cutting-edge discussions of management, policy, and program issues in emergency care
TRANSCRIPT
CUTTING-EDGE DISCUSSIONS OF MANAGEMENT,POLICY, AND PROGRAM ISSUES IN
EMERGENCY CARE
Authors: Jeff Solheim, RN, CEN, CFRN, FAEN, and AnnMarie Papa, MSN, RN, CEN, CAN, FAEN,Doyelstown, PA, and Keizer, OR
WALKING REPORT
Do the nurses in your unit use walking report at
shift change?
Answer 1:We have been using walking report in our department fornearly 2 years. Report occurs in the nurses’ station wherenurses have access to the electronic chart. After pertinentinformation is exchanged, both nurses proceed to the bed-side, where the off-going nurse introduces the oncomingnurse. This gives the patient the opportunity to meet his/her new nurse and gives the nurses the opportunity toquickly assess the patient and address any equipment/sup-ply needs. They also have the opportunity to meet anyimmediate needs that the patient or family may have.
Staff initially was not receptive to this process change,and we still go through periods where they have to bereminded of the process. Overall, feedback from patientsand many staff members has been quite positive. We havealso seen a decrease in issues such as missing equipmentand dirty rooms when staff rounds on unoccupied roomsas well as occupied rooms.—Terri DeWees, RN, MSN,CEN, Director of Emergency Services, Carteret General Hos-pital, Morehead City, NC; E-mail: [email protected]
Answer 2:We attempted walking rounds at my previous place ofemployment. Although it sounds nice in theory, in reality,it did not work. After 12 hours, everyone just wants to givereport and go home. We also found the people coming ondid not want to start off with walking rounds.—David
Marsh, RN, BSN, Director Emergency Services, Artesia GeneralHospital, Artesia, NM; E-mail: [email protected]
Answer 3:We began walking report a little over a year ago for severalreasons. First, the noise level in the nurses’ station at shiftchange was too high, with everyone trying to talk over eachother, and the doctors and patients complained. The walk-ing report also introduced the oncoming nurse to thepatient and allowed the oncoming nurse to make surethe room was in order and the patient’s chart was complete.If something was wrong, this gave the oncoming nurse achance to have the off-going nurse fix it before leavingthe hospital. This helped with the accountability of ournurses to keep their rooms as clean as possible and theircharts as complete as possible. I believe it has helped withnurse as well as patient satisfaction. If a room is dirty or achart incomplete, the oncoming nurse who received reportat the bedside cannot complain later. He or she had his orher chance to have the problem fixed by the off-goingnurse. The patients like it because they get to meet theirnew nurse, and for a patient who may have been waitingfor a time, he or she has some type of contact with staff. Italso gives the patient a chance to express any needs.
If someone is looking to implement this type of report,it takes some time to get the nurses on board and walkingat every report. They seem to want to migrate back to thenurses’ station every now and then.—David M. Solomon,RN, BSN, CEN, EMT-P, Patient Care Coordinator, CatawbaValley Medical Center, Hickory, NC; E-mail: [email protected]
ED BOARDING
What measures has your department implemented to
reduce boarding of inpatients in the
emergency department?
Answer 1:We have a bed-ahead program that allows our medical andsurgical intensive care units to staff critical care beds in
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 2010;36:497-500.
Available online 23 July 2010.
0099-1767/$36.00
Copyright © 2010 Published by Elsevier Inc. on behalf of the EmergencyNurses Association.
doi: 10.1016/j.jen.2010.06.017
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September 2010 VOLUME 36 • ISSUE 5 WWW.JENONLINE.ORG 497
advance of a patient admission. Our hospital has alsoadded hospitalists to decrease the “cap” on our medicineand family practice admit teams.—Kathy Guttierez, RN,BSN, CEN, Care Coordinator, Fletcher Allen Health Care,Burlington, VT; E-mail: [email protected]
Answer 2:We have a 5-bed Clinical Evaluation Unit that has beenused for multiple purposes. In the winter it turns into aholding area for patients awaiting available inpatient beds.Previously, this area was staffed by both emergency andinpatient nurses. In an effort to support our staff, webrought travelers in this year to cover this unit. On thefew days that the unit is not open, those nurses are floatedto units that are having staffing shortages because of issuessuch as illness. Bringing the travel staff in has helped toreduce the fatigue experienced when regular RN staff hasto work mandatory overtime.—Terri DeWees, RN, MSN,CEN, Director of Emergency Services, Carteret General Hospi-tal, Morehead City, NC; E-mail: [email protected]
Answer 3:Several years ago, our organization hired a consulting firmto streamline our ED process, which included admissionsfrom the emergency department. Before this change, it wascommon for us to hold critical care patients in the emer-gency department. The changes that were made includebed assignments made solely by the administrator on duty.We also changed the process in which our rooms werecleaned when a patient was discharged, giving priorityto those rooms that were needed for admissions.—DavidM. Solomon, RN, BSN, CEN, EMT-P, Patient CareCoordinator, Catawba Valley Medical Center, Hickory, NC;E-mail: [email protected]
SAFE HAVEN LAW
How does your facility handle children who are
brought to your department under the safe haven law?
Answer 1:In July of 2008 Nebraska became the last state in the UnitedStates to pass a “safe haven” law. These laws allow parentswho feel that they cannot adequately care for a child to leavethat child in a safe environment, such as a hospital. In itshaste to pass a law, the state legislature did not put a limiton the age of children who could be left at a hospital, allow-ing parents to leave newborns up to 19-year-old children.Over the 3 months before the law was revised, the statereceived national attention as 36 children—many of them
hard-to-handle teenagers (and one family comprising 6kids)—were dropped off at hospitals by desperate parents.
When the law was first passed, we received an E-mailfrom hospital administration expressing happiness that thisnew development would increase safety for children in thestate. As an ED night shift charge nurse, I knew that Iwould be a likely receiver of a safe haven “drop off” andsent an E-mail back asking that we have a policy or somesort of guidance for these situations. I knew, of course, thatby sending this E-mail, I was prompting the formation ofsome sort of committee and presenting myself as a naturalcandidate to be a part of it.
Representatives from all 3 hospitals in Lincoln,Nebraska (including various areas such as the emergencydepartment and labor and delivery), met with local policeand social services to craft a unified and consistent responsefor safe haven “drop offs.” In our city the police depart-ment is the initial gateway to child protective services.Our policy was crafted to facilitate a smooth transition intothe social services system. We knew that the lack of an agelimit was going to be problematic. The ensuing use (orabuse) of the law proved to be such a debacle that the leg-islature convened a special session to revise the age limit ofchildren eligible for safe haven to 30 days or younger.Since this revision in November 2008, we have not hadany children left at our hospital under this law. The situa-tions created by the original (lack of) age limit prompted amuch closer look at the need for greater social services forchildren in the state.
Our current hospital policy, under the revised statelaw, states that if parents present with their child to anyhospital associate requesting safe haven for their child,they are escorted to the emergency department to beregistered (if they are not already a postpartum patient)with security and the house supervisor is summoned tofacilitate the child’s process into the social services system.Our security officers are off-duty law enforcement, so theyare there as a resource to answer questions until on-dutypolice arrive.
An ED provider performs a medical screening exami-nation and assesses for signs of abuse or neglect. Law enfor-cement, in collaboration with child protective services,facilitates the child’s final placement.
Our emergency department’s one experience with safehaven during the initial 3 months of the no–age limit lawinvolved a teenager who ended up going home with herparents after a long discussion with social services. BecauseI was the department safe haven “expert,” I received a callat home from the triage nurse when the parent initiallybrought the child to the emergency department invokingthe safe haven law. When I arrived for work that night,
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the teen was still in the department and I took over as theprimary nurse for the patient. With the arrival of police andsocial services, the involvement of the department, the hos-pital, and myself was pretty minimal.
With the close involvement of local law enforcementand social services, we put together a process that worksin our community. The use of (the revised) safe havenlaw has been minimal. The situations created by the origi-nal form of the law spotlighted the need for greater socialservices for children in the state—a topic that continuesto be debated in the media and by the government.—Curtis Olson, RN, BA, EMT-P, CEN, Staff Nurse, Emer-gency Department, Saint Elizabeth Regional Medical Center,Lincoln, NE; E-mail: [email protected] (Thanksto Libby Raetz, Emergency Department Director, and JoMiller from Public Relations for input.)
WIRELESS COMMUNICATION DEVICES
Does your department use wireless communication
devices? If so, what are the positive aspects and what
lessons have you learned?
Answer 1:Our emergency department moved into a new patient carespace in July 2008. We changed from the original “arena”-style emergency department with examination roomsaround one central nursing station to teams with distinctareas. We now have 4 patient care teams, a minor careroom, and a resuscitation room. Each team has its ownnurses’ station, supply room, and medication/nourishmentroom. This was very challenging for communicationbecause we could no longer see each other and the foot-print of the emergency department increased greatly. Afterrecommendations from FreemanWhite (Charlotte, NC) tolook at a few systems, we settled on Vocera (San Jose, CA).
The product is a 1-button push-to-talk, lightweighthands-off communication device. You can definitely mul-titask, walk and talk, page people, or make and receivephone calls while using Vocera. If you are with a patientand need help, there is one button to push and talk andthat is it! We use the “locate” feature when staff want totalk face to face but do not want to interrupt the personwith a call—Vocera tells you exactly where they are. Theshift flow coordinator can “broadcast” a message to theentire staff regarding flow or system issues, an incomingambulance, and so on. All disciplines in the emergencydepartment use Vocera—registered nurses, patient caretechnicians, physicians, registration personnel, radiologypersonnel, environmental services, social workers, financial
counselors, and case managers. We went live with Vocerain our emergency department 1 month after moving in.
The one thing we struggle with still is speaking tooquickly. It is an ED thing, always pushed for somethingelse to do or another place to be but you cannot interruptthe voice on Vocera (the “Genie”) and you cannot speakbefore she is finished!
Here are some tips we learned during our implemen-tation. Go to the Vocera user forum as soon as you can.One person from the information technology departmentand myself went to the Vocera user forum when we were inthe planning stage of converting from Spectralink phones(San Jose, CA) to Vocera. We were able to talk to lots ofcurrent users and Vocera staff about what we needed tomake implementation and use a success as well as whatobstacles to watch for. On the user forum, Vocera hasworkshops that cover everything from reports to asset man-agement, voice recognition, and staff use as well as theinformation technology components.
We also did a site visit to a hospital that was in fullswing with Vocera. Vocera staff stay very active throughoutplanning and implementation so that you are successful.When implementing and planning, do everything thatVocera says to do, including training to go live.
Our compliance department was involved in the plan-ning and policy writing. It is our policy that everyone wearsheadsets for compliance with privacy regulations of theHealth Insurance Portability and Accountability Act andnoise reduction.
Here are some comments from our staff:“I love that when I need a doctor for a question or con-
cern, I do not have to wait for a call back or I can leave amessage and move on with my cares. The issue is takencare of for me and the patient. Contacting coworkers isquick and easy too. No searching around. No more havingto stop what I am doing to go answer the phone at thenurses’ station.”
“Vocera is much better than using phones.”“It helps when the ED is busy and you can respond
right away.”“Vocera definitely helps the financial counselors. They can
just ask for the flow coordinator on Vocera, get me, and I canquickly print off a patient’s face sheet and be in their roomshortly thereafter, as sometimes, we are needed right beforethe patient is discharged.”
“… from a communicator standpoint … it’s great to locatepeople with!”
“Vocera has definitely helped in our communication notonly with the nursing staff but also the physicians. It is mucheasier to find the nurse you are looking for to ask questions orreceive updates regarding patients. It is also much smaller to
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carry with you than traditional phones. Also having multipleways to get a hold of CT [computed tomography] and radiol-ogy staff makes it easier too.”
“It is very convenient to locate another user and have quickquestions answered very timely. I especially appreciate it whenI go up to the floor to get signatures. In most places in thehospital my Vocera has access. I can be up on the fourth floorgetting signatures and either answer a simple question forsomeone in the ED or let them know I am on my way backdown so I can see a patient before discharge.”
“I love it! We can walk and talk and work at the same time,and I think it’s really efficient.”
“Vocera has helped me as a communicator to be able tolocate specific staff to have them sign orders and ask ques-tions. With Vocera, I am able to transfer radiology and otherinternal calls directly to staff, while they continue to movearound freely within the department. Vocera helps improvethe speed of which phone calls are transferred and questionsare answered by staff.”—Laurie Salerno, RN, ED Business &Financial Coordinator, Froedtert Hospital, Milwaukee, WI;E-mail: [email protected]
Answer 2:We currently use Spectralink telephones at our hospital.When we first received them, every nurse and emergencydepartment technician received one. It was not long beforethey began to be dropped on the floor or in the toilet,accidentally taken home, or lost. They did not hold upwell to these conditions and were very expensive to repairor replace. We currently have 4 in use in the treatmentarea and 3 in use by management. The cost to replace aphone was about $600 but has since dropped to around$300. We are no longer able to obtain replacement partsfor the model we use. An upgrade to the phone becameavailable several years ago that costs $1000 to buy new.
We have researched other devices such as the Voceraand Nextel (Reston, VA), but because of cost, we havenot switched.
In researching other systems, they all have theirgood and bad points. Nurses will lose them, dropthem in the toilet, and otherwise abuse them so agood warranty is a must. I would suggest visiting anemergency department that already uses any systemyou are thinking of buying to get the real scoop oneach system from those already using them.—DavidM. Solomon, RN, BSN, CEN, EMT-P, Patient CareCoordinator, Catawba Valley Medical Center, Hickory,NC; E-mail: [email protected]
Answer 3:We have cordless phones with paging capabilities for allstaff. Initially, we frequently “dropped” calls, and licensedindependent contractors especially were frustrated with thereception issues. We changed carriers, upgraded our phonesand wireless transmitters, and have resolved that problem.The charge nurse sends pages to alert staff about arrivingambulances or when admit beds are ready and to provideany information needing to be shared with staff. As withany paging service, you can group pages or send to indivi-duals. Nurses can now phone providers, saving tripsaround the emergency department. The ED attendingphysicians have consults paged to their phones, and callscan be transferred to them if needed. It has cut our over-head pages to hardly any. The phones do not have vibrateas an option, which is our only regret, but otherwise workwell. It is not cheap; staff occasionally drop them in thetoilet, or break the holders, but it is improving.—DonnaChicoine, RN, BSN, CEN, Nurse Educator EmergencyDepartment. Fletcher Allen Health Care, Burlington, VT;E-mail: [email protected]
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