Journal of Emergency Nursing - Articles in Press

Emergency Nurses' Perception of Department Design as an Obstacle to Providing End-of-Life Care - Corrected Proof

Renea L. Beckstrand, Ryan J. Rasmussen, Karlen E. Luthy, Sondra Heaston — 2012-05-17

Introduction: Of the 119.2 million visits to the emergency department in 2006, it was estimated that about 249,000 visits resulted in the patient dying or being pronounced dead on arrival. In 2 national studies of emergency nurses' perceptions of end-of-life (EOL) care, ED design was identified as a large and frequent obstacle to providing EOL care. The purpose of this study was to determine the impact of ED design on EOL care as perceived by emergency nurses and to determine how much input emergency nurses have on the design of their emergency department.Methods: A 25-item questionnaire regarding ED design as it affects EOL care was sent to a national, geographically dispersed, random sample of 500 members of ENA. Inclusion criteria were nurses who could read English, worked in an emergency department, and had cared for at least one patient at the EOL. Descriptive statistics were calculated for the Likert-type and demographic items. Open-ended questions were analyzed using content analysis.Results: Two mailings yielded 198 usable responses. Nurses did not report that ED design was as large an obstacle to EOL care as previous studies had suggested. Nurses reported that the ED design helped EOL care at a greater rate than it obstructed EOL care. Nurses also believed they had little input into unit design or layout changes. The most common request for design change was private places for family members to grieve. Thirteen nurses also responded with an optional drawing of suggested ED designs.Discussion: Overall, nurses reported some dissatisfaction with ED design and believed they had little to no input in unit design improvement. Improvements to EOL care might be achieved if ED design suggestions from emergency nurses were considered by committees that oversee remodeling and construction of emergency departments. Further research is needed to determine the impact of ED design on EOL care in the emergency department.

How to Manage the Patient in the Emergency Department with a Left Ventricular Assist Device - Corrected Proof

Patricia Anne Kroekel, Leena George, Noha Eltoukhy — 2012-05-17

The Centers for Disease Control and Prevention estimates that 5.8 million persons in the United States have heart failure, with 670,000 new patients diagnosed each year. Not all of these patients are responsive to medical management, and they may require more advanced treatment options including heart transplantation, for which there are a limited number of donor candidates. Because of advancements in technology and the high level of patient care, heart failure patients—who as few as 10 years ago were unable to leave the hospital because of their failing hearts—are now being sent home with left ventricular assist devices (LVADs) while awaiting transplantation. Technology has improved the patients’ quality of care by allowing them to stay at home and even travel with their portable battery backpacks. With this freedom, however, come the concerns with not having to remain near a transplant center. Therefore it is possible that these individuals could arrive in a community hospital emergency department.

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

S. Kay Sedlak — 2012-05-17

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.

Moving an Emergency Department: Lessons Learned - Corrected Proof

Patricia Kunz Howard, Penne Allison, Matthew Proud, Roger Humphries — 2012-05-17

The transition to a new emergency department is challenging. Increased volume, operational efficiency, patient flow, and new concepts in physical design complicate planning for emergency care areas. Planning involving key stakeholders, site visits, and engaged staff involvement is critical to success. The University of Kentucky, an academic medical center—verified by the American College of Surgeons as a level 1 trauma center for adult and pediatric patients—moved into a new patient care facility (PCF) on July 14, 2010. After years of planning and preparation, the actual move-in day was seamless and without incident. The most important lesson we learned was that the impact of geography is hard to measure and plan for until occupancy occurs. Staff engagement made the transition a positive experience. The staff had significant input into planning and operations from the onset of the project and at all phases of implementation. The new emergency department is their department, and they took great pride in being involved in all processes from designing standard room layouts to determining how orientation would occur.

Advanced Cardiac Life Support: What's New, What's Old? - Corrected Proof

Jamie M. Rosini, Meredith K. Hollinger — 2012-05-17

Approximately 300,000 out-of-hospital cardiac arrests occur in the United States each year. The American Heart Association (AHA) supports implementation of the “chain of survival” to rescue people who experience cardiac arrest in the community. The “chain of survival” consists of early recognition and emergency activation (phone 9-1-1), CPR, defibrillation, and advanced care. Advanced Cardiac Life Support (ACLS) encompasses elements designed to increase survival in patients who experience sudden cardiac death. ACLS provides recommendations to trained providers regarding optimizing circulation, airway management, cardiac rhythm management via defibrillation and/or administration of medications, and stabilization of the patient's condition.

Patient Input into the Development and Enhancement of ED Discharge Instructions: A Focus Group Study - Corrected Proof

2012-05-11

Objectives: Previous research indicates that patients have difficulty understanding ED discharge instructions; these findings have important implications for adherence and outcomes. The objective of this study was to obtain direct patient input to inform specific revisions to discharge documents created through a literacy-guided approach and to identify common themes within patient feedback that can serve as a framework for the creation of discharge documents in the future.Methods: Based on extensive literature review and input from ED providers, subspecialists, and health literacy and communication experts, discharge instructions were created for 5 common ED diagnoses. Participants were recruited from a federally qualified health center to participate in a series of 5 focus group sessions. Demographic information was obtained and a Rapid Estimate of Adult Literacy in Medicine (REALM) assessment was performed. During each of the 1-hour focus group sessions, participants reviewed discharge instructions for 1 of 5 diagnoses. Participants were asked to provide input into the content, organization, and presentation of the documents. Using qualitative techniques, latent and manifest content analysis was performed to code for emergent themes across all 5 diagnoses.Results: Fifty-seven percent of participants were female and the average age was 32 years. The average REALM score was 57.3. Through qualitative analysis, 8 emergent themes were identified from the focus groups.Conclusions: Patient input provides meaningful guidance in the development of diagnosis-specific discharge instructions. Several themes and patterns were identified, with broad significance for the design of ED discharge instructions.

Reducing False-Positive Peripheral Blood Cultures in a Pediatric Emergency Department - Corrected Proof

Michelle A. Marini, Amy W. Truog — 2012-05-04

Introduction: False-positive peripheral blood cultures due to contamination pose clinical and financial consequences for patients, families, and hospitals. Educating staff who draw peripheral blood cultures about hospital policy, using a blood culture–drawing kit, having a dedicated team obtaining peripheral blood cultures, and following up with staff who draw a contaminated peripheral blood cultures have been shown to reduce the rate of false-positive peripheral blood cultures. The objective of this study was to reduce the rate of false-positive peripheral blood cultures in a pediatric emergency department using the previously mentioned measures.Methods: This quality-improvement initiative used a retrospective chart-review approach to examine false-positive peripheral blood cultures drawn in 2009. In June 2010 a month-long education campaign about the initiative was conducted for nurses and clinical assistant staff to reduce false-positive peripheral blood cultures. From July 2010 through June 2011, monthly retrospective chart audits of false-positive peripheral blood cultures were completed in conjunction with bimonthly e-mail communication about the study, development of a blood culture–drawing kit, and follow-up with staff who drew the false-positive cultures.Results: In 2009 the false-positive peripheral blood culture rate in the emergency department was 2.1%. After educational interventions and use of a blood culture–drawing kit, the rate of false-positive peripheral blood cultures decreased to 1.4%.Discussion: The decline in contaminated blood cultures shows that the interventions described significantly reduced the rate of false-positive peripheral blood cultures in the emergency department.

Hypoglycemia in the Emergency Department - Corrected Proof

Andrew D. Harding — 2012-05-04

Diabetes is an epidemic in the United States and a worldwide pandemic. The causes of the type 2 diabetes public health crisis have been attributed to many of the amenities of modern life, including supermarkets, insufficient exercise, sedentary work, and processed foods, which have led to obesity. Patients have many sequelae of diabetes with which to be concerned, but 1 acute health issue that affects emergency departments is hypoglycemia.

Nurses Gone Wild: The Role of Nurses in Wilderness Medicine - Corrected Proof

Ann Wislowski — 2012-05-04

The sagebrush snagged my pant leg as I crawled through the dusty arroyo. My headlamp cast a dull beam on the mock victim, whose lips were painted blue for cyanotic effect. My watch glowed the time: 9:30 pm. I was participating in a wilderness medicine (WM) course for health care providers, along with 20 other providers, in a desert on the outskirts of Santa Fe, New Mexico. We had been divided into teams of 2 and were given a scenario: a flash flood had swept away a group of hikers. Our mission was to comb the area for victims, assess them, and provide appropriate interventions, just as we would have in a real-life situation.

Mass Transfusion to Combat Trauma's Lethal Triad - Corrected Proof

Jennifer Sweeney — 2012-04-23

Trauma is the leading cause of death for persons 1 to 44 years of age. Hemorrhagic shock is a leading cause of these deaths. Uncontrolled bleeding causes death in 30% of trauma patients who make it to the hospital and more than 50% of patients found dead at the scene. In practice, death related to hemorrhagic shock and the controversy over how best to correct this shock is a common concern. In recent years, research has turned from the crystalloid versus colloid debate to the prevention, early identification, and treatment of the fatal physiologic response. This physiologic response, frequently referred to as the “lethal triad,” includes acidosis, hypothermia, and coagulopathy.

Health Promotion: Healing Through Loss - Corrected Proof

Kelly Jo Olson — 2012-04-23

Abstract: For many women, miscarriage constitutes an often sudden, unexpected physically as well as psychologically traumatic event. A large percentage of women having miscarriage must present to an outpatient setting, primarily the emergency department, for care during this time. Studies indicate that health care professionals are failing to meet the needs of women and their families during and after miscarriage and that greater emphasis should be placed on psychosocial and interpersonal skills. The problem has been identified as how to assist or prepare emergency nurses to better care for the physical and psychological needs of women having early, unanticipated loss of pregnancy. At one rural Midwest medical center, it was the women's health staff who took the initiative to address this problem. They recognized the need for a holistic approach to care for women experiencing pregnancy loss. This would be accomplished through bridging the gap between outpatient services and primary care. This resulted in creating a support group called Ended Beginnings, which was organized to help women convalesce through the physical, emotional, and spiritual hardships associated with pregnancy and infant loss. Positive feedback has been received from both patients and staff with regard to the extent to which collaborative services provide a positive impact for both the patient and staff assisting the patient during a time of sudden, unanticipated loss.

Training Nurses in a Self-Learning Station for Resuscitation: Factors Contributing to Success or Failure - Corrected Proof

Melissa De Regge, Koenraad G. Monsieurs, Martin Valcke, Paul A. Calle — 2012-04-23

Many studies report poor CPR performance by health care professionals during training programs and real-life CPR. A critical determinant of the effectiveness of training is corrective feedback. During traditional training and retraining sessions, feedback is usually provided by an instructor. Three potentially important shortcomings of these instructor-led courses are the instructors' competence, high labor costs, and organizational problems. CPR training and retraining in a computerized self-learning (SL) station may overcome some of the limitations of instructor-led courses.

Meeting the Needs of New Graduates in the Emergency Department: A Qualitative Study Evaluating a New Graduate Internship Program - Corrected Proof

Penelope Glynn, Sheila Silva — 2012-04-18

Background: The purpose of this study was to explore the experiences of new graduate emergency nurses participating in a structured internship program. In order to meet the needs of new graduate nurses in emergency departments, these departments have developed a variety of orientation programs, some more successful than others. One type of program involves a combination of didactic content and hands-on clinical experience. This study examines the experiences of new graduate nurses in an internship program at a 200-bed community hospital.Methods: A qualitative design was used. Interviews with 8 of 9 nurses who participated in the new graduate internship program between 2006 and 2007 were conducted. Content analysis was used to analyze the data.Results: Three themes were identified from the experiences and expectations reported in the interviews: (1) the acquisition of new knowledge and skills in a specialty area, (2) becoming more proficient, and (3) assistance with role transition. The significant role and importance of the unit-base clinical nurse specialist (CNS) and the nurse preceptors were also identified.Conclusions: The findings of this study suggest that a structured internship program is helpful to new graduate nurses when orienting to a critical care area such as the emergency department. Furthermore, the combination of didactic and clinical content, and the roles of the preceptor and unit-base CNS appear to be key factors in the successful transition from new graduate to emergency nurse.

Improving the ED Experience with Service Excellence Focused on Teamwork and Accountability - Corrected Proof

Sharon Kelly, Lou Faraone — 2012-04-18

Providing a compassionate, caring ED visit, coupled with competent, safe, quality patient care, makes one institution stand apart from another. Patients currently have many choices when it comes to health care, and this competitive edge is important, even more so today, with reimbursement linked to patient satisfaction scores.

An Integrative Review: Triage Protocols and the Effect on ED Length of Stay - Corrected Proof

Dana J. Robinson — 2012-04-18

Abstract: The purpose of this integrative review is to identify the effectiveness of using triage protocols to decrease ED length of stay. The review method described by Ganong was used to guide the review process. Data sources included CINAHL (Cumulative Index to Nursing and Allied Health Literature), Medline, the Cochrane Library, Mosby's Nursing Consult, and the National Guideline Clearinghouse. In addition, reference lists of all articles were reviewed, 3 authors of previous articles were contacted for more current or updated work, and a hand search of the Journal of Emergency Nursing was conducted. The search generated 56 articles, 8 of which met inclusion criteria. Data were interpreted and evaluated by use of a data summary sheet. Key conclusions drawn from the appraisals included that a decrease in length of stay was related to protocol use and nurses were able to initiate diagnostic testing and treatments appropriately. These conclusions apply to acuity levels 3 and 4, which require either little or no testing or require testing to facilitate a disposition decision. The implications for nursing are that appraisals of evidence lead to better practice decisions, protocols can provide greater nursing autonomy and satisfaction, and protocols are able to increase the facilitation of patient care in the emergency department.

A Review of Epinephrine Administration in Pediatric Anaphylaxis - Corrected Proof

Wendy J. Hemme — 2012-04-11

Epinephrine is a high-risk medication that has the potential to save lives. However, in stress-filled and high-acuity environments like the emergency department, there is a greater risk for error with epinephrine. Children are further at risk from errors in weight-based calculations and confusion over drug concentration expression. When administered incorrectly, epinephrine has the potential for significant harm. This review of the literature examines the use of epinephrine in the treatment of pediatric anaphylaxis and discusses commonly identified issues associated with its administration.

How Much and Where: Assessment of Knowledge Level of the Application of Cricoid Pressure - Corrected Proof

Susan J. Black, Elizabeth M. Carson, Andrea Doughty — 2012-03-14

Introduction: Application of cricoid pressure is a frequently used technique in both rapid sequence intubation in multiple settings and in a more controlled setting in the operating room. In a survey of emergency department personnel performed at the University of Michigan, it was found that there is a knowledge deficit in the recommended force and the anatomic localization of cricoid pressure. Participants in the original study, which included emergency nurses, medical residents, and attending physicians, rated their training in cricoid pressure as poor or nonexistent. A review of the literature shows that, although cricoid pressure is used during endotracheal intubation to protect against regurgitation of gastric contents, many people applying cricoid pressure do not have a good knowledge of where to apply the pressure or how much pressure to apply to be effective. Because cricoid pressure is applicable in areas other than the emergency department, our study surveys personnel in emergency medical services/flight crew; emergency, intensive care unit, and operating room nurses; and respiratory therapists. Even though the use of cricoid pressure is no longer recommended, it is still routinely used. Although applying cricoid pressure is a simple procedure, persons using it must be thoroughly trained and retrained to prevent complications.Methods: When we replicated the University of Michigan study at a 254-bed tertiary care facility, a potential of 325 staff members were given access to an online survey using the questions in the original survey. Staff were assigned to a HealthStream module and sent an invitation through their employee e-mail account. The module included a link to the questionnaire, and demographic data were gathered. The module was optional and results confidential.Results: Operating room nurses were most likely to receive supervised instruction on anesthetized patients. These operating room nurses also showed the highest overall knowledge level about the application technique of cricoid pressure.Discussion: There continues to be a lack of knowledge about the application of cricoid pressure during intubation. There is an opportunity for collaboration between staff and academic educators to allow for additional theoretical as well as hands-on practice.

Use of Multiple Pedagogies to Promote Confidence in Triage Decision Making: A Pilot Study - Corrected Proof

2012-03-14

Background: The purpose of this pilot study was to determine whether the addition of educational interventions to required clinical hours promotes confidence in triage decision making among nursing students enrolled in a final capstone course.Methods: An experimental design was implemented with randomization of students (n = 14) to 1 of 3 intervention groups or the control group. The Triage Decision Making Inventory was used as a pretest-posttest. Educational strategies implemented included an Advanced Cardiac Life Support course and simulations with debriefing. Interventions were in addition to required clinical hours.Results: A mixed analysis of variance was used to examine the 4 groups by time, with all groups exhibiting higher scores on the Triage Decision Making Inventory from the pretest to the posttest (F (3, 10) = 4.51, P = .03 (η2 = .575). Students who received both the simulations and the Advanced Cardiac Life Support course demonstrated a significant difference across time.Conclusions: As nursing education evolves with the integration of technology, the combination of multiple pedagogies also can enhance confidence in triage decision making among experienced and novice nurses in emergency settings.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.