Managers ask and answer

• Question

What can be done to enhance customer satisfaction?

Answer No. 1 We found tha t the wai t at t r iage was a hot spot of d issa t is fact ion a m o n g parents who brought their chi ldren to our e m e r g e n c y depar tment . We noted a t r e n d - - p a r e n t s w a n t e d to be informed. Children 's a s ses smen t s , for example, l i s ten ing to the

chest, were done bu t the f indings were not shared wi th the parents .

We have developed a "script" for t r iage nu r ses tha t was pr in ted and shared wi th staff. It inc ludes three essent ia l aspects : 1. Give the result of your assessment . "Your child 's

ches t is clear (or OK) right now." 2. Describe a reason for the wai t wi th a t ime esti-

mate. "Your child is s table r ight now and w e ' v e had a t r auma vict im. It will be approximately an hour wai t to see the doctor."

3. Keep c o m m u n i c a t i o n open b e t w e e n the nurse and the parents . "If you have any problems while you are wai t ing , p lease come and see me and I'll reassess your child." We advoca te a "broken record technique ," for example, keep r epea t ing

the s ame types of answers to help handle the emot ions a n d hect ic pace durir lg-ihigh-volume

t imes. We opened ourselves to evaluat ion from the hos-

pital 's family, advocacy council. Parents volunteered to give feedback on five i tems: staff m e m b e r s ident i - fying themselves , c leanl iness of the depar tment , parents allowed to be wi th chi ldren (cons is tent wi th our miss ion s t a t e m e n t of "Partners in Care"), explanat ion of wa i t i ng t ime wi th adequa t e pa t i en t flow, and staff k indness and respec t toward pa t i en t s and families.

The opinions expressed are those of the respondents and should not be construed as the official position of the institution, ENA, or the Journal. J Emerg Nurs 1997;23:470-80. Copyright © 1997 by the Emergency Nurses Association. 0099-1767/97 $5.00 + 0 18/62/84759

The volunteers reported very high marks to administration. The feedback was great posi t ive reinforce- m e n t for the staff.

Our e m e r g e n c y depa r tmen t has a play area that inc ludes a set of table and chairs for children. Our vol- un t ee r is ass is ted by a par t - t ime (two 8-hour afternoon shifts per week) Child Life Ass is tant . We have a TV a nd a VCR for w a t c h i n g chi ldren 's movies. There are also short v ideotapes for pa ren t s abou t injury pre- ven t ion and immuniza t ions .

We are cons ider ing add ing a coffee courtesy cart du r ing busy t imes and a family l iaison volunteer to

c o m m u n i c a t e wi th pa ren t s and log their concerns a nd complaints . I also follow up every compla in t with bo th a phone call a nd a letter. Al though my responses t e n d to be noncommi t t a l ("I've d i s cus sed your concerns wi th the involved staff."), pa ren t s consis tent ly r e spond that they are pleasant ly surpr i sed tha t their concerns were t aken seriously.--Robert Ready, RN, MN, Clinical Manager, Emergency Department, Hasbro Children's Hospital, Providence, Rhode Island

W e are c o n s i d e r i n g a d d i n g a co f f ee c o u r t e s y cart d u r i n g b u s y t i m e s a n d a f a m i l y l ia i son v o l u n t e e r to c o m m u n i c a t e w i t h p a r e n t s a n d log the ir c o n c e r n s a n d c o m p l a i n t s .

Answer No. 2 We used a large, sound da t abase from our contrac t wi th Endre sen Research, collaborated wi th our physic ians , and buil t a p rogram that deals wi th the major concerns of our pat ients . A key factor was admin is t ra t ion ' s wi l l ingness to pu rchase this solid methodic source of informat ion and make a

470 Volume 23, Number 5

Zimmermann/JOURNAL OF EMERGENCY NURSING

c o m m i t m e n t t ha t a d e q u a t e t ime would be p rov ided for i m p l e m e n t i n g t h e effort. E a c h quar ter , t h e r e sea rch firm m a k e s follow-up t e l ephone surveys to 175 r andomly se l ec t ed p a t i e n t s from all acu i ty levels, and repor ts t h e f indings in 7 weeks .

The consu l t an t ' s da t a g a v e us t he s ta t i s t ica l ly va l ida ted key a s p e c t s t ha t pa t i en t s use to d e c i d e w h e t h e r t hey r ece ived "good" care, s u c h as the nurse t ak ing t ime to l is ten and hav ing e n o u g h h o m e care informat ion w h e n they are d i scha rged . An ou t s ide c o m p a n y t r a ined staff on w a y s to m e e t t h e s e needs . Part of the p roce s s is he lp ing nur ses be l ieve tha t go ing b e y o n d b e i n g exper t c l in ic ians and a d d i n g good peop le skills is essent ia l . This inc ludes enforc- ing the c o n c e p t b e y o n d lip se rv ice b y m a k i n g em- p loyees a c c o u n t a b l e for thei r per formance .

W e f o r m e d a s t a f f - p a t i e n t s a t i s f a c t i o n c o m m i t t e e w i t h r e p r e s e n t a t i o n from e a c h job c l a s s i f i c a t i o n a n d shift .

Nurses are held accoun tab le , w i th counse l ing and disc ip l ine , for pa t i en t s ' pe rcep t ions . As a result , t he re is a n e w level of effort and awarenes s . One nurse, for example , g r ew by b e c o m i n g a t t u n e d to s imple behav io r s she could fix. She eventua l ly real- ized t ha t t a k i n g a h is tory whi le she w a s s t a n d i n g in the doorway ra ther than s i t t i ng in the room and talk- ing at a fast p a c e con t r ibu ted to the m i s p e r c e p t i o n tha t she was "curt and rude."

Other a d j u s t m e n t s inc lude a r e p r e s e n t a t i v e for pa t ien t s , a r e m o d e l e d t r i age area, and LOGICARE®* c o m p u t e r d i s c h a r g e ins t ruct ions . We n o w have two pa r t - t ime pa id staff m e m b e r s who in t e rac t a n d trou- b leshoo t p r o b l e m s wi th famil ies and ac t as p a t i e n t r ep resen ta t ives . They work for 6 hours, 4 days each week. They are s c h e d u l e d to work dur ing the p e a k per iods on the even ing shift, w e e k e n d s , and hol idays . They use s low per iods to m a k e cal lbacks. The posi - t ion w a s d e s i g n e d for s o m e o n e wi th a c u s t o m e r ser- v ice backg round , bu t w e h i red a nurse who w a s not p r a c t i c i n g a n d she has b e c o m e an incred ib le role model.

Our r e m o d e l e d g l a s s - enc losed t r i age a rea n o w ensures p r ivacy for conversa t ions , and the vis ib i l i ty g ives a warm, a p p r o a c h a b l e feeling. However , in real- ity, our n e w s e t u p has also i n c r e a s e d secur i ty wi th

*LOGICARE® is a registered trademark of the LOGICARE Corporation, (800)848-0099.

bul le t -proof glass, a k e y p a d d e d b a c k door tha t could be u s e d as an e s c a p e opt ion, and a "hot but ton." Add- ing the LOGICARE d i s c h a r g e p a c k a g e has d ramat i - cally i m p r o v e d our ra t ings for a d e q u a t e h o m e care information.

W e e m p h a s i z e t h a t 100 % of t h e s ta f f i n t r o d u c e t h e m s e l v e s b e c a u s e p a t i e n t s s a i d t h e y did n o t k n o w w h o w a s t a k i n g care of t h e m .

Staff m e m b e r s w e r e in i t ia l ly hos t i l e to t he changes , bu t r e s i s t a nc e d i m i n i s h e d as it b e c a m e clear t ha t th is w a s a h igh admin i s t r a t i ve priority. With all ou r d r ama t i c improvemen t s , w e are n o w the role mode l for the inst i tut ion.

Our miss ion s t a t e m e n t is to be the "bes t hea l th care service" and our cha l lenge is to not b e c o m e com- p l a c e n t bu t con t inue to s eek only "top box" ra t ings . To this end, w e are do ing follow-up t ra in ing on a vol- un tee r bas i s and "pulling apa r t our success" ; for example , ana lyz ing exac t ly w h a t w e are do ing tha t is different and is working. As our own d a t a b a s e grows, w e also w a n t to look at w h i c h i s sues vary du r ing different quarters.--Janet Wright, RN, MS, CNAA, CHE, Manager of Emergency Services, and Michele Stewart, RN, Staff Nurse, Stevens Hospital, Edmonds, Washington

T h e r e h a s b e e n a g r a d u a l sh i f t in a t t i t u d e as w e r e w a r d our o w n s ta f f a n d i n c o r p o r a t e the i r s i m p l e y e t e f f e c t i v e i d e a s .

Answer No. 3 We have h a d t r e m e n d o u s s u c c e s s in improv ing cus tomer sa t i s fac t ion by focus ing on our staff sa t i s fac t ion . This has i nc luded a c k n o w l e d g i n g t h e m as ind iv idua ls by r ecogn iz ing t h e m for excel len t work, m e e t i n g thei r s c he du l i ng needs , and a l lowing t h e m the a u t o n o m y to try the i r ideas .

We randomly d raw a staff m e m b e r ' s n a m e and this pe r son is d e s i g n a t e d as the "smiley face of the week." Interest ingly, a n e w d i m e n s i o n was b rough t out in peop le w h e n t hey we re se lec ted . They felt a n e e d to be more p l e a s a n t and each m a d e it some-

October 1997 471

JOURNAL OF EMERGENCY NURSlNG/Zimmermann

t h i n g specia l . One wro te a dai ly h u m o r o u s p o e m a n d ano the r b r o u g h t in food t r ea t s b e c a u s e "eve rybody dese rves it." As silly as i t m a y seem, th is cos t - f ree p r og ram is a mora le booster .

We fo rmed a s t a f f /pa t i en t sa t i s fac t ion c o m m i t t e e wi th r e p r e s e n t a t i o n from e a c h job c lass i f ica t ion and shift. Be ing a w a r e of the l i t t le t h ings b e h i n d the com- p la in t s w a s the first s t ep t o w a r d t h e solut ions. For example , w e now p u t two chairs, i n s t e a d of one, in cub ic les b e c a u s e p a t i e n t s ' famil ies c o m p l a i n e d t ha t t hey d id no t have a p l ace to sit. We ins i s t t ha t peop l e b e kep t in formed b e c a u s e a recur r ing compla in t w a s t ha t t hey d id not know w h y they w e r e wai t ing . A card ina l rule n o w is t ha t staff i n t e r ac t w i th e a c h p a t i e n t eve ry 30 m i n u t e s even if t he re are no n e w deve lopmen t s . C o m m i t t e e m e m b e r s gent ly r e m i n d o ther staff, "Have you c h e c k e d wi th your p a t i e n t s in t he las t 30 minu tes?"

Resu l t s s h o w e d that 43.7% of t h e tr iage nurse ' s t i m e w a s s p e n t dea l ing w i t h n o n e m e r g e n c y ques t ions , for e x a m p l e , "Where are the p h o n e s . . , v e n d i n g m a c h i n e s . . , bathrooms?"; 58.1% of the q u e s t i o n s c a m e from vis i tors .

Finally, w e e m p h a s i z e 100% t h a t staff i n t roduce t h e m s e l v e s to p a t i e n t s b e c a u s e t h e y sa id t hey d id not know w h o w a s t a k i n g ca re of them. I m a k e rounds , a sk p a t i e n t s how t h e y are doing, a n d t hen add, "By the way, w h o is your nu r se today?-"~-If t he p a t i e n t can tell m e t h e nu r se ' s name , the nu r se .gets a token r e w a r d (car w a s h token or movie renta l cer t i f icate) for m e e t i n g our goal.

We dea l t w i t h this by add ing a "greeter" and b e t t e r d irect ional s igns .

There has b e e n a g radua l shif t in a t t i t ude as w e t ake ca re of our o w n staff and incorpora t e thei r s imple ye t effect ive ideas . We recen t ly w o n an a w a r d for our n o t e w o r t h y i m p r o v e m e n t s in c u s t o m e r sa t i s fac- t ion su rvey ra t ings .

I a m cons ide r ing m a k i n g a c u s t o m e r sa t i s fac t ion v ideo to use in t he future w h e n I hire e m e r g e n c y nurses . I w a n t our staff to sha re thei r guide l ines , expec t a t i ons , a n d culture, help a p p l i c a n t s under - s t a n d w h a t is impor t an t to us, and d e c i d e if th is is w h e r e t h e y fit.--Betty Taylor, RN, MSN, Director of Emergency Department, Silver Cross Hospital, Johet, Illinois

We n o w perform p r e g n a n c y t e s t s , c h e c k v i sua l acuitY, do x-ray e x a m i n a t i o n s , and a d m i n i s t e r o v e r - t h e - c o u n t e r med ica t ion , for e x a m p l e , a c e t a m i n o p h e n (Tylenol), in the tr iage area.

Answer I~e. 4 Our d a t a col lect ion s t u d y clearly in- d i c a t e d tha t w e n e e d e d to focus on t r i age and the w a i t there . Resul ts s h o w e d tha t 43.7% of t he t r iage nu r se ' s t ime w a s s p e n t dea l ing w i t h n o n e m e r g e n c y ques t ions , for example , "Where are t he p h o n e s . . v e n d i n g m a c h i n e s . . , ba throoms?" ; 58.1% of t he ques- t ions c a m e from visi tors. We dea l t w i t h th is b y a d d i n g a "greeter" and be t t e r d i rec t iona l s igns .

Stress from e x t e n d e d w a i t i n g "in case they w e r e needed" w a s also l i s ted by famil ies as a frequent stressor.

The wa i t w a s i m p r o v e d by a d d i n g point -of-ser- v ice t r i age t e s t i n g and i n c r e a s i n g staff to two regis- t e r e d nu r ses a n d two or th ree t e c h n i c i a n s pe r shift for our 104,000/year census . We n o w per form p r e g n a n c y tes ts , check visual acuity, do x- ray examina t ions , and a dmin i s t e r ove r - the -coun te r med ica t ion , for example , a c e t a m i n o p h e n (Tylenol), in the t r i age area. Pa t i en t flow is e n h a n c e d by s e n d i n g n o n a c u t e ped ia t r i c p a t i e n t s to our o u t p a t i e n t ped ia t r i c cl inic du r ing its opera t iona l hours, and b u s i n e s s office pe r sonne l get- t i ng i n su rance informat ion at t he b e d s i d e i n s t e a d of in a s e p a r a t e r eg i s t ra t ion area.

We plan to a d d other i m p r o v e m e n t s , i nc lud ing a fish t ank in t he w a i t i n g a rea a n d a small , phys ica l ly s e p a r a t e w a i t i n g a rea for p a t i e n t s w h o have h ighly infec t ious d i s e a s e s such as ch ickenpox .


Zimmermann/JOURNAL OF EMERGENCY NURSING

We n o w have 80% of our p a t i e n t s t h rough the t r iage p roce s s in 5 m i n u t e s or less a n d are s t r iv ing to r each l O0%.--Jeanne Whalen, RN, Education Coordi- nator, Emergency Department, Carolinas Medical Center, Charlotte, North Carolina

We s o l v e d this p r o b l e m by ren t ing digital p a g e r s w i t h f u n d i n g from an Innov i s ion grant s p o n s o r e d by t h e Greater Chicago Chapter of the A m e r i c a n A s s o c i a t i o n of Critical-Care Nurse s .

Answer Ne. 5 A n inhe ren t p rob lem in our ICU customer sa t i s fac t ion was re la ted to family c o m m u n i c a - tion. Wherea s families r anked f requent c o m m u n i c a - t ion as the i r mos t impor t an t need , often nu r ses t hough t tha t f requent c o m m u n i c a t i o n s wi th family m e m b e r s c a u s e d in te r rup t ions in p a t i e n t care. S t ress from e x t e n d e d wa i t i ng "in case t hey were n e e d e d " was also l i s ted b y famil ies as a f requen t stressor.

We solved this p rob lem b y ren t ing digi ta l p a g e r s wi th fund ing from an Innovis ion g ran t s p o n s o r e d by the Grea te r Ch icago Chap te r of the A m e r i c a n Asso- c ia t ion of Cr i t ica l -Care Nurses . 1 Pagers were color- c o d e d and a s s i g n e d to spec i f ic ICU areas, a n d t hen any ICU nurse could give one per family. The r e spon- sible family m e m b e r was i n s t ruc t ed in how to u se the p a g e r and s i g n e d an a c c e p t a n c e of accountabi l i ty . Each p a g e r w a s also a c c o m p a n i e d b y an exp lana to ry p a m p h l e t d e v e l o p e d by our project t eam.

S o m e famil ies d i s tr ibuted t h e p a g e r n u m b e r s to o ther family m e m b e r s for daily u p d a t e s ; this e a s e d t h e staff's b u r d e n for d i s p e n s i n g informat ion.

Fol low-up eva lua t ions found tha t famil ies who r ece ived p a g e r s cons i s ten t ly e x p e r i e n c e d less s t r e ss b e c a u s e t hey we re able to t ake a b reak wi thou t worry or guil t abou t po ten t i a l n e e d s of the hosp i t a l i zed family member . Staff also e x p e r i e n c e d u n e x p e c t e d bene -

fits. Some famil ies d i s t r i bu t ed the p a g e r n u m b e r s to other family m e m b e r s for dai ly upda te s ; th is e a s e d the staff 's b u r d e n for d i s p e n s i n g information. P lanned t imes for family educa t ion , ra ther than p i e c e m e a l sna t ches , are also e n h a n c e d . Be c a use of the s u c c e s s of t h e p r o g r a m , t he h o s p i t a l vo lun tee r p r o g r a m a s s u m e d a role in the cos t of t he p a g e r s and dis- b u r s e m e n t after the g ran t m o n e y was gone.--Daiwai Olson, RN, CCRN (formerly at Genesis Medical Center, Davenport, Iowa), Neuroscience ICU, Duke University Medical Center, Durham, North Carolina

We formed s t a f f - n u r s e - l e d focus c o m m i t t e e s to look at di f ferent areas (charge nurses , triage, t r e a t m e n t area, d i scharge , and cos t and value) .

Answer Ne. 6 We were hav ing p rob lems wi th customer sa t i s fac t ion and exces s ive a m b u l a n c e diver- s ions b e c a u s e t he e m e r g e n c y d e p a r t m e n t w a s sa tu ra ted . We formed s t a f f -nur se - l ed focus commi t - t ee s to look at different a r ea s (charge nurses , t r iage, t r e a t m e n t area, d i scharge , and cos t and value) and by us ing Solut ion Point* pos tv i s i t cus tomer sa t i s fac t ion t e l ephone surveys .

Some of the c h a n g e s w e have m a d e include: 1. Repr ior i t i z ing the n e w l y a d m i t t e d i n p a t i e n t s '

c o m p u t e d t o m o g r a p h y (CT) scan. B e c a u s e inpa- t i en t s were las t on the pr ior i ty list to rece ive CT scans , the re w a s a t e n d e n c y to keep pa t i en t s in t he e m e r g e n c y d e p a r t m e n t so t hey would rece ive the i r CT s c a n s first. Now, t h e s e p a t i e n t s keep the s a m e t e s t priority, even if t h e y are a d m i t t e d to t he hospital .

2. Ad jus t i ng staff ing hours. We have i n c r e a s e d the n u m b e r of staff work ing dur ing peak t imes , from 10 AM unti l m i d n i g h t and weekends . We also n o w have b a c k u p suppor t from our cl inical educa to r or an ACLS-cer t i f ied nurse from the hosp i t a l -w ide n u r s i n g Crisis Team. This ex t ra nu r se of ten a c c o m p a n i e s cri t ical ly ill pa t i en t s dur ing proce- du re s and transfer, or he lps in t r i age so tha t staff who are p rov id ing d i rec t pa t i e n t care are not t a k e n a w a y from the d e p a r t m e n t .

3. A d d i n g hosp i t a l -w ide b e d avai labi l i ty "triage." From 7 AM to 7 PM, a " t r iage nurse" m a k e s hourly

*Solution Point, Inc., Nashville, TN, (800)457-3450.

October 1997 4 7 3

JOURNAL OF EMERGENCY NURSiNG/Zimmermann

4.

5.

rounds throughout the hospital and lists available beds and possible ED admissions. Interventions are made to facilitate admissions as early as possible. Relocating the admission history and physical obtained by the resident from the emergency department to the inpatient unit. Rearranging housekeeping hours because most patients were discharged in the afternoon but more housekeeping staff were scheduled to work in the morning. This helped resolve the delay in cleaning an empty bed in the afternoon.

departments use our results to benchmark their per- formance with the best emergency departments in the nation.

Our large database shows that the major concerns of ED patients vary depending on the size of the institution. Chief complaints about small emergency departments (under 25,000 visits a year) were (1) the bill (15%), (2) the physicians (11%), (skill, concern, and respect, how frequently patients are checked, and discharge instructions), and (3) the time and effi- ciency of discharge instructions (9%).

We h a v e i n c r e a s e d t h e n u m b e r of s ta f f w o r k i n g d u r i n g p e a k t i m e s , f rom 10 AM unt i l m i d n i g h t a n d w e e k e n d s . W e a l so n o w h a v e b a c k u p s u p p o r t from our c l in ica l e d u c a t o r or an A C L S - c e r t i f i e d n u r s e from t h e h o s p i t a l - w i d e n u r s i n g Cris is T e a m .

In addition there was a major psychologic adjust- ment. Before, there was a casual attitude toward diverting patients to other facilities; now it is not considered an active option. The charge nurses developed a tool to identify signs and causes of imminent ED saturation. When this showed that a major problem was the inability to transfer admitted patients to their rooms, this was recognized as a hospital-wide issue, not just an ED problem. A new attitude of aggressive prevention became the~norm. As a result of all of these changes, our customer" s~tisfaction has improved and we have decreased oti'r'monthly diver- sions from 30 to 40 per month to one in 4 m o n t h s . - Barbara Karagosiaw, RN, MS, CNAA, Director, Emergency Services, Cedars-Sinai Medical Center, Los Angeles, California

Answer No. 7 Our company uses statistical outcomes to help hospitals reengineer, meet regulatory and accreditation requirements, and address issues of managed care, risk, and quality. We conduct surveys and provide decision support for more than 150 hospital and health care systems. Our measurement systems include surveys and national data bases for inpatient, outpatient, and ED patients. Emergency

F r o m 7 AM tO 7 PM, a "tr iage nurse" m a k e s hour ly r o u n d s t h r o u g h o u t t h e h o s p i t a l a n d l i s t s a v a i l a b l e b e d s a n d p o s s i b l e ED a d m i s s i o n s .

Patients had the same three complaints about medium-sized emergency departments (25,000 to 45,000 visits annually) plus concerns about coordina- tion (9%) (teamwork of staff), and nurses (9%) (skill, concern, and respect; how frequently patients are checked, and communication).

Eight statistically significant issues were associ- ated with large emergency departments (more than 45,000 visits a year). Large emergency departments shared the previous five complaints with medium and small emergency departments, but the complaints were in slightly different order and represent- ed higher percentages of disappointed patients. Additional complaints included entry problems (No. 3 at 14%) (ease of locating the department, demonstrat- ing proper sense of urgency), facilities (No. 4 at 14%) (adequacy of facility for family, provisions for privacy, condition of treatment area), and registration (No. 8 at 12%) (ease of process, respect from staff.)

Before , t h e r e w a s a c a s u a l a t t i t u d e t o w a r d d i v e r t i n g p a t i e n t s to o t h e r faci l i t ies; n o w it is no t c o n s i d e r e d an a c t i v e opt ion .

In general, the larger the emergency department, the less satisfied the patients were because they felt lost in the bureaucracy. Results suggest that, from the

4 7 4 Volume 23, Number 5

Zilnmermann/JOURNAL OF EMERGENCY NURSING

p a t i e n t ' s v iewpoin t , a h igh vo lume e m e r g e n c y d e p a r t m e n t would provide bet ter service if it would "act" as if it were a smaller emergency d e p a r t m e n t wi th in a larger one. An example of this is se t t ing up a separate fast track or pediatr ic area.--David I~ Furse, PhD, Founder and Chief Consultant, Solution Point, Inc., Nashville, Tennessee, (800) 467-3450

The larger t h e e m e r g e n c y d e p a r t m e n t , the l e s s sa t i s f i ed the p a t i e n t s w e r e b e c a u s e t h e y felt lost in t h e bureaucracy .

Answer No. 8 As a quali ty expert, I am conce rned w h e n ins t i tu t ions focus only on numer i c ra t ings about cus tomer satisfaction. This ac t ion enforces five myths abou t cus tomer satisfaction: 2 1. Customer satisfaction is objective and straight-

forward. Determin ing cus tomer a t t i tudes takes though t and exper imenta t ion inc lud ing looking

at pat terns . 2. Customer satisfaction is easily measured. Cus-

tomer sat isfact ion is a complex at t i tude, and cus tomers ' previous exper iences with products usually ma t ch their expectat ions. Low expecta- t ions will be satisfied wi th a s u b s t a n d a r d perfor- mance . However, cus tomer sat isfact ion is also inf luenced by factors tha t are not directly related to previous experiences, such as reputat ion.

3. Customer satisfaction is accurately and precisely measured. Att i tudes vary both a m o n g people and also in the same people at different t imes. Most ra t ing scales conta in response bias and people opt for the middle ra t ing or one of the extremes. Rather t h a n just concen t ra t ing on the m e a n rat- ing, there are other more informative measu re s tha t should be considered, such as the percent - age of the highly satisfied or dissat isf ied respon-

dents , or a we igh ted sum of all responses . 4. Cus tomer satisfaction is quickly and easily

changed. Rather t h a n heroic-effort mental i ty , con t inuous quali ty improvemen t builds satisfac- t ion wi th repeated cus tomer experiences. Unless

the exper iences are below or above expectat ions , it takes t ime before a shift in cus tomer satisfac- t ion m e a s u r e m e n t takes place; it is usually a lag- g ing indicator. Concent ra te on current detai led inpu t from focus groups, cus tomer visits, and cus tomer complaints.

5. It is obvious who the customer is. Every organi- zat ion has dis t inct , different groups of con- sumers, and it is impor tan t to identify which groups are dissatisfied. The answer is to incorporate cus tomer involve-

m e n t rather t han just measu re satisfaction. Without that, even if the n u m b e r s are valid, they canno t be ac ted on be c a use they do not give clues about why cus tomers are or are not satisfied. Six s teps to incorporate cus tomer invo lvement are as follows: identify who the cus tomers are, ask cus tomers to identify major issues, ascer ta in how widespread the issues

are, inves t iga te root causes and ini t ia te improve- m e n t s , eva lua te the resul ts , a nd ins t i tu t iona l i ze cus tomer invo lvement a nd the m e a s u r e m e n t of satisfaction.--Jarrett Rosenberg, Phi), CQE, CRE, statisti- cian and quality engineer, Sun Microsystems, Inc., Mountain View, California

References

1. Olson D. Paging the family: using technology to enhance communication. Crit Care Nurse 1997;17:39-41. 2. Rosenberg J. Five myths about customer satisfaction. Quality Progress 1996;29:57-60.

• Question

Outside of annual raises, is anyone providing incentives/ rewards for staff?.

Answer No. 1 We found that staff m e m b e r s w a n t their work rewarded wi th some th ing tangible, usable, and individual , rather t h a n general depa r tmen ta l events or consumab le i tems such as pizzas. Many bel ieve that apprec ia t ion of their individual extra efforts has b e e n lost in the t eam emphasis .

As part of our cus tomer sat isfact ion program, we s t a r t ed offering i ncen t ive s . A preferred pa rk ing space, immedia te ly outs ide the en t rance door, is des- igna ted for the w inne r of the Silver Standard Award. Staff m e m b e r s who are m e n t i o n e d in re turned pa t i en t sat isfact ion surveys have their n a m e s en te red in a drawing, and one of t hem wins the use of the space for 1 month. The winne r ' s n a m e is p laced on a s ign at

the space. In addit ion, staff earn "silver nugget" car wash

tokens or free movie rental certificates to reward other actions, such as rece iv ing posit ive c o m m e n t s from pat ients , agree ing to work on short notice, be ing indus t r ious on a chaotic day, or s tay ing late. Nugge t collections can be r edeemed for a mone ta ry award

October 1997 475

JOURNAL OF EMERGENCY NURStNG/Zimmermann

($25). T h e s e a w a r d s are funded by a spec ia l hosp i ta l program.

We also have eur own cos t - f lee p rog ram in t he e m e r g e n c y d e p a r t m e n t . Staff m e m b e r s are encour- a g e d to wr i t e a no te d e s c r i b i n g s o m e t h i n g spec ia l t ha t ano ther staff m e m b e r did. After a month , the per- son wi th t he mos t m e n t i o n s has a p a i d day off and a sa lar ied m a n a g e r works t he shift--Betty Taylor, RN, MSN, Director of Emergency Department, Silver Cross Hospital, Joliet, Illinois

W h e n n u r s e s l e a r n a b o u t t h e s u b s t a n t i a l m o n i e s ( $ 1 3 0 0 to $ 5 0 0 0 ) , t h e y are m o r e m o t i v a t e d to p u r s u e t h e i r o w n i d e a s .

Answer No. 2 Our 2-year-old Professional E n h a n c e - m e n t P rogram a w a r d s m o n i e s to staff nu r ses for do ing projects abou t educa t ion , cos t -e f fec t iveness , or qual- i ty improvement . To qualify, the pro jec t m u s t be a major endeavor tha t is b e y o n d rout ine ly e x p e c t e d in-serv ice and con t inu ing educa t i on c red i t s and m u s t inc lude qual i ty a s s u r a n c e data . One p r o g r a m involved se t t i ng up and m a n a g i n g a t r i age c lass inc lud ing ob- t a in ing con t inu ing e d u c a t i o n credi ts . In another , a staff nu r se ' s i nves t iga t ion of a major e q u i p m e n t c h a n g e in t he ICU eventua l ly s aved the hospi ta l thou- s a n d s of dollars.

The nur ses ' i d e a s a re p r e s e n t e d to a hosp i ta l c o m m i t t e e and po in t s are a w a r d e d d e p e n d i n g on the a m o u n t of work requ i red and the i m p a c t it will achieve . A l though the dollar a m o u n t s of the a w a r d s are officially confident ial , t he n u m b e r s often leak out. W h e n nur ses learn abou t the subs t an t i a l mon ie s ($1300 to $5000), t hey are mere m o t i v a t e d to pu r sue thei r own ideas . The chief nurse execu t ive m a k e s a formal p r e s e n t a t i o n to the hosp i ta l further e m p h a s i z - ing the pe r son ' s a c c o m p l i s h m e n t . The p rog ram is funded w i th mon ie s from the hosp i t a l ' s opera t iona l b u d g e t and will soon inc lude l i censed prac t ica l nurses and cer t i f ied nurse ass i s t an t s . The Professional E n h a n c e m e n t P rogram has c h a n g e d the staff 's v i ews abou t w h a t one ind iv idua l can do.--Karen Roederer, RN, CEN, Clinical Educator, St. Joseph's Hospital, Tampa, Florida

Answer No. 3 We str ive to suppor t nu r ses who m e e t educa t i on and cer t i f ica t ion r e q u i r e m e n t s and main - ta in cl inical excel lence. Requi red courses , for exam-

ple, A d v a n c e d Card iac Life Support , a re p rov ided free to staff nurses , and they are c o m p e n s a t e d for their t ime. Every r eg i s t e r ed nurse also r ece ives one annual p a i d educa t iona l day tha t can be u s e d to a t t e n d pro- g r a m s ou t s ide our hosp i ta l after the i r m a n d a t o r y training is comple ted . Min imal m o n e t a r y a s s i s t a n c e is avai lable .

In addi t ion, w e pay for the ini t ial a n d r enewa l test ing fees w h e n a nurse success fu l ly p a s s e s a spe- c ia l ty cer t i f ica t ion examina t ion , such as Cert i f ied E m e r g e n c y Nurse. Many free spec ia l ty cer t i f ica t ion r ev iew courses are also avai lable at t he h o s p i t a l . - - Debby Berkey, RN, MS, Vice President Nursing, Akron General Medical Center, Akron, Ohio

Answer No. 4 We e n c o u r a g e and r e w a r d nu r s ing clinical scho la r sh ip a n d p romote t hose nu r ses who are expe r t p rac t i t ioners , use r e sea rch f indings, and share the i r k n o w l e d g e w i th o ther nurses . Our hosp i ta l d e v e l o p e d a F r i ends of Nurs ing F u n d to suppo r t nursing act iv i t ies , such as a t t e n d i n g profess iona l mee t - ings and pa r t i c i pa t i ng in cl inical projects . The fund is one of t he benef ic ia r i e s of t he annua l hosp i t a l com- m u n i t y fund- ra i s ing drive. We also have a s e c o n d fund t ha t f inances nu r s ing r e s e a r c h pro jec t s de- s i g n e d by nurses in our sys tem.

We also suppor t the i n c r e a s e d use of a c u t e care nurse p rac t i t ioners in t oday ' s c h a n g i n g hea l th care env i ronment . Mas t e r ' s -p r epa red , cl inical ly excel len t nu r se s rece ive full- t ime t ra in ing for 9 m o n t h s wi th 100% tu i t ion r e i m b u r s e m e n t a n d m a i n t a i n the i r sa lary and benef i ts . In exchange , w e rece ive a 3-year e m p l o y m e n t c o m m i t m e n t . The n e e d for t h e s e pract i - t ioners is growing. Currently, our hea l th s y s t e m ' s qual i f ied nurses have first p re fe rence to en te r our program, bu t w e a n t i c i pa t e tha t some nur ses w h o do not work for our s y s t e m will eventua l ly b e a d m i t t e d to keep up wi th the de ma nd . This p r o g r a m has b e e n very successful.--Isabelle Reymann, RN, MPA, Vice President and Chief Operating Officer, Summa Health System, Akron, Ohio

• Question

Any tips on handling budgeting?

Answer No. 1 I have p o s t e d a con t inuous gr id tha t d e p i c t s las t yea r ' s a c t u a l / b u d g e t e d v is i t s to t he emer- g e n c y d e p a r t m e n t and the cur ren t yea r ' s ac tua l and b u d g e t e d visits. By us ing a vers ion of a m o v i n g a h e a d a ve ra ge (MAA), I have b e e n able to accu ra t e ly project


Zimmerrnann/JOURNAL OF EMERGENCY NURSING

Moving Ahead Average (MAA)

Forecast (f)= [3M1 + 2M2 + 1M3]/6 where M1 = prior month's data

M2 -- 2 months ago data M3 = 3 months ago data

Example: Monthly ED v i s i t s

January = 1800 February = 1750 March = 1650 April = 1550 May = 1600 June = 1700 July = [5100 (1700 x 3) + 3200 (2 x 1600) +

1550 (1 x 1550)]/6 = 1642 (Simple averages = 1675)

August = [4926 (1642 x 3) + 3400 (1700 x 2) + 1600 (1 x 1600)]/6 = 1654

(simple average = 1649)

September = [4962 (1654 x 3) + 3284 (1642 x 2) + 1700 (1700 x 1)]/6 = 1658

(simple average = 1634)

Figure 1 From Bertram DL, Wilson JL. AACN management series: Financial management in critical care nursing. St. Louis: Mosby-Year Book, 1991:86.

ED visits. The M A A is a t ime-se r i e s analysis tha t is

sens i t ive to month ly t rends and more accu ra t e than

annual iza t ion (Figure 1).

the hospi tal aga ins t med ica l advice, deaths , vo lume

by da te and week, and ED pa t ien t s who are admit ted .

I have found that p rov id ing the nurses wi th data

and ge t t i ng t h e m involved in the ground level b u d g e t

p rocess helps t h e m unde r s t and how financial deci-

s ions are m a d e and inspires t h e m to identify cost-

effect ive ways to offer h igh-qual i ty care. Data can

also be c o m p a r e d wi th ENA's Project Benchmark to

justify staffing and operat ional costs to represen ta -

t ives from f inance and administration.--David Unkle, RN, MSN, CCRN, CEN, CNA, FCCM. A t the time this answer was written, the author was Nurse Manager, Emergency Department, ICU and PC, West Jersey Hospital, Camden, N e w Jersey

T h e a d m i t t i n g d e p a r t m e n t a s s i g n s a g e n e r a l uni t bu t not a spec i f i c b e d for t h e ED pat i en t . A n e m e r g e n c y n u r s e ca l l s t h e i n p a t i e n t uni t w i t h a p r e l i m i n a r y c o n d i t i o n report , a b e d a s s i g n m e n t is m a d e , a n d a n u r s e w h o w o r k s on t h e i n p a t i e n t uni t r e c e i v e s a full report .

We c a l c u l a t e t h e fair m a r k e t v a l u e for renta l s p a c e w h e n w e u s e a r o o m in our faci l i ty for a c o m m u n i t y e d u c a t i o n c l a s s for "safe s i t ters ."

Budge t information is r ev i ewed at our month ly

staff mee t ings . Data inc lude the full-time employees

used (product ive /nonproduct ive) c o m p a r e d wi th the

b u d g e t e d n u m b e r s (pay per iod total and runn ing to-

tal), over t ime utilization, hours per pa t i en t visit, criti-

cal care b o a r d e r - p a t i e n t hours, and supply ut i l izat ion

(operational costs). The following vo lume / s t a tu s indi-

cators also provide a m e a n s for b u d g e t justif ication:

ED visits, p e r c e n t a g e of ED pa t ien ts who leave

wi thou t b e i n g seen, ICU and Progress ive Care Unit

boarders and hours, bypass and diver t even t s and

hours, pa t i en t s per t r iage category, pa t ien ts who leave

Answer No. 2 In today ' s heal th care arena, not-for-

profit heal th care providers are more f requent ly be ing

r e q u e s t e d to d e m o n s t r a t e and quant i fy c o m m u n i t y

benefi t . A l though Kentucky currently does not have a

legis la ted formula for just i fying not-for-profit status,

w e are now proact ively a c c o u n t i n g for our chari ty

and c o m m u n i t y work dollars in our budget .

Beyond the an t i c ipa ted costs of char i ty care (for

example , e m e r g e n c y su rge ry for an u n i n s u r e d

pat ient) or bad deb t write-offs, w e try to prec ise ly

def ine any di rec t or indi rec t dollars w e spend for com-

muni ty -bene f i t i ng projects tha t do not have a finan-

cial return. For example, w e calculate the fair marke t

value for rental space w h e n w e use a room in our

facility for a c o m m u n i t y educa t ion class on "safe sit-

ters." We also i t emize and d o c u m e n t nurs ing t ime

and suppl ies for any c o m m u n i t y projects, such as our

Teddy Bear Clinics. This p rocess enab les us to

express b u d g e t needs in f inancial t e rms tha t every-

one unde r s t ands ins tead of c o m p e t i n g wi th a propos-

al tha t an t i c ipa tes f inancial return or inves tment . A

October 1997 4 7 7

JOURNAL OF EMERGENCY NURSING/Zimmermann

clearer compa r i son b e t w e e n different projects also e m e r g e s a n d he lps d e t e r m i n e w h e r e our c o m m u n i t y benef i t dollars can b e s t b e spent.--Larry Gray, MDiv, MHA, Mission Effectiveness, and Liz Santen, RN, MSW, Coordinator, Project Development, Central Baptist Hospital, Lexington, Kentucky

of ant ib io t ic , c h a n g i n g IV t u b i n g from the t y p e tha t w a s in se r t ed by the p a r a m e d i c s to t h e i n - h o u s e - c o m - pa t ib l e infusion p u m p tub ing , and pe r fo rming all l abe l ing requ i red by the Board of Health.--Mary Jensen, RIV, Swedish Covenant Hospital, Chicago, Illinois

• Question

Calling a nursing division to give report on a patient is often such a hassle. How are other emergency departments handling that?

Answer No. 1 I cha i r t he Correc t ive Ac t ion Team, and w e are work ing t h rough the ent i re a d m i s s i o n process . We found t ha t one root c a u s e for de lay is the i npa t i en t un i t ' s de lay in t a k i n g report .

We are t ry ing to shift t he p a r a d i g m by t ak ing the a d m i s s i o n office "out of t he loop." Now, the a d m i t t i n g d e p a r t m e n t a s s i gns a gene ra l uni t b u t not a spec i f ic b e d for t he ED pa t ien t . A n e m e r g e n c y nurse calls the i npa t i en t un i t w i th a p re l iminary cond i t ion report , a b e d a s s i g n m e n t is m a d e , and a nu r se who works on the i npa t i en t uni t r ece ives a full report . It is h o p e d tha t th is will i nc rea se t he buy- in from the i npa t i en t uni t and m i n i m i z e "misp laced" pa t i en t s , such as an alert p a t i e n t who is p l a c e d in the s a m e room wi th a confused, no isy pa t ien t .

We also e m p h a s i z e t ha t th is is a "transfer" of care to a different level ra ther than an off - the-s t ree t ad- miss ion. We are t ry ing to a id this c o n t i n u u m of care by t ransfer r ing a d e q u a t e ED p a p e r w o r k to p r ev e n t need l e s s r epe t i t ion on the i npa t i en t unit.---Karen Humphries, RN, BSN, CEN, Clinical Educator for Emergency Services, Uniontown Hospital, Union- town, Pennsylvania ....... ~. ....

. . . . • f .

We felt t h e s u r v e y i n g t e a m w a s look ing for e v i d e n c e of an ins t i tu t iona l t e a m effort.

Answer No. 2 A t a sk force inc lud ing r e p r e s e n t a t i v e s from the e m e r g e n c y d e p a r t m e n t a n d major i npa t i en t uni t s m e e t s to sha re thei r different pe r spec t ives . As a result, it is no longer a c c e p t a b l e for staff to re fuse to t ake repor t b e c a u s e the a s s i g n e d nurse is not available. Rather, ano ther nurse , such as t he cha rge nurse, t akes t he report . The e m e r g e n c y nurse he lps the i npa t i en t uni t nu r se by admin i s t e r i ng the ini t ial dose

The p h y s i c i a n e x a m i n e r a s k e d a b o u t t h e f o l l o w i n g i tems: mul t i l ingua l pa t i en t s , cho ice of ca l lback pa t i en t s , f o l l ow-up of x-ray a n d culture results , EMS educat ion , d i sas ter p lann ing , pediatric c o m p e t e n c i e s and care (particularly resusc i ta t ion) , and variable s taf f ing dur ing c e n s u s f luc tuat ions .

Answer No. 3 I e m p h a s i z e communica t i on . I was an ICU nurse and I r e m e m b e r how o v e r w h e l m i n g the i npa t i en t uni t s can be. E m e r g e n c y nur ses who have w o r k e d on i npa t i en t uni t s also have an e m p a t h i c u n d e r s t a n d i n g of t he s i tua t ions .

I e n c o u r a g e the e m e r g e n c y staff nurse , if possible , to a c c o m m o d a t e t he i npa t i en t un i t ' s r e q u e s t for extra t ime. It bui lds a t ru s t ing work ing re la t ionship , wh ich is impor t an t w h e n the e m e r g e n c y d e p a r t m e n t is over- w h e l m e d and staff m u s t move p a t i e n t s immedia te ly . I also e n c o u r a g e invo lvemen t of bo th c h a r g e nurses to faci l i ta te a c c u r a t e and t imely informat ion and plan- ning.--Diane Knecht, RN, MBA, MSHA, El) Nurse Manager, University Hospital, Denver, Colorado

• Question

Help! Joint Commission is coming; what have others learned?

Answer No. 1 Our co l leagues s u g g e s t e d a collabora- t ive p r e s e n t a t i o n tha t t hey u s e d w h e n v i s i t ed by the Joint Commiss ion on A c c r e d i t a t i o n of Hea l thcare Organiza t ions . A n ED t e a m c o m p o s e d of phys ic ians , nurses , and m e m b e r s of m a n a g e m e n t t a lked briefly


Zimmernaann/JOURNAL OF EMERGENCY NURSING

abou t pe r fo rmance improvemen t , future plans, and s p e c i a l - n e e d s pa t ien ts . It w a s very well rece ived .

Our e x a m i n e r focused on the cr i ter ia a n d moni - tor ing of our sec lus ion room, consc ious seda t ion , v i c t ims of abuse , i n c a r c e r a t e d pa t ien t s , a n d docu- m e n t i n g c o m p e t e n c y in n e w staff. Staff were s t o p p e d and a sked a b o u t c rash car t checks and the ac t ion they would t ake if the re we re a d i sc repancy . The rev iewers also aud i t ed char t s for d i s c h a r g e ins t ruc- t ions g iven to pa t i en t s w i th spec ia l needs . We were a sked to verba l ly walk the e x a m i n e r s t h rough the s t eps of the c o n t i n u u m of care p roces s from the t ime pa t i en t s arr ive at the e m e r g e n c y d e p a r t m e n t , are a d m i t t e d to an ICU, and finally are t ransfer red to a rehabi l i t a t ion unit.

Overall, w e felt the su rvey ing t e a m was looking for e v i d e n c e of an ins t i tu t ional t e a m effort. Our success w a s largely b e c a u s e of early and tho rough staff invo lvement from the b e g i n n i n g of the p repa ra to ry work.--Ann Griswold, RN, MS, Manager for the Emergency Department, Morristown Memorial Hospital, Morristown, New Jersey

T h e n u r s e e x a m i n e r l o o k e d for c o n s i s t e n c y in t h e u s e of c o n s c i o u s s e d a t i o n h o s p i t a l - w i d e , a n d s h e ver i f i ed s ta f f c o m p e t e n c y a n d cer t i f i ca t ion t h r o u g h our e d u c a t i o n a l d e p a r t m e n t . S h e a l so a s k e d a b o u t t h e c o n t i n u u m of care, u s i n g t h e e x a m p l e of a p a t i e n t w i t h c o n g e s t i v e h e a r t d i s e a s e .

Answer Ne. 2 We ne tworked wi th other ins t i tu t ions and h i red a p a i d consu l t an t to help us p r epa re for our visit. From our p a s t exper iences , w e focused our a d v a n c e work on ensur ing compl i ance wi th code car ts r equ i remen t s , refr igerator t empe ra tu r e s , and sharps conta iners .

The p h y s i c i a n examine r a sked abou t the following i tems: mul t i l ingual pa t i en t s , choice of ca l lback pa t ien t s , follow-up of x- ray and cul ture results , EMS educa t ion , d i s a s t e r p lanning , ped ia t r i c c o m p e t e n c i e s and ca re (part icular ly resusc i ta t ion) , and var iab le s taff ing dur ing census f luctuat ions. He speci f ica l ly w a n t e d to k n o w abou t our "door to d rug t ime" for t issue p l a s m i n o g e n ac t iva tor and ca rd iac ca the te r i za -

t ion labora tory and w h e t h e r a t t e n d i n g phys i c i ans were g iven a copy of the ED chart .

On the tour of our d e p a r t m e n t , the phys i c i an e x a m i n e r focused on t r iage, the u se of our d e s i g n a t e d x- ray room, and pa t i en t vis ibi l i ty from the nur ses ' s ta- tion. He specif ica l ly ver if ied tha t only the p h a r m a c y c h e c k e d and locked our code carts . However , he d id not ac tua l ly go into any p a t i e n t care area, nor d id he ask ques t ions of any staff nurse .

Our s tory b o a r d a b o u t q u a l i t y i m p r o v e m e n t w i t h p h y s i c a l r e s t r a i n t s w a s r e a d t h o r o u g h l y , a n d t h e r e v i e w e r s u g g e s t e d t h a t a g o o d top ic for t h e f u t u r e w o u l d b e t h e a m o u n t of t i m e from t h e init ia l r e q u e s t for a CT s c a n for a p a t i e n t w i t h a h e a d injury to t h e t i m e t h e r e s u l t is o b t a i n e d .

The nurse examine r looked for c o n s i s t e n c y in the u se of consc ious s eda t ion hosp i ta l -wide , and she ver- if ied staff c o m p e t e n c y a n d cer t i f ica t ion th rough our educa t iona l depa r tmen t . She also a sked abou t the c o n t i n u u m of care, u s ing the e xa mple of a pa t i en t wi th c onge s t i ve hea r t d i sease .

T h e r e s e e m e d to b e m o r e of an effort to offer i d e a s a b o u t b e t t e r w a y s to do t h i n g s ra ther t h a n w h a t h a d b e e n p e r c e i v e d in t h e p a s t to b e a j u d g m e n t a l p u n i t i v e a p p r o a c h .

Al though no speci f ic pol icy w a s p i n p o i n t e d for review, some were p r e s e n t e d by us as par t of our m a n a g e m e n t a p p r o a c h in dea l ing wi th i ssues . Three char t s were rev iewed , and the examine r i n d i c a t e d tha t not u s i n g our d i s c h a r g e condi t ion check-off box, even if wr i t t en in the nu r se s notes , could resul t in a Type I c i ta t ion. Our s tory board abou t qual i ty im- p r o v e m e n t wi th phys i ca l r e s t ra in t s w a s r ead thor-

October 1997 4 7 0

JOURNAL OF EMERGENCY NURSING/Zimmerumnn

oughly, a n d t h e r e v i e w e r s u g g e s t e d t h a t a g o o d t o p i c

for t h e fu tu re w o u l d b e t h e a m o u n t of t i m e f rom t h e

in i t ia l r e q u e s t for a C T s c a n for a p a t i e n t w i t h a h e a d

in jury to t h e t i m e t h e r e su l t is o b t a i n e d .

A l t h o u g h w e h a d b e e n w a r n e d t h a t sa fe ty w o u l d

b e a ma jo r e m p h a s i s , r e p r e s e n t a t i v e s f rom e a c h of our

n e t w o r k ' s h o s p i t a l s w e r e a s k e d f e w q u e s t i o n s on t h a t

top ic . Overal l , I f o u n d th i s visi t , c o m p a r e d w i t h m y

p r e v i o u s e x p e r i e n c e s , to b e m o r e e d u c a t i o n f o c u s e d .

T h e r e s e e m e d to b e m o r e of an effort to offer i d e a s

a b o u t b e t t e r w a y s to do t h i n g s r a the r t h a n w h a t h a d

b e e n p e r c e i v e d in t h e p a s t to b e a j u d g m e n t a l p u n i -

t i v e approach.--Doran Stamps, RN, BSN, CEN, Unit Director of the Emergency Department, Montclair Baptist Medical Center, Birmingham, Alabama

Many thanks to Barb Pierce, RN, MS, Director, The Children's Hospital of Alabama, Birmingham, Alabama, for her assis tance with this column.

M a n a g e m e n t questions f r o m nurses are welcome, as are names a n d addresses of nurses in management who are interested in answering questions. Submit to Polly Gerber Zimmermann, RN, MS, MBA, CEN, 4200 N. Francisco, Chicago, IL 60618; p h o n e (312) 828-0100, ext 235; E-mail: pz immer@cmeinfo , com.

A Look Back: Battle of the bulge

During the early 1800s, surgeons focused their energy and expert ise on the plight of those afflicted with an arterial aneurysm---and with good reason. Living with these thin-walled bulges was like living with a live grenade. Specific types of arterial aneurysms were first descr ibed in 1804, by a brilliant, although ruthless, Italian surgeon, Antonio Scarpa (1752-1832), who began his medical career at 15 years of age. Scarpa's findings intr igued several n ineteenth century surgeons who devised several doubtful therapeutic procedures including:

• Injection of a special fluid to harden the aneurysm, not fully realizing how quickly such fluids are swept away in the bloodstream.

• Wrapping the aneurysrn with steel wire or wi th t issue taken from the neck.

• Placing needles in afflicted blood vessels and passing an electric current be tween them in hopes of coagulat ing the blood (this method was still be ing a t tempted in the 1930s).

• Charles H. Moore (1821-1871), a London surgeon, is regarded as the most resourceful when dealing with aneurysm repair. Moore "reinforced" the aneurysm with steel wire fed through a cannulated tube. In one case, he did not stop until he had filled the aorta with 26 yards of steel wire, an idea he may have got ten from the concept of reinforced concre te . - Linda Manley, RN, BSN, Columbus, Oh4o

Suggested reading Haeger K. The illustrated history of surgery. New York: Bell; 1988. p. 248-9.


Documents

Managers ask and answer