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, Keizer, OR, and AnnMarie Papa, DNP, RN,CEN, NE-BC, FAEN, Philadelphia, PA
SHARED GOVERNANCE
Have you implemented a shared-governance
program in your department? If so, what are the
strengths and weaknesses of the program?
Answer 1:I am a strong proponent of shared governance and have usedthis in both the ED and intensive care unit setting with suc-cess. What has worked for me is to find a topic the staff isreally passionate about. When they see the influence theycan have on that topic using a shared-governance model,then attendance at councils improves significantly. I have astaff member run the council, which includes setting anagenda, running the meeting, and distributing minutes.This chairperson also solicits staff input when needed viasurveys or discussion. When staff members experience thepositive outcomes from one idea and realize the potentialof their influence on unit processes, the council processbuilds upon itself and becomes more effective. The shared-governance councils work even better when multiple dis-ciplines provide input to resolve issues or concerns. Wehave multiple councils in my current unit: leadership,quality (multidisciplinary), and practice. All of these meetthe same day at staggered times. I also have a night coun-cil that is led by the night staff, works on night-specificissues, and alternates its monthly meeting with an educa-tional offering. Staff members have responded passio-nately to the shared-governance structure, and we havevery active councils.—Pamela Smith, MSN, MBA, RN,CEN, Nurse Manager, Surgical Trauma Intensive CareUnit, Medical University of South Carolina, Charleston,SC; E-mail: [email protected]
CONTROLLING RECIDIVISM
What measures have you instituted to reduce
recidivism and narcotic abuse in your department?
Answer 1:We have a couple of different approaches for any patientswho frequent our emergency department. For those seenregularly or with an anticipated increase in visits, we sendtheir primary care provider a “plan of care” form to com-plete. This form asks for the primary care physician (PCP)to indicate a suggested course of treatment for the patientwhen he or she comes to the emergency department toseek care for a specific complaint, such as a migraine.We emphasize the necessity for patients to be treated col-laboratively. Appropriate and safe treatment is stressed,and the plan of care serves only as a recommendation tothe provider on duty, not as physician orders. The EDstaff will then treat patients as they deem appropriatebased on their assessment at the time. Plans of care foreach patient are kept within the emergency departmentin a file, along with copies of the most recent ED visitpaperwork and information specific to providing consis-tent treatment of the patient, such as length of time thepatient must wait after being medicated, interventions,dressings, and tips on intravenous access—all to ensureconsistency in our approach to treatment. As is well-known, these patients are great at manipulation, and anyinconsistency can be interpreted as leverage. Plans of careare re-evaluated for updates minimally every quarter by theED senior charge nurse.
Nursing staff members are a tremendous resource byidentifying any patients they see at risk through trendingvisits or behaviors exhibited while in the emergencydepartment. If a patient is at risk of being unsafe, showsany adverse effects from a treatment, or has a repeat visitinvolving any impairment, the plan of care is amended toextend periods of observation or discourages use of anymedication that may cause mental impairment. If a patientrefuses to stay for observation after being medicated, he orshe is required to sign out against medical advice. Thepatient is told we will call the police if we are concerned
The opinions expressed are those of the respondents and should not be con-strued as the official position of the institution, ENA, or the Journal.
J Emerg Nurs 2011;37:284-8.
Available online 24 March 2011.
0099-1767/$36.00
Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc.All rights reserved.
doi: 10.1016/j.jen.2011.01.007
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for his or her safety and we change his or her treatmentplan accordingly.
At times of minor escalation with regard to behaviorand frequency of visits and/or hospitalizations, the MedicalDirector or I will call the PCP to come up with a safe, col-laborative approach to helping repeat patients. This maymean a change to a medication regimen or a patient/familymeeting with the PCP. For excessive escalations, we haverequested care management consultations and haverequired the patient to be evaluated by the behavioralhealth or crisis management department each time he orshe presents to the emergency department. We have alsorecommended pain specialist consultations and have soughtand been successful with having the patient being admittedto a psychiatric unit.
Lastly, because physician assistants and nurse practi-tioners primarily staff the emergency department, bypolicy, they may not write prescriptions for any Sche-dule II drugs. If this Schedule of drugs is deemed neces-sary, prescriptions for Percocet and similar drugs arerequired to be written by the hospitalist or the on-callphysician, who may have to be called in from home.—Chris Costello, RN, CEN, Director of Emergency andObstetrical Services, Mount Desert Island Hospital, BarHarbor, MN; E-mail: [email protected]
Answer 2:In our emergency department we developed a “frequent user”program to address this issue. We took the following steps:
• I create an order in our computer system that is an EDsocial worker (SW) referral for “frequent user.” Anyclinician can order this consultation (nurse or provider).
• The ED SW then reviews the case for number of vis-its and reasons to determine whether it appears that,indeed, this is a frequent user—someone who is usingthe emergency department for care that is best deli-vered elsewhere (such as primary care provider).
• If the patient is deemed a frequent user, then the EDSW e-mails that information to the EmergencyDepartment Medical Director for Quality. He reviewsthe case for medical clearance, so to speak. If, after thisprocess, the patient is then finally deemed a frequentuser, the medical director notifies the ED SW, whoenters that information into our computer system.
• I developed a step where, once the patient returns, ablue dot appears next to the patient’s name on ourtracker to flag him or her to the clinicians.
• The patient is expedited into the emergency depart-ment and seen as soon as possible.
• The ED SW is called to meet with the patient anddiscuss alternate care sites such as primary care
clinics, wound care, home care, and so on. TheSW will also work with these patients to set up appoint-ments and other activities to facilitate alternate carelocations. Finally, the SW also has them review a patientcare plan/agreement.
• Narcotic dispensing is limited to prescription only, anda maximal number of tablets are specified.
• All providers are expected to follow this program unless,of course, the patient presents with emergent needs.
• If the frequent user presents for emergent needs, then thecase is again reviewed and the person may be removedfrom the program.
• We removed Dilaudid from our emergency department.• The ED SW keeps a running list of all frequent usersand monitors their care and progress.
This has led to a significant reduction in frequent userspresenting for various reasons including potential narcoticabuse.—Celeste Surreira, RN, BSN, CEN, Director of Emer-gency Services and Preparedness, DeKalb Medical, Atlanta,GA; E-mail: [email protected]
COMMUNICATING WITH INPATIENT UNITS
What type of communication do emergency nurses
use to give report when moving patients to an
inpatient bed?
Answer 1:We currently use a traditional telephone report, whichoften leads to delays in moving patients from the emer-gency department to the floors. A frustration expressedby many ED staff members is that there is never anyoneavailable to take report when they call, and often, whenthe nurse on the unit calls back to the emergency depart-ment, the emergency nurse is involved in another patientcare activity, increasing the delay.—Terri DeWees, RN,MSN, CEN, Director of Emergency Services, Carteret GeneralHospital, Morehead City, NC; E-mail: [email protected]
Answer 2:We stopped giving face-to-face report to all medical/surgical units except the critical care unit about 3 yearago. Before the patient is transported to the floor, the pri-mary nurse puts pertinent information into a computerreport specifically designed by the floor nurses. That infor-mation is accessible to the nurses on the floor. The reportincludes the emergency nurse’s contact number, and it isexpected that if the floor nurse has any questions, the emer-gency nurse will be available for 30 minutes after thepatient leaves the department (including after shift change).
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Our experience with this type of reporting has not beenvery good. The floor nurses were not reading the ED reportbefore the patient’s arrival to the floor. Communicationfrom the administrator on duty through the floor chargenurse to the primary nurse was non-existent, so when thepatient arrived to the floor, the nurses were surprised. Whenthe patient arrived to the floor, the room was not ready andsometimes it was dirty. Equipment such as oxygen regula-tors, intravenous pumps, and even beds were not in theroom. The floor nurses have been pushing for face-to-facereport to return. Our director of nursing has said that face-to-face report will not return so that has helped our case.
The good thing about computer report is that emer-gency nurses do not spend a lot of time outside of thedepartment waiting on equipment to be delivered to theroom. They do not have to wait until the floor nurse isready to give report, and that allows them to continue todirect their attention to the never-ending stream of patientsentering the emergency department. They also do not leavethe other 3 or 4 patients already under their care whentransporting the additional patient to the floor.
For the emergency nurse, I do not see a downside tothis type of reporting. Everything the floor nurse needs toknow is readily available, either in the computer or by call-ing the emergency nurse.
If someone is considering this type of reporting, he or sheshould expect that the floor nurses will not like it. Supportfrom administration is imperative when the floor nursesrevolt. If you let them know that there is not anything morein the computer/faxed report that the floor nurse needs toknow, it may help you convince them that face-to-face reportis a waste of time and slows patient care in the emergencydepartment.—David M. Solomon, RN, BSN, CEN, EMT-P,Patient Care Coordinator, Catawba Valley Medical Center,Hickory, NC; E-mail: [email protected]
Answer 3:In our facility we moved from a full faxed report to aninformation technology solution in combination with afaxed notice. We currently use an ED clinical summary,which we designed to pull in pertinent information fromthe ED electronic medical record into specific categoriesincluding, but not limited to, presentation informationfrom triage (chief complaint, allergies, home medications,medical history, triage level), interventions, most recentassessments, vital signs, and diagnostic tests and theirresults. These areas include the S, B, and A segments ofthe SBAR handoff (SBAR is an acronym for situation,background, assessment, recommendations). To alert theinpatient nurse, the emergency nurse faxes a “faxed notice”that states that the nurse should review the ED clinical
summary. Also written is the recommendation of outstand-ing or in-progress items, as well as the nurse’s name andportable telephone number for questions. After 15 min-utes, if there are no questions, the patient is transported.This solved issues of legibility, significantly increased theamount of visible information, and reduced concernsregarding missing information.—Celeste Surreira, RN,BSN, CEN, Director of Emergency Services and Preparedness,DeKalb Medical, Atlanta, GA; E-mail: [email protected]
VISITING POLICIES
Have you implemented a nonrestrictive visiting
policy in your department? If so, what have been
the advantages of this system? What words of
wisdom would you share with others who are
thinking about implementing a similar policy?
Answer 1:Several years ago, we lifted our visitor restrictions. We allowthe patient to have as many visitors with them as they wouldlike. If a procedure needs to be done or if the nurse cannotsafely care for the patient, then we explain this to the patientand visitors. We then ask that a few rotate out. We did havepushback from the staff in the beginning. We educated staffas to why we were doing this, and once everyone saw that thisis what our patients wanted, the pushback subsided.
As emergency nurses, we all want to know the “why”behind everything we do. This is no different. If youexplain to staff that patients want their loved ones withthem, then they will allow them to stay.—Tonya Whitaker,RN, CEN, Assistant Manager, Gaston Memorial Hospital,Gaston, NC; E-mail: [email protected] 2:In our emergency department, we moved to have a moresystematic process by which to monitor visitation forpatient and staff safety reasons. Visitors must all sign intoour log at the ED security desk, which is now staffed24 hours per day. Security then notifies the patientrepresentative, who contacts the primary registered nurse.If the patient’s care allows for a visitor, the registered nursethen speaks with the patient to see if he or she would like tosee that visitor. If the patient agrees, the visitor is given abadge with the patient’s room number and escorted by thepatient representative. This process improves security,clearly demarcates visitors within the department, allowsthe patient control over his or her own visitation, andreduces the number of visitors entering incorrect roomsand wandering within the department. We also now have
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a log of visitors should any concerns arise. Our patient repre-sentatives also serve as the liaisons between our patients, visi-tors, and staff.—Celeste Surreira, RN, BSN, CEN, Directorof Emergency Services and Preparedness, DeKalb Medical,Atlanta, GA; E-mail: [email protected]
PATIENT FALLS
What has your department done to identify patients
at high risk for falls and reduce those falls?
Answer 1:All patients who are identified as being at risk for falls have aseparate “fall precautions” bracelet to identify them as such.A sign is placed on the door so that all staff members areaware of the patients’ risks. Patients are also offered nonslip
socks if needed. One-on-one sitters can be used if needed.We have worked with staff to help them identify patientswho need to be on fall precautions. Lastly, we implementeda “post-fall huddle.” When a patients falls, the primarynurse, physician, and charge nurse all meet to discuss the fall,possible causes, and further prevention measures that needto occur.
We also “investigate” every fall in the department tomonitor for trends as well as possible educational opportu-nities.—Tonya Whitaker, RN, CEN, Assistant Manager,Gaston Memorial Hospital, Gaston, NC; E-mail: [email protected]
Answer 2:Our ED Patient Safety Council conducted a literaturereview and was unable to identify a fall-risk assessment
FIGURE
Instructions for completing fall risk assessment and interventions: (1) If the patient (Pt) meets one or more of the fall-risk assessment indicators, implement all of thefall-risk interventions, except the “starred” interventions (those preceded by an asterisk). Starred interventions are optional at this phase and may be implementedbased on clinical judgment. (2) If the patient meets one or more of the starred fall-risk assessment criteria, implement all of the fall-risk interventions, including thestarred interventions (those preceded by an asterisk). ETOH, alcohol use.
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and intervention tool that is validated in the ED setting.Our council decided to develop and trial our own tool.We first conducted an evaluation of all falls that occurredin our emergency department over a 12-month period. Weidentified the most frequent risk factors and then devel-oped a set of corresponding interventions. The Figureshows the tool used to identify these risk factors and theaccompanying interventions.
On the patient’s admission to the emergency depart-ment, the nurse uses a simple checklist tool to evaluate forfall-risk indicators. If the patient has 1 or more fall-risk indi-cators, we apply a bundle of fall precautions, including placinga yellow fall-risk arm band on the patient, placing the bed rails
up, placing the bed in the low position, instructing the patientnot to get out of bed unassisted, asking family to stay with thepatient, and offering toileting hourly. Staff must remain withfall-risk patients when they are out of bed toileting.
In addition, if a patient has risk indicators that includealtered mental status, or alcohol or drug involvement, he orshe receives an expanded fall-precaution bundle, includingall of the previously mentioned precautions, plus the roomdoor and curtain are left open, the patient receives redsocks, and a bed alarm is applied.—Louann Sears Bean,RN, BSN, Director, Emergency and Urgent Care Services,Harrison Medical Center, Bremerton, WA; E-mail: [email protected]
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