Journal of Emergency Nursing - Articles in Press

Understanding the Role of Oxygen in Acute Coronary Syndromes - Corrected Proof

Sheila R. Finamore, Lindsay Kennedy — 2012-01-16

The routine administration of oxygen to patients presenting with features of acute coronary syndrome (ACS) is a practice that is deeply embedded in the routine of frontline health care professionals, and it has been a primary intervention for persons with ACS for more than 100 years. It is noteworthy that this tradition was supported by the American Heart Association (AHA) from 1975 through 2005 in the form of recommendations for treatment, and it was supported by the American College of Cardiology through 2007 as well. This practice of administering oxygen has been supported by research completed during the past century, which concluded that supplementary oxygen could diminish the size of myocardial ischemic injury resulting from ACS. However, the conclusions derived from the aforementioned research were generalized from animal models. More recently, members of the scientific community have questioned these generalizations and the validity of the studies, noting the vast differences in the 2 species (dogs and humans) in terms of coronary anatomy, collateral circulation, natural disease state, and hemodynamic responses. The routine administration of oxygen for all patients presenting with symptoms suggestive of ACS has become a treatment of tradition that may not be supported by scientific evidence., In fact, the 2010 Advanced Cardiac Life Support guidelines recommend oxygen supplementation for uncomplicated ACS only with an oxyhemoglobin saturation of ≤94% or with signs and symptoms suggestive of respiratory distress.

Redesign of an Urban Academic Emergency Department: Action Research Can Make a Difference - Corrected Proof

2012-01-16

In 2006 the Institute of Medicine put the spotlight on a weak link in the US health care system—emergency care. Faced with increased demand for both routine and emergency medical services, as well as a myriad of scheduling challenges, emergency departments have long been synonymous with overcrowding, long waiting times, and boarding of patients, who are held in the emergency department for long periods until an inpatient bed becomes available. The complexity and negative consequences of ED overcrowding and boarding are well documented: disability and death from delayed diagnosis and intervention, increased total length of stay (LOS) in patients boarded in the emergency department, sick patients who leave the emergency department without care and later require admission, increased medical errors, increased risk of death, ambulance diversion, and increased risk of physician malpractice.

Evaluation of a Flexible Acute Admission Unit: Effects on Transfers to Other Hospitals and Patient Throughput Times - Corrected Proof

Christien van der Linden, Cees Lucas, Naomi van der Linden, Robert Lindeboom — 2012-01-16

Introduction: To prevent overcrowding of the emergency department, a flexible acute admission unit (FAAU) was created, consisting of 15 inpatient regular beds located in different departments. We expected the FAAU to result in fewer transfers to other hospitals and in a lower length of stay (LOS) of patients needing hospital admission.Methods: A before-and-after interventional study was performed in a level 1 trauma center in the Netherlands. Number of transfers and LOS of admitted ED patients in a 4-month period in 2008 (control period) and a 4-month period in 2009 (intervention period) were analyzed.Results: Of 1,619 regular admission patients, 768 were admitted in the control period and 851 in the intervention period. The number of transfers decreased from 80 (10.42%) to 54 (6.35%) (P = .0037). The mean ED LOS of both the non-admitted patients and the admitted patients needing special care significantly increased (105 minutes vs 117 minutes [P = .022] and 176 minutes vs 191 minutes [P < .001], respectively). However, the mean LOS of FAAU-admissible patients was unaltered (226 minutes vs 225 minutes, P = .865).Conclusions: The FAAU reduced the number of transfers of admitted patients to other hospitals. The increase in LOS for special care patients and non-admitted patients was not observed for regular, FAAU-admissible patients. Flexible bed management might be useful in preventing overcrowding.

Logistics and Lessons Learned: ED Redesign 3 Years Later—A Follow-Up to “How to Create a New Emergency Department in 21 Days or Less” - Corrected Proof

Gina Castillo, Patty Wilson — 2012-01-16

The article entitled “How to Create a New Emergency Department in 21 Days or Less” describes a process in which a 35-bed emergency department redesigned its process to drastically reduce turnaround time (TAT) and the number of patients who left without being seen using existing staff and space. The success of the process required the willingness of the ED staff, the emergency physician group, and the facility administration. The new process has been successful in reducing TAT and the number of patients who left without being seen. It has also increased patient and staff satisfaction and revised the use of limited ED space. Most importantly, 100% of patients presenting to intake are evaluated by a physician, rather than delaying physician evaluation until a stretcher is available (the historical and antiquated triage process).

Emergency Medical Services Triage Using the Emergency Severity Index: Is it Reliable and Valid? - Corrected Proof

Holly M. Buschhorn, Tania D. Strout, J. Matthew Sholl, Michael R. Baumann — 2012-01-16

Introduction: Efficient communication between emergency medical services (EMS) and ED providers using a common triage system may enable more effective transfers when EMS arrives in the emergency department. We sought (1) to evaluate inter-rater reliability between Emergency Severity Index (ESI) assignments designated by EMS personnel and emergency triage nurses (registered nurses [RNs]) and (2) to evaluate the validity of EMS triage assignments using the ESI instrument.Methods: This prospective, observational study evaluated inter-rater reliability in ESI scores assigned by prehospital personnel and RNs. EMS providers were trained to use the ESI by the same methods used for nurse training. EMS personnel assigned triage scores to patients independent of assignments by the RN. Inter-rater reliability, differences based on provider experience, and validity of EMS triage assignments (sensitivity and specificity) were evaluated.Results: Seventy-five paired, blinded triages were completed. Overall concordance between EMS providers and RNs was 0.409 (95% confidence interval [CI], 0.256-0.562). Agreement for EMS providers with less experience was 0.519 (95% CI, 0.258-0.780), whereas concordance for those with more experience was 0.348 (95% CI, 0.160-0.536) (χ2 = 1.413, df = 1, P = .235). Sensitivity ranged from 0% to 67.86%. Specificity ranged from 68.09% to 97.26%.Conclusions: We observed moderate concordance between EMS and RN ESI triage assignments. EMS sensitivity for correct acuity assignment was generally poor, whereas specificity for correctly not assigning a particular level was better. Additional research investigating the potential causes of the poor agreement that we observed is warranted.

The ENA Lantern Award: The Process and the Celebration - Corrected Proof

Tami Morin, Susan Rees — 2012-01-16

The Lantern Award program to recognize emergency departments that exemplify exceptional and innovative performance in the core areas of leadership, practice, education, advocacy, and research was announced in the fall of 2010. Applications for the inaugural award were due to the ENA on May 1, 2011. In December 2010 the Emergency Department at the University of Wisconsin Hospital and Clinics (UWHC) made the decision to pursue this award. In July 2011 UWHC was notified that it was 1 of 20 emergency departments to receive the award. This article will describe the process used to apply for the award and the celebrations that occurred to acknowledge receiving the award.

Early Recognition and Treatment of the Septic Patient in the Emergency Department - Corrected Proof

Lisa Wolf — 2012-01-16

A 70-year-old woman is wheeled to triage by her daughter-in-law. “She's just not right!” says the daughter-in-law. “She can't take care of herself.” The daughter-in-law describes a 3-day history of increasing confusion, urinary incontinence, and fatigue. The patient tells you she “doesn't feel well” and looks a little pale. Her vital signs at triage are as follows: blood pressure, 110/82 mm Hg; heart rate, 93 beats/min; respiratory rate, 22 breaths/min; and oxygen saturation, 95% on room air. Her oral temperature is 96.2°F. The triage nurse suspects a urinary tract infection, but because the vital signs mostly fall within normal range, the patient is triaged as Emergency Severity Index 3, or “urgent”; asked for a urine sample; and sent to the waiting room to wait for an available bed.

Sex and the Older Adult - Corrected Proof

Joan Somes, Nancy Stephens Donatelli — 2012-01-16

Marybeth, aged 72 years, presents to the emergency department with complaints of painful urination and suprapubic pain for 2 days. There is no urinary frequency or blood in the urine. She has no flank or back pain. She denies any other symptoms including nausea or vomiting. Her last bowel movement was today, and it was normal. Her blood pressure is 150/78 mm Hg; heart rate, 82 beats/min; respiratory rate, 17 breathes/min; and temperature, 98.1°F. She rates her pain as 2 of 10. The triage nurse has collected a urine specimen and sent it to the laboratory for routine urinalysis. Marybeth has been placed in an examination room to see the provider and wait for the results of the urinalysis. The laboratory personnel call to verify that the urine specimen actually belongs to the patient because they noted many polymorphonuclear leukocytes (white cells) and motile trichomonads. It was the trichomonads that prompted the laboratory technician's call because, as stated by the laboratory technician, “we usually only see these if the patient has an STD [sexually transmitted disease]! Isn't she old!?” The nurse verifies that the urine does belong to this patient, because not only did the nurse help collect it but Marybeth is currently the only patient in the emergency department and proper procedures related to laboratory specimens were followed.

Oral Rehydration of the Pediatric Patient with Mild to Moderate Dehydration - Corrected Proof

Stephen Jablonski — 2012-01-16

Acute gastroenteritis is a very common illness in infants and children that accounts for more than 1.5 million outpatient visits, 200,000 hospitalizations, and approximately 300 deaths a year. A significant number of these children will be needlessly subjected to blood work and intravenous rehydration during the course of their treatment. This article will explain why oral rehydration for pediatric patients with mild to moderate dehydration is the preferred method of treatment and why the common use of intravenous (IV) therapy should be avoided.

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

Carrie A. McCoy — 2012-01-16

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.

Working Toward Perfection on the Pneumonia Core Measure - Corrected Proof

Darin C. Roark — 2012-01-16

In 2001, the Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services began launching a series of quality initiatives aimed at improving the quality of health care available for all Americans. During the past decade, the quality initiatives have evolved and have become known as the Hospital Care Measures (www.cms.gov). Hospitals across the United States now report their outcomes data on several key metrics, provided in the .

Lateral Violence in Nursing - Corrected Proof

Patricia L. Blair — 2012-01-16

Lateral violence in the nursing workplace can be defined as horizontal violence, bullying, and workplace incivility. As with many problems, part of the solution may be the very recognition of it. Kirchner found that 1 in 6 employees in the health care industry have experienced lateral violence. Roberts, Demarco, and Griffin reported that lateral violence in different medical facilities ranged between 46% and 100%. A Joint Commission survey found that 77% of physicians and 65% of nurses had witnessed disruptive workplace behavior. Tools that accurately measure lateral violence are available; however, the difficult work is in creating actions to correct this behavior.

How Do Emergency Department Patients Store and Dispose of Opioids After Discharge? A Pilot Study - Corrected Proof

Paula Tanabe, Judith A. Paice, Jennifer Stancati, Michael Fleming — 2011-12-28

Introduction: Opioid abuse and overdose have increased drastically in recent years. Diversion of opioids used to treat pain, either through theft or sharing, is increasing and may contribute to this misuse. Based on these trends, we designed a study to investigate opioid storage and disposal practices of patients who were prescribed these agents in the emergency department.Methods: A prospective cohort pilot study was conducted. All adults (aged ≥18 years) with a chief complaint of either minor musculoskeletal trauma, renal colic, or acute back pain who were discharged home with an opioid prescription were eligible for inclusion; persons with chronic pain were excluded. Patients were asked to participate in two home interviews in which the research assistant viewed the storage location of the opioid prescription. Safe storage was defined as being stored in a locked container or cabinet. Safe disposal was defined as returning the drugs to a designated location or mixing unused pills with an undesirable substance, placing in a sealable container, and then in the trash. Patients self-reported disposal methods. Feasibility of study methods evaluated the ability to conduct home interviews after the ED visit. Descriptive statistics were used to analyze the data.Results: Twenty-five subjects consented to participate; 20 patients completed both home interviews. None of the medications were safely stored. Only 1 patient disposed of the medication, yet did so improperly.Conclusion: This pilot study revealed widespread improper storage and disposal of opioids. The study has major implications for education for ED physicians, nurses, and residents.

Effect of Weather on Medical Patient Volume at Kansas Speedway Mass Gatherings - Corrected Proof

2011-12-28

Introduction: Provision for the safety and health care of persons attending mass-gathering events presents unique challenges to organizers. This study was designed to determine the factors that contribute to patients seeking medical care during these events.Methods: We performed a retrospective review of patient care records for visits that occurred during race weekends at the Kansas Speedway from April 2007 to October 2010. Data were collected regarding the overall gathering size of each event to calculate the number of patient encounters per 10,000 attendees. Patients’ final disposition was determined to calculate the transfer-to-hospital rate per 10,000 attendees. Weather data, including temperature, humidity, and precipitation, were documented for each event. Negative binomial regression was used to test the relationship between weather factors and the rate of patient encounters.Results: Twenty-two event days over 6 race weekends were evaluated, with a total of 1305 patients (58% male; mean age: 37 years), a mean patient encounter rate of 13 per 10,000 attendees, and a mean transfer-to-hospital rate of 0.24 per 10,000 attendees. Our regression model demonstrated that each 0.55°C (1°F) increase in daily mean temperature was associated with a 4% increase in the rate of total complaints (P = .03) and a 6% increase in major trauma presentations (P = .019). Major trauma events were 2.4 times more frequent at ambient temperatures >17.2°C (63°F) (P = .03). Each inch of precipitation was associated with a 61% decrease in total patient volume (P = .05).Conclusion: Weather factors significantly and predictably affect the use of medical services at the Kansas Speedway. Such data regarding mass-gathering events can be used for resource planning.

Understanding Youth Street Gangs - Corrected Proof

Cliff Akiyama — 2011-12-16

Throughout the United States in urban, suburban, and rural communities, emergency nurses are treating victims and offenders of gang violence who are admitted to the emergency department on a daily basis. It was once thought that gangs only convened in selected areas and that the emergency department was “neutral” territory. Unfortunately, gang violence has now entered the emergency department, putting patients, personnel, and visitors at risk for injury or even death.

Woman with Risks for Torsades de Pointes Dying within Hours of Leaving the Emergency Department - Corrected Proof

David Pickham, Kimberly Sickler — 2011-12-05

A 66-year-old woman presented to an emergency department late one afternoon with a 3-day history of diffuse abdominal pain, inability to eat, nausea, vomiting, diarrhea, and persistent coughing. In the triage area she rated her abdominal pain as being 6, on a 10-point pain scale. Her initial vital signs were all unremarkable. The woman's medical history was significant for type II diabetes mellitus, renal failure (for which she was undergoing dialysis 3 times a week, with her last dialysis session 2 days earlier), amputation of her left leg above the knee, and amputation of her right leg below the knee. In addition to her obvious comorbidities, the patient's current drug list () suggested a history of hypercholesterolemia, hypertension, hypothyroidism, nonspecific cardiac disease, and depression.

The Clinical Nurse Leader: Improving Outcomes and Efficacy in the Emergency Department - Corrected Proof

Andrea Perry — 2011-12-02

Emergency departments across the country are in a state of crisis. The impending shortage of nurses and nurse educators, increasing complexity of illness, and uncertainty regarding the future of health care are just some of the issues being faced today. In addition, as outcomes become an increasingly critical measure of success, the education level of nurses has come under examination. Studies have shown that higher levels of education result in improved outcomes, leading several professional organizations to recommend a baccalaureate degree as the minimum degree for entry-level practice. These recommendations include requiring nurses licensed after 2012 to earn a master's degree within 10 years and transitioning advanced practice degrees from master's to doctoral degrees. As health care becomes increasingly complex, the bedside nurse not only needs to be skilled in practice but needs to be knowledgeable about policy, outcome evaluation, and evidence-based practice. In response to these concerns and others raised by professional and credentialing organizations, the role of the Clinical Nurse Leader (CNL) was developed.

Being Prepared for the Unprepared: A Phenomenology Field Study of Swedish Prehospital Care - Corrected Proof

Birgitta Wireklint Sundström, Karin Dahlberg — 2011-11-16

Introduction: This paper presents a study of prehospital care with particular focus on how ambulance personnel prepare themselves for their everyday assignments.Methods: The caring science field study took a phenomenological approach, where data were analyzed for meaning. Two specialist ambulance nurses, three registered nurses, and six paramedics participated.Results: The previously known discrepancy between in-hospital care and prehospital care was further interpreted in this study. The pre-information from an emergency medical dispatch (EMD) center provides ambulance personnel with basic expectations as to what they will have to take care of. At the same time that they maintain their certainty and control, our major findings indicate that prehospital care in emergency medical service requires the personnel to be prepared for an open and flexible encounter with the patient; to be prepared for the unprepared, i.e., to be open and to avoid being governed by predetermined statements.Discussion: Our findings suggest that the outcomes of good prehospital care affect patient security. The seemingly time-consuming dialogue with the patient facilitates understanding and decision-making regarding the patient's medical needs, and it is comforting to the patient. The ambulance personnel need to be well prepared for this task and fully understand that the situation might differ considerably from the information provided by the EMD centers. All objective information is of great value in this care context, but ultimately it is the patient who provides reliable information about her/his own situation.

Abuse Experiences, Substance Use, and Reproductive Health in Women Seeking Care at an Emergency Department - Corrected Proof

Melissa A. Sutherland, Heidi Collins Fantasia, Natalie McClain — 2011-11-16

Introduction: Abuse experiences can have negative health consequences for women. Many women present to the emergency department for episodic, nonemergent care and may have unique needs as survivors of abuse. The purpose of this study was to describe child sexual abuse experiences, intimate partner violence, substance use, and reproductive health outcomes in a sample of adult women who were seeking care from a rural emergency department to better understand the health care needs of this unique population.Methods: One hundred forty-five adult women (18-45 years old) were recruited at an emergency department in the southeastern United States. Questionnaires were used to assess for demographic characteristics, history of child sexual abuse (CSA), intimate partner violence, reproductive health, and substance use.Results: In the sample, 42.8% of women (n = 62) reported a positive history of CSA and 34.7% of women (n = 49) experienced intimate partner physical violence during the past year. More than 46% of the women (n = 65) had harmful drinking patterns in the past year and more than 50% reported some type of substance use in the past 3 months. Women who experienced CSA had a significantly greater number of lifetime sexual partners, were more likely to report pain with sexual intercourse, and were more likely to report a medical history of an abnormal Papanicolaou smear.Discussion: The women in this sample had high rates of abuse, harmful drinking patterns, and substance use and were at risk for sexually transmitted infections. Through screening for lifetime violence, including sexual violence, emergency nurses can be an important liaison between women who have experienced CSA and appropriate referrals within the health care system.

Early Detection and Treatment of Severe Sepsis in the Emergency Department: Identifying Barriers to Implementation of a Protocol-based Approach - Corrected Proof

2011-11-14

Introduction: Despite evidence to support efficacy of early goal-directed therapy for resuscitation of patients with severe sepsis and septic shock in the emergency department, implementation remains incomplete. To identify and address specific barriers at our institution and maximize benefits of a planned sepsis treatment initiative, a baseline assessment of knowledge, attitudes, and behaviors regarding detection and treatment of severe sepsis was performed.Methods: An online survey was offered to nurses and physicians in the emergency department of a major urban academic medical center. The questionnaire was designed to assess (1) baseline knowledge and self-reported confidence in identification of systemic inflammatory response syndrome and sepsis; (2) current practices in treatment; (3) difficulties encountered in managing sepsis cases; (4) perceived barriers to implementation of a clinical pathway based on early quantitative resuscitation goals; and (5) to elicit suggestions for improvement of sepsis treatment within the department.Results: Respondents (n = 101) identified barriers to a quantitative resuscitation protocol for sepsis. These barriers included the inability to perform central venous pressure/central venous oxygen saturation monitoring, limited physical space in the emergency department, and lack of sufficient nursing staff. Among nurses, the greatest perceived contributor to delays in treatment was a delay in diagnosis by physicians; among physicians, a delay in availability of ICU beds and nursing delays were the greatest barriers. Despite these issues, respondents indicated that a written protocol would be helpful to them.Discussion: Knowledge gaps and procedural hurdles identified by the survey will inform both educational and process components of an initiative to improve sepsis care in the emergency department.

The War Against Warfarin: Evaluating Current Treatment Guidelines for Patients Who Have Had an Acute Ischemic Stroke and Are Taking Warfarin - Corrected Proof

Megan A. Brissie — 2011-11-14

A 52-year-old white woman was brought to the emergency department because of altered mental status. When she entered the treatment area, she was slumped down in her wheelchair with a left-sided facial droop. As the staff assisted her onto the stretcher, they recognized her garbled speech and delayed responses as symptoms of a possible acute ischemic stroke (AIS).

Lessons Learned in Developing and Implementing the Nurse Practitioner Role in an Urban Canadian Emergency Department - Corrected Proof

Mary Dimeo, Michael Postic — 2011-11-14

With an ever-increasing public demand for emergency care combined with government mandated wait-time targets and shrinking financial and human resources, an alternative to the model of the physician as the sole emergency medicine provider is needed.

A 48-year-old Woman with Amnesia - Corrected Proof

Adam Herzog, Alendia Hartshorn — 2011-11-14

A 48-year-old woman was brought to the emergency department by her husband and daughter. The patient was unable to verbalize a complaint, but repeatedly stated, “Something is wrong.” Family members had left home that morning. When they returned in the early afternoon the woman was confused about the day of the week and repeatedly asked where her family had been. The patient had no recollection of the morning’s events and did not recognize her own home. Her long-term memory appeared to be unaffected. In the emergency department, the patient denied any physical complaints but continued to ask repetitive questions. She had no history of recent fever, chills, infections, seizures, injury, or unusual stress. The woman’s husband believed the confusion was improving, but the patient still was not at her baseline.

What Factors Increase the Accuracy and Inter-Rater Reliability of the Emergency Severity Index Among Emergency Nurses in Triaging Adult Patients? - Corrected Proof

Julie Dateo — 2011-11-14

Within an emergency department, a preliminary patient assessment is performed by the triage nurse to identify life-threatening conditions and prioritize patients according to acuity or level of urgency. The Emergency Severity Index (ESI) triage algorithm is a reliable and valid 5-level triage scale that rates the emergency on a Likert scale ranging from 1 (most urgent) to 5 (least urgent) based on acuity and resource needs. This index was developed in the United States in 1999, by emergency physicians Richard Wuerz and David Eitel. The ESI was designed for triage nurses to rapidly identify those patients who require immediate attention and those who can safely be evaluated in a less urgent setting. It requires the triage nurse to accurately determine patient acuity and make a clinical judgment to maximize the efficacy of the ESI in a short period. The triage nurse's clinical judgment must obtain the right resources for the patient and assign him or her to the right place at the right time. Each patient is unique. The triage nurse must use critical thinking skills to efficiently advocate for patients in a dynamic and complex environment. The purpose of this article is to clarify the importance of the triage nurse's assessment and identify factors to increase the accuracy of the ESI scale.

A 68-year-old Man with Bright Red Emesis - Corrected Proof

Jennifer C. Byerly — 2011-11-07

A 68-year-old man presented to the emergency department via ambulance after a 911 call was made by his wife. Paramedics reported that the patient was experiencing epigastric pain and had been vomiting for the past 2 hours. Initially the emesis had the appearance of coffee grounds, but it was now bright red. Medics found the patient to be cool, clammy, and diaphoretic. Vital signs were as follows: blood pressure, 81/61 mm Hg; heart rate, 102 beats per minute; respirations, 24 per minute; oxygen saturation, 93% on room air; and oral temperature, 35.8°C (96.4°F). High- flow oxygen was administered, 2 large intravenous (IV) catheters were inserted, and normal saline solution was infused with the aid of pressure bags.

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

Scott DeBoer, Michael Seaver — 2011-10-07

January 2009 marked the start of the Certified Pediatric Emergency Nurse (CPEN) examination. In support of this certification, three times a year JEN features this 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.

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

Scott DeBoer, Michael Seaver — 2011-10-07

A Simulation Study to Improve Quality of Care in the Emergency Department of a Community Hospital - Corrected Proof

Zhen Zeng, Xiaoji Ma, Yao Hu, Jingshan Li, Deborah Bryant — 2011-10-03

In this article, a computer simulation study to improve the quality of care at the emergency department at a community hospital in Lexington, Kentucky, is presented. The simulation model is capable of evaluating the quality of care in terms of length of stay, waiting times, and patient elopement and has been validated by being compared with the data collected in the emergency department. Sensitivity analyses have been carried out to investigate the impact of workforce and diagnosis equipment on quality performance. The results suggest that, to ensure better clinical outcome, more nurses are needed; in addition, an additional computed tomography scanner is recommended. The model also shows that implementing team nursing policy (for 2 nurses) could lead to significant improvement in the emergency department’s quality of care. Such a model provides a quantitative tool for continuous improvement and flow control in the emergency department and is also applicable to other departments in the hospital.

Condition Yellow: A Hospital-Wide Approach to ED Overcrowding - Corrected Proof

Lisa Hoyle — 2011-10-03

ED overcrowding is a nationally recognized problem negatively impacting patient care and safety. At 1 academic medical center, there was neither a method to measure ED overcrowding nor any hospital-wide response to appropriately allocate resources to address the needs of the staff and patients. The Condition Yellow Project was undertaken to develop processes that would address ED overcrowding.

Emergency Nurse Perceptions of Individual and Facility Emergency Preparedness - Corrected Proof

Elizabeth Whetzel, Gayle Walker-Cillo, Garrett K. Chan, Jessica Trivett — 2011-10-03

Introduction: Disasters of any variety can occur at any given moment. Emergency departments are at the forefront of the response system, serving as the gateway to the most appropriate care of victims. The intent of the survey described in this article was to assess nurses' perception of their role in a disaster and their perceived susceptibility to a disaster. In addition, basic knowledge and role preparation was reviewed.Methods: A descriptive survey using survey methodology was utilized. The 56-question survey, including 16 demographic questions, was developed for the purpose of this study.Results: The results reflect that many emergency nurses have not taken basic actions to prepare themselves for a disaster, either personally or professionally.Discussion: This article highlights the importance of disaster education geared to the needs of the emergency nurse.

Evaluation of a Train-the-Trainer Workshop on Sickle Cell Disease for ED Providers - Corrected Proof

2011-09-21

Objective: (1) Determine the difference in pre-test and post-test knowledge scores for attendees of a train-the-trainer workshop and (2) determine the number of attendees who disseminated the content within 6 months of attending the workshop.Methods: A one day, train-the-trainer workshop focusing on sickle cell disease (SCD) was developed. ED nurses and physicians from the emergency departments with the highest number of patients with SCD were invited to participate at no cost. A panel consisting of 6 SCD and ED experts planned the workshop and developed 20 items for pre-test and post-test knowledge evaluation. The pre-test and post-test were administered at the beginning and end of the workshop, respectively. All attendees received a flash drive with all conference materials and were asked to disseminate workshop content to other ED colleagues. After 6 months, a brief survey was sent to the participants using Survey Monkey asking the number and type of providers trained.Results: Fifty-five participants attended the workshop. The mean (SD) pre-test score for the entire cohort was 13 (2) and the post-test score was 16 (2); mean difference (95% CI) 2.96 (2.36, 3.57). Items that scored low included questions dealing with pathophysiologic complications, addiction, or ED utilization. Eighteen participants completed the 6-month follow-up survey. Seven participants reported disseminating workshop content to a total of 99 providers.Conclusion: A train-the-trainer workshop specifically designed for emergency physicians and nurses that discussed the broad spectrum of SCD was well attended, and 6 months later, 99 additional providers received training.

Visually Guided Male Urinary Catheterization: A Feasibility Study - Corrected Proof

Paul A. Willette, Kevin Banks, Lynn Shaffer — 2011-09-21

Introduction: Ten percent to 15% of urinary catheterizations involve complications. New techniques to reduce risks and pain are indicated. This study examines the feasibility and safety of male urinary catheterization by nursing personnel using a visually guided device in a clinical setting.Methods: The device, a 0.6-mm fiber-optic bundle inside a 14F triple-lumen flexible urinary catheter with a lubricious coating, irrigation port, and angled tip, connects to a camera, allowing real-time viewing of progress on a color monitor. Two emergency nurses were trained to use the device. Male patients 18 years or older presenting to the emergency department with an indication for urinary catheterization using a standard Foley or Coudé catheter were eligible to participate in the study. Exclusion criteria were a current suprapubic tube or gross hematuria prior to the procedure. Twenty-five patients were enrolled. Data collected included success of placement, total procedure time, pre-procedure pain and maximum pain during the procedure, gross hematuria, abnormalities or injuries identified if catheterization failed, occurrence of and reason for equipment failures, and number of passes required for placement.Results: All catheters were successfully placed. The median number of passes required was 1. For all but one patient, procedure time was ≤ 17 minutes. A median increase in pain scores of 1 point from baseline to the maximum was reported. Gross hematuria was observed in 2 patients.Discussion: The success rate for placement of a Foley catheter with the visually guided device was 100%, indicating its safety, accuracy, and feasibility in a clinical setting. Minimal pain was associated with the procedure.

Time and Expenses Associated with the Implementation of Strategies to Reduce Emergency Department Crowding - Corrected Proof

Megan McHugh, Kevin J. Van Dyke, Julie Yonek, Dina Moss — 2011-09-12

Introduction: The Emergency Nurses Association and other groups have encouraged the adoption of patient flow improvement strategies to reduce ED crowding, but little is known about time and expenses associated with implementation. The purpose of this study was to estimate the time spent and expenses incurred as 6 Urgent Matters hospitals planned and implemented strategies to improve patient flow and reduce crowding.Methods: We conducted key informant interviews with members of the hospitals’ patient flow improvement teams at 2 points in time: immediately after strategy implementation and approximately 6 months later. A total of 129 interviews were conducted using a semistructured interview protocol. Interviews were recorded, transcribed, and coded for analysis.Results: Eight strategies were implemented. The time spent planning and implementing the strategies ranged from 40 to 1,017 hours per strategy. The strategies were largely led by nurses, and collectively, nurses spent more time planning and implementing strategies than others. The most time-consuming strategies were those that involved extensive staff training, large implementation teams, or complex process changes. Only 3 strategies involved sizable expenditures, ranging from $32,850 to $490,000. Construction and the addition of new personnel represented the most costly expenditures.Discussion: The time and expenses involved in the adoption of patient flow improvement strategies are highly variable. Nurses play an important role in leading and implementing these efforts. Hospital, ED, and nurse leaders should set realistic expectations for the time and expenses needed to support patient flow improvement.

“Did You Just Say . . . the Baby's Coming!!??”: A Nurse's Guide to Prepare for a Safe Precipitous Delivery in the Emergency Department - Corrected Proof

Connie Blake — 2011-09-09

A precipitous delivery is the result of a rapid labor that lasts less than approximately 3 hours. In 2008 the Centers for Disease Control and Prevention documented 4,247,694 live births in the United States. Of those births, 96,180 were reported as precipitous in nature. These deliveries commonly occur from chorioamnionitis; hypertension; previous preterm or precipitous labor; low resistance of the muscles, ligaments, and tissue of the birth canal; or atypical strong uterine contractions; they can also be a result of illicit drug use. So, although precipitous labor is not the norm, emergency nurses must be able to provide competent nursing care to any woman in labor.

Can Emergency Nurses' Triage Skills Be Improved by Online Learning? Results of an Experiment - Corrected Proof

James A. Rankin, Karen L. Then, Lynda Atack — 2011-09-09

Introduction: Emergency nurses deal with increasing complexity of patients. In 2003 there were over 14 million ED visits in Canada. The Canadian Triage and Acuity Scale (CTAS) is a 5-level system used by ED triage nurses to classify patients. There is a need for standardized training for all triage systems. In an effort to improve access to CTAS training, a 6-week Web-based CTAS workshop was developed. We determined the impact of Web learning on the accuracy of the triage skills of registered nurses (RNs).Methods: An experimental method was used in which 132 RNs were randomized to an intervention group (n = 65) or control group (n = 67). All RNs received exactly the same content and learning activities. The experimental group differed from the control group in 3 ways: a mandatory tutorial, awarding of marks for online discussion, and completion of a workplace project. Data were collected using standard instruments, chart audit, and interviews.Results: The Web course provided a standardized and effective educational experience that enhanced emergency nurses' triage accuracy. The mandatory online tutorial, online discussion, and workplace project increased the RNs' preparation for online learning, and these educational methods were successful in transferring triage learning to practice.Discussion: Web learning can help professionals maintain competency and support professional practice. Further research is needed to provide evidence for best practices in E-learning for RNs. The accuracy of the RN's triage assessment impacts patient health, hospital accreditation, and funding.

A 54-year-old Woman with a “Machine On My Back” - Corrected Proof

Colleen Claffey — 2011-09-05

A 54-year-old woman presented to the emergency department accompanied by relatives who claimed the patient was having “a mental breakdown.” Family members explained that the patient had been watching television approximately 1 hour before arrival at the emergency department when she suddenly began yelling, pacing, and ranting, “I have a machine on my back.” The woman had an extensive history of psychiatric illness, was diagnosed with schizophrenia at the age of 20 years, and had been repeatedly admitted to psychiatric facilities for long-term treatment. However, during the past few months, the patient had lived with family members and had experienced no acute psychotic episodes.

Mild Traumatic Brain Injury: Are ED Providers Identifying Which Patients Are at Risk? - Corrected Proof

2011-07-20

Objective: To identify patients with specific ED discharge diagnoses reporting symptoms associated with a mild traumatic brain injury (MTBI), compare frequency/severity of MTBI symptoms by discharge diagnosis, investigate head injury education provided at ED discharge, and learn about changes made by MTBI patients after injury.Methods: The Post Concussion Symptom Scale, a demographic questionnaire, and open-ended questions about the impact the injury had on patients' lives were completed by 52 ED patients, at least 2 weeks after injury, discharged with concussion/closed head injury, head laceration, motor vehicle crash (MVC), or whiplash/cervical strain diagnoses.Results: Between 1 and 23 MTBI symptoms were reported by 84.6% of the participants. Headache and fatigue were the most common; female patients had almost twice as many symptoms on average as male patients. Of MVC patients, 83.3% reported moderate severity scores for all 4 Post Concussion Symptom Scale categories, and these represented the highest overall severity scores. Concussion/closed head injury diagnosis patients received the most head injury education. The majority of patients were more cautious afterinjury.Conclusion: Most participants reported having MTBI symptoms. Although MVC participants reported the most severe MTBI symptoms, they had the least head injury education. Emergency nurses need to be aware patients may have an MTBI regardless of their presenting symptoms or injury severity.

Case Management and the Expanded Role of the Emergency Nurse - Corrected Proof

Jacqueline S. Howenstein, Loretta Sandy — 2011-07-20

Registered nurses (RNs) in the emergency department are expected to meet the needs of the patient, the patient's family, and the entire health care team. Patients look to the emergency nurse for comfort, understanding, education, and empathy. Families look to the emergency nurse for information, education, and reassurance that everything is being done in a timely manner. The physician depends on the emergency nurse to monitor the patient's hemodynamic status. The emergency nurse helps communicate and coordinate care among all the health care providers. The emergency nurse is responsible for seeing the entire picture and functions as the wheel that keeps the system moving.

Pain Care Management in the Emergency Department: A Retrospective Study to Examine One Program's Effectiveness - Corrected Proof

Bat Masterson, Marian Wilson — 2011-07-18

Introduction: No clear consensus exists regarding the most appropriate approach to reducing repetitive ED visits for pain complaints. These visits create a burden on health care resources and may contribute to inappropriate and excessive use of opioid medications. The purpose of this study was to examine the pain management program in 1 emergency department (1) to determine whether ED visits significantly decreased among program enrollees; (2) to quantify program interventions applied to enrollees; and (3) to explore relationships between enrollee characteristics (sex, age, comorbidities, health coverage plans) and the program's interventions and outcomes.Methods: A retrospective, descriptive, correlational design was used to examine the medical records of 134 patients who were enrolled in a pain care management program during a 1-year period.Results: Study subjects' ED visits were reduced by 77%, from 3,689 total visits during the pre-enrollment year to 852 in the post-enrollment year (P < .001). As a result of the program, patients were referred to primary care providers (58%), addiction specialists (14%), dentists (4%), neurosurgeons (4%), and neurologists (4%). The most common pain management program interventions were narcotic restriction (65%), establishment of a non-narcotic treatment regimen (57%), and enactment of a “1 pharmacy/1 provider” restriction (23%).Discussion: This study supports existing evidence that patients with an excessive number of ED visits for pain-related complaints can be managed with a proactive pain care management program that includes coordination with a primary care provider and a supportive ED medical staff.

Non–violence-related Workplace Injuries Among Emergency Nurses in the United States: Implications for Improving Safe Practice, Safe Care - Corrected Proof

2011-07-18

Introduction: Health care workers are more likely than most other occupations to experience work-related injuries, and emergency nurses frequently encounter job-related hazards in their daily routine. Risk factors for non–violence-related workplace injuries among nurses include heavy workloads, aging of the nursing workforce, workplace environmental factors, obesity, and non-standard work schedules. These factors impact nurses’ decisions regarding whether or not to return to their job or to stay in their field of practice, thereby exacerbating workforce shortages and hindering recruitment and retention efforts.Methods: To better understand non–violence-related workplace injuries among emergency nurses, ENA conducted a survey of its members in 2009. Of the 2294 nurses who responded to the survey, one in five nurses (n = 440) reported that they experienced a non–violence-related injury while working in their emergency department during the previous year.Results: The logistic regression model found three factors that were related to the occurrence of a non–violence-related workplace injury: (1) hospitals having safe patient handling policies and programs, (2) access to decontamination and post-exposure treatment, and (3) emergency nurses’ perception of staffing in their emergency department.Discussion: While these results provide only a preliminary understanding of ED non–violence-related workplace injuries, they form the basis of a fundamental model for prevention of workplace injuries among emergency nurses. The model can be used to help establish a culture of ED workplace safety through the integration of safety policies and programs, access to safety equipment and controls, and optimal staffing levels. Support from hospital administrators for ED workplace safety initiatives that address these three components, along with current best practice recommendations from the field of occupational health and safety, have the potential to improve workplace safety for emergency nurses.

Implementation of Early Goal-directed Therapy for Septic Patients in the Emergency Department: A Review of the Literature - Corrected Proof

Stephanie K. Turi, Diane Von Ah — 2011-07-18

Introduction: The Surviving Sepsis Campaign outlines the elements of early goal-directed therapy when treating patients with sepsis in the emergency department. The success of these guidelines relies on their implementation in order to attain optimal patient outcomes. The purpose of this article is to review the literature regarding the implementation of the sepsis guidelines in emergency departments.Methods: Using the search terms systemic inflammatory response syndrome, emergency service, and sepsis, the Cumulative Index of Nursing and Allied Health, MEDLINE, and Cochrane database were searched for information pertaining to implementing early goal-directed therapy for sepsis in the emergency department.Results: Studies that discussed collaboration, preplanning, and education were able to implement monitoring of central venous pressure, mean arterial pressure, and central venous oxygen saturation. However, nursing interventions recommended by the Surviving Sepsis Campaign such as measuring urine output and obtaining blood cultures were less often considered.Discussion: This review provides some factors important for the successful implementation of the Surviving Sepsis Campaign guidelines. Operational and system issues significantly influenced the success of implementing sepsis protocols or bundles. More research is needed to overcome barriers to implementing early goal-directed therapy and to uncover which elements of the guidelines are most important and feasible to achieve optimal patient outcomes.

Development of Consensus Statement on Definitions for Consistent Emergency Department Metrics - Corrected Proof

2011-07-18

One of the Emergency Nurses Association's (ENA) top three clinical priorities is crowding in the emergency department (ED). Crowding, which is defined as an excessive number of patients, was brought to the forefront of health care discussion via the 2006 Institute of Medicine report The Future of Emergency Care. Crowding is becoming progressively worse as the current recession creates additional pressure on our already strained health care system. Whether it is state funding cuts that result in closing psychiatric care facilities, individuals losing health care coverage, or individuals not being able to afford the medications that they or their families need, all of these situations result in more people coming to the emergency department for their health care of last resort.

Decreasing ED Length of Stay with Use of the Ottawa Ankle Rules Among Nurses - Corrected Proof

Eric L. Sorensen, Arlene Keeling, Audrey Snyder, Scott Syverud — 2011-06-29

ED crowding threatens patient safety and public health. Several studies have evaluated the ability of emergency departments in the United States to handle the demands that are being placed on them daily. ED crowding is widespread throughout the United States, with little evidence that the problem is being resolved. Emergency departments play a valuable role in the health care system because they act like a type of safety net. However, according to a recent report by the Institute of Medicine, this safety net is at a point where it is no longer effective.

Efficacy of Triage by Paramedics: A Real-Time Comparison Study - Corrected Proof

2011-06-24

Objectives: Triage has evolved as an effective method of separating patients who require immediate medical attention from patients with non-urgent problems. The aim of this study was to assess the agreement between paramedics and emergency residents about triage decisions using the 3-level triage (3L) system and the 5-level (5L) Australian triage scale in real time.Methods: All patients who presented to a central triage area during a 1-week period were triaged by paramedics and emergency residents. The chance-adjusted measure of agreement kappa (κ) was calculated to evaluate the agreement between triage decisions made by paramedics and by emergency residents.Results: A total of 731 patients were included in the final data analysis. Admitting time and waiting time were significantly consistent in the triage area. Agreement between the triage decisions made by paramedics and by emergency residents was 47% (κ = 0.47) when using the 3L triage scale and 45% (κ = 0.45) when using the 5L triage scale across all cases. A strong correlation existed among the general conditions of the patients, the 3L triage scale, and the 5L triage scale.Discussion: Triaging is commonly performed by nurses in the American emergency system, and triage by paramedics is not common. Few studies are available about triage by paramedics, and more studies are necessary. A new triage scale may be necessary for untrained personnel so that all emergency departments can conduct simple triage.

Evaluating and Improving the Handoff Process - Corrected Proof

Brenda D. Braun — 2011-06-06

One of the most critical pieces of patient care is the handoff. This is the point of time when crucial information on the patient's care is communicated to the patient's new care provider. In the current system in place at one hospital, the information that is most important to patient care is gathered from throughout the patient's paper chart, from reports from ancillary services, and from a variety of computer forms in the patient's electronic medical record (EMR). This information is transcribed (in writing) to a paper form, which is then faxed to the receiving unit. Calls are then placed to verify receipt of the fax, and this information is documented on the form. This paper is intended to remain part of the permanent medical record and yet can be misplaced. The intent of this article is to propose to improve this system by allowing the EMR to gather the information from the sources, have the nurse edit information as needed, and have the form electronically reviewed by the receiving unit, thus decreasing the time the emergency nurse is using to rewrite the information and standardizing the information given.

Needlestick and Sharp Object Injuries Among Health Care Workers in Hamadan Province, Iran - Corrected Proof

2011-06-06

Introduction: Exposure to septic fluids through mucus and needlestick injuries is of great concern among health care workers (HCWs). The purpose of this study was to acquire epidemiological data, including occupation, level of education, and mode of exposure, in HCWs.Methods: The data on this group was gathered during 6 months and analyzed using SPSS version 16.Results: In this study, we detected 89 cases of needlestick injuries and exposure to septic body fluids in the health care centers. Nurses were the most exposed group (39.3%). The most exposed age group was 25-34 years (51.6%). Of those injured, 51.7% were evaluated for antibody titration after vaccination, and of them, 47.2% had titration above 10 mIU/mL and the remaining had titration below 10 mIU/mL.Discussion: Numerous educational programs on care are still necessary to inform active workers in the health system about the warning trends and consequences in this part of Iran.

Improving Stable Patient Flow through the Emergency Department by Utilizing Evidence-Based Practice: One Hospital's Journey - Corrected Proof

Melissa A. Popovich, Cheryl Boyd, Terri Dachenhaus, Duane Kusler — 2011-06-06

Many patients utilize hospital emergency services for non-emergent care. The lack of access to primary care providers, lack of insurance, and lack of information about when to use the emergency department have contributed to the crowding of emergency departments with non-emergent cases. Crowding has created longer wait times and an increased number of people leaving without a medical screening examination. Studies suggest a growing need to improve patient flow through the emergency department and to maximize resource utilization. Through a patient flow improvement project, this organization identified internal benchmarks related to total length of stay for stable patients presenting to the emergency department to promote early intervention and rapid treatment. In an attempt to meet internal as well as national benchmarks related to total length of stay, a satellite area where stable patients could be treated in a timely manner was created. One identified need was the development of a protocol that addressed the timely staffing of the satellite area to improve stable patient flow. A volume-driven protocol was developed and implemented through the use of published evidence focused on essential endpoints of measurement. The process used for the development, implementation, and evaluation of the protocol was the Iowa Model of Evidence-Based Practice.

Female Genital Injury Following Consensual and Nonconsensual Sex: State of the Science - Corrected Proof

Jocelyn C. Anderson, Daniel J. Sheridan — 2011-04-25

Introduction: Nurses who evaluate patients following sexual assault are often faced with the task of identifying genital injuries and providing legal testimony regarding the nature of the injuries. Following a 2000 Virginia State court decision, sexual assault nurse examiners have had to struggle to answer the questions, “Are the genital injuries consistent with the patient's history?” and “Are the genital injuries consistent with sexual assault?”Methods: A search of the relevant scientific literature was conducted. Sources were examined and reviewed to identify what is presently known about adult female genital injuries associated with either consensual or nonconsensual sexual intercourse.Results: Female genital injuries occur with both consensual and nonconsensual sexual contact. Although some studies suggest that differences in injury patterns, types, or locations may exist, the data do not unequivocally confirm these findings.Discussion: Currently, the presence or absence of genital injury should not be used to render an opinion regarding consent to sexual intercourse. Further research is necessary to determine if injury patterns can indeed distinguish consensual from nonconsensual sex.

Motivational Interviewing for Emergency Nurses - Corrected Proof

Steven L. Baumann — 2011-04-25

Identified or not, a large percentage of ED visits in the United States are related to substance abuse and other behavioral health issues. Some patients with these problems are seen so frequently in the emergency department that they become well known to many of the staff. Even in emergency departments with mental health professionals on staff or who are available for consultations, the bulk of patient encounters, particularly at night and on weekends, is with nurses. Motivational interviewing (MI) is an evidence-based approach that has been shown to improve the effectiveness and reduce the frustration of ED staff who work with persons who have addictions and exhibit other self-destructive behaviors. The purpose of this article is to help ED nurses better understand persons with addictions and self-destructive behaviors and provide nurses with additional knowledge and skills that are useful when working with these patients and their families.

The Pressure Is On! An Innovative Approach to Address Pressure Ulcers in the ED Setting - Corrected Proof

2011-04-25

An overlooked area in pressure ulcer development has been the emergency department, which is frequently the point of entry for patients who require hospitalization. The risks associated with pressure ulcer prevention are not considered a priority to be addressed in the emergency department. However, patients often remain in the emergency department for hours. Most mattress surfaces in the emergency department are designed for transport or short-term use. Patients who remain on these surfaces are at risk for the development of pressure ulcers. A pressure ulcer can develop in two hours if precautions are not implemented. This situation presents an opportunity for early identification and intervention for patients at risk. This article will provide the reader with examples of tools used at two Sutter Health facilities to identify skin issues and prevent pressure ulcers in the emergency department. Sutter Health is a not-for-profit organization with 23 affiliated hospitals plus physician care centers serving patients and their families in more than 100 Northern California cities and towns.