Journal of Emergency Nursing - Articles in Press

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

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

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

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

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

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

Family Presence During Trauma Activations and Medical Resuscitations in a Pediatric Emergency Department: An Evidence-Based Practice Project - Corrected Proof

2010-02-01

Introduction: The existing family presence literature indicates that implementation of a family presence policy can result in positive outcomes. The purpose of our evidence-based practice project was to evaluate a family presence intervention using the 6 A's of the evidence cycle (ask, acquire, appraise, apply, analyze, and adopt/adapt). For step 1 (ask), we propose the following question: Is it feasible to implement a family presence intervention during trauma team activations and medical resuscitations in a pediatric emergency department using national guidelines to ensure appropriate family member behavior and uninterrupted patient care?Methods: Regarding steps 2 through 4 (acquire, appraise, and apply), our demonstration project was conducted in a pediatric emergency department during the implementation of a new family presence policy. Our family presence intervention incorporated current appraisal of literature and national guidelines including family screening, family preparation, and use of family presence facilitators. We evaluated whether it was feasible to implement the steps of our intervention and whether the intervention was safe in ensuring uninterrupted patient care.Results: With regard to step 5 (analyze), family presence was evaluated in 106 events, in which 96 families were deemed appropriate and chose to be present. Nearly all families (96%) were screened before entering the room, and all were deemed appropriate candidates. Facilitators guided the family during all events. One family presence event was terminated. In all cases patient care was not interrupted.Discussion: Regarding step 6 (adopt/adapt), our findings document the feasibility of implementing a family presence intervention in a pediatric emergency department while ensuring uninterrupted patient care. We have adopted family presence as a standard practice. This project can serve as the prototype for others.

Anxiety is the Last Diagnosis on the List - Corrected Proof

Lisa Wolf — 2010-02-01

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

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

Kathleen Carlson — 2010-02-01

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

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

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

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

Rounding for Outcomes: An Evidence-Based Tool to Improve Nurse Retention, Patient Safety, and Quality of Care - Corrected Proof

Stephanie J. Baker — 2010-01-28

Today in the emergency department, most of what we do in caring for our patients involves evidence-based clinical practices. Yet, the consistent use of evidence-based leadership practices is far less common. This series considers 3 foundational evidence-based leadership tactics that have been time-tested and proven to deliver strong service, clinical, and operational results in hundreds of emergency departments when used consistently. They are rounding for outcomes, discharge phone calls, and bedside shift report. This month, rounding for outcomes will be addressed.

First-aid Home Treatment of Burns Among Children and Some Implications at Milas, Turkey - Corrected Proof

Banu Karaoz — 2010-01-18

This descriptive study was conducted among 130 families in Milas, Turkey, who have children ages 0 to 14 years. Among the 130 families, a total of 53 children (40.8%) experienced a burn event. Twenty-seven subjects (51%) had treated the burn with inappropriate remedies including yogurt, toothpaste, tomato paste, ice, raw egg whites, or sliced potato. Of the 28 subjects (52.8%) who had applied cold water to the burn site, 21 patients (39.6%) applied only cold water and 7 patients (13.2%) used another substance along with cold water. In addition, 13 subjects (24.5%) applied ice directly on the skin at the time of the burn. Excluding the subjects who had treated their burns with only cold water or with only ice, raw egg whites were the most commonly used agent, both alone (n = 3) or accompanied by cold water or ice (n = 6) in a total of 11 subjects (21%) who applied eggs. Based on these observations, it is suggested that educational programs emphasizing first-aid application of only cold water to burn injuries would be helpful in reducing morbidity and mortality rates. A nationwide educational program is needed to ensure that young burn victims receive appropriate first aid and to reduce the use of inappropriate home remedies and burn morbidity.

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

Christina Travis — 2010-01-18

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

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

Wen Chu, Li-Ling Hsu — 2010-01-15

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

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care - Corrected Proof

Jeff Solheim, AnnMarie Papa — 2010-01-14

We realize that length of stay is our biggest challenge. Treatment protocols were developed to decrease length of stay and improve patient satisfaction. The protocols are initiated by the nurse in both the triage area and treatment area. These protocols include but are not limited to:

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

Carrie A. McCoy — 2010-01-07

Cardiovascular Emergencies Questions - Corrected Proof

Scott DeBoer, Michael Seaver — 2010-01-04

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

Open to Being Different… - Corrected Proof

Chenit Ong-Flaherty — 2010-01-04

In 1989 I was a second-year nursing student doing my rotation in a trauma center in southeastern England. I was assigned the night shift. On my second night, the Accident and Emergency Department was busy. Staffed by a combination of staff nurses and second-year student nurses, we were given specific areas to cover in the department. It was my turn in the observation area. A staff nurse gave me a brief report on a middle-aged man, Mr Owens (patient's name has been changed for privacy purposes), who was brought in for paranoia. The patient was a known schizophrenic. The parting words of the staff nurse were simple: “Just watch him. He should be no problem.”

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

Scott DeBoer, Michael Seaver — 2010-01-04

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

Pediatric Obesity: Implications for Fall Injuries - Corrected Proof

Rockan Sayegh, Darlene Bradley, Federico Vaca — 2010-01-04

Emergency nurses are in a key position to influence the health and well-being of children who are obese. Often the only opportunity for preventative care of obese children is when parents bring their ill or injured child to the emergency department for episodic care. This article focuses on the significance of pediatric obesity and its impact on injuries resulting from falls.

Poison Control in the Emergency Department - Corrected Proof

Andrew D. Harding — 2009-12-31

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

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

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

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

Identified Safety Risks With Splitting and Crushing Oral Medications - Corrected Proof

Susan Paparella — 2009-12-28

Emergency nurses are occasionally in a position to administer oral medications to patients who, because of age or a variety of reasons, may not be able to swallow a tablet or capsule. Although some medications can be safely chewed, crushed, or cut (tablet splitting) to assist with administration, there is a growing list of products that, because of their formulations or pharmacokinetic properties, are deemed unsafe to manipulate in this manner. These drug classes are varied and include, but are not limited to, analgesics, cardiovascular medications, nonsteroidal anti-inflammatory agents, antiepileptics, and antibiotics. Drugs that should not be chewed or crushed include commonly used medications such as phenytoin, isosorbide, nifedipine, verapamil, Losec, MS Contin, oxycodone, and erythromycin.

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

2009-12-28

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

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

Andrew Storer — 2009-12-28

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

International Nurses: Pending Policy for Reform and Ethical Recruitment - Corrected Proof

Kristin A. Hellquist — 2009-12-28

Nursing and health care–related organizations have taken many diverse positions on the issues of immigration and recruitment reform for nurses who wish to work in the United States but were educated abroad. Some stakeholder groups favor the recruitment of nurses internationally when nurses are needed to fill vacancies. Other groups are immigration neutral and respect the right of individual nurses to migrate to the country of their choice and work as nurses if they are similarly qualified to nurses educated in the United States and all applicable laws and regulations are met. Still other organizations do not support the immigration of nurses to work in the United States because they believe health care employers should work on the retention and recruitment of US nurses before soliciting the import of foreign nurses.

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

Etienne Nsereko, Petra Brysiewicz — 2009-12-25

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

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

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

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

Unique Foreign Body Ingestions in the Pediatric Population - Corrected Proof

Sheila Isabelle Goertemoeller, Rachel M. Sweeney — 2009-12-25

Children have a natural tendency to place objects in their mouth. The most commonly ingested objects are coins, toy parts, button batteries, glass, jewelry, crayons, buttons, marbles, and pen caps. The majority of these exposures occur in children aged between 6 months and 3 years. Although most objects that can successfully traverse the esophagus into the stomach will pass through the gastrointestinal (GI) tract without difficulty, there are some that pose unique risks beyond the possibility of obstruction. Foreign body ingestions cause serious morbidity in less than 1% of children in the United States. Emergency departments continue to triage the degree of urgency for foreign bodies ingested by children to determine the best management course.

Initial Presentation to Triage: Does it Matter? - Corrected Proof

Sally Sulfaro — 2009-12-25

Patients present through our doors every hour of every day, entering beneath a sign that says “EMERGENCY” in big red letters. Some patients can clearly tell us why they came. Others try to tell us or think that they have told us why they came. Because of processes that are built into the front end of ED visits, patients and their caregivers are often expected to clearly and accurately articulate their chief complaints to someone or something lacks the knowledge and experience to ask the right questions or the ability to discern potentially high-risk presentations.

Assessing Cranial Nerves With a Stick of Gum - Corrected Proof

Jeff Strickler, Alberto Bonifacio — 2009-12-25

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

Trauma Patients at Non-trauma Centers: Tips for Detection and Improved Outcomes - Corrected Proof

Tobin Miller, Angela Shannon — 2009-12-25

It's 3:02 am and you hear the telltale tire screeching at the ED doors. You go outside to find a 25-year-old man with multiple gunshot wounds to the chest, abdomen, and left leg. Unfortunately, this scene may be familiar for nurses working in both trauma centers and in non-trauma centers. Treating trauma patients at designated trauma centers, and treating the severely injured at a level I center, designated by the American College of Surgeons, is associated with improved survivial. However, some areas are still without organized trauma systems or field trauma triage criteria. Some hospitals may choose not to pursue American College of Surgeons designation because of the cost and resources required. Even in areas with organized trauma systems, trauma patients can walk into or be dropped off at a non-trauma hospital by private car.

Simulators are Under-used - Corrected Proof

Sarah Clark — 2009-12-25

I thoroughly enjoyed the article “Assessing Competency With the Use of Human Patient Simulation in the Emergency Department” in the September 2009 issue. This article discussed how patient simulators are being used to determine nurse competency in the emergency department. Gomez did an excellent job of explaining how competency can be measured with the simulators and how different scenarios can unfold with the simulator. She also discussed the benefits of patient simulators and how helpful they really are.

Advising Parents with Asthmatic Children - Corrected Proof

Vanessa Monk — 2009-12-25

The article “Are Pediatric ED Nurses Providing Tobacco Cessation Advice to Parents?” in your September 2009 issue caught my attention. I just finished my pediatric and mother-baby clinical rotations in a hospital located in a moderately sized city where many vulnerable populations seek care. It was astonishing to see how many new mothers were stepping outside for a cigarette soon after giving birth and to experience the overwhelming aroma of cigarette smoke when walking into a closed room where pediatric patients were being treated. Given the many negative implications of smoking, I believe it is all too prevalent, especially in homes where young children are directly in contact with environmental tobacco smoke. As a soon-to-be nurse who is interested in working with the pediatric population, I believe nurses have an important obligation to be an advocate for this vulnerable population. Sometimes that means treating not only the children but also the parents.

Quality Control Work Group Focusing on Practical Guidelines for Improving Safety of Critically Ill Patient Transportation in the Emergency Department - Corrected Proof

2009-12-23

Adverse events have been estimated in up to 70% of intrahospital transports of critically ill patients. Situations sometimes arise that necessitate transporting a critically ill patient from the emergency department to the radiology department, operating room, ICU, or other departments within the hospital; however, critically ill patients are at risk of adverse events during intrahospital transport, including tachycardia, change in blood pressure (BP), anxiety, diaphoresis, and pain. Transport of critically ill patients may create increased risks for mishaps and adverse events because of the need to disconnect such individuals from the equipment in the emergency department and connecting them to some type of transport gear, shifting them to another stretcher, and reducing the availability of personnel and the equipment around them. Risk can be minimized and outcomes improved with careful planning, the use of appropriately qualified personnel, and selection and availability of appropriate equipment. Several articles related to practical guidelines or equipment for intrahospital transport are available. However, the effectiveness and quality control for practical guidelines in intrahospital transport have not been well evaluated. Intrahospital transport of critically ill patients is an important practical issue in the emergency department, but no articles relating to guidelines about intrahospital transport of critically ill patients from the emergency department are available.

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

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

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

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

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

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

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

Andrea L. Farwell — 2009-12-21

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

Subarachnoid Hemorrhage - Corrected Proof

Mark R. Reinhardt — 2009-12-21

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

Screening Out Does Little to Address ED Overcrowding - Corrected Proof

Jenny Key — 2009-12-21

I found the September 2009 article “Guesting Area: An Alternative for Boarding Mental Health Patients Seen in the Emergency Department” to be extremely interesting. I currently work in a rural emergency department in central North Carolina that has 36 regular ED beds, 4 trauma rooms, and a 10-bed holding area for patients waiting on a bed assignment when admitted. We constantly are confronted with cases of psychiatric patients coming to the emergency department, being admitted, and then having no place to go. Often our behavioral unit upstairs is full or the patients who are being admitted do not meet the criteria for admission at our facility, which means the task of finding an accepting facility then begins. We have had patients wait in our emergency department for more than 18 hours at a time because they simply don't have an accepting facility to go to.

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

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

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

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

2009-12-10

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

Do Patients Understand Discharge Instructions? - Corrected Proof

Sandra Zavala, Carol Shaffer — 2009-12-10

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

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

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

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

Central Pontine Myelinolysis - Corrected Proof

Kerri Hromanik — 2009-12-09

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

The Use of Early Warning Scores in the Emergency Department - Corrected Proof

Alison Day, Carol Oldroyd — 2009-12-04

ED nurses play a vital role in rapid patient assessment and monitoring to enable appropriate treatment to be instigated. Because of the unpredictable conditions of the emergency department, it can be difficult to identify patients who are seriously ill or at risk of clinical deterioration.

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

Keith Stephens-Borg — 2009-11-27

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

Evaluating Care in ED Fast Tracks - Corrected Proof

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

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

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

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

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

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

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

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

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

Ruthie Robinson — 2009-11-13

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

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

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

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

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

2009-09-16

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

H1N1 2009: One Pediatric Emergency Department's Experience - Corrected Proof

Nayda Boehm, Maricar Cabral, Marie Hankinson, Cathy Sakers — 2009-09-14

On a Monday morning in April 2009 at Joe DiMaggio Children's Hospital's Pediatric Emergency Department in Hollywood, Florida, a teenage girl quietly signed in at the triage area with flu-like symptoms. During the triage interview, she revealed that she had recently returned from Mexico City after attending her uncle's funeral. With that revelation, everyone present realized the possibility of exposure to the then-labeled “swine flu.” An N95 mask was immediately placed on her and she was escorted to a private room as far away from the general ED population as possible.