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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
Boarding Psychiatric Patients
Secret Shopper
Special Needs Children
Lessening the Fear of Public Speaking
Self-Scheduling Guidelines
Requiring Vital Signs at Discharge
Meeting the 4-hour Window for Community-acquiredPneumonia
Crisis Code to Help the Saturated Emergency Department
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 2006;32:333-8.
Available online 30 May 2006.
0099-1767/$32.00
Copyright n 2006 by the Emergency Nurses Association.
doi: 10.1016/j.jen.2006.03.015
August 2006 32:4
BOARDING PSYCHIATRIC PATIENTS
Increasingly we are holding psychiatric patients while
waiting for an inpatient admission bed. How can we better
manage this population?
Answer 1:
Our 37-bed emergency department is often holding 3 to
7 psychiatric patients (and once we even held 12!). It has
taken up to a week until a patient placement could be made.
We sought to apply the same level of care to this popu-
lation as we do to the critical care patients we are holding.
To accomplish this goal, we developed a Behavioral Health
Task Force and instituted the following measures:. We created 3 secure, monitored rooms and altered
5 medical rooms that can be secured and used as
low- to moderate-risk rooms. All supplies in these
rooms can be locked behind accordion doors.. We employed full-time security officers to watch the
patients, normally at a ratio of 1:3. If a patient is at
high risk, the ratio is 1:1.. We use ‘‘regular’’ hospital beds if a patient in a tran-
sitional room is held overnight or longer; the beds have
been modified by security to ensure patient safety.. We have a full-time social worker available 24 hours
a day. The social worker makes locating an appro-
priate admission bed for a held ED patient a priority.. We have daily visits by a psychiatrist for all pediatric
patients (including adolescents). Adults are prioritized
to receive a psychiatrist visit if it will facilitate any pos-
sible discharge.. We receive assistance from behavior health person-
nel several times during the day to help prioritize
and facilitate the admission process. We are working
toward having therapists in the department to have
more ongoing therapeutic conversational therapy with
the patients.
JOURNAL OF EMERGENCY NURSING 333
M A N A G E R S F O R U M / Z i m m e r m a n n
. We developed medication protocols and standing or-
ders for this population.
As a result of all of these measures, our facility was
cited in 2005 as a role model by the Joint Commission
for Accreditation of Healthcare Organizations (JCAHO).
They considered our facility to have a best practice in
how to handle this population in the emergency depart-
ment.—Susan Kuknhausen, RN, CEN, Providence Portland
Medical Center, Portland, Ore; E-mail: susankuhnhausen@
aol.com
Answer 2:
We have boarded admitted psychiatric patients up to
72 hours in our emergency department. We created pre-
printed ‘‘psych holding orders,’’ in cooperation with our
hospital’s attending mental health physicians, to deal with
these ‘‘holds.’’ The orders include diet, activity, one-time
emergency medication for a violent outburst, nicotine patch/
gum, and medications for routine needs (eg, pain and sleep)
that are safe to use with this population. Since the imple-
mentation of these orders, we have improved communication
with our psychiatric team, response to psychiatric patient
needs, and continuity of care.—Valerie Brumfield, RN, MBA,
CCRN, Clinical Nurse Specialist, Department of Emergency
Nursing, The University of Texas Medical Branch at Galveston,
Galveston, Tex; E-mail: [email protected]
SECRET SHOPPER
Our senior administration is considering adding a ‘‘secret
shopper’’ program in which people are paid to pretend to
be patients and then provide feedback. Is this legal?
Answer:
The practice of hospitals using ‘‘secret shoppers’’ to assess
their emergency departments appears to be gaining in popu-
larity. The stated goal usually is to improve the delivery of
health care and patient satisfaction.
Typically the programs are not being implemented
for purposes of job performance review, nor is the actual
quality of medical care being evaluated. As such, these
programs are generally considered legal, and presumably
come under the umbrella of quality assurance. I recom-
mend that before administration uses the findings for an
employee job performance review or disciplinary action,
they should seek legal counsel. From a third-party liability
334 J
standpoint, there is probably little risk if the ‘‘pretend’’ pa-
tient is not distracting care from patients with true, high-
acuity presentations.
However, I have 2 personal concerns. A potential exists
for the program to affect the provider/staff-patient rela-
tionship. Health care is based on a relationship of trust
between the patient and the health care provider, and that
relationship may be affected if providers are aware of
the possibility that the patient in front of them may only
be ‘‘pretending.’’
Second, efforts aimed at reducing adverse medical events
and patient dissatisfaction have focused increasingly on
system-related problems. These programs should not deter
that effort by overly emphasizing the actions of individual
staff members. —Kevin C. Giordano, JD, Defense Attorney,
Keyes and Donnellan, PC, and Educator and Lecturer,
SafeHarbor Institute, Springfield, Mass; E-mail: kgiordano@
keyesanddonnellan.com
SPECIAL NEEDS CHILDREN
What initiatives are emergency departments implementing
to prepare staff and prehospital providers for children
with special health care needs?
Answer:
Our new program, Ryan Alert, was developed in conjunc-
tion with the office of Maine Emergency Medical Services
and EMS for Children. It is being offered to serve children
with special health care needs better. These children have
chronic physical, developmental, behavioral, or emotional
problems and require more intense or complex care than
do those typically seen in the ED pediatric population. The
purpose of this program is to lower the stress level of the
children and families and to provide better preparation for
emergency personnel to provide the needed care.
The Ryan Alert (named for a local special needs child)
uses the Emergency Information Form adopted in 1990 by
the American College of Emergency Physicians and the
American Academy of Pediatrics. This 2-page form is filled
out by both the family and health care provider and sent to
the child’s regional Ryan Alert Facilitator.
The facilitator alerts the local EMS service that a child
in their area is enrolled in the program. Dispatchers ‘‘f lag’’
the address in the event a 911 call is placed. The process
OURNAL OF EMERGENCY NURSING 32:4 August 2006
M A N A G E R S F O R U M / Z i m m e r m a n n
meets confidentiality and HIPAA requirements. In addi-
tion, educational needs of providers are identified and ap-
propriate special training is offered.
At this time, the program is limited and being offered
only to our local family practice and pediatric physician
offices in the Tri-County area. As additional resources be-
come available, we plan to offer the service to all special
needs children in Maine.—Jennifer Messinger, RN, BSN,
Ryan Alert Program Facilitator, E-mail: [email protected],
and Carmen Hetherington, RN, BSN, CEN, EMS Educa-
tor, Tri-County EMS and Staff Nurse, E-mail: hetheric@cmhc.
org, Central Maine Medical Center, Lewiston, Maine
LESSENING THE FEAR OF PUBLIC SPEAKING
I still have trouble managing the ‘‘jitters’’ when I have to do
a public presentation at the hospital. What can help?
Answer:
I interviewed consultants and experts who give the fol-
lowing advice:. Identify childhood fears. Consultant Morty Lefkow
traces many irrational responses to beliefs we picked
up in childhood. A common belief is that if we do a
bad job, people won’t like us, which of course is not
true. Once you can identify your misguiding belief,
you can change how you act.. Expose yourself to the fear. Stefan Hoffmann, Di-
rector of the Social Anxiety Program at Boston Uni-
versity’s Center for Anxiety and Related Disorders,
recommends doing public speaking as much as pos-
sible. As with any phobia, the first time is horrible,
but the 100th time is not so bad.. Join Toastmasters International. Toastmasters Pres-
ident Jon Greiner endorses the practice and prep-
aration that the organization provides to members as
they give speeches to each other, as a tool for confi-
dence building. (For more information, visit the Web
site www.toastmasters.org or write to Toastmasters In-
ternational, PO Box 9052, Mission Viejo, CA 92690.). Abandon perfectionism. The higher you raise the
stakes in your own mind, the harder time you will
have. Give yourself permission to make mistakes—
and accept that you will make them.
August 2006 32:4
. Take a hh-blocker. If it is safe for you to do so,
taking a mild dose of a h-blocker, such as propran-
olol (Inderal), controls a racing heart. It prevents the
natural fight-or-f light response from veering inappro-
priately out of control after sensing a little fear.1—Ryan
Underwood, Writer, Fast Company, Boston, Mass.
REFERENCE:
1. Underwood R. Speak easy. Fast Company March 2005;30.
SELF-SCHEDULING GUIDELINES
We are thinking of switching to self-scheduling. What
guidelines have others used to make this
practice effective?
Answer 1:
I put out the schedule 4 weeks in advance and the staff
has 1 week to fill it out in the order of full time, f lex pool,
overtime, and then agency, if needed. A written request is
required if a staff member must have a specific day off.
I stopped infighting by telling the staff that either
they work it out among themselves or I would make the
schedule. It only took one time, and they now work it out
pretty well. One other rule I have is that if I change one
person’s written-in schedule, I change everyone else’s at least
one day and then allow them to trade with my approval.
This way there are no favorites and the system is fair for
everyone.—Kevin D. Trainor, RN, CEN, Nurse Manager,
Emergency and Trauma Services, Christus Santa Rosa Hos-
pital, San Antonio, Tex; E-mail: [email protected]
Answer 2:
We do the schedule in 6-week increments. Staff on weekend
rotation A fill out the first 3 weeks and staff on weekend
rotation B fill out the second 3 weeks first, and then they
swap. For the following schedule, weekend B gets the first
3 weeks, etc. There is a staff Matrix Committee that counts
the numbers and ‘‘fine-tunes’’ the schedule. People are asked
to cover shifts by talking with one another, but at times, that
does not always happen and then the Committee has to
make some changes.—Lisa Doddy, RN, BSN, CEN Patient
Care Manager, St Luke’s Hospital and Health Network,
Bethlehem, Pa; E-mail: [email protected]
JOURNAL OF EMERGENCY NURSING 335
M A N A G E R S F O R U M / Z i m m e r m a n n
Answer 3:
Although currently we do not do self-scheduling, I am used
to it from other facilities. What was generally a key guide-
line was to preprogram the weekends, because they were
not an option. Each person was required to work at least
one Monday and one Friday each month. Ultimately, some-
one (the nurse manager, in my experience) has to make a
final determination that the requested schedule is balanced
and fair.—Liz Hunter, RN, ED Nursing Director, St John’s
Hospital Lebanon, Lebanon, Mo; E-mail: EEHunter@sprg.
mercy.net
REQUIRING VITAL SIGNS AT DISCHARGE
Do other emergency departments require a set of discharge
vital signs on every patient at the time of discharge?
Answer 1:
Several years ago we did not require vital signs before a
patient was discharged. The recommendation by our on-site
EMTALA investigator was to document discharge vital signs
for all ED patients along with providing a written discharge
statement regarding their stability for discharge.
Our policy now states that all ED patients will have
a discharge/transfer statement that speaks to the patient’s
stability and documented vital signs within 30 minutes of
discharge or transfer. The exception is fast-track patients,
who must have vital signs documented within 1 hour of
their discharge.—Kay Smith, RN, BSN, Emergency Nurse
Clinician, Northeastern Georgia Medical Center, Gainesville,
Ga; E-mail: [email protected]
Answer 2:
We require a reassessment of all patients at time of dis-
charge. We specify that this must include noting any changes
in vital signs, pain scale, and ‘‘current clinical status.’’—
Elizabeth Murphy, RN, CEN, BSBA, Quality Assurance Rep-
resentative, Rex Healthcare, Raleigh, NC; E-mail: emurphy1@
nc.rr.com
Answer 3:
Many persons subscribed to the theory that discharge vital
signs were the indicator of stability for discharge. How-
ever, as part of a focused examination, I advocate that vital
signs alone do not necessarily indicate a patient’s medical
336 J
stability (on paper or in actuality). On the other hand,
obtaining a set of vital signs takes time, may serve to delay
the discharge time, and may result in a failure to assess the
patient’s primary concern.
The following 2 scenarios illustrate why vital signs
are not always needed or beneficial in determining dis-
charge readiness.
1. A patient with a small laceration arrives with normal
vital signs and has minimal bleeding. The patient remains
talkative, alert, and has no dizziness while standing to dis-
cuss the discharge instructions after the suturing is com-
pleted. Will vital signs give you any additional pertinent
information about this patient’s readiness for discharge?
2. A patient arrives with diarrhea and vomiting with tachy-
cardia and hypotension. With f luids, the vital signs im-
proved, but the patient is still unable to tolerate any oral
intake. Does a normal set of vital signs signal that the
patient is ready to go home?
Vital signs after medication and treatment are more
likely to have meaning to determine readiness for discharge
than those automatically taken as the patient is ready to
walk out.
In the past, I have abolished the policy of a routine
set of vital signs at discharge. Our current triage policy for
reassessment every 2 hours is a ‘‘problem-focused reassess-
ment’’ (versus vital signs). This means, for instance, that
bleeding is reassessed for a patient with a laceration, a tem-
perature is taken on a patient with a fever, and the pain
rating is noted for a patient with back pain.—Ann Marie
Tyrell, RN, MS, CEN, Consultant, HealthLink, Inc, Wil-
mington, NC; E-mail: [email protected]
MEETING THE 4-HOUR WINDOW FOR
COMMUNITY-ACQUIRED PNEUMONIA
We are struggling to meet the standard of administering
the first dose of antibiotics within 4 hours from arrival
(not admission) when an ED patient is diagnosed with
community-acquired pneumonia. What do other
emergency departments do to meet this standard?
Answer:
We just could not seem to meet this standard until I de-
veloped a bright-colored, 8 � 11 inch form that goes with
OURNAL OF EMERGENCY NURSING 32:4 August 2006
M A N A G E R S F O R U M / Z i m m e r m a n n
the patient throughout their ED stay. The form includes
2 blank clocks. The nurse draws the time on, representing
the start time (triage time) and then the goal or 4-hour
time limit in which the antibiotics should be given. We
also have a space below that the nurse can write in the
triage time, chest radiograph time, blood cultures drawn,
and antibiotics given.
Having the actual visual end time for the nurses helped
them prioritize. In fact, it got to be a race to see just how
fast we could get the entire form completed.
The form is not part of the medical record because
we do all computerized charting. However, it serves as an
excellent tracking tool while in the emergency department.
It proves that adage once again, ‘‘Keep it simple.’’—Sylvia
Reimer, RN, LP, CEN, Educator, Emergency Center, Memo-
rial Hermann Hospital, Houston, Tex; E-mail: sylvia.reimer@
memorialhermann.org
CRISIS CODE TO HELP THE SATURATED
EMERGENCY DEPARTMENT
What practices have other emergency departments
developed to deal with an overwhelming number
of patients?
Answer 1:
We developed a high-census plan that is initiated when all
critical care and medical/surgical beds are full (the NICU
and behavioral services unit census are not considered). Pa-
tients may be held in the following areas: the emergency
department, labor and delivery area, postanesthesia care
unit, and extended care area. Our plan includes notifying
senior administration, conducting frequent bed rounds, and
having all physicians contact the patient placement co-
ordinator prior to accepting any admissions or referrals.—
Dotty Kuell, RN, BSN, CEN, ED Manager, FirstHealth
Moore Regional Hospital, Pinehurst, NC; E-mail: DKuell@
firsthealth.org
Answer 2:
To avoid going on diversion, the ED charge nurse can
activate a ‘‘code help’’ by calling the operator. When ‘‘code
help’’ is called, the following people report directly to the
emergency department: administrative supervisor, critical
care f loat nurse, transport aid, phlebotomist, storeroom (to
August 2006 32:4
restock essential supplies), dietary (to stock the patient
food refrigerator), EKG, and a patient care technician. The
linen department also brings an additional linen cart to
the unit. The hospital intensivist begins triage of telemetry
patients and/or rapid transport of ICU patients, and all
admitted patients are transported to their available beds
even if the ordinary admission workup is not completed.—
Celeste Surreira, RN, BSN, Emergency Department Manager,
Mercy Medical Center, Springfield, Mass; E-mail: Celeste.
Answer 3:
In my consulting work, I have run across many variations
of ‘‘code help’’ or ‘‘code purple’’ to get the emergency de-
partment the help it needs when it is saturated. All of the
plans have some common aspects, such as notification of
the appropriate administrators and an assessment of the cur-
rent bed situation, and they have some unique differences.
One hospital’s ‘‘Code Help’’ is called by the charge
nurse and ED attending physician. An additional hospital
nurse is assigned to the emergency department (if needed),
along with an extra transporter and a housekeeping super-
visor. All nursing units are responsible for accepting ad-
mitted patients immediately.
Another hospital uses a ‘‘Code White’’ when there is
a sudden inf lux of many ED patients in a short time or all
ED beds are full with ED patients being boarded and there
are no available inpatient monitored beds. When ‘‘Code
White’’ is called, all staff are to report to their respective
units (even if they are on break) to assist in an expeditious
movement of patients. Discharged patients awaiting trans-
portation are brought to the diabetic conference waiting
room, and ED reports are faxed to the receiving f loors for
admitted patients. Ancillary departments, such as radiology
and laboratory, will reassign personnel to give a priority to
the tests for ED patients.
A third hospital activates a Divert Avoidance Response
Team when there are 3 ICU/CCU patients being held in
the emergency department and/or 10 admitted patients are
being held in any combination of levels of care. The post-
percutaneous transluminal coronary angioplasty recovery
area becomes an outpatient holding area. Pre-operative
lounge chairs are used for discharged patients waiting for
transportation, and an extra area behind the emergency
JOURNAL OF EMERGENCY NURSING 337
M A N A G E R S F O R U M / Z i m m e r m a n n
department is used for controlled mental health patients
awaiting placement and inebriated patients who are ‘‘sober-
ing up.’’ In addition, some practices they changed include
the following:. A standardized short order sheet for initial orders.
This sheet allows a quicker initiation of the patient in
the admission administration process, which usually
is not started at this hospital until admission orders are
written. (The original time from decision to comple-
tion of initial admission orders was 60 to 75 minutes.). A nurse/transporter team. The team not only trans-
ports the patient to the inpatient room but also per-
forms the initial orders and room orientation. This
process eliminates delays resulting from the receiving
nurse being unavailable.. A gatekeeper. This person’s role includes meeting
and greeting ambulances upon arrival and enforcing
ICU/CCU admission criteria. Transportation and venipuncture practices. Radi-
ology staff rather than ED staff transport patients
from the emergency department, and laboratory
personnel perform venipuncture on patients in radi-
ology. Before this practice was initiated, phleboto-
mists waited for patients to return to the emergency
department, and this resulted in delays.
A fourth hospital triggers a ‘‘yellow light’’ when there
are only 5 ICU beds, 8 telemetry beds, or 8 medical/
surgical beds available. Actions include putting directly
admitted patients on a standby list, not accepting transfers
from non-network inpatient facilities, and implementing
discharge holding areas (eg, individual lounge areas on each
unit and the endoscopy unit after 1:00 PM). The persons
in charge of overseeing these actions are the bed control
manager and administration representatives.
When only 2 ICU beds, 4 telemetry beds, and/or
4 medical/surgical beds are available, patients will not be
accepted from outpatient surgery centers, and the centers
may stay open for 24 hours. Overf low units may be opened.
The persons in charge of this are administration representa-
tives and nurse managers.
A ‘‘red light’’ is triggered when the bed availability is
limited further. Actions include putting directly admitted
patients on a standby list and holding elective surgical pa-
tients and ‘‘boarders’’ on inpatient units (one per unit).
The person in charge is the nursing director.
338 J
The final trigger for ‘‘Code White’’ occurs when there
are no available beds of any type; the administrator on call
becomes the person in charge.
We encourage the establishment of these types of pro-
tocols. The plans indicate a specific capacity level and in-
terventions, even involving housekeeping and security.
With a plan like this, the hospital is more likely to re-
solve capacity problems and prevent ED diversion.—Mike
Williams, MPA/HAS, The Abaris Group, Walnut Creek,
Calif; E-mail: [email protected]
OURNAL OF EMERGENCY NURSING 32:4 August 2006
