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:
JOURNAL OF EMERGENCY NURSING 31:3 June 2005
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:
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
9M A N A G E R S F O R U M / Z i m m e r m a n n
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:
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
M A N A G E R S F O R U M / Z i m m e r m a n n
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
JOURNAL OF EMERGENCY NURSING 291
M A N A G E R S F O R U M / Z i m m e r m a n n
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.
292 J
. 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:
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:
OURNAL OF EMERGENCY NURSING 31:3 June 2005
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 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]
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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:
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]
OURNAL OF EMERGENCY NURSING 31:3 June 200
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5
M A N A G E R S F O R U M / Z i m m e r m a n n
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;
E-mail: [email protected]
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:
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]
JOURNAL OF EMERGENCY NURSING 29
5M A N A G E R S F O R U M / Z i m m e r m a n n
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;
E-mail: [email protected]
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.
OURNAL OF EMERGENCY NURSING 31:3 June 2005
M A N A G E R S F O R U M / Z i m m e r m a n n
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