News

On behalf of the board, let me say that we look forward to working in partnership with Sue to continue the great work of ENA. Her commitment to excellence combined with her strong background as a long time ENA member and as an emergency nurse will serve as the perfect foundation for moving ENA forward.

A press release will be going public in the coming days, but as your president, I am committed to keeping our members informed. ENA is truly a member-driven organization and in that spirit I wanted to make sure that the members were informed as quickly as possible.

Please join me in congratulating Sue and in wishing her many years of success in this exciting new role.

Sincerely,

Hospitals Overhaul ERs to Reduce Mistakes/span>
By LAURA LANDRO

MAY 9, 2011
The Wall Street Journal

An 18-year-old man with fever and chills is sent home from the emergency room with Tylenol and later dies of sepsis, a blood infection. A 42-year-old woman with chest pains is discharged, only to suffer a heart attack two hours later. A 9-year-old girl's appendix ruptures after doctors rule she's just got a bellyache.

Half of all malpractice claims against emergency rooms stem from a faulty diagnosis, like a heart attack that is mistaken for indigestion. Laura Landro explains how insurance companies are working with hospitals to make ERs safer.

Hospitals are drawing on lessons learned from these worst cases of missed or delayed diagnosis to overhaul emergency departments, where errors, oversights and a lack of teamwork between doctors and nurses can harm or kill patients. They are adopting new triage systems to ensure doctors and nurses jointly see at-risk patients soon after they arrive, requiring physicians and nurses to huddle to make sure no information is overlooked, and using time-outs at discharge to prevent patients with unresolved problems from leaving the ER.

Often chaotic and overcrowded, with scant data available about new patients, the emergency room is among the top hospital departments responsible for malpractice suits—and diagnostic errors account for 37% to 55% of cases in studies of closed claims. The average payments and legal expenses for ER cases have more than doubled over the past two decades, according to the Physician Insurers Association of America, a nonprofit trade association whose members cover about 60% of emergency physicians.

Insurance broker Aon Corp. estimates malpractice suits arising from emergency-room incidents in 2009 alone will cost hospitals $1 billion.  A serious ailment can look a lot like something else in the hubbub of emergency rooms, where nearly 124 million people a year are treated.

While emergency-room errors often happen because a doctor misjudges symptoms, in almost all cases of missed or delayed diagnoses essential pieces of information weren't available at the time the doctor made a decision, according to Dana Siegal, program director of risk-management services for Crico/RMF Strategies, whose parent company insures hospitals affiliated with Harvard University.

Gaps can include a missing medical history, no record of abnormal vital signs such as blood pressure or heart rate, a lack of timely access to radiology or lab reports, or information lost in a shift change. Crico's analyses show poor doctor-nurse communication at critical times often causes mistakes.

Crico/RMF is working with 16 hospitals on a project to improve communication between doctors and nurses. Mannequins will be used to simulate various emergencies, and participants discuss what could have been done differently.

Among the strategies being tried by participating hospitals is a new system for triaging patients, dividing the emergency department into separate areas, such as pediatrics, obstetrics and psychiatry.

At Abington Memorial Hospital near Philadelphia, Sue Cissone, clinical coordinator of the Emergency Trauma Center, says a pilot project is moving patients immediately to beds in the treatment area where they can be seen by a doctor and nurse together, helping ensure both hear vital information.

Hospitals working with Crico are also using nurse-doctor huddles to review patient data.

At Taylor Hospital in Ridley Park, Pa., where 30,000 emergency patients are treated annually, emergency chief Gregory Cuculino says maintaining electronic medical records has had an unexpected downside: Staffers type information into the system but don't verbally communicate with each other. "Huddles allow everyone to go over the case, so if someone says, 'Mrs. Smith in room four looks good,' the nurse has a chance to say, 'She just threw up again,' " says Dr. Cuculino.

Because heart attacks are among the most commonly missed diagnoses, insurers are urging emergency departments not to assume women and men under the age of 55 are less likely to suffer one than an over-60 male. CNA Financial Corp., which provides malpractice insurance, suggests in a guide developed for its hospital clients that all patients with chest pain be admitted to the hospital, even if a heart attack is only a possibility, because the death rate among patients whose heart attack is missed is almost double that of patients who are admitted.

Strokes are also often missed in younger patients, too, according to a study by a team at Wayne State University and Detroit Medical Center released in February. The study showed 15% of patients with a median age of 37.9 who reported to an emergency room with stroke symptoms were initially misdiagnosed. It recommended that younger patients with seemingly minor symptoms like vertigo and nausea be meticulously assessed and that an MRI be performed as soon as possible.

Emergency departments are also adopting time outs before a patient is released to allow nurses to stop the discharge process if they see anything that may have been overlooked, such as a vital sign that remains abnormal, or a patient's statement that didn't come out when a medical history was first taken.

For example, meningitis, a bacterial infection with symptoms including headache, fever and dizziness, is often missed, closed claims show.

If a patient treated for a severe headache develops a fever during his stay in the emergency room and mentions for the first time at discharge that he passed at out at home before coming to the ER, "that is going to make us think about whether we should consider meningitis, when we had not been going down that track," says Assaad Sayah, who runs the emergency departments for the three hospitals in the Cambridge Health Alliance and is participating in the Crico project.

Beth Israel Deaconess Medical Center in Boston has started using a so-called trigger system that looks for abnormalities in five vital signs, including elevated heart rate and blood pressure, to determine which patients should be seen and treated faster. "If they meet one of the five triggers we intervene as quickly as we can," says Carrie Tibbles, associate director of graduate medical education.

Dr. Tibbles urges patients and families to provide as much information as possible up front about symptoms and medical history in the ER, along with contact information for their primary care doctor. Patients should also inquire about diagnostic tests and what they are for, and what the turnaround time is for results. "But recognize there are limitations in the system," she says. "Don't assume because you've shared your history once that the next person coming in the door knows about it."

The changes to emergency-room systems come as ERs face a growing work load. In a survey released last month, the American College of Emergency Physicians said 80% of its members are reporting increased visits to emergency rooms and more than 90% expect increases next year.

David Seaberg, president-elect of the group, says a growing shortage of primary-care physicians is driving many patients to the ER.

Dr. Seaberg says the intense environment of the ER can make precision difficult. His group studies closed claims to find how patients can be better diagnosed while keeping the flow of patients moving efficiently, and offers programs to foster teamwork.

National ENA 2012 Elected 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 on the 2012 ENA board of directors and the Nominations Committee:

2012 ENA President-elect (will serve as the 2013 ENA President)
JoAnn Lazarus, MSN, RN, CEN
Longview, Texas

2012 ENA Secretary/Treasurer
Deena Brecher, MSN, RN, APRN, ACNS-BC, CEN, CPEN
Wilmington, Delaware

Directors
(3-year term: January 1, 2012 - December 31, 2014)
Michael D. Moon, MSN, RN, CNS-CC, CEN, FAEN
San Antonio, Texas

Karen K. Wiley, MSN, RN, CEN
Omaha, Nebraska

(1-year term: January 1, 2012 - December 31, 2012)
Ellen H. Encapera, RN, CEN
Huntington Beach, California

ENA Nominations Committee
Region 2 – Scott E. Stover, MSN, MBA, APRN-BC, CEN
Katy, Texas

Region 4 – Cathy C. Fox, RN, CEN, CPEN
Virginia Beach, Virginia

Region 6 – Ellen E. Ruja, MSN, RN, CEN, FAEN
Mount Pleasant, South Carolina

Past Board Member – Tiffiny Strever, BSN, RN, CEN
Glendale, Arizona

Lantern Award Applications- Calling all Exemplary Emergency Departments- Due 2/29/12

ENA is now accepting Lantern Award applications for 2012. The ENA Lantern Award recognizes exemplary emergency departments that demonstrate exceptional and innovative performance in the core areas of leadership, practice, education, advocacy and research. To register and begin the application process, visit www.ena.org.

New for this call for applications is a Coaching Guide to help you identify how best to demonstrate your emergency department’s achievements in the application. To view the Coaching Guide and other Lantern Award materials visit www.ena.org.  Awards will be announced at the ENA 2012 Annual Conference in San Diego.

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.

Emergency Nursing is Recognized by ANA

To my Nursing Colleagues:

After 2 long years of research, writing and editing, the Emergency Nurses’ Association Scope of Practice and Standards of Practice has been approved by the American Nurses Association as a specialty.  EDNA (Emergency Department Nurses Association) and later ENA was established in 1970 and has continued to represent nursing in the emergency department and in all areas of emergency nursing.   It was a challenge but great opportunity to be involved in the development of this document. Click here to view the document.

Just thought I would share this great news.

Mary Alice Vanhoy, RN, MSN, CEN, CPEN, NREMT-P

Maryland State ENA President 2011

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.

A Day in the Life of an Emergency Room Nurse

Sarah Carlson – a 28 year old Critical Care Nurse from Boston

September 2011

Four years of nursing school, textbooks and classroom lectures have failed to fully calm my heart, mind, and spirit as our next trauma patient is rushed through the double doors of the emergency room on a wobbly six foot stretcher. Injuries uncertain, responsiveness still to be determined, vital signs unknown.

"CODE TRAUMA NOW" resounds throughout the department on the overhead pager. MD Attending, MD Resident, OR Residents, Respiratory Specialists, Nurses and Emergency Service Assistants arrive in the trauma room of the ER. Each clinician dons gowns, gloves, and glasses and the patient is methodically moved from the Paramedic's stretcher to the hospital stretcher. Like clockwork, the Paramedic begins to report, as all eyes in the room are on the pale, female, approximately 19 years old, lying before us covered in blood under a white blanket. Both her arms appear broken, glass is strewn in her hair, deep cuts line her face along her eyes and nose. Her head is swollen, bloody and bruised. The room is silent as the paramedic describes what happened. While we try to stabilize the patient I hear bits and fragments of the paramedic's report.

High-speed motor vehicle accident?… What?… Unconscious at scene?… I think to myself, is that what I just heard?

Then the doctor's trauma assessment begins. The MD Resident, a tall dark haired 29 year old woman takes charge. The attending faculty physician looks on—as the young doctor begins her verbal full body assessment of the young motor vehicle accident victim. While the team listens—they work quickly to get the young patient's clothing off and bring the necessary equipment to the bedside to perform emergent imaging to make sure there is no damage to her internal organs. One of the nurses in the room begins to document all trauma findings on the trauma flow sheet as the MD Resident dictates. An Emergency Service Assistant hastily places the cardiac monitor on the patient to get a current set of vital signs. Blood pressure: 82/54, heart rate: 130's, respiratory rate: 26.

My role as the trauma nurse is to find intravenous access to immediately begin administering fluids, medications and blood products. I look at the bloodied, severely injured patient to find a place where I can access a vein with an IV catheter. My first attempt to place the needle in a vein in her left forearm fails because her bones are broken and her veins there are weak. I look for another vein and easily place a large IV in her right wrist, followed by a second large IV in her right anticubital area—inside her elbow. I am successful and the IV fluids are running through the patient as the MD resident continues her assessment. The resident has ordered me to begin administering blood products because the patient's blood pressure is low which can indicate she has lost a lot of blood from her motor vehicle accident. I grab a bag of blood from the coolers that are in the trauma room and start giving it through the IV's.

Thoughts continue to rush through my head. Is the patient breathing on her own? Are we going to need to intubate her and should I begin to draw up the necessary medications to perform this procedure? What are her current vital signs? What is her respiratory rate, heart rate, blood pressure, and temperature now? Are these stable? Are my IV's working and running? At this point I only have visual clues as to the status of my patient. I see blood coming from her legs—how deep are the cuts? Is her leg broken? There is bruising around her abdomen—is she bleeding internally?

The MD resident states that because the patient is loosing a lot of blood, her injuries are not completely known at this time, and her blood pressure is low, heart rate is fast, and she is breathing at a rapid pace. We need to place a breathing tube down her throat to allow a ventilator to breath for her. The resident yells out the dose and medications she wants to use for the intubation and I quickly draw them up in a syringe ready to administer them. Respiratory personnel are present in the trauma room and have the ventilator ready. With encouragement and cooperation from the emergency medical team the resident asks me to administer the medications to paralyze, sedate, and take away all feeling of pain the patient may be experiencing. Easily the tube is placed down her throat and her chest starts to rise with the breaths given to her body by the ventilator.

The patient is then moved to radiology for x-rays and CT scans. It turns out she has a broken left arm, broken right femur, multiple facial fractures around her eyes and mouth, two broken vertebras in the middle of her back, and a cut on her liver causing her to lose a lot of blood.

Through all my emotions and through quick thinking and using my knowledge to help perform the necessary interventions to help save this patient's life, I am able to stay calm, for I see that everyone in that room is working as a team, an Emergency Medical Team, and together we are delivering the best care we can for this patient.

I chose to become an ER nurse because I thought it would be a job where I would never get bored. The energy, excitement, teamwork and the goal to save lives and the knowledge needed to do this is what continues to drive my daily passion for Emergency nursing. Whether I am the trauma room nurse or taking care of patients suffering from chronic illnesses, whether I am helping alleviate someone's pain from a broken bone or cut hand, whether I am sitting and talking with someone who does not feel safe to himself or to others around him, I desire to pour out comfort and compassion to those around me. I want to be a calming voice in the time of chaos and uncertainty. In the ER I never see the same thing that I saw the day before. Each patient is unique and the knowledge needed to assess every new patient is something that I know I will learn better through time and experience.

Some days are harder than others for me to care for my patients but this is my greatest challenge to come here every day ready to work and give of my time, knowledge, caring, calmness, and love to those who are often facing major turmoil.

Middle TN hospitals take steps to halt ER violence

Survey shows high rate of attacks on nurses
By Tom Wilemon

August 28, 2011
The Tennessean

A man jerks a metal vent out of a wall, pounds it into a crude shank and brandishes it threateningly.

He’s not in a prison. He’s in a hospital emergency room.

The incident happened at Vanderbilt University Medical Center, but it has no monopoly on ER violence. Workplace assaults and threats have risen to the point that Middle Tennessee hospitals are ramping up security measures and teaching ER workers de-escalation techniques.

The increased focus on prevention comes after a national organization representing ER workers exposed the hidden scabs behind nurses’ uniforms. Between 8 percent and 13 percent of nurses are victims of physical violence every week, according to a survey conducted by the Emergency Nurses Association.

Another survey, this one conducted by the federal Substance Abuse and Mental Health Services Administration, determined that violent incidents committed in emergency rooms by patients with drug and alcohol problems increased 31.5 percent from 2006 to 2008.

“The statistics were just mind-boggling,” said Marsha Price, ER operations manager at Vanderbilt, which has begun training its workers on how to lessen the likelihood of assaults and protect themselves.

Workers, who once suffered in silence and considered the attacks part of a day’s work, are demanding action. The U.S. Occupational Safety and Health Administration fined a Maine hospital in January and a Connecticut hospital in July 2010 after employees complained about inadequate safeguards.

But in many cases, workers don’t even tell their supervisors.

“Probably the only time they report it is when they are physically assaulted,” said Jennifer Elliott, director of emergency services at Baptist Hospital. “When patients spit and bite and scratch and curse the staff, I would say that they typically do not report that.”

The assailants are not always patients. Sometimes they are family members. That’s why Dr. Brad Hoover, chairman of the emergency department at Summit Medical Center in Hermitage, continually stresses a simple rule.

“Don’t allow yourself in a room with a patient or a family member between you and the door,” Hoover said.

When Summit recently remodeled and expanded its emergency department, the hospital made sure the security headquarters stayed right next to the ER and added more doors for direct, quick access.

“Just the presence of the officers in the department gives a sense of security,” he said.


Psychiatric wards add to worker risks

Summit and Vanderbilt are both hospitals with psychiatric wards, putting workers at even more risk for violence. It was in Vanderbilt’s psychiatric intake area, which is part of that hospital’s emergency department, where the incident with the shank recently occurred.

Vanderbilt also has a Level 1 trauma center, taking in people injured from gunshot wounds. That’s why the hospital installed a metal detector a few years ago. Once, a man shot himself in the buttocks trying to remove his gun before he walked through a metal detector.

At Baptist, the gunshot victims are often drive-up patients.

“The victim of a crime or the assailant of a crime that gets hurt shows up in our parking lot,” Elliott said. “Then you have staff out in the middle of the night in the parking lot trying to pull somebody that has been shot out of a car.”

Workers don’t know whether someone else might drive up to finish a gunbattle.

Baptist launched a pilot program in June in its emergency department for crisis prevention intervention training.

“We did a medical floor, plus we did our clinical manager and charge nurses,” said Debbie Roberts, the hospital’s director of risk management. “Then it will spread throughout the rest of our house.”

This week, Vanderbilt began training another round of workers in Handle with Care classes. The program began in March. One session focuses on verbal de-escalation techniques, while a second covers physical techniques.

“How do you defend yourself from someone who is fragile — a patient with Alzheimer’s and osteoporosis or a mentally retarded person or maybe a child with autism?” said Mike Malone, a Vanderbilt paramedic who does the training. “You have to defend yourself without hurting the other person.”

Williamson Medical Center and Southern Hills Medical Center are two other area hospitals that conduct de-escalation training.

Michelle Ingram, a mental-health specialist at Vanderbilt, knew some of the verbal techniques before her training, such as speaking in calm, low tones and giving patients choices whenever possible. That can be as simple as letting someone choose between apple juice and orange juice, she said. Listening and letting people vent also help.

“A lot of ER nurses don’t have any psychiatric background,” Ingram said. “It’s really important that they also know how to deal with this because they are confronted with it constantly.”

Sarasota Memorial Hospital launches retraining
By DAVID GULLIVER


Sarasota Memorial Hospital has launched a sweeping retraining of its staff after a mismanaged emergency room case triggered federal and state inspections.

The effort focuses both on specific practices, like managing diabetes cases, and on broad philosophy, such as the importance of attending to patients’ emotional needs as well as their physical needs.

Gwen MacKenzie, Sarasota Memorial’s chief executive officer, said the hospital has people skilled at both aspects of care, but needs a better way of bringing them together when needed.

“Part of the solution is reminding our staff that we have all these specialized resources available at our fingertips,” she said via email. The changes are about “developing a seamless process that encourages them to collaborate and ask for help when patients are experiencing particularly difficult or emotional health issues.”

The failure to link those resources was at the core of the case that led to the inspections.

A woman, diabetic and nearly 13 weeks pregnant with twins, came to the hospital’s emergency room on July 1 with pelvic pain and vaginal bleeding. Over the next eight hours, she miscarried both fetuses.

During that time, inspectors found, hospital staff failed to promptly perform some necessary tests, including a six-hour delay in measuring the patient’s blood-sugar level. They also did not monitor blood loss and did not adequately assess the patient’s emotional status. The emergency physician also misread a radiology report on the health of one fetus, while a nurse said her workload delayed performing another test.

The patient complained to the state, triggering an inspection. Regulators did not blame the hospital for the miscarriage but found inadequate care in that case and seven other cases of troubled pregnancies.

The inspectors’ findings stunned the hospital, which has enjoyed a national reputation for high-quality care for a decade. MacKenzie addressed that in an Aug. 31 memo to staff.

“Our entire staff has been humbled by this experience -- and the disturbing realization that some of the deficiencies reported in this case were not isolated to one patient’s unique circumstances,” she wrote. “It’s been a difficult reminder that no one is perfect and that no matter how many awards and accolades we may receive, we can never allow ourselves to be lulled into complacency.”

The hospital submitted its response to the inspection, called a plan of correction, on Sept. 2. The state Agency for Health Care Administration has declined to release the response, saying it is reviewing the plan. But in the memo, MacKenzie outlined the steps the hospital is taking:

• Developing guidelines to improve communications between the emergency care center and women’s and children’s services department. The guidelines address how to meet both the physical and emotional health needs of expectant mothers, how and when to notify obstetricians when their patients come to the emergency room, and how to meet specific needs of obstetrical patients.

• Retraining emergency room staff in how to manage diabetes patients, including fluid management and glucose level monitoring with lab work and test strips.

• Setting new standards for attending to and documenting blood loss by patients who are experiencing vaginal bleeding.

• Retraining all nursing staff on assessing and reassessing patients.Revising the emergency room’s pain management policies.

• Training staff to better understand and respond to needs of women who have lost an early stage pregnancy.

Doing so means better integrating some of the hospital’s specialized staff -- such as high-risk labor and delivery nurses, social workers, mental health therapists, chaplains and grief counselors -- into these emergency cases.

“This situation reminds us that we have all the resources we need right here to make sure that women suffering the loss of a pregnancy are taken care of -- physically, mentally and spiritually,” MacKenzie said.

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.