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

Cutting-edge Discussions

of Management, Policy, and Program Issues

in Emergency Care

M A N A G E R S F O R U M

Polly Gerber Zimmermann, RN, MS, MBA, CEN

Pharmacy Checking Medication Orders

Collecting Money at Discharge

Remodelling Lessons

Pediatric Routine Vital Signs

Defining ‘‘Pediatric’’

Providing Children’s Toys

Crowd Control During an ED Trauma Code

Triage Brochure

Transmitting EMS Field EKGs to EDs

EMTALA Awareness

Decreasing Cell Phone Ringing During Meetings

The 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 2005;31:288-97.

0099-1767/$30.00

Copyright n 2005 by the Emergency Nurses Association.

doi: 10.1016/j.jen.2005.01.003

288

PHARMACY CHECKING MEDICATION ORDERS

How do emergency departments handle the requirement

of the Joint Commission on Accreditation of Healthcare

Organizations (JCAHO) to have the order for a first dose of

a new prescriptive medication checked by a pharmacist

prior to administration (JCAHO MM.4.10 (TX.3.5.2)?

Answer 1:

The emergency department is considered an ‘‘exception’’ to

the pharmacy review of orders because our medications are

given ‘‘under the direction’’ of a physician. The JCAHO

would like to have pharmacy review in the outpatient areas,

but ED doses are given ‘‘on demand’’ and the pharmacy re-

view is not supposed to hinder patient care.

In-house orders are checked by pharmacy, and there

are some safeguards built into the automated medication

dispenser (Pyxis) to help avoid drug interactions and dos-

ing errors. The emergency department actually has some

‘‘ticklers’’ built into the Pyxis. For example:. Vistaril (hydroxyzine hydrochloride) has the re-

minder ‘‘Can only be given IM.’’. With f luoroquinolones such as levofloxacin (Leve-

quin), the question is asked, ‘‘Have you given cal-

cium, magnesium, or iron in the last hour?’’. With Integrilin (eptifibatide), the question is asked,

‘‘Have you checked your patient’s renal function?’’

As a further medication safety measure, we ask that

2 nurses check the dosing before administration on a few

medications that are considered ‘‘high risk,’’ such as hepa-

rin, insulin, and Natrecor (nesiritide). This process was ac-

ceptable on our July 2004 JCAHO survey.

—Diane Gurney, RN, MS, CEN, Educator & Trauma

Coordinator, Cape Cod Hospital, Hyannis, Mass; E-mail:

[email protected]

JOURNAL OF EMERGENCY NURSING 31:3 June 2005

mailto:[email protected]

M A N A G E R S F O R U M / Z i m m e r m a n n

Answer 2:

We do not need a pharmacy review for the ED stocked

medications. However, if it is a special request medication,

we must send a copy of the original physician order before

pharmacy will release the medication. We use the fax or

tube system and it actually works pretty well most of

the time.

—Bev Beard, RN, ED Staff Nurse, Providence Everett Medi-

cal Center, Everett, Wash; E-mail: [email protected]

Answer 3:

All of our ED medications are considered ‘‘stat.’’ However,

if we are hanging a dose of ‘‘inpatient’’ medication ordered

for a patient who is being admitted, such as heparin or

an antibiotic, we will obtain pharmacy verification. All of

our automated medication stations (MedSelect) are ‘‘non-

profiled’’ in the emergency department.

—Robert G. Flade, RN, BS, Director, Emergency Depart-

ment, New Britain General Hospital, New Britain, Conn;

E-mail: rgf [email protected]

Answer 4:

We stock truly life-sustaining medications and frequently

used medications, such as like narcotics and antiemetics,

but we do need to order other medications, such as anti-

biotics. All of our Pyxis medications are on override. At

Baptist Memorial Hospital in Memphis, our pharmacy in-

stalled a specific fax for STAT medications so they knew

anything arriving by that fax was a priority.

All ED medications are considered ‘‘stat,’’ and our

hospital policy is to administer stat medications within

30 minutes of the order. If the medication has not arrived

in 10 to 15 minutes, we follow up with a call.

—Ouida Lester, RN, Staff ED RN, Western Baptist Hospital,

Paducah, Ky; formerly ED Night Head Nurse, Baptist

Memorial Hospital, Memphis, Tenn; E-mail: Ouida509@

aol.com

Answer 5:

If the licensed independent practitioner (LIP) who ordered

the order is present in the area, then he or she should be

able to do the first-dose medication review, and a phar-

macy review of the orders does not have to occur. JCAHO

made this exception (along with the operating room and

June 2005 31:3

cardiac catheterization laboratory) because an independent

pharmacy review of orders would introduce a treatment

delay that could have a negative impact on patient care.

—Vicky Nelson, RN, Director of Critical Care and Emer-

gency Services, and J. Michael Harper, PharmD, Director of

Pharmacy Services, Munroe Regional Medical Center, Ocala,

Fla; E-mail: [email protected]

COLLECTING MONEY AT DISCHARGE

We are considering starting to try to collect some

payment at the times of patients’ discharge. How has

that procedure worked out for other departments?

Answer 1:

Charts of patients who owe a co-pay or are ‘‘self-pay’’ are

flagged with a sticker by the registration staff, then at the

time of discharge the patient is instructed to stop at the

discharge desk. A script was developed to help the staff.

The nurses say, ‘‘You need to stop at the discharge desk to

complete your discharge process. Your instructions and

prescriptions will be given to you there.’’ The nurse takes

the patient’s discharge papers and prescriptions to the fi-

nancial counseling area. The nurse checks off the patient’s

name and account number in a log that is tracked, just as

any other data (eg, census, admissions, etc).

The registration person says, ‘‘How will you be making

your co-pay (or down payment for self-pays) today?’’ It was

important to designate a specific private desk so that person

was not tied up doing registration. It has worked well for us

at Baptist Memorial Hospital in Memphis.

—Ouida Lester, RN, Staff ED Nurse, Western Baptist

Hospital, Paducah, Ky; formerly Night ED Head Nurse,

Baptist Memorial Hospital, Memphis, Tenn; E-mail:

[email protected]

Answer 2:

Initially our organization did not collect co-pays because

we feared it would have a negative impact on our customer

service. However, most other area hospitals were collecting,

and our experience is that most patients pay without

question. We collect an average of $500 per day. Prior to

JOURNAL OF EMERGENCY NURSING 28
9






collection at discharge, we had the expense of billing for co-

pays and payments were not received.

—Darlene Rowe, RN, CEN, Director of Emergency Services,

Evangelical Community Hospital, Lewisburg, Pa; E-mail:

[email protected]

Answer 3:

We started asking for payment in May 2004. Patients

without insurance are asked for a $300 deposit (the average

ED bill is $795); patients with insurance are asked for the

copayment. We do not hold prescriptions or any type of

care before persons go to the discharge station.

The reason for the change was to help decrease the

$91 million the Medical Center had billed for in 2003 that

was never paid. We are now collecting about $28,000 a

month, and small incentives (eg, meal tickets and movie

tickets) have been given to the employees who consistently

help with the process to thank them for their efforts.

In addition, we hoped the collections may serve as a

deterrent for inappropriate use of the emergency depart-

ment. About one third of the 71,402 ED patients treated

in 2003 did not need emergency care.

—Donna Mason, RN, MS, CEN, Director, Emergency Ser-

vices, Vanderbilt University Medical Center, Nashville, Tenn;

E-mail: [email protected]

Answer 4:

During peak hours of the day, we have a nurse practi-

tioner (NP) (who works for the ED Physician Group) con-

duct a medical screening examination immediately after

triage. If the NP determines that the patient does in fact

have an emergency medical condition, the patient will either

go directly to the treatment area for stabilizing treat-

ment, have diagnostic examinations ordered by protocol,

return to the waiting room to await results and/or further

evaluation/re-evaluation, or, if appropriate, a disposition is

made immediately.

At any time while we are obtaining the name, date of

birth, and social security number for registration purposes,

we will accept insurance information if the patient offers it.

We do not, however, initiate any requests until after the

medical screening examination is complete.

Regardless of funding, if it is determined that the

patient does not have an emergency medical condition, he

or she is referred to a financial counselor to decide whether

to remain and be seen in the emergency department or to

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self-refer themselves to a list of community resources that

are provided. Patients who elect to stay and be seen in the

emergency department must pay (in advance) any deduct-

ibles and/or co-payments due as determined by their in-

surance company. If they are nonfunded, we request an

advance payment of $110.

To help expedite the process and decrease congestion at

registration, we have an ‘‘MSC’’ (medical screening com-

plete) check-off box on our physician order form for pa-

tients who go straight to the treatment area. After the

doctor checks and times it, the fourth copy of the form

is given to the registration clerk, who can then begin col-

lection efforts.

At discharge time, the nurse provides the discharge

instructions and escorts all patients to the registration area.

The nurse gives the instructions and prescriptions to the

financial counselor or (during off-peak hours) the registrar,

who then hands them to the patient after they have talked

to the patient regarding payment.

All patients, regardless of payer status, are discharged

this way, so there is no discriminatory practice. Financial

counselors will also assist those with a need to apply for

sources of funding. This may include victims of crime,

Medicaid, etc.

We take the attitude that $5 collected is $5 we did

not have before. There is a recognition program for staff

who are the ‘‘top collectors.’’ The system works very well

even though we are a downtown facility and 30% of the

patients we see are self-pay.

—Kevin Trainor, RN, CEN, Nurse Manager, Emergency and

Trauma Services, Christus Santa Rosa Hospital, San Antonio,

Tex; E-mail: [email protected]

Answer 5:

We have been collecting money at the end of the visit for

more than 20 years. The bedside registration staff takes

anyone who needs to pay or make arrangements for payment

out to a collector’s office. Registration personnel enter a code

on the tracking board for patients who can leave directly

from their room.

Our customer satisfaction scores are in the 90s, and

I have not heard any anecdotal complaints. People expect

to pay at a doctor’s office; why should this be different? It

has actually been a good thing because those who cannot

pay end up getting assistance to enter a charitable program

OURNAL OF EMERGENCY NURSING 31:3 June 2005





or to set up payment plans. The collectors receive rewards

based on their collections, so they have become experts

at what they do.

—Dotty Kuell, RN, BSN, CEN, ED Manager, FirstHealth

Moore Regional Hospital, Pinehurst, NC; E-mail: Dkuell@

firsthealth.org

REMODELING LESSONS

We are starting an ED remodeling project. Does anyone

have suggestions to help us?

Answer 1:

Several key lessons learned when we remodeled our emer-

gency department are as follows:. Choosing the appropriate design firm is critical.

It is important to have a firm that specializes in

improving the ED workflow and processes while

developing the structure. Many times they have the

expertise to work around structural constraints of

pre-existing walls and pillars, for example.. Know your patient acuity statistics for the initial

design phases. What is your percentage of patients

in each triage category?. Consider your current (or planned future) supply

distribution. Designs of the treatment room need

to be adjusted accordingly depending on whether

you use a supply cart exchange or bedside stocking.. Keep the treatment areas as flexible as possible. We

put monitoring, suction, and oxygen in each main

ED treatment room.. Share the design with as many people as possible,

and involve the ED staff at every turn in the pro-

cess. We included a few nursing members (ED man-

agement, staff RN, and ED technician) when the

initial plans began.

Once our design plans were more fully developed, we

met with the entire staff before finalizing them. Some of

the ‘‘flaws’’ identified by the staff included:. Not enough hand-washing stations.. Physical isolation of one treatment pod that required

either a change in structure or staff assignment.. Lack of hallway storage alcoves for our bedside regis-

tration kiosks.

When you think you are done, ‘‘walk’’ through your

plan as the patient, the nurse, and the physician before

agreeing to the final plan. We found this quick exercise

June 2005 31:3

can be revealing and prevents problems at the end of the

project. And, finally, do not hesitate to ask lots of questions.

—Jim Richmann, RN, BS, CEN, Coordinator, Patient Care

Services, Emergency Department, Underwood-Memorial Hos-

pital, Woodbury, NJ; E-mail: [email protected]

Answer 2:

At FreemanWhite, we specialize in improving ED patient

flow, operational processes, and environments. We stress the

need to involve staff representatives from the very begin-

ning of the project on the ED Design Committee. We

include RNs, ED physicians, ED technicians, unit secre-

taries, and registration staff from various shifts, and we

encourage clients to involve their most negative staff mem-

bers. It brings tremendous results because the involvement

empowers them as the ‘‘owners and operators’’ of the busi-

ness processes. They are the ones who make sure that

emergency services are provided to our patients and will

know what is and is not currently working well.

We recommend that clients look at the ED utiliza-

tion projections and growth projections for the next 5 to

10 years so that the redesigned/remodeled area remains

operationally successful. For instance, consider if the fa-

cility is starting a new cardiac program or expanding the

orthopedic services.

Other considerations when redesigning emergency

departments include the following:. Become knowledgeable of the code minimums

in your state. Most of the time, if you start to reno-

vate one section of the emergency department, you

will be forced to comply with current building codes

throughout the emergency department. Examples

include the number of required bathrooms (1 per

every 6 treatment rooms) and the size of a patient

treatment room (bare minimum of 120 square feet

or 10 feet � 12 feet). In our experience, a room built

to meet the code’s minimum size is too small for

emergency care today. Aim for 140 to 150 square

feet per treatment room.. Design your emergency department to enhance

visibility of treatment rooms from the nursing

and physician work stations. Using a racetrack ED

design with glass-walled spaces is most practical for

ED nurses and physicians. This means that clean and

soiled rooms should be placed on the periphery of the

department and central medication and nourishment





stations are in the work stations with glass walls so

open visibility is not encroached. Design each patient treatment room to be the

same so that any patient could be seen in any

room, if needed (except for resuscitation or trauma

patients). Portable carts for commonly used equip-

ment, such as suture, ear, nose, throat, gynecological,

or orthopedics, can be stored centrally and taken

into the rooms for completing necessary procedures.

This approach will enhance your room flexibility,

which improves patient flow, rather than stocking

each room for any occasion or designing complaint-

specific rooms.

All rooms should be wired and prepared for medical

gases, electricity, and plumbing, even if not all be used

as clinical space immediately. For instance, the clean and

soiled utility rooms could become patient treatment rooms

in the future.

We also recommend designing the Fast Track–type

rooms exactly like the main ED rooms so they could be-

come rooms for higher acuity patients in the future. Doing

this decreases costs in the long run as you do not need to

retrofit the rooms if change is needed.. Use inner sub-waiting rooms/space. The number

depends on the planned use of the space, but com-

mon areas in which such an area is useful are Fast

Track, the main emergency department, or workers’

compensation areas (if that component is in your

design). Similarly, while 2 chairs per treatment bed

is considered the ‘‘rule,’’ you need to review your

institution’s policy about the number of visitors

allowed for patients in the treatment area and plan

accordingly. Internal sub-waiting should be designed

so nursing staff have visualization of the space and

people waiting there, but consider glass enclosers to

achieve privacy (HIPAA).. Add a small ‘‘quick’’ break room near the patient

treatment area so staff have someplace to take a

quick break. These small rooms, with a table and

chair, are distinguished from the larger staff ‘‘lounge’’

that is usually in the back of the department. Staff

are not supposed to have drinks at the work sta-

tions, so this space serves as a convenient location

for staff to keep their drinks or quick snacks. They

would go to the main ED break room for their full

breaks or meals.

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. Using building materials that bring in and dis-

sipate the natural light. Most ED staff want to be

able to see the outside, if possible, by integrating

windows and natural lighting. If there is not a

second story planned for the emergency department,

it would be possible to integrate clerestory windows

over the ED work stations to bring in natural light

without having direct sunlight beaming down into

your work space. If this is not possible, you can de-

sign windows into ED treatment rooms that run

along the outside of the emergency department at

the top of the rooms so no one could see it from the

outside. The use of breakaway sliding glass doors on

each individual treatment room is another way to

spread natural light coming in through exterior win-

dows throughout the emergency department.

—Joanne Ingalls McKay, RN, MSN, CEN, Principal

& Senior Healthcare Consultant, FreemanWhite; Con-

tingent staff emergency nurse, Oakwood Healthcare-

Canton, Canton, Mich; Huron Valley Chapter; E-mail:

[email protected]

PEDIATRIC ROUTINE VITAL SIGNS

What vital signs are other emergency departments

obtaining for pediatric patients? We are questioning the

value of obtaining a child’s routine blood pressure

reading when there is not a systemic complaint.

Answer 1:

Our protocol states that we are to take routine triage blood

pressure readings on all patients aged 5 years and older.

The protocol is to also take a blood pressure reading on any

child on whom we are starting an intravenous line and any

child who is being admitted (regardless of the reason).

However, we use our nursing judgment and take blood

pressure readings on younger children who present with

any symptoms or a history that could affect the blood

pressure, such as vomiting, diarrhea, or trauma.

This protocol allows us to streamline our assessment on

children with minor illnesses or isolated injuries, such

as simple lacerations, sore throats, and sprained ankles. It

also keeps the level of anxiety down as much as possible for

the child.

—Melissa Anderson, RN, Staff Nurse, Emergency Depart-

ment, Schneck Medical Center, Seymour Tenn; E-mail:

[email protected]





Answer 2:

We obtain routine blood pressure readings for children

older than 4 years, and then for any child with a systemic

condition that would warrant it. We obtain temperatures for

all pediatric patients regardless of the presenting complaint.

Many patients have temperature elevations, and noting the

elevation has led to the identification of other problems.

We now perform only rectal (versus tympanic) tem-

perature readings because of the wide variability of results,

depending on the probe placement. Our ED physicians

requested rectal readings because they believed the tym-

panic temperature readings were too inconsistent.

—Barbara Wolfe, RN, Staff/Charge Nurse, Emergency

Department, MetroHealth Medical Center, Cleveland, Ohio;

E-mail: [email protected].

Answer 3:

I developed age-specific guidelines and patient care stan-

dards after reviewing about a dozen emergency and nursing

references. Our standards include:. Do not obtain a blood pressure reading for patients

younger than 18 years with a minor illness or ex-

tremity injury.. Obtain respiratory rate and pulse prior to blood

pressure and temperature (because obtaining those

readings could cause crying and raise the rates).. Obtaining a tympanic or rectal temperature reading

is recommended for children younger than 6 years.. Obtaining a tympanic temperature reading is not rec-

ommended if the child is younger than 3 months or

if an abnormal body temperature is suspected.. Obtain the child’s height and weight if the child is

12 years or younger unless he or she has a minor illness.

We excluded the blood pressure reading for many

pediatric patients because it is a late sign of problems and

the omission does save time for a child with a minor,

localized injury. Having this as a standard works well as

a defense for not having a blood pressure reading on every

pediatric patient. In light of the current trend of increas-

ing pediatric obesity, we eventually may need to rethink

this standard.

We do check the blood pressure reading of all adults

with minor injuries as a screening tool or when we are moni-

toring a patient with known hypertension.

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

Hospital, Watseka, Ill; E-mail: [email protected]

June 2005 31:3

Answer 4:

We obtain blood pressure readings on all of our pediatric

patients as part of their initial assessment, and we retake

blood pressures after interventions, such as a fluid bolus. I

do think the practice is useful. We have identified an ele-

vated blood pressure reading on a number of infants with

undiagnosed renal disease.

We obtain weights for all children. In addition, we

also obtain heights for all of our pediatric patients with

suspected diabetic ketoacidosis because the treating fluid

resuscitation is based not only on weight but on body

surface area.

—Rebecca Steinman, RN, MS, CEN, CCRN, CCNS,

Clinical Educator, Emergency Department, Children’s

Memorial Hospital, Chicago, Ill; E-mail: rsteinmann@

childrensmemorial.org

Answer 5:

I measure blood pressures on children I can engage verbally

for 2 simple but important reasons:

1. To demystify the process. I want the children to

get in the habit early of having vital signs checked;

in addition, it is a chance to interact directly with

the child instead of the parent, and it provides a

teaching opportunity. It helps kids from being

frightened. I see it as sort of an ‘‘Officer Friendly’’

program for nursing.

2. To encourage nursing as a career. I raise the ques-

tion with every child (boy or girl), ‘‘Are you going to

be a nurse when you grow up?’’ I will point out how

interested or curious they seem and that ‘‘this is a very

important quality to be a great nurse.’’

Children may answer that they want to be a doctor

(‘‘Nurses have more fun!’’), something esoteric, such as a

marine biologist, or ‘‘I don’t know yet.’’ I then respond,

‘‘That’s OK, you don’t have to decide yet, but think about

it. The important thing is that if you read a lot and study

hard in school, you can do anything you set your mind

to do.’’

—Tom Trimble, RN, Staff ED Nurse, University of

California–San Francisco Medical Center, San Francisco,

Calif; List-Owner EM-Nsg-L; E-mail: [email protected]







DEFINING ‘‘PEDIATRIC’’

Is anyone using a definition for a pediatric besides

arbitrary ages, such as younger than 12 or 16 years? I am

looking for something more size-specific.

Answer:

This question is interesting because there is confusion in care

settings. The American Heart Association guidelines indi-

cate that the age of an infant goes up to 1 year and a ‘‘child’’

is defined as 1 to 8 years of age. Various other organizations

us different ‘‘cut-offs’’ of age 12, 14, or 16 years.

When I was the EMS-C Coordinator for the North

Carolina Office of the Emergency Medical System, the

decision was made to define ‘‘pediatric,’’ for the purpose of

use of protocols and equipment, as a patient who fits on the

Broselow tape. We continue to make that recommendation.

This guideline does not address developmental issues,

but any child that is ‘‘off the tape’’ will basically use adult-

sized equipment and medication dosing. That is particularly

helpful in a situation where you have no confirmed weight or

age, such as a disaster scenario.1

—Sue Hohenhaus, RN, BS, FNE, former Project Director,

Enhancing Pediatric Patient Safety; Emergency Medical

Services for Children; Duke University Medical Center,

Durham, NC

REFERENCE

1. Hohenhaus SM. Is this a drill? Improving pediatric emergencypreparedness in North Carolina’s emergency departments.J Emerg Nurs 2001;27:568-70.

PROVIDING CHILDREN’S TOYS

How do emergency departments that see both adults

and children handle pediatric toys? We had a large

communal play area but we are concerned about toy

cleansing and infection control.

Answer 1:

We keep a supply of small handheld toys, puzzles, puppets,

coloring sheets, etc, for our pediatric patients, who then can

take the toy home with them. We order these inexpensive

items in bulk from the Oriental Trading Company, Inc,*

*Oriental Trading Company, Inc, PO Box 2308, Omaha, NE 68103-2308;1-800-228-2269; www.orientaltrading.com

294 J

keeping in mind the different age groups. We find these

toys keep the children quite occupied!

—Sherry Clark, RN, BSN, Director of Patient Care,

Emergency Department & Outpatient Services, Sterling

Regional MedCenter, Sterling, Colo; E-mail: sherry.clark@

bannerhealth.com

Answer 2:

One of the most satisfying things I have done as an ED

Director is to purchase a plastic treasure chest, and then

individual, inexpensive toys, coloring books, crayons, etc,

from a company called Medibadge.y The cost of the chest

was less than $20, and the Ladies Auxiliary also helps us

with toy donations.

We keep the chest back behind the nurses’ station and

let the kids come in and pick out their toy. The kids love

it and so do we!

—Suzanne Price, RN, BSN, CEN, CCRN, Director of

Emergency, Cardiac, & Critical Care Services, Hazard

Appalachian Regional Medical Center, Hazard, Ky; E-mail:

[email protected]

Answer 3:

A local church has ‘‘Bear Day’’ every quarter. Stuffed ani-

mals are donated by members and ‘‘blessed.’’ Each bear

has a tag (tied on with an easily removable ribbon) with

the church name and a scripture verse. The bears are do-

nated to the department and children can pick out a bear

of their choice to take home.

—Deltah Lowrimore, RN, ED Nurse Manager, Marion

County Medical Center, Marion, SC; E-mail: DLowrimore@

mcmed.org

CROWD CONTROL DURING AN ED TRAUMA CODE

It almost seems that we need to set up bleachers to

accommodate all the people who show up when a

trauma call goes out. How do others limit the situation

to an appropriate number of people?

Answer 1:

The best strategy I have found is to address the issue of

crowd control before the patient arrives. For instance, we

yMedibadge, Inc, PO Box 12307, Omaha, NE 68112, [email protected]


;

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often have all available respiratory staff (6 or 7 people)

respond to the first call before the patient arrives. If I am

the charge nurse, I just ask, ‘‘Who is staying?’’ If they say

everyone, I address it then.

—Bev Beard, RN, ED Staff Nurse, Providence Everett Medi-

cal Center, Everett, Wash; E-mail: [email protected]

Answer 2:

First I like to emphasize the need to have practice pediatric

codes, with simulations, in our own clinical settings be-

yond the basic education of the Emergency Nurse Pediatric

Course. Resources that can help include a comprehensive

document for education and training of pediatric ED nurses

from the American Academy of Pediatrics (http://aappolicy.

aapulbications.org/cgl/content/full/pediatrics%3b107/4/=)

and Gausche-Hill and Wiebe’s Guidelines for Preparedness

of Emergency Departments that Care for Children: A Call

(Pediatrics 2001;107:773-4).

I find too many people in a code can lead to confu-

sion about who is giving orders, and the number of people

present is inversely proportioned to the size of the child!

We did try baseball caps for team members at one place,

but they disappeared after several traumas. I have suggested,

tongue only partially implanted in my cheek, that we should

use kid’s fire helmets (with a flashing light beacon) for the

lead physician.

—Sue Hohenhaus, RN, BS, Project Manager, EMS for

Children; Duke University Medical Center, Durham, NC;


Answer 3:

Only the members of the trauma team are actually allowed

in the trauma bay and each designated role (eg, trauma nurse,

nurse recorder, respiratory therapist, trauma resident) has

their designated physical ‘‘squares’’ located next to the pa-

tient. Anyone who is not providing direct care, including

the supervising trauma surgeon, must stand behind the red

line in the room.

We have a similar type of procedure for our cardiac

arrest codes. It works well for us in controlling the potential

congestion.

—Karen J. Crouse, RN, EdD, APRN, FNP, BC, CEBN,

Assistant Professor, Western Connecticut State University

Nursing Department, Danbury, CT and Per Diem ED Staff

Nurse, Yale New Have Hospital, New Haven, Conn; E-mail:

[email protected]

June 2005 31:3

Answer 4:

I work in the pediatric emergency area, but we use the

adult trauma bay for a major pediatric resuscitation. We

have a separate pediatric trauma team, but the adult team

covers until the pediatric team arrives (there is only one

team after hours).

Our pediatric team includes the pediatric ED attend-

ing, a PICU attending, plus the surgery teams and residents.

Crowd control of unnecessary people is essential: I once

counted 26 people present!

The attending in charge is responsible for crowd con-

trol and excuses the nonessential personnel from the bay. It

is important to establish the roles of every team member

before the patient arrives.

—Pamela Smith, RN, BNS, Clinical Nurse Leader, Medical

University of South Carolina, Children’s Emergency Depart-

ment, Charleston, SC; E-mail: [email protected]

TRIAGE BROCHURE

We are considering use of a patient brochure for triage.

What are others doing?

Answer 1:

We hand out a 1-sheet paper to our incoming patients

entitled, ‘‘What you can expect from the Christus Santa

Rosa Emergency Department.’’ The information, written

directly to the patient, states:. You will be taken directly back if a bed is available.. We ‘‘will do everything possible’’ so that a doctor sees

you as soon as possible.. The charge nurse will come out hourly with infor-

mation about delays.. The ‘‘nurse responsible for your care’’ will keep

you informed and let you know about any delays at

least hourly.

We indicate that we will make ‘‘every effort to expedite

your care, admission and/or discharge from the Emergency

Department’’ and ask they contact me if they feel that we

are not meeting those expectations.

—Kevin D. Trainor, RN, CEN, Nurse Manager, Emergency/

Trauma Services, Christus Santa Rosa Hospital, San Antonio,

Tex; E-mail: [email protected]

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http:\\aappolicy.aapulbications.org\cgl\content\full\pediatrics%253b107\4\%3D






Answer 2:

A 2-color informational brochure, ‘‘What to Expect from

Your Visit to an Emergency Care Center,’’ can be down-

loaded free from the ENA Web site. It is a 2-page pamphlet

that describes a standard visit to any emergency department

or urgent care center from admitting procedures through

discharge and payment.

To view and/or download the brochure, go to the

Members Only section at www.ena.org. Contact Member

Services at 800-243-8362 for more information.

—Patti Kunz Howard, PhD, RN, CEN, President, Emer-

gency Nurses Association, Des Plaines, Ill: Staff Development

Specialist, Emergency Department, University of Kentucky

Hospital, Lexington, Ky; E-mail: [email protected]

TRANSMITTING EMS FIELD EKGs TO EDs

Do the paramedics transmit 12-lead EKGs in other systems?

Is the hospital’s cardiac catheterization laboratory

‘‘activated’’ based on that transmission, or do you

still wait for the patient’s arrival?

Answer 1:

Our system’s paramedics do 12-lead EKGs in the field and

transmit them to the emergency department. However,

we do not ‘‘call in’’ the cardiac laboratory personnel based

on it.

We have had some problems with transmissions, for

example, the fax did not come through or the paramedics

are located in a low area and unable to transmit. The ED

physician prefers to quickly see the patient while the RN gets

the patient prepared. The cardiologists (who activate the

catheterization laboratory) also prefer that the ED physician

call them after seeing the patient. Our cardiac catheter-

ization personnel are here about 12 hours a day and are on

call 24 hours a day/7 days a week. On-call laboratory

personnel are required to arrive within 20 minutes.

Our goal is door-to-balloon time of 90 minutes, and

we are usually close in meeting that goal with this practice.

—Terri M. Repasky, MSN, RN, CEN, EMT-P, Clinical

Nurse Specialist, Emergency Center, Tallahassee Memorial

Healthcare, Tallahassee, Fla; E-mail: [email protected]

Answer 2:

I have worked in an EMS system that was sending

paramedic-obtained 12-lead EKGs by fax to the emergency

departments. However, we stopped because most of the

296 J

emergency departments did not look for them and were

not aware they had been sent.

The system switched to having the 12-lead EKG sent

to medical command. Medical command would then relay

the information to the receiving facility. The paramedic

would then hand the 12-lead tracing to the ED staff when

the patient arrived. The cardiac catheterization team is

activated if the patient is a candidate after the ED evaluation.

—Ray Bennett, RN, BSN, CEN, NREMT-P, Chief Trans-

port Nurse, RWJUH-SPUH EM,; New Brunswick, NJ;


Answer 3:

We utilize prehospital 12-lead EKGs all the time. They

are transmitted prior to arrival, and once we are alerted to

a Code Heart, in combination with the EMS radio call,

we can appropriately alert the catheterization laboratory

team. We have had several patients for whom this shaved

15 to 30 minutes off the door-to-table time.

—Melinda Stibal, RN, BSHC, Administrative Director,

Emergency/Trauma Services, Memorial Regional Hospital,

Hollywood, Fla; E-mail: [email protected]

EMTALA AWARENESS

How are others keeping their staff compliant with

EMTALA regulations?

Answer:

We deal with this issue by constant awareness. We have

a monthly staff meeting, and EMTALA is on every single

agenda. We give different scenarios and discuss how to

handle them. The hospital compliance officers provide

many of the example situations from the Internet or re-

ports from other hospitals’ incidences.

We also realized that the issue affects more than our

department. We are a pediatric facility, but medical screen-

ing must be offered to an adult who would walk up to any

employee, such as a housekeeper, and indicate they wanted

to see a physician or requested care. Therefore, our com-

puterized EMTALA educational module is required for all

hospital staff. We also offer educational sessions to any

hospital that transfers patients to our tertiary center.

—Maryann Henry, RN, Risk Management; former Nurs-

ing Administrative Director of Emergency/Trauma Services;

Miami Children’s Hospital, Miami, Fla; E-mail: maryann.

[email protected]


http:\\www.ena.org








DECREASING CELL PHONE RINGING DURING MEETINGS

Does anyone have any ideas about how to prevent cell

phones from ringing during a group meeting? They are so

disruptive. I have heard people ‘‘threaten’’ violators

with mandatory donations to charity, but I was hoping

for a less hostile approach.

Answer:

We encourage speakers at our American Association of

Critical-Care Nurses’ annual educational conference, the

National Teaching Institute, to try these suggestions.. Place a ‘‘slide’’ at the beginning of the presentation

(have it on as attendees come in to the room) asking

everyone to turn cell phones to vibrate.. Reinforce this expectation with an announcement

at the start of the session. Ask anyone who must take

a call to leave the room.. Begin the session with a question. ‘‘Does anyone

here have a cell phone? If you do, hold it up.’’ Pause,

then state, ‘‘Now please turn it to vibrate.’’

Overall, participants appreciate your efforts, and there

are fewer interruptions. Word the message carefully, how-

ever. One speaker brought down the house when she said,

‘‘Now turn on your vibrators!’’

—Bonnie Baker, RN, MHA, Program Development Specialist,

AACN, Aliso Viejo, Calif; E-mail: [email protected]

Acknowledgements

Many thanks to Joanne Ingalls McKay, RN, MSN, CEN, formerly ofFreemanWhite, Canton, Mich; Stephen A. Frew, JD, PIC, Wisconsinand medlaw.com, Madison, Wis, and Tom Trimble, RN, for theirhelp with sources, ideas, or information for this column.

June 2005 31:3 JOURNAL OF EMERGENCY NURSING 297

Documents

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