News

HICS is an incident management system based on the Incident Command System (ICS) that assists hospitals in improving their emergency management planning, response and recovery capabilities for unplanned and planned events.

HICS will strengthen hospital disaster preparedness activities in conjunction with community response agencies and allow hospitals to understand and assist in implementing the 17 Elements of the hospital-based NIMS guidelines.

Keep Your Emergency Nursing Skills Up to Date

If you want to enhance your ED skills, Emergency Nursing Procedures, 3rd Edition, by Jean A. Proehl, is a must-have item and is now available at ENA Marketplace. This new guide features a complete description of almost 200 emergency nursing procedures - reflecting the latest changes and developments in practice. Emergency Nursing Procedures, 3rd Edition is a comprehensive manual featuring contributions from expert emergency nurses nationwide, providing an expansive perspective. Unlike some manuals that offer an overview, this guide offers step-by-step procedure descriptions. Novices will find the basic procedures a helpful review and experienced nurses will appreciate information about new or infrequently performed procedures. This guide provides clear, pertinent information to help you perform or assist with procedures. Research findings have been incorporated whenever possible to provide a scientific basis for practice. To order your copy, call 800/243-8362 or log onto ENA Marketplace at www.ena.org

ENA Marketplace Now Offers Emergency Nursing Procedures, a Comprehensive Reference for ED Nurses

Emergency Nursing Procedures, the definitive "how to" book, is a reference guide featuring a complete description of almost 200 emergency nursing procedures. This comprehensive manual features contributions from expert emergency nurses nationwide, providing a national perspective. Unlike some manuals that offer an overview, this guide offers step-by-step procedure descriptions. Novices will find the basic procedures a helpful review and experienced nurses will appreciate information about new or infrequently performed procedures. This guide provides clear, pertinent information to help you perform or assist with procedures. Research findings have been incorporated whenever possible to provide a scientific basis for practice. To order your copy, call 800/243-8362 or log onto ENA Marketplace at www.ena.org/store/

ENA GUIDELINES FOR EMERGENCY DEPARTMENT NURSE STAFFING – AN EXCELLENT TOOL FOR ALL EMERGENCY DEPARTMENT  

The ENA Guidelines for Emergency Department Nurse Staffing, developed to help ED managers and administrators easily determine their staffing needs, is an excellent tool designed to be used in all types of emergency departments. The guidelines were developed to calculate effective staffing solutions based on six key components: Patient census, patient acuity, nursing interventions, length of stay, skill mix, and non-patient care time. Take advantage of the member-only price of $100 by ordering your copy at the Marketplace on the ENA Web site or call Member Services at 800/243-8362.

USAMRIID MEDICAL MANAGEMENT OF BIOLOGICAL CASUALTIES HANDBOOK AVAILABLE TO ENA MEMBERS

Learn what the U.S. Army knows about medical management of biological casualties. Get your free copy of this U.S. Army Handbook by calling ENA Member Services at 800/243-8362. This book is provided as a service from ENA and the United States Department of Health and Human Services.

2010 ENA Board of Directors and Nominations Committee

As an ENA member you have exercised your right and privilege to vote for our association's leaders and your voice has been heard. Congratulations to the candidates you elected to serve.

2010 ENA President-Elect (will serve as the 2011 President)
AnnMarie Papa, RN, MSN, CEN, NE-BC, FAEN

Glenside, PA

2010 ENA Secretary/Treasurer
Gail Pisarcik Lenehan, RN, MSN, EdD, FAEN, FAAN

Hingham, MA

Directors

(3-year term: January 1, 2010 - December 31, 2012)

Mitch Jewett, RN, CEN Halstead, KS

Deena Brecher, RN, APRN, MSN, CEN, CPEN, ACNS-BC
Wilmington, DE

Matthew Powers, RN, MS, CEN, MICP
Pleasant Hill, CA

(1-year term: January 1, 2010 - December 31, 2010)

Tiffiny Strever, RN, BSN, CEN
Glendale, AZ

Mary Kamienski, RN, PhD, APN, CEN, FAEN 
Montville, NJ

ENA Nominations Committee

Western Region:

Bettie McCarter, RN, CEN

Gilbert, AZ

Central Region:

LeeAnn Stearnes, RN, BSN, CEN

Memphis, TN

Eastern Region:

Lawrence "Jeff" Jefferies, RN

Woodbine, MD

Past ENA Board Member:

Annabelle "Anne" May, RN, BSN

Gaithersburg, MD

Call for SBIRT (ED Alcohol Screening Program) Volunteers

ENA is currently recruiting nurse champions who are interested in having a positive impact on their community by promoting a reduction in the number of trauma related injuries with alcohol involvement. This would be accomplished through the use of the SBIRT (Alcohol Screening, Brief Intervention and Referral to Treatment) Program that is to start in 2008. Goals would be to reduce

• Initial and repeat alcohol related trauma injuries
• Alcohol consumption
• Emergency department visits
• Health care costs

 Champions will advance ED SBIRT in their emergency departments or place of practice and communities.  They will serve as leaders in promoting and disseminating SBIRT toolkits that were developed in collaboration with National Highway Traffic Safety Administration (NHTSA) and emergency departments across the country. 

   “Many studies show that the SBIRT procedure is an effective prevention intervention for reducing alcohol consumption, repeat injuries, repeat emergency department visits and health care costs” (ENA Connection, Nov. 2007, pg 8).  The SBIRT toolkit, which will be sent to 5,000 hospitals in the Spring of 2008, includes:

• Education Module for emergency health care professionals
• Motivational video
• Power point presentation for nurse educators
• Pocket guide
• Fact sheet
• Drinking agreement
• Patient brochures and
• Other resources.

Many Champions are needed.  Complete a SBIRT Champion Profile on the ENA website www.ena.org/ipinstitute/SBIRT/Benefits.asp or contact the Injury Prevention Institute via email at ipinstitute@ena.org, or call 842-460-4112, or 1800-900-9659x8 and the staff will be happy to help you.

Thank you for helping to reduce alcohol related injuries.  

Anne May, Assistant ENCARE Chairperson

New Process/Procedure Ideas

Have you implemented a new process/procedure that facilitated patient flow in your ED or hospital? If so, we'd like to hear from you. We are looking for new and innovative practices to share with all ENA members in support of their efforts to decrease crowding and lengthy stays. Please send brief descriptions of your best practices (process/procedure) that can be published on the ENA Web site. E-mail your descriptions, with your permission for the Web-site posting, to Kathi Ream, ENA Washington representative, at enagov@aol.com.

Call for Photographs

ENA invites members to contribute photographs of themselves and their emergency nurse colleagues—in and out of the ED setting—for Association promotional campaigns. Your photos will help ENA show emergency nursing at its best and put a real face on the profession. For guidelines on picture-taking, submissions (via mail, CD or e-mail) and the required release form, log on to www.ena.org/statecouncils/PhotoCall/default.asp. For more information, please contact Terri Vargulich in the ENA Marketing Department at tvargulich@ena.org.

Connection Wants to Hear From You

The editors of your member publication, ENA Connection, hope to hear from you in 2007. Feel free to send suggestions, questions and comments to our e-mail address at connection@ena.org. We read every message we receive and welcome the dialogue.

Interested in International Travel?

Do you enjoy international travel? Do you speak a foreign language? The Trauma Nursing Core Course (TNCC) and Emergency Nursing Pediatric Course (ENPC) continue to generate interest outside of our borders. Nurses from Italy, Portugal, Israel, and Singapore are interested in bringing these courses to their countries to help improve patient care.

Sign Up for E-Mail Alerts on Issues Related to Your State

New features have been added to ENA's Legislative Action Center that enable "E-Mail Alerts" to be sent directly to those ENA members who reside in the state or district of the congressional members that we need to target. These alerts provide strategic information to affect key policy issues of interest to ENA and emergency nursing. Go to http://capwiz.com/ena/home/ to sign up for future alerts.

Update on Hospital Standing Orders

In case you haven’t heard, thanks to ENA and other health care organizations, the Centers for Medicare & Medicaid Services (CMS) issued a revised version of its guidelines regarding standing orders and written protocols for drugs and iological in hospitals.  In the clarification, CMS said previous standing orders should be written in the patient’s chart and signed by the practitioner responsible for the care of the patient, but that the timing of such documentation should not be a barrier to effective emergency response, timely and necessary care, or other patient safety advancements. 

Click here for a copy of the revised guidelines.

American Nurses Association Needs Your Input on Safety Issues

Double the Value of Your Gift to the ENA Foundation

Take advantage of your hospital’s matching gift program, and increase the value of your monetary contribution to the ENA Foundation. Many hospitals match their employees’ charitable contributions; just ask your hospital’s matching gift officer (usually in the human resources or community relations department) for a matching gift form. After completing the form, forward it to the ENA Development Office. The Foundation will complete the paperwork. Mail to: ENA Foundation, 915 Lee St., Des Plaines, IL 60016-6569, or email at development@ena.org.

Over half of nurses suffered violence on job: study

By Joe Carlson

ENA Foundation Legacy Society

If you would like to

-         Include the ENA Foundation in your estate planning

-         Have included the ENA Foundation in your estate planning

-         Would like more information regarding making a planned gift to ENA Foundation

Contact ENA Foundation through the website at Foundation@ena.org or by calling 847-460-4103.

Use Tdap Instead of Td for Routine Tetanus Boosters

The Advisory Committee on Immunization Practices (ACIP) recommends that health care providers use Tdap (tetanus, reduced diptheria, and aceullular pertussis vaccine) instead of Td for routine tetanus boosters and wound management in adolescents and adults. This vaccine will provide the same level of protection against tetanus while stemming the continued rise in pertussis cases. Education materials regarding this new recommendation are available at: www.ena.org/nursing/collaborative/default.asp.

Advocacy Packet for Procedural Sedation in the ED Now Available Online

An advocacy packet is available online to assist state leaders in developing collaborative strategies to advocate for state board of nursing policies that support the administration of medications such as propofol during procedural sedation in the ED. ENA supports the delivery of medications used for procedural sedation and analgesia by credentialed emergency nurses working under the direct supervision of an emergency physician given compliance with regulatory and professional standards of care. Safe, quality patient care is ENA’s primary goal. Patient safety, as well as patient comfort, must be equally balanced during the provision of care in the ED. Download the packet from the ENA Web site by using the following link: www.ena.org/government/Advocacy/default.asp.

How to Stop the Bleeding

Emergency-room health care is in a state of emergency. What the best minds in the medical community prescribe to begin to treat the crisis.

By Arian Campo-Flores

   When the Institute of Medicine, a nonprofit arm of the National Academy of Sciences, published three massive reports on the state of emergency care in the U.S. last June, Dr. Arthur Kellerman imagined they might serve as a call to action. The well-regarded studies—conducted over the course of three years by a committee of about 40 medical and policy professionals, including him—presented a dismal picture of overburdened, understaffed and underfunded emergency rooms. Yet despite a big rollout for the reports, including press conferences and congressional briefings, barely anyone seemed to notice. “It was disappointing,” says Kellerman. “I was hoping that report would be viewed with as much concern, even alarm, as the committee had when it generated it.”

   The public may have grown inured to sirens warning about the emergency-room crisis, but the situation is more distressing than ever. Among the Institute of Medicine (IOM) committee’s findings: a worrisome dearth of on-call specialists like neurosurgeons; poor coordination between ambulance squads and hospitals; and a woeful lack of preparedness for major disasters such as pandemic flu or a terrorist attack. While emergency department visits nationwide grew by 26 percent from 1993 to 2003, according to the IOM study, the number of hospital beds dropped by 17 percent and the number of ERs dropped by 9 percent. The authors also found a troubling increase in the practice of “boarding”—storing patients for hours or even days in the ER while they wait to be admitted to the hospital. In a survey of 90 ERs across the country on a typical Monday evening, 73 percent reported that they were boarding two or more patients. Then there’s the issue of “diversion”—the rerouting of ambulances as hospitals reach the saturation point. One study found that a half-million ambulances were diverted in 2003—an average of one per minute. “It’s a system that’s just hanging together, and it’s on the verge of collapse,” says Dr. Brent Eastman, chief medical officer at Scripps Health in San Diego, and an IOM committee member. “This is one of the most profound crises that American medicine has ever faced.”

   So what can be done? With a health-care system as complex as the U.S.’s, no single, sweeping solution exists. But the IOM reports offered numerous recommendations to tackle the problems piecemeal. For starters, there’s the basic issue of funding. The uninsured population is now estimated to exceed 45 million, and many among their number resort to the ER for their health-care needs. As a result, hospitals often get stuck with the bill. Though some safety-net providers qualify for additional Medicaid and Medicare money, it’s usually not nearly enough. Hence the IOM’s suggestion that Congress dedicates additional funding to those institutions that offer large amounts of uncompensated care (that idea has yet to gain traction on Capitol Hill). Some advocate a more ambitious agenda: universal health care coverage. “If we had that, we wouldn’t be fooling around with all these complicated formulas all the time,” says Richard Knapp of the American Association of Medical Colleges, which represents the nation’s teaching hospitals. Yet that’s a long shot politically, and would take years to accomplish.

   Other ideas in the IOM reports appear more feasible. The authors, for instance, proposed that Congress create a lead agency for emergency care in the Department of Health and Human Services (HHS). Currently, that responsibility is spread out over numerous agencies—a situation, the committee says, that hampers decision-making and limits accountability. Another IOM suggestion seeks to remedy fragmentation among service providers, from ambulances to community hospitals to ERs. In most of the country, these entities don’t have especially good communication with one another. A paramedic transporting a patient with a particular condition often has no idea where the most relevant treatment options or specialists are available at that moment. That information gap not only generates inefficiency, but it can cost the patient precious minutes. To address the problem, the IOM committee recommended the creation of regional trauma care systems—like one in Maryland—that can function as a sort of air-traffic control for patients, doctors and hospitals.

   Officials at HHS, the main agency with responsibility for emergency care, say they’ve studied the IOM reports. “We’re in the process of looking at how we can implement some of those recommendations,” says Dr. Kevin Yeskey, director of HHS’s Office of Preparedness and Emergency Operations. The agency has created a working group of representatives from all of HHS’s operating divisions, such as the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services. That group is looking closely at three IOM ideas in particular: the establishment of a lead agency for emergency care, the creation of regional trauma-care systems and the funding of additional emergency-care research.

   Another area HHS is devoting attention to: disaster preparedness. With ERs stretched to the limit, many worry about the ability of hospitals to handle catastrophic events, like a bioterrorism attack, that produce mass casualties. So the agency is addressing things like “surge capacity”—the ability of the emergency-care system to mobilize additional resources and personnel quickly to deal with a sudden influx of patients. HHS funding for hospital preparedness—things like protective equipment and decontamination showers—has increased from $135 million in 2002 to $470 million this fiscal year. The best defense, though, remains a solid, well-coordinated emergency and trauma care system. “Better daily emergency care will result in better medical care in response to disasters,” says Dr. David Marcozzi, a senior medical adviser at HHS’s Office of the Assistant Secretary for Preparedness and Response.

   Many members of Congress argue that much more needs to be done. Democratic Rep. Henry Waxman, chair of the House Committee on Oversight and Government Reform, says he’s been trying to draw attention to the woeful state of emergency care since the 9/11 terrorist attacks. Now that Democrats have taken over Congress, he’s ramping up scrutiny of the administration in this area. Around mid-June—the one-year anniversary of the release of the IOM study—he plans to hold an oversight committee hearing to examine, as he terms it, “the federal government’s failure to address the crisis in emergency care.” Other congressional committees plan to take up the issue as well. The House Committee on Homeland Security has two hearings planned for later this year—one to focus on surge capacity, the other to address the Emergency Medical Services system. And the House Committee on Ways and Means—whose health subcommittee held a hearing last year on the IOM reports, then chaired by Republican Rep. Nancy Johnson—is examining the issue of on-call specialists, who often aren’t available to hospitals; when they are, they can cost a fortune.

   There is also a lot that hospital administrators themselves can do. Consider the issue of overcrowding. Eugene Litvak at the Boston University Health Policy Institute has studied the flow of patients in and out of hospitals—not just those in the ER but throughout the facility. His conclusion: if elective surgeries like angioplasty or hip replacement could be scheduled in a more organized way, the ER might not get so backed up. Christy Dempsey, vice president for surgical and emergency services at St. John’s Hospital in Springfield, Mo., put Litvak’s plan to work in 2002. Surgeons began “smoothing” their elective surgeries throughout the week, rather than bunching them together on Mondays, Tuesdays and Wednesdays. They also carved out blocks of time to ensure that ER patients requiring surgery would have the beds and operating rooms they needed. The reforms created 59 percent more available space for inpatients—without actually adding any beds, says Dempsey. And they helped unclog the ER, resulting in better patient and staff satisfaction and less overtime. “It was a win-win for everybody,” she says.

Some hospitals have introduced innovations to deal with the boarding problem. Dr. Peter Viccellio, vice chair of the Department of Emergency Medicine at Stony Brook School of Medicine in Stony Brook, N.Y., came up with a simple fix: move patients waiting to be admitted from hallways in the ER to hallways in specialized units elsewhere in the hospital. They’re still not in rooms, but they receive better care and rest more comfortably outside of the ER. At Stony Brook, the program has reduced the average length of stay in the hospital from 6.2 days to 5.4 days—a dramatic savings in resources and money. The move has also reduced the strain on ER nurses, because patients awaiting admission usually require more attention. Since Viccellio’s innovation was implemented, Stony Brook has never had to divert a patient (it receives about 75,000 ER visits per year, compared to around 170,000 at a large urban hospital like Grady Memorial in Atlanta).

   In the absence of grand solutions from government, hospitals will have to focus on internal steps like these. “You just keep chipping away at the stone and hope that at some point, someone will say, ‘We’ve got to fix this’,” says Dr. Frederick Blum, past president of the American College of Emergency Physicians. “We’re not there yet, but we’ll keep chipping away.” Hopefully it won’t take a catastrophic failure for others to realize the state of emergency the emergency health-care system is in.

Nursing Perspectives: Emergency Department Crowding:

More Than Just a Longer Wait or a Real Crisis?

By Laura Stokowski, RN, MS

"Emergency department crowding" evokes visions of rows of people in rigid plastic chairs: coughing, moaning, or holding towels to their wounds, anxious faces turning each time the door opens, eager for the summons that will bring them to the coveted inner sanctum of the emergency department (ED) where blessed relief awaits them. Inconvenient and frustrating, to be sure, but hardly a crisis.

If only ED crowding was as simple as a few extra patients in the waiting room...or a slightly longer wait. But the problem of ED crowding is complex and far-reaching, affecting the entire emergency care system, from pre-hospital to post-emergency care. Although it is receiving a great deal of attention from many quarters, crowding continues to occur in the nation's EDs, where nurses are doing their best to cope in environments that are dramatically different from those to which they are accustomed.

The Real Problem of Crowding

Contrary to its name, ED crowding is not an ED problem; it is a systemic, or hospital, issue.[1] A crowded hospital is the true source of a crowded ED. Strictly speaking, crowding describes a situation when the identified need for emergency services outstrips the available resources.[1] Crowding is a function of patient volume, patient acuity, physical space, and the number of on-duty staff.[2]

The problem starts with a mismatch in demand and supply. From 1994 to 2004, ED visits increased from 93 to 110 million annually in the United States, an increase of 12%. But in the same 10-year span, the number of hospital EDs fell by 18%, forcing the remaining hospitals to absorb the excess patient load. Furthermore, the aging of the population and increasing rates of chronic illness are bringing sicker patients to the ED than ever before.[3]

Against this backdrop of higher volume-higher acuity, additional factors have come into play to create gridlock in the ED. It was formerly believed that ED crowding was caused by a growing volume of ED visits by people who were uninsured or had Medicaid and were using the ED to be seen for nonurgent conditions.[2] It is now recognized that the real bottleneck in the hospital is the operating room. Many surgeries are scheduled for Tuesdays, Wednesdays, and Thursdays, filling inpatient intensive care units (ICUs) and medical-surgical unit beds on those days. When beds are needed for patients from the ED, they are unavailable and these acutely ill patients start backing up in the ED.

Eventually, the ED is full and, unable to take any more patients, and must place ambulances on divert to other area EDs. Walk-in patients are subject to extremely long waits, and many leave the ED without being seen.

In a Holding Pattern

The nurse manager of an academic medical center ED recently oversaw an expansion of her department from 25 to 53 beds. "All we did was become the largest med-surg unit in the hospital 3 days a week," she said (Donna Mason; personal communication; March 10, 2007).

This illustrates the greatest ED nursing problem generated by hospital crowding: the necessity to hold, or board, patients in the ED who require admission to the hospital but for whom there are no available beds on inpatient units. "Holding" and "boarding" are terms used interchangeably to describe the practice of providing continued care for a patient within the ED after a decision to admit or transfer has been made.[4] As pointed out in a recent report by the Institute of Medicine, however, the term 'boarder' is a misnomer because it implies that these patients require little care.[3] The truth is, they are often the sickest, most complex patients in the ED, which is why they need to be admitted to the hospital.[3] By occupying beds and nursing time in the ED, boarders prevent new patients from being admitted into the ED.[2]

The problem of boarding is nationwide. A survey conducted in a cross-section of ospitals throughout the country on a typical Monday evening found that 73% of hospitals were boarding at least 2 patients.[5] Kathleen A. Ream, Washington Representative of the Emergency Nurses Association (ENA) frequently talks to nurses from around the United States about patients being boarded for up to 24 hours in the ED. "We believe it is unacceptable because it is not in the best interest of patients," states Ream of the ENA's position on boarding or holding in the ED.

Holding or boarding in many EDs often takes place in non-treatment areas such as hallways, conference rooms, offices, and even shower stalls because there are simply too few rooms.[5] These areas lack equipment and outlets necessary for patient care requirements. Family members are unable to remain with the patient the same way they would in an inpatient room. Even when ED rooms are available, there are no attached bathrooms, greatly hindering patient privacy.

Patient confidentiality can be threatened in other ways when EDs are crowded. Some EDs become so full, and patient waits so long, that emergency nurses have begun providing care right in the waiting room (Donna Mason; personal communication; March 10, 2007). Diagnostic tests, such as radiographs and laboratory work have been obtained, and basic interventions such as intravenous therapy and breathing treatments have been provided to patients in the waiting room because no beds were available in which to put them.

Working Outside of the Comfort Zone

ED nurses, by nature of their work, have a broad knowledge base. They routinely care for patients ranging from newborns to the elderly, a daunting responsibility given the variability between various age groups in normal vital signs, laboratory values, medication dosages, and so forth. Emergency nurses must maintain competence in providing care for all trauma, urgent, and nonurgent health problems that present in the ED. Furthermore, these nurses usually do not have access to complete medical records or patient histories.

Nonetheless, because care in the ED is ordinarily acute and episodic, nurses are able to provide safe care to the full spectrum of patient types and problems encountered in the ED. As a rule, emergency nurses enjoy the rapid turnover of patients and the swiftly changing environment. In fact, it is "the pace that gives the pleasure," notes ENA President Donna Mason.

Mason explains further that the routine practice of boarding patients in the ED when inpatient beds are full has forced emergency nurses to adopt 2 different ways of practicing nursing, often simultaneously. A nurse might have a patient load comprising 2 typical ED patients, along with 2 boarders. The type of care required by boarders can be dramatically different from that required by ED patients. Scheduled medications, pulmonary hygiene, maintenance of intravascular catheters, and bathing patients are only a few of the routine nursing interventions that ED nurses are not used to, but must perform when caring for boarded patients.

"Their number one concern is not being able to provide the kind of care they know patients should be receiving," says Kathi Ream, describing the sheer frustration felt by emergency nurses. Their frustration is understandable, for unfamiliarity with patient care requirements does not provide a rationale for failing to provide safe, quality care for boarded patients. The Joint Commission of Healthcare Organizations addresses care for boarded patients by stating that "patients with comparable needs receive the same standard of care, treatment, and services throughout the hospital."[6] Similarly, in their position statement, Holding Patients in the Emergency Department, the ENA states that "patients held in the emergency department must be provided the same level of care they would receive in inpatient units if their discharge from the emergency department is delayed."[4]

And, not surprisingly, safety problems can arise as a result of boarding or holding in the ED. The most common of these tend to be errors of omission, such as forgetting to give scheduled medications or treatments, or failing to complete required assessments such as those for skin, nutrition, or fall risk. "Emergency nurses just aren't geared to the routines of med-surg nursing," explains Donna Mason.

This situation creates difficulties for the recruitment and retention of emergency nurses, according to Mason. "Holding is the number one reason nurses leave the ED. They love what they do, but they don't want to be med-surg nurses or ICU nurses." The issue also surfaces when Mason interviews nurses for vacant positions in the ED. "The first things they ask are, how often do you hold, and how many patients do you hold?" Mason has recently taken the unusual step of hiring med-surg nurses to care for boarded patients in her ED to relieve some of the strain on the emergency nursing staff.

There is 1 bright spot. Mason has found that for once, she has no trouble staffing the ED on the weekends. Emergency nurses actually prefer working weekends, but it isn't because of higher pay differentials. On weekends, the ED reverts to normal because there are no elective admissions on the medical-surgical units, therefore fewer boarded patients in the ED.

Long Waits and Violent Behavior

An inevitable consequence of hospital crowding is that patients in the emergency department must wait longer to be seen. Prolonged waiting and crowded or unsatisfactory waiting room conditions can lead to verbal expressions of anger and frustration or even physical assaults upon healthcare workers.[7]

It is believed that the majority of abusive incidents perpetrated by patients, family, and visitors toward ED nurses are never reported through usual hospital channels.[8] Some limited data, however, are available indicating that very high levels of assault and abuse are directed at ED nurses. In a 2002 study, 100% of ED nurses surveyed reported having been verbally assaulted and 82.1% reported having been physically assaulted within the preceding year. Among the most common reasons cited for abusive behavior directed toward nurses was anger related to long wait times.[9]

A high prevalence of violence directed toward ED nurses was confirmed in a survey of ENA members in 2006. Eighty-six percent of ED nurses reported having been the victim of violence by a patient or a patient's family member when working in the ED. More than 40% of respondents felt only somewhat safe or not safe at all at work.[8]

Because the problem of crowding is not likely to be solved quickly, nurses and other emergency providers will continue to be vulnerable to workplace violence related to dissatisfaction with the healthcare system. The ENA has addressed this problem in detail and emphasizes that "health care organizations must take preventive measures to circumvent workplace violence and ensure the safety of all health care workers, their patients, and visitors."[10]

What Does the Future Hold?

What will it take to return the ED to its former status as the place we depend on to treat urgent medical conditions and manage trauma -- promptly, safely and competently -- any hour of the day or night, every day of the week?

Many believe it will take an entirely new emergency care system, one that corrects the inefficiencies and fragmentation of the current system. The emergency care system of the future should be coordinated, regionalized, and accountable.[11] Coordinated, in the sense that from the patient's point of view, the delivery of emergency services is seamless. Regionalized, in the sense that hospitals, emergency medical service providers, and others work as a unit to provide services to everyone within a single region. And accountable, meaning there will development of well-defined standards and ways of measuring performance against those standards and reporting them to the public.[11]

In the meantime, hospitals must find internal solutions to ease the problem of crowding in the hospital that seriously affects the ability of the ED to function normally. "Some hospitals are very enlightened," according to Kathi Ream. "Ambulance diversion is not acceptable to them. If the hospital administration is not behind the issue that crowding is unacceptable, you are not going to get the relief that you need. Even little things can help, like having cleaning crews on hand to clean your rooms immediately when you discharge patients."

ED nurses are critical to the emergency care system of the future. I am certain that I am not alone in hoping that they can weather the storm in which they now find themselves, and in offering my sincere gratitude to them for facing this arduous challenge.

Editor's Note -- About the Emergency Nurses Association

The Emergency Nurses Association (ENA) is the only professional nursing association dedicated to defining the future of emergency nursing and emergency care through advocacy, expertise, innovation, and leadership. Founded in 1970, ENA serves as the voice of more than 32,000 members and their patients through research, publications, professional development, injury prevention, and patient education. Additional information is available at ENA's Web site, at www.ena.org.

References

   1. American College of Emergency Physicians. Emergency Department

Crowding. 2004. Available at:

http://www.acep.org/webportal/PracticeResources/issues/crowd/default.htm

Accessed March 27, 2007.

   2. Bernstein SL, Asplin BR. Emergency department crowding: old

problem, new solutions. Emerg Med Clin North Am. 2006;24:821-837.

Abstract

   3. Institute of Medicine, Board on Health Care Services.

Hospital-Based Emergency Care: At the Breaking Point. Washington, DC:

National Academies Press; 2006.

   4. Emergency Nurses Association. Emergency Nurses Association

Position Statement. Holding Patients in the Emergency Department. 2006.

Available at:

http://www.ena.org/about/position/PDFs/629CF897DF7D43F38CF40D5E20

      D5769D.pdf Accessed March 27, 2007.

   5. Schneider SM, Gallery ME, Schafermeyer R, Zwemer FL. Emergency

department crowding: a point in time. Ann Emerg Med. 2003;42:167-172.

Abstract

   6. Joint Commission on Accredition of Healthcare Organizations.

Comprehensive Accredition Manual for Hospitals. Oak Brook, Ill: JCAHO;

2006.

   7. National Institute for Occupational Safety and Health. Centers

for Disease Control and Prevention, Department of Health and Human

Services. Violence: Occupational Hazards in Hospitals. DHHS (NIOSH)

Publication No. 2002-101. April, 2002. Available at:

http://www.cdc.gov/niosh/2002-101.html#wheremay Accessed March 27,

2007.

   8. Emergency Nurses Association. Survey on Emergency Nurses

Perceptions of Their Profession. Desplaines, Ill: ENA; 2006.

   9. May DD, Grubbs LM. The extent, nature and precipitating factors

of nurse assault among three groups of registered nurses in a regional

medical center. J Emerg Nurs. 2002;28:11-17. Abstract

  10. Emergency Nurses Association. Emergency Nurses Association

Position Statement. Violence in the Emergency Care Setting. 2006.

Available at:

http://www.ena.org/about/position/PDFs/CFAC59534C2B4BFF8C23F1972

      A2E00FF.pdf Accessed March 27, 2007.

  11. Institute of Medicine. Report Brief. The Future of Emergency Care

in the United States Health System. June 2006. Available at:

http://www.iom.edu/Object.File/Master/35/014/Emergency%20Care.pdf

Accessed March 27, 2007.

Laura Stokowski, RN, MS, Staff Nurse, Inova Fairfax Hospital for

Children, Falls Church, Virginia; Editor, Medscape Ask the Experts

ENA Promotes AAN Guideline on Comatose Survivors

In November, the ENA Board of Directors approved the dissemination of a new guideline developed by the American Academy of Neurology (AAN). Certain tests can predict with great accuracy whether a person in a coma after CPR (cardiopulmonary resuscitation) will have a poor outcome, according to AAN. The full guideline along with a clinician summary and patient version can be found at www.aan.com/professionals/practice/guideline/index.cfm.

If ER Nurses Crash, Will Patients Follow?

I'm so overworked that I go home at night praying I haven't made a mistake that might hurt someone

Hazardous conditions: Paul Duke says the ERs he works in have too many patients, not enough staff'

By Paul Duke
Newsweek

Feb. 2 issue - I was sprinting down the hall when a patient waiting to be seen by a doctor asked me for a blanket. She was in her mid-70s, cold, scared and without any family or friends nearby. Did I have time to get her that blanket, or even stop to say a few words to let her know she wasn't alone? No, I didn't.

As an emergency-room nurse, I'm constantly forced to shuffle the needs of the sick and injured. At that particular moment, half of my 12 patients were screaming for pain medication, most of the others needed to be rushed off to tests and one was desperately trying not to die on me.
Was that blanket important in the grand scheme of things? Not really. She wasn't going to die without it. So it got tossed on the back burner, along with my compassion.
I often find myself hopping from task to task just to keep everyone alive. By the end of the shift I often wonder, did I kill anyone today? I go home tired and beaten down, praying like mad that I didn't make any mistakes that hurt anyone.

For five years I have worked in one of the busiest emergency rooms in southeastern Michigan. For the last two I have picked up overtime by working in four other hospitals, including the busiest emergency room in inner-city Detroit. No matter where I am, I experience the same problem--too many patients, not enough staff.

When I started emergency-room nursing five years ago, I would typically have four or five patients. I could spend a few minutes chatting with them and answering their questions. Let's face it, when you are in a drafty emergency room in just a flimsy paper gown and your underwear, it is nice to have someone actually talk to you. It's a scary experience to get poked and prodded in various parts of your anatomy.

But now on an average day I have 10 to 12 patients. Once I even had 22. On that night I was feeling swamped, so I went to the charge nurse for help. She was as busy as I was, so she told me to take the five sickest patients and keep them alive, and get to the rest when I could. Now, here's a question: do you want to be one of the five sickest who get attention right away, or one of the others who have to wait maybe seven, eight or even 10 hours before someone gets to you?

That night I staggered home grateful that nobody had died. But I wondered, do I really want to do this job? I love the emergency room, but I was so damn frustrated. Was it just me?
I did an informal survey of the emergency rooms where I work. Every nurse I spoke to said the patient load had at least doubled in the last three years. None of them expected the situation to get better soon.

Troubling, but hardly scientific, so I did a little digging for some real statistics. According to the Centers for Disease Control and Prevention, from 1997 through 2000 the annual number of emergency-room visits went from 95 million to 108 million, while the number of ERs decreased. So who picked up the slack? The staff at emergency rooms, like mine, that are still standing.
The journal Nursing 2003 reports that approximately three out of 10 R.N.s believe their hospital has enough nurses to provide excellent care. Not exactly what you want to hear from the people responsible for your loved ones' health.

The future doesn't look any brighter. Studies show that by 2010, 40 percent of all registered nurses will be over 50. That's when most of us are getting ready to cut back our hours or switch from direct patient care to chart review. By 2020 there will be an estimated shortfall of 808,400 nurses, partly because many will have retired or become so dissatisfied that they've quit, but also because fewer people are entering the profession. Yet the number of Americans older than 65 is expected to double from 35 million to 70 million over the next two decades. As someone who knows just how often the elderly visit ERs due to heart attacks, strokes and falls, I see trouble ahead.

Don't get me wrong--my colleagues are some of the hardest-working and most professional nurses you will find. But when you're given 20 patients when you should have six, well, you're only so good.

After all this you must wonder why I don't quit. The truth is, I love nursing. It's what I am good at. I love the challenge of not knowing what will come crashing through the doors. Emergency-room nurses rise to the occasion. But we are being steamrolled, stretched thin and beaten down, and the best of us are frustrated.

At the end of my 18-hour shift I got that little old lady her blanket and spent a few minutes talking to her. She took my hand, smiled and said thank you.
I'm frustrated, but I'll be back.

Duke lives in Southgate, Mich.
© 2004 Newsweek, Inc.

OSHA Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances

WASHINGTON -- The U.S. Department of Labor's Occupational Safety and Health Administration (OSHA) released on December 21, 2004 information to help hospitals safeguard their own employees as they care for patients injured in incidents involving chemical, biological or radiological materials.