recall the class in anatomy and physiology when we learned the great common memory aid, “On Old Olympus Towering Tops A Finn And German Viewed Some Hops” in an effort to learn the names of the 12 cranial nerves. For many of us, that moment was one of the last times we gave cranial nerves any thought. However, with diagnoses such as head injury and stroke continuing to rank highly on the morbidity and mortality charts, the ability of an emergency nurse to identify and monitor symptoms of neurologic dysfunction has become ever more critical. Trying to remember what functions are to be assessed with each nerve is enough to cause many registered nurses in the emergency department to break out in a cold sweat. The good news is that a full assessment can be performed quickly with a single stick of gum.

Impact of an Emergency Nurse–Initiated Asthma Management Protocol on Door-to-First-Salbutamol-Nebulization-Time in a Pediatric Emergency Department - Corrected Proof

Khajista Qazi, Saleh A. Altamimi, Hani Tamim, Khandee Serrano — 2009-12-23

Objective: To determine the effect of an ED nurse-initiated asthma management protocol on door to first salbutamol nebulization time.Methods: This was a prospective before-after study. Asthmatics, aged 1 to 12 years presenting to the ED with an exacerbation during the pre and post nurse-initiated care phases (from 1/22/08 to 2/8/08 and from 2/12/08 to 3/4/08), were eligible. An asthma training program was administered to nurses prior to post phase. Respiratory therapists started the first nebulization after a physician order during the pre phase, whereas bedside nurses initiated it before physician evaluation during the post phase. Mean differences and confidence intervals (CI) were calculated.Results: Each of the study groups had 125 patients. Door to first nebulization time was reduced by a mean of 31.3 minutes (CI 23.0, 39.6) in the post phase. Door to steroids, second nebulization, and bedside nurse evaluation time intervals were reduced by 22.8 minutes (CI 8.8, 36.9), 21.7minutes (CI 9.1, 34.4) and 15.6 minutes (CI 7.5, 23.7) respectively.Conclusion: An ED nurse-initiated asthma management protocol expedited initiation of medications essential for relief of symptoms of acute asthma and bedside evaluation by nurses. Standing nurse-initiated care protocols may proveto be beneficial in improving acute asthma care in crowded EDs.

Reunification of the Child and Caregiver in the Aftermath of Disaster - Corrected Proof

Stacy M. Jemtrud, Robyn D. Rhoades, Nancy Gabbai — 2009-12-21

Disaster preparedness is a central focus for health care workers and has been for decades, particularly for staff in emergency departments. The events of this millennium, most notably the 9/11 attacks and Hurricane Katrina, as well as subsequent storms, have elevated the awareness of pitfalls in our current domestic response plans. This article addresses the problem of parent-child reunification in the immediate aftermath of a natural or manmade disaster.

Saving Muscle: Evidence-Based Strategies for Reducing Door-to-Balloon Times for ST-Segment Elevation Myocardial Infarction Patients - Corrected Proof

Andrea L. Farwell — 2009-12-21

Coronary artery disease is the number one killer of both men and women in the United States. Each year, 1.2 million individuals with coronary artery disease will have a myocardial infarction (MI), and an estimated 38% of those individuals will die as a result. Emergency departments are challenged to reduce mortality and morbidity rates in these patients through timely restoration of cardiac tissue perfusion.

Subarachnoid Hemorrhage - Corrected Proof

Mark R. Reinhardt — 2009-12-21

Subarachnoid hemorrhage (SAH) is a condition defined by extraverted blood in the subarachnoid space. Blood activates meningeal nociceptors leading to occipital pain and meningism signs. Approximately 80% of patients with nontraumatic SAH have ruptured saccular aneurysms. If an SAH is left untreated, the patient will have a poor prognosis or will die. Therefore it is imperative that ED staff know how to recognize the early signs and start treatment immediately upon SAH confirmation. For the purpose of this article, SAH will be discussed from an ED perspective to include diagnosis and treatment.

Initial ECG Acquisition Within 10 Minutes of Arrival at the Emergency Department in Persons With Chest Pain: Time and Gender Differences - Corrected Proof

Jessica Zègre-Hemsey, Claire E. Sommargren, Barbara J. Drew — 2009-12-11

Introduction: The American Heart Association recommends all patients presenting to the emergency department with complaints of chest pain/anginal equivalent symptoms receive an initial ECG within 10 minutes of presentation. The Synthesized Twelve-lead ST Monitoring & Real-time Tele-electrocardiography (ST SMART) study is a prospective randomized clinical trial that enrolls all subjects who call 911 for ischemic complaints in Santa Cruz County, California. ST SMART is a 5-year study ending in 2008. The primary aim of the ST SMART study is to determine whether subjects who receive prehospital ECG have more timely hospital intervention and better outcomes.Objective: The aims of this secondary analysis of a subset of ST SMART study data were to determine (1) the rate of adherence to the American Heart Association goal in smaller community hospitals in less populous areas of receiving initial hospital ECG within the recommended 10 minutes and (2) whether there were gender differences in meeting this goal.Methods: The dataset included patients 30 years of age and older who were transported by ambulance to 1 of 2 rural hospitals in Santa Cruz County. All patients received an initial hospital ECG after arrival at the emergency department.Results: In this analysis of 425 patients (mean age, 70.4 years; 53% male), the mean time for all patients from ED arrival to initial ECG was 43 minutes (±145). The mean time to initial ECG was 34 minutes (±125) in male patients versus 53 minutes (±165) in female patients (Mann-Whitney test, P = .001). Forty-one percent of all patients presenting with ischemic symptoms received an initial ECG within 10 minutes of arrival. Forty-nine percent of male patients versus 32% of female patients received an initial ECG in 10 minutes or less (Fisher exact test, P = .000).Conclusion: In this analysis, the majority of patients with ischemic symptoms did not receive an ECG within 10 minutes of hospital presentation as recommended in evidence-based guidelines. There is a significant delay in door to time-to-ECG for women. ED nurses are in a unique position to initiate efforts to establish processes to decrease time to initial ECG for patients with ischemic symptoms. Attention to timely ECG acquisition in women may improve treatment of acute coronary syndromes in this group.

Strategies to Prevent Urinary Tract Infection From Urinary Catheter Insertion in the Emergency Department - Corrected Proof

2009-12-10

Urinary catheters are commonly placed in ED patients to manage urine output, provide bladder drainage, and facilitate the care of patients with unstable hemodynamics. Many of these patients are admitted to the hospital for treatment, and the catheter may remain in place for days or during the entire time of hospitalization. There are risks associated with the use of urinary catheters. They can cause such complications as urethritis, urethral strictures, hematuria, and mechanical trauma. Bladder perforation and encrustation of the catheter leading to blockage of the urine flow are other potential problems. One of the most common complications is a urinary tract infection (UTI). UTI accounts for 32% of all health care–associated infections. Eighty percent of these infections are attributable to the use of an indwelling catheter. Use of best practice techniques by emergency nurses can help prevent UTIs from occurring as a result of urinary catheter insertions in the emergency department. The Centers for Disease Control and Prevention (CDC) guidelines for prevention of catheter-associated UTIs (CAUTIs) recommends that hospital personnel and others who take care of catheters should be given periodic in-service training that stresses use of the correct technique and potential complications of urinary catheterization.

Do Patients Understand Discharge Instructions? - Corrected Proof

Sandra Zavala, Carol Shaffer — 2009-12-10

Introduction: Adherence to aftercare instructions following an emergency department visit may be essential for facilitating recovery and avoiding complications, but conditions for teaching and learning are less than ideal in the ED. The objective of this study was to identify and describe areas of patient confusion about ED discharge instructions.Methods: Follow-up telephone calls were made to 50 ED patients on the day after discharge to inquire how they were doing and whether they had any questions about their instructions.Results: Fifteen subjects (31%) requested information about their aftercare instructions that required further clarification by the investigator, and 15 subjects (31%) described a diagnosis-related concern that revealed poor comprehension of instructions.Discussion: This study demonstrated that patients commonly remain confused about aftercare information following treatment in an ED. Follow-up telephone calls may be useful for identifying and addressing ongoing learning needs.

Diagnostic Accuracy of Emergency Nurse Practitioners Versus Physicians Related to Minor Illnesses and Injuries - Corrected Proof

Christien van der Linden, Resi Reijnen, Rien de Vos — 2009-12-09

Introduction: Our objectives were to determine the incidence of missed injuries and inappropriately managed cases in patients with minor injuries and illnesses and to evaluate diagnostic accuracy of the emergency nurse practitioners (ENPs) compared with junior doctors/senior house officers (SHOs).Methods: In a descriptive cohort study, 741 patients treated by ENPs were compared with a random sample of 741 patients treated by junior doctors/SHOs. Groups were compared regarding incidence and severity of missed injuries and inappropriately managed cases, waiting times, and length of stay.Results: Within the total group, 29 of the 1,482 patients (1.9%) had a missed injury or were inappropriately managed. No statistically significant difference was found between the ENP and physician groups in terms of missed injuries or inappropriate management, with 9 errors (1.2%) by junior doctors/SHOs and 20 errors (2.7%) by ENPs. The most common reason for missed injuries was misinterpretation of radiographs (13 of 17 missed injuries). There was no significant difference in waiting time for treatment by junior doctors/SHOs versus ENPs (20 minutes vs 19 minutes). The mean length of stay was significantly longer for junior doctors/SHOs (65 minutes for ENPs and 85 minutes for junior doctors/SHOs; P < .001; 95% confidence interval, 72.32-77.41).Discussion: ENPs showed high diagnostic accuracy, with 97.3% of the patients being correctly diagnosed and managed. No significant differences between nurse practitioners and physicians related to missed injuries and inappropriate management were detected.

Central Pontine Myelinolysis - Corrected Proof

Kerri Hromanik — 2009-12-09

A 66-year-old woman was found convulsing on the floor 2 weeks after beginning therapy with diuretic medication. Her serum sodium level was 95 mmol/L when it was first measured in the emergency department. She underwent intravenous (IV) infusion 500 mL of 3% saline solution. On the second day of her hospital stay, the patient's serum sodium level had increased to 111 mmol/L and she was awake and following commands. Her serum sodium concentration continued to increase to 122 mmol/L by the next day. An additional 800 mL of 3% saline solution was infused to further increase her sodium level. The patient's condition continued to improve; after 4 days of hospitalization, her sodium concentration was 146 mmol/L. She was awake, alert, and oriented, and she no longer required mechanical ventilation.

The Crystal Chalice: Investigating the Source of Fiberoptic Science - Corrected Proof

Keith Stephens-Borg — 2009-11-27

Devices using the technology of fiberoptics, from the direct visual laryngoscope to the flexible endoscope, all share a common light source; nevertheless, throughout their daily use in clinical areas, to even consider excluding the knowledge of focused illumination would be unimaginable. Endoscopes for medical examinations were widely manufactured in Tuttlingen, Germany, by Karl Storz in the 1940s; however, the more agile digital equipment together with a variety of synthetic materials only appeared within the past 20 years following the birth of fiberoptics—the vanguard in the dawn of robotic surgery.

Evaluating Care in ED Fast Tracks - Corrected Proof

Veronica Quattrini, Beth Ann Swan — 2009-11-27

Hospital emergency departments play a variety of roles in the American health care system. Once considered a source of care for major injuries and life-threatening medical conditions, the emergency department has become part primary care and part social work to many Americans. From 1992 to 2002, the number of ED visits in the United States increased by 23%, with an estimated 110.2 million visits per year. Because of this phenomenon and in conjunction with other variables, emergency departments across the United States are in crisis, with more people than ever seeking their services. Because of this, emergency departments usually place the highest demands on hospital services. Personnel in the emergency department have no control over the type of patients who present for care, the pace of their arrival, or the acuity level. No one is refused care, even when the hospital is at capacity, which results in long waiting times, overworked staff, overcrowded departments, and patient dissatisfaction. The number of patients in need of non-emergent services overwhelms many of the emergency departments in America. Sixty-two percent of the nation's emergency departments report that they are “at” or “over” operating capacity. Successful resolution of the vast number of problems facing staff and patients in the emergency department is a monumental task. To address this critical problem, emergency departments are developing and implementing new models of care. One model that has been shown to decrease overcrowding and facilitate patient flow is through implementation of a fast-track (FT) area within an emergency department. As FTs evolve, it is essential to examine the relationship of structure, process, and outcome. The purpose of this evidentiary review is to examine the structure, process, and outcomes and role of nurse practitioners (NPs) in ED FTs.

The Effect of Training Programs on Traditional Approaches That Mothers Use in Emergencies - Corrected Proof

Nurcan Özyazıcıoğlu, Sevinç Polat, Hatice Bıçakcı — 2009-11-23

Introduction: The approach of the residents of central Kars, Turkey, to emergencies in our conservative district is shaped by the effect of the culture. In emergency actions, many traditional approaches are preferred, using herbs and other available materials. Some of these approaches might be directly hazardous and some create danger indirectly as they prolong the treatment period.Methods: The study was performed using a one-group pretest/posttest design. Data were collected between June 3, 2006, and August 28, 2007. Two thousand sixty mothers completed the sociodemographic pretest and survey and attended the educational program. The final sample included 1754 mothers who completed the sociodemographic and pretest survey, attended the educational program, and completed the posttest survey. The posttest survey was administered 6 months following the educational program.Results: In this study; the percentage of mothers resorting to traditional approaches in the pretest were at burns, 29.0%; lacerations, 21.4%; fractures, 25.7%; and poisoning, 45.1%; and in the posttest burns, 16.1%; lacerations, 12.7%; fractures, 15.6%; and poisoning, 34.4%. Mothers with higher educational levels were less likely to use traditional practices and the educational program significantly reduced the prevalence of using traditional practices. The training program had a positive effect in decreasing the incidence of resorting to traditional practices for certain emergencies.Discussion: It was proven that the application of various harmful traditional practices had been used in first aid cases and that the rate decreased in the post training period. It is interesting to note that an additional 540 mothers who did not complete the pretest and sociodemographic questionnaire also attended the educational program because word of the program had spread throughout the region.

Alcohol Screening, Brief Intervention, and Referral to Treatment Conducted by Emergency Nurses: An Impact Evaluation - Corrected Proof

Pierre M. Désy, Patricia Kunz Howard, Cydne Perhats, Suling Li — 2009-11-20

Introduction: In a quasi-experimental study, control and intervention group outcomes were compared following implementation of alcohol screening, brief intervention, and referral to treatment (SBIRT) by emergency nurses. The primary hypothesis was: Trauma patients who participate in nurse-delivered ED SBIRT will have greater reductions in alcohol consumption and fewer alcohol-related incidents than those who do not.Methods: Patients were screened for alcohol use and those with risky drinking were randomly assigned to either the intervention or usual care group. Those in the intervention group received a brief motivational intervention and referral to appropriate follow-up services. Using medical and driving history records, subjects' alcohol consumption, alcohol-related traffic incidents, repeat injuries, and repeat ED visits were compared between groups at baseline and three-month follow-up.Results: Alcohol consumption decreased by 70% in the intervention group compared to 20% in the usual care group. Drinking frequency also decreased in both groups. Fewer patients from the intervention group (20%) had recurring ED visits compared to patients in the usual care group (31%).Discussion: The SBIRT procedure can impact alcohol consumption and potentially reduce injuries and ED visits when successfully implemented by staff nurses in the emergency department environment. Further research is needed to improve follow-up methods in this hard to reach, mobile patient population.

Myths and Stereotypes: How Registered Nurses Screen for Intimate Partner Violence - Corrected Proof

Ruthie Robinson — 2009-11-13

Introduction: Intimate partner violence, sometimes referred to as domestic violence, is a prevalent problem in the United States and across the world. Emergency nurses are often the first health care providers to ask individuals about this health issue and are often the first to offer intervention and prevention measures.Methods: This study used a phenomenological qualitative approach to examine the role of the registered nurse in the emergency setting as it relates to intimate partner violence. Thirteen emergency nurses from the South Central United States were interviewed for this study.Results: Four major themes emerged during analysis of the interviews. The 4 themes were (1) myths, stereotypes, and fears; (2) demeanor; (3) frustrations; and (4) safety benefits.Discussion: This study suggests that emergency nurses are not screening for intimate partner violence based on a protocol as suggested by many professional organizations but rather are screening certain patients for violence based on the nurses' perception of whether particular patients are likely to be victims of violence.

Barriers to Change Hindering Quality Improvement: The Reality of Emergency Care - Corrected Proof

Åsa Muntlin, Marianne Carlsson, Lena Gunningberg — 2009-11-09

Purpose: The aim of this study was to investigate physicians' and nurses' perspectives and prerequisites for quality improvement in the emergency department based on results from a previous patient survey.Method: The study used an explorative design with a qualitative approach and was conducted at the main emergency department of a Swedish university hospital. Interviews were conducted with 5 focus groups. In total, the groups comprised 22 respondents.Results: The respondents suggested goals and quality improvements, such as more patient-centered care, reduced waiting times, and better pain management. However, barriers to quality improvement also were identified and represented 3 themes: the patient is looked upon as an object or a problem; the physicians and nurses belong to different organizational cultures; and the hospital's organization hinders the optimal flow of patients and improvements to quality.Discussion: When assigning priority to the topic areas, most of the focus groups ranked “information, respect, and empathy” as most important to improve. Adequate information, proper care, and treatment within a reasonable time in the emergency department were cited as the goals for patient care, but the health care professionals perceived barriers to change in the hospital culture and organization. To ensure quality care and patient safety, these barriers should be addressed by leaders on all levels in the organization, including the hospital board. Health care professionals' perspectives of quality of care are valuable and should be included in quality improvement work.

Modeling and Analysis of the Emergency Department at University of Kentucky Chandler Hospital Using Simulations - Corrected Proof

2009-09-16

Introduction: In this article, we present a simulation study conducted in the emergency department at the University of Kentucky Chandler Hospital.Methods: Based on analysis of process and flow data, a simulation model of patient throughput in the emergency department has been developed.Results: What-if analyses have been proposed to identify bottlenecks and investigate the optimal numbers of human and equipment resources (eg, nurses, physicians, and radiology technology). The simulation results suggest that 3 additional nurses are needed to ensure desired clinical outcomes. Diagnostic testing, the computed tomography scan in particular, is found to be a bottleneck. As a result, acquisition of an additional computed tomography scanner is recommended. Hospital management has accepted the recommendations, and implementation is in progress.Discussion: Such a model provides a quantitative tool for continuous improvement and process control in the emergency department and also is applicable to other departments in the hospital.

Orientation to Emergency Nursing: Perceptions of New Graduate Nurses - Corrected Proof

Barbara Patterson, Elizabeth W. Bayley, Krista Burnell, Jan Rhoads — 2009-08-31

Introduction: Emergency nursing is one of the most challenging and understaffed areas of professional nursing. Currently, little is known about how new graduate nurses perceive their experiences as novice emergency nurses. The purpose of this study was to gain an understanding of how new graduate nurses who are oriented to emergency nursing as their first professional area of nursing employment perceive the orientation program and emergency nursing at the beginning and end of a 6-month program.Method: This descriptive study incorporated qualitative and quantitative methods consisting of interviews and a survey. Study participants included 15 women and 3 men. Their mean age was 32 years. All were employed full time in their first position as a graduate nurse. They were asked their perceptions of the program at 3 and 6 months.Results: Participants shared their perceptions of why they had been attracted to the program, characteristics of the emergency department and emergency nursing, being in a new job and role, reflections on their performance, the classroom and clinical components of the program, and their recommendations for future orientation programs. Results of the quantitative survey on participants’ perceptions of their first job as a registered nurse indicated that they found the work of the orientation program to be stressful.Discussion: Understanding the experience of new graduate nurses to the emergency setting provides crucial information for orientation program design. Incorporating active teaching and socialization strategies early in the program may facilitate the transition from novice to beginning competent emergency nurse.

Understanding Non-Emergency Patients Admitted to Hospitals Through the Emergency Department for Efficient ED Functions - Corrected Proof

Jee-In Hwang, Hyejung Chang — 2009-08-27

Introduction: ED overcrowding and inefficient flow are closely related to the presence of non-emergency patients. This study aims to examine the characteristics of the non-emergency patients admitted to hospitals through the emergency department by comparison with emergency ED patients and inpatients admitted through outpatient departments, in terms of patient demographics and health care utilization and outcomes.Methods: This study used an exploratory descriptive design. The retrospective data of 280,104 patients from 38 hospitals were analyzed. χ2 Tests and logistic regression analyses were performed to determine significant differences among the 3 patient groups.Results: Among the patients admitted through the emergency department, 13.1% were non-emergency patients. These non-emergency ED patients showed different health care utilization characteristics: 42.8% had 4 or more diagnoses, 90.3% had 5 or more laboratory tests, and 89.4% had radiology tests. After we controlled for patient characteristics and health care utilization variables, mortality risk of emergency ED patients was 2-fold higher than that of non-emergency ED patients and standard inpatients (odds ratio, 2.1), but the referral rate to other facilities on discharge was the highest in non-emergency ED patients compared with standard inpatients (odds ratio, 3.3).Discussion: Non-emergency patients admitted to hospitals through the emergency department showed special needs for health care services: care continuity, improved access, and fast tracking for acute care hospital-level treatment. Health care policies and strategies are suggested for efficient ED functions.

Mild Traumatic Brain Injury/Concussion: A Review for ED Nurses - Corrected Proof

Karen Bergman, Esther Bay — 2009-08-17

Traumatic brain injury (TBI) affects 1.4 million Americans annually, and severity can range from mild to severe. Mild traumatic brain injury (MTBI) accounts for approximately 75% of those injured. Following evaluation, many patients with mild noncomplicated TBI can be safely treated and released from the emergency department. In addition to those that are treated for their injury, there is an estimated 25% to 42% of persons who experience MTBI and do not seek treatment; thus, the true prevalence of MTBI is unknown.

Patient Complaints in the Emergency Department - Corrected Proof

Senay Karadag Arli, Fatma Eti Aslan, Sevim Purisa — 2009-06-26

Introduction: This study was conducted for the purpose of determining patients’ complaints in an emergency department.Methods: This study, designed as a descriptive and analytic type of research, was conducted between December 9, 2006, and June 30, 2007, with 1514 patients in the emergency department of a private hospital in Istanbul. Data collected consisted of 3 measures: (1) a 13-question “Individual Characteristics Form”; (2) a 35-item “Evaluation of Patient Complaints Form,” which utilized a face-to-face interview method; and (3) a “Triage Categories Form,” a 5-tier triage tool used by the emergency department where this study took place.Results: In this study, 70% of the patients were between 16 and 43 years of age, 57% were female, 76% were triage category 4 (less urgent patients needing to be treated within, at the most, 1 hour), and 62.3% (n = 943) stated that they were “very pleased” with the service they received in the emergency department. However, some of the patients who rated themselves as having a very serious health problem were not satisfied at all with the emergency department. In turn, as the period of time increased before their first emergency intervention was begun, their dissatisfaction with their emergency care increased. Among the ED patient complaints, the most common was “the presence of curtains between the beds in the rooms and the beds being uncomfortable.”Conclusions: The characteristic need of an ED patient is (a desire to) receive service within a short period. A high percentage of patients with serious health problems waited 5 minutes or extra time before their first emergency intervention was begun. Based on these results, it is recommended that ED physician and nursing leadership create policies and practices that allow emergency interventions to occur as soon as possible upon patient arrival.

Four Steps to Reducing Door-to-Balloon Time - Corrected Proof

Belinda B. Hammond — 2009-06-26

A 56-year-old man presents to the emergency department with substernal chest pain of 1-hour duration. He is diaphoretic and nauseated. The triage nurse obtains a 12-lead ECG and takes the patient to a treatment room while his family completes the registration process. The physician looks at the ECG and determines that the patient is experiencing an ST elevation myocardial infarction (STEMI). Time elapsed from patient presentation: 15 minutes.

The Efficacy of a Brief Behavioral Health Intervention for Managing High Utilization of ED Services by Chronic Pain Patients - Corrected Proof

Jonathan Woodhouse, Mary Peterson, Clark Campbell, Kathleen Gathercoal — 2009-05-20

Introduction: Patients with chronic pain continue to seek medical care from emergency departments nationwide despite the fact that an emergency department is a less-than-optimal environment for meeting their specific and specialized needs. As the scientific community has gained a more sophisticated understanding of the mechanisms that contribute to the development and maintenance of chronic pain, the central role of psychological factors have emerged. Therefore, an ED-based, behavioral health intervention for chronic pain patients is needed to better serve this population and to help hospitals provide cost effective treatment at the appropriate level of care.Methods: The setting was a 40-bed, acute-care hospital with a 15-bed emergency department seeing 16,500 patients annually. All participants were chronic pain patients utilizing the emergency department for pain management. This study was a program evaluation utilizing a quasi-experimental, retrospective, pre-test/post-test, split-plot design.Results: A repeated measures analysis of variance (ANOVA) was used to compare high-utilizers (>4 emergency department visits in 6 months) to low utilizers in total ED visits 6 months before and after the intervention. The low utilizers mean ED visits remained stable before and after the intervention while the high utilizers showed a decrease in ED utilization. This differential response between groups was statistically significant (P < .05).Discussion: This study suggests that an ED-based behavioral health consultation may be useful for reducing high utilization of ED services by some chronic pain patients, particularly those who consume the most services.