Secret Shoppers in the Emergency Department

Expedited Medical Screening Examinations

Nurse-initiated Pain Relief Triage Protocols

Triage Technician to Help With WaitingRoom Reassessment

Using Protocols in Triage

Using the Web to Staff Difficult Shifts

Cutting-edge

of Management, Policy

in Emergen

M A N A G E R S F O R U MFinding Out Bad NewsDecreasing Educational Programs CostsInjection Wait TimesPolly Gerber Zimmermann, RN, MS, MBA, CENThe opinions expressed are those of the respondents and should not beconstrued as the official position of the institution, ENA, or the Journal.

J Emerg Nurs 2004;30:559-64.

0099-1767/$30.00

Copyright n 2004 by the Emergency Nurses Association.doi: 10.1016/j.jen.2004.09.004

December 2004 30:6can also be effective, but covert use of a bogus patient doesSECRET SHOPPERS IN THE EMERGENCY DEPARTMENT

Our hospital wants to institute regular secret shoppers

who will come in pretending to be patients to evaluate

how staff is treating patients. I am opposed. Any

suggestions for arguments to use against it?

Answer:

If the mayor of your village, town, or city had someone pull

a fire alarm in order to see how quickly the local fire de-

partment responded, what would it be called?A False

Alarm! If your neighbors house was destroyed by a fire

because the fire department was delayed in responding be-

cause of the false alarm, what would you call it?Criminal!

Does the secret shopper who presents to the

emergency department and utilizes the resources and time

of the staff at the expense of the true cardiac patient

represent anything less abhorrent?

Spying on ED staff represents the worst in hospital

management. One certainly can see the need to ensure

professionalism in our departments, and it is understand-

able to want to provide the best care possible. However, isnTtthat what patient surveys are all about? Casual observation

not demonstrate trust in your staff. What is the message

Discussions

, and Program Issues

cy Carebeing sent?

If they are willing to send in a phony patient, test my

patience, all at the expense of real people in need of help,

they obviously mistrust me.

Im not sure I would want to work in such an oppres-

sive environment, nor would I want to be treated there.

In a world of limited resources, inadequate staffing,

and overcrowding, shouldnt we be supporting our

emergency care providers? Patients want a nurse looking

at them, not behind their backs.

One has to wonder what the administrator would

say if his or her family member was in the emergency

JOURNAL OF EMERGENCY NURSING 559

procedure so that the nurse escorts all discharged patients

acutely ill and injured patients.

M A N A G E R S F O R U M / Z i m m e r m a n nto the financial desk. Our increase in collections is due

to both up-front and posttreatment collections.

As a result of this new screening process, about 8% of

the ED patients (approximately 260 patients a month)

choose not to be seen after the MSE. Our preliminary data

show that 38% of those 260 patients did seek care else-department and media secret shoppers presented as part of

an expose. He or she would probably want them arrested.

If the shoe fits. . .Bernard Heilicser DO, MS, FACEP,

Director, Medical Ethics Program, Medical Director, South

Cook County Emergency Medical Services System, Ingalls

Hospital, Harvey, Ill; bernardh47@yahoo.com

EXPEDITED MEDICAL SCREENING EXAMINATIONS

I have heard that some hospital emergency departments

perform an expedited medical screening examination

(MSE) for patients in nonacute triage categories. These

patients are then asked to pay or they are referred to

other community and clinic resources for their nonacute

condition. How does that work?

Answer:

The University of Colorado Hospital started an MSE system

in fall 2002. All patients still receive a traditional triage.

Patients triaged at a level 4 or 5 receive an expedited MSE

to rule out a medical condition needing immediate care.

ED nurses receive a special 3-hour training to be qualified

to perform the MSE for category 5 patients. Physicians or

physician assistants perform MSEs for category 4 patients.

After the MSE, the patients go to the financial desk

and a deposit is requested. The amount depends on the

insurance status of the patients and can range from a $3 co-

payment to $260 for patients without any insurance. If the

patient chooses not to give a payment, referrals to

alternative community providers and resources are given.

Those who pay return to the waiting room and are seen

after more emergent patients.

We now collect an average of $20,000 a month (average

110 ED visits daily with an 18% admission rate), up from

the previous $1500/month (for an average daily volume

of 160 patients). However, it is important to understand that

our collections did not improve until we changed ourwhere. There have been no negative patient outcomes.

560 JWe are using a patient education brochure from

the American College of Emergency Physicians, What

You Should Know about the Emergency Department.

It includes a discussion about the issue of ED over-

crowding.Lorna Prutzman, RN, BSN, Director, Emer-

gency Nursing (Lorna.Prutzman@uch.edu) and Kathleen

Oman, RN, PhD, CNS, ED Clinical Nurse Specialist and

Research Nurse Scientist (Kathyoman@uch.edu); University

of Colorado Hospital, Denver, Colo

NURSE-INITIATED PAIN RELIEF TRIAGE PROTOCOLS

What are other departments using for protocols for pain

relief in triage?

Answer 1:

Our policy since 1999 is that adults are offered acetamino-

phen (Tylenol), 650 to 1000 mg, or ibuprofen (Motrin),

600 mg. Ibuprofen is only offered to persons who have taken

the drug before, have no allergies or gastric disease, and are

not taking warfarin (Coumadin). Children (younger than

13 years) are given weight-based doses: 15 to 20 mg/kg for

acetaminophen or 10 to 12 mg/kg for ibuprofen.

The triage pain control protocol is not initiated if the

patient has abdominal pain (traumatic or nontraumatic) or

if the child has a painful extremity and fever (eg, hip pain

with a fever that could be a septic joint). We find theSome EMTALA violation claims have been made, but

the investigations supported the screening and decision-

making process. No financial information is ever discussed

before the screening examination.

The intent of this program was to support ED Ser-

vices in its mission, regarding the ability to care for the

acutely ill and injured patient. The goal was to reduce

waiting times and to decrease hours on diversion. Our

diversion hours have been reduced from 120 hours per

month to less than 10 hours per month.

We have had some negative local press coverage, pre-

senting this policy as denying care to those in need. In

retrospect, it would have been better to do more proactive

work beforehand in the community. We want the public

to understand that the purpose is to control the wait times,

reduce diversion hours, and improve throughput times forOURNAL OF EMERGENCY NURSING 30:6 December 2004

M A N A G E R S F O R U M / Z i m m e r m a n n. Patient is first asked if he or she has taken anything

for pain in the last 4 hours, if there are allergies,

history of liver, peptic ulcer, or renal disease, or if he

or she is taking Coumadin.

Medications:

Acetaminophen: 10 to 15 mg/kg by mouth (children);

650 to 1000 mg by mouth (adults)

Ibuprophen: 10 mg/kg by mouth (children); 600 to

800 mg by mouth (adults)

Nonpharmacologic pain relief measures should be

considered, including cleansing, dressings, application of

cold, immobilization, rest, and elevation. We also encour-

age distraction (games for children, reading material, or

relaxation techniques).Nina M. Fielden, MSN, RN, CEN,

Clinical Nurse Specialist, Emergency Department, Cleveland

Clinic Foundation, Cleveland, Ohio; fielden@ccf.org

REFERENCES

1. Merkel SL, Voepel-Lewis T, Malviya S. Pain assessment in in-fants and young children: the FLACC scale. Am J Nurs 2002;102:55-7.

2. Merkel SL, Voepel-Lewis T, Shayevitz JR, Malviya S. TheFLACC: a behavioral scale for scoring postoperative pain inyoung children. Pediatr Nurse 1997;23:293-7.

Answer 3:every 4 hours), and within 1 hour of any intervention.

Pain relief guidelines:. Patient must be hemodynamically stable, without

complaints of chest pain, abdominal pain, or trau-

matic pain.waiting area but allows nurse-initiated analgesia if the

patient is waiting in the treatment area for the physician.

Barbara Wolfe, RN, Staff /Charge Nurse, Emergency De-

partment, MetroHealth Medical Center, Cleveland, Ohio;

brwolfe@cox.net

Answer 2:

Our pain protocol, which can be initiated at triage, includes

the following:

Assess pain using a 0 to 10 numerical scale, Wong-

Baker Faces for children younger than 3 years, or Faces,

Legs, Activity, Cry, and Consolibility (FLACC) scale1,2 for

nonverbal children 0 to 7 years of age. Pain is assessed upon

initial assessment, when vital signs are taken (minimum ofprotocol not only provides for patient comfort in the triage/We have 6 pain protocols, 5 of which are nurse initiated.

The physician must activate the acute pain protocol

December 2004 30:6for pain z6/10. The protocol allows the nurse to givehydromorphone (Dilauded) 0.5 mg intravenous push to

patients younger than 65 years of age (0.2 mg if 65 years

or older) every 5 minutes (assessing after each dose) to the

maximum amount of 2.0 mg. Sedation is monitored, with

prn orders for naloxone (Narcan) if the sedation score is

0 and/or respiratory depression (respiratory rate V10 andSao2 b92% on 3 L/min). There are also prn orders for nau-

sea management.

The nurse-initiated protocols have specific inclusion

and exclusion criteria. These criteria include extremity in-

jury, back pain, and dental pain (allowing acetaminophen

and hydrocodone [Lortab] for pain rated at 4 to 10), eye

pain (allowing 2 drops of proparacaine [Alcaine] into the

conjunctival sac of the affected eye if the eye pain is asso-

ciated with trauma (eg, foreign body sensation, no pene-

trating injury), age 12 years or older, and no caine allergy.

In addition, the nurse may initiate patient-administered

nitrous oxide (nitronox) to treat pain associated with frac-

tures and burns, prior to painful procedures (such as intra-

venous line insertion and wound care) and to relieve anxiety

associated with painful conditions and procedures. It pro-

vides rapid onset analgesia (2 to 6 minutes), but it is quickly

reversible (2 to 5 minutes).

Criteria include that the patient must be able to self-

administer to prevent oversedation. As patients become

relaxed, they are unable to create an adequate amount of

negative pressure to trip the demand valve. The maximum

administration time is 30 minutes.

The administration is contraindicated in patients who

have an altered level of consciousness (because of risk of

aspiration), chest injuries (there is a potential for pneu-

mothorax), chronic obstructive pulmonary disease, preg-

nancy, abdominal pain, facial injuries impairing the seal,

air embolism, or decompression sickness. This is because

the nitronox collects in dead air spaces and can expand the

pre-existing pockets of air.

These protocols have had a very positive inf luence on

patient, staff, and physician satisfaction. We can display our

compassion for patients with pain without disrupting the

care of our more critically ill or injured patients. Diana

Meyer, RN, MSN, CCRN, CEN, Clinical Nurse Specialist,

Emergency Services, St Joseph Hospital, Bellingham, Wash;

DMeyer@peacehealth.orgJOURNAL OF EMERGENCY NURSING 561

service ratings, and our scores have since greatly improved.

M A N A G E R S F O R U M / Z i m m e r m a n nTRIAGE TECHNICIAN TO HELP WITH WAITING

ROOM REASSESSMENT

Is anyone else using technicians to help with waiting

room reassessments?

Answer 1:

We have an annual census of approximately 106,000

patients, which translates into 250 to 300 patients per

24-hour period. As a result of inpatient admissions being

held in the emergency department, we often have many

patients in the waiting room.

We recently developed a program for reassessment in

the waiting room using a new position called Triage

Reassessment Associates (TRAs). We hired and trained

persons who already had basic EMT training and use them

24 hours a day, 7 days a week.

The TRAs do minimal assessments, including patients

pain level, level of consciousness, vital signs, and circu-

lation, motion, and sensation (CMS) in extremity injuries.

They also specifically ask the patient if anything has

changed. They do not do more complex physical assess-

ments, such as lung sounds or neurologic assessments.

TRAs perform their reassessments according to the fre-

quency guidelines in our 5-level acuity system. Patients at

level 3 are reassessed every hour while in the waiting room;

patients at level 4 and 5 are reassessed every 2 hours. The role

functions under the direction of the triage nurse, and changes

are reported to the triage nurse.

Preliminary data have indicated increased nurse

satisfaction and improved identif ication of patients who

now need to be triaged up to a higher level. Patients have

even sought out a TRA when something has changed.

Their use helps us provide the same level of quality care to

our patients, regardless of their current location.Marjorie

Keyes, MS, RN, Clinical Nurse Specialist, Baystate Medical

Center, Springfield, Mo; MARJORIE.KEYES@BHS.ORG

Answer 2:

We place 1 or 2 clinical technicians (CTs) in the triage area.

These CTs take vital signs, weigh the patients, and imple-

ment triage orders per our triage guidelines, as directed by

the triage nurse. These orders include drawing blood and/

or obtaining urine for laboratory and point-of-care tests,taking the patient to obtain radiograph, and obtaining an

EKG in the triage area. The CTs also take the patient back

to the rooms, where they help the patient get undressed.

562 JConni Tucker, RN, CEN, ED Supervisor, Glens Falls

Hospital, Glens Falls, NY; cptcat@yahoo.com

USING PROTOCOLS IN TRIAGE

How do other emergency departments use protocols

in triage?

Answer 1:

I developed more than 42 emergency department proto-

cols, including triage and initial interventions, from about

a dozen emergency and nursing resources. These patient

care standards cover key historical factors to ask, related

assessments to make, problems or nursing diagnoses, and

age-specific considerations. They also include the standard

of care with the desired outcome corresponding to the

initial and eventual essential interventions.

For instance, the care standard for surface trauma in-

cludes methods of controlling the bleeding and to ask about

obtaining a culture if the wound is more than 8 hours old.

Cleaning protocol is outlined, depending if it involves an

abrasion, avulsion, puncture, foreign body, or a laceration.

Essential discharge instructions are also included.They will attach the cardiac monitor and apply oxygen

(2 L per nasal cannula only) as needed.

We have had CTs for 10 years now, and they are

invaluable to the nurse in triage in implementing the tri-

age orders.Nina Fielden, MSN, RN, CEN, Clinical Nurse

Specialist, Emergency Department, Cleveland Clinic Founda-

tion, Cleveland, Ohio; f ielden@ccf.org

Answer 3:

We hired a retired RN as a patient advocate instead of a

triage technician. This nurses job is to make frequent trips

to the waiting room to check on patients who are waiting to

be brought back to a room. She reassesses their conditions,

checks vital signs, etc, and reports to the charge nurse if

there are any changes in the patients conditions. She also

rounds on every patient waiting for disposition to help care

for their needs, such as bed pans, feeding (if indicated), or

just using good interpersonal skills to help alleviate their

frustrations or anxieties.

We instituted this program as a result of poor customerIn addition, guidelines for the policy or protocol are

outlined for various procedures, such as determining the

OURNAL OF EMERGENCY NURSING 30:6 December 2004

for any antibiotic injection is a 20-minute wait regardless.

approved or will require management approval. It is simi-

M A N A G E R S F O R U M / Z i m m e r m a n nDeneen A. Brown, RN, Director, Emergency Services,

Lexington Memorial Hospital, Lexington, NC; dbrown@

lmh.cc

Answer 2:

We usually have a patient wait 30 minutes if they have

been given an antibiotic or other type of injection. If the

intramuscular or intravenous medication is one that would

impair the patients driving ability, we make sure they have

a designated driver in the emergency department prior to

giving them the medication.

We also have that designated driver sign a form (we

affectionately call it a Drive Me Home Form). The

form basically states that this person knows the patientsize of urinary catheters or that an intravenous pump

or volume control set must be used on all patients aged

6 years and younger.

For us, the standards have served four purposes

very well:. Set the minimum expectation for a given situation. Serve as a reference for experienced nurses facing an

infrequently seen situation. Aid the inexperienced nurse who needs more fre-

quent guidance. Use as a teaching tool during orientation

Abby Purvis, RN, CEN, ED Director, Iroquois Memorial

Hospital, Watseka, Ill; agpurvis@iroquoismemorial.com

INJECTION WAIT TIMES

How long do other emergency departments require

someone to wait before discharge after receiving

an injection?

Answer 1:

Our hospital has a small outpatient unit for scheduled

injections. The unit is primarily for outpatient surgery and

endoscopies, but it also processes follow-up rabies, f luids

for hyperemesis gravidarum, blood transfusion, and serial

injections. The ED manages the unit after hours.

Our rule of thumb for any injection is a 20-minute

wait, and we try very hard to not give any injection im-

mediately before a patients discharge. Our standard of carereceived a medication that makes it risky for them to

operate a motor vehicle and that this person is going to

be responsible for seeing that the patient gets home. The

December 2004 30:6lar to self-scheduling, only with less managerial input.

Unless the system indicates it is pending, nurses are

confirmed for their shifts and these shifts are then con-

sidered noncancelable. Only after that point can they

view whom they are scheduled to be working with.

Other features that can be added include tracking those

employees certifications and Internet messages. I recom-

mend starting small and then growing.

In one successful example, St Peters Hospital in

Albany, New York, saved more than $1.7 million through

online bidding. Although the average bid was $37 per

hour, about 30% higher than the base rate paid to RNs,form is posted on the ENA Web site in the Document

Sharing Area (www.ena.org/document_share).

What they actually do once they are in the parking lot

is their business. At least we have a record that everyone

knew that the patient was not supposed to be doing any

driving. If the patient does not have someone available,

most of the ED physicians then only provide a prescrip-

tion and, depending on the time of day, maybe a take-

home pack of medications.Dennis M. McCool, Bed JD

RN, Manager of Critical Care Services, Good Hope Hospital,

Erwin, NC; dmccool@goodhopehospital.org

USING THE WEB TO STAFF DIFFICULT SHIFTS

I hear about using the Web for staffing. How does

that work?

Answer:

The Internets prevalence and low cost makes it a natural

tool to use for staffing. It can change scheduling from an

act of human organization to automation.

To use the Web as an adjunct tool, the needs are

posted for the upcoming schedule. It allows prn nurses who

moonlight from other departments or hospitals to readily

see your needs without trying to reach them by phone.

(Besides, with everyone having caller identification now,

sometimes calls may not be answered!)

As a full system, you can buy software that sets up

core scheduling and needs per day. It can be structured to

restrict nurses to certain hours (eg, so night nurses do not

take day shifts), and indicate if overtime is automaticallyit was less than the average $49 per hour that agency nurses

JOURNAL OF EMERGENCY NURSING 563

substantial savings.June Stacey, RN, BSN, DEN, President-

part of the drill.

M A N A G E R S F O R U M / Z i m m e r m a n nElect, Vermont Emergency Nurses Association, Hartland, Vt,

Staff Nurse, Emergency Department, Dartmouth Hitchcock

Medical Center, Lebanon, NH; june.Stacey@hitchcock.org

Answer 2:

We like to use ENA products for door prizes or awards

when we host the New England Regional Symposium.

When we used the theme Education is in the bag, I called

the ENA national office to buy unused past ENA conference

bags. We put the bags from all the various years together in a

bin and let participants pick out the one they wanted.

In addition, we ask for annual meeting attendees to

put any unwanted around-the-neck identification holdersreceive. About two thirds of the bidding comes from

St Peters employees, with part-time nurses as the main

bidders and then salaried nurses who are paid overtime

for these worked shifts. If nonhospital nurses bid, they

must pass an orientation process.1

I think eventually we will find ourselves as comfort-

able with Internet scheduling as we have become with its

other uses.Tony Torti, RPh, HealthNet Staffing, Toledo,

Ohio; ttorti@HealthNetStaffing.com

REFERENCE

1. Chang A. Nurses use web to choose shifts and pay. 2003 Dec 7,Associated Press.

DECREASING EDUCATIONAL PROGRAMS COSTS

We have a local live educational program, but the

expenses keep going up and we are worried about

needing to eventually charge a prohibitive

registration fee. How do others keep costs down?

Answer 1:

The New England states (Connecticut, Maine, Massachu-

setts, New Hampshire, Rhode Island, and Vermont) al-

ternate hosting the yearly 3- or 4-day New England Regional

Symposium. This year, I had the local vocational school stu-

dents print our pamphlet. They are able to create a multi-

color brochure with a cover picture, are supervised by the

experienced professional instructor, and welcomed the chal-

lenge. I ended up spending around $300 for 3000 brochures.

They also have done our letterhead and other stationery forinto a collection box at the end of the conference. We

cleaned the more than 300 donated holders and made our

conference ID cards a size that will fit into them. The

564 J. Act on what you know. People wont come forward

if they think that whatever they tell you will just

languish. Show you are willing to work on problems

you already know about.

Scott Kirsner, Writer, Fast Company, Boston, Massparticipants loved the high quality and its historical

ties.Maureen Heyder, RN, BSN, CEN, President, Vermont

Emergency Nurses Association, East Randolph, Vt, Staff Nurse,

Emergency Department, Dartmouth Hitchcock Medical Cen-

ter, Lebanon, NH; Maureen.A.Heyder@Hitchcock.org

FINDING OUT BAD NEWS

I sometimes learn of bad news about the department

long after I should have been told. How can I find

out in a more timely manner?

Answer:

What you do not know can hurt you. Individuals do not go

looking for bad news, and we do not like telling it to

others. So often, bad news does not get to the people who

can actually do something about it.

I interviewed business experts and some of their tips

include1:. Dont shoot the messenger. Even with an open-

door policy, people need to feel they can challenge you

without being snapped at. If one person has a bad ex-

perience, it sends a horrendous message to everyone else.. Assume there is a pattern. Do not be quick to

discount bad news as an isolated incident. It is

probably part of a pattern, and it may actually be

worse than this tip of the iceberg.. Have a network. Develop a system of front-line

contacts that will keep you informed. Usually

people who do not report to you directly are more

likely to tell you what is really going on.. Work with the staff. Spend some time outside the

off ice, working alongside the staff. During that time,

ask them some tough questions.. Make bad news legitimate. Whenever working on

an analysis or project idea, spend some time on a

worst-case scenario. Make bringing up bad news aREFERENCE

1. Kirsner, S. How to get bad news to the top. Fast Company 2002September; Issue 62:56.

OURNAL OF EMERGENCY NURSING 30:6 December 2004

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency CareSECRET SHOPPERS IN THE EMERGENCY DEPARTMENTOur hospital wants to institute regular secret shoppers who will come in pretending to be patients to evaluate how staff is treating patients. I am opposed. Any suggestions for arguments to use against it?Answer

EXPEDITED MEDICAL SCREENING EXAMINATIONSI have heard that some hospital emergency departments perform an expedited medical screening examination (MSE) for patients in nonacute triage categories. These patients are then asked to pay or they are referred to other community and clinic resou ...Answer

NURSE-INITIATED PAIN RELIEF TRIAGE PROTOCOLSWhat are other departments using for protocols for pain relief in triage?Answer 1Answer 2REFERENCES

Answer 3

TRIAGE TECHNICIAN TO HELP WITH WAITING ROOM REASSESSMENTIs anyone else using technicians to help with waiting room reassessments?Answer 1Answer 2Answer 3

USING PROTOCOLS IN TRIAGEHow do other emergency departments use protocols in triage?Answer 1

INJECTION WAIT TIMESHow long do other emergency departments require someone to wait before discharge after receiving an injection?Answer 1Answer 2

USING THE WEB TO STAFF DIFFICULT SHIFTSI hear about using the Web for staffing. How does that work?AnswerREFERENCE

DECREASING EDUCATIONAL PROGRAM'S COSTSWe have a local live educational program, but the expenses keep going up and we are worried about needing to eventually charge a prohibitive registration fee. How do others keep costs down?Answer 1Answer 2

FINDING OUT BAD NEWSI sometimes learn of bad news about the department long after I should have been told. How can I find out in a more timely manner?AnswerREFERENCE