AnnMarie Papa

Emergency Nursing Resource: Family Presence During Invasive Procedures and Resuscitation in the Emergency Department

ENA’s Emergency Nursing Resources (“ENR”) are developed by ENA members to provide emergency nurses with evidence-based information to utilize and implement in their care of emergency patients and families. Each ENR focuses on a clinical or practice-based issue, and is the result of a review and analysis of current information believed to be reliable. As such, information and recommendations within a particular ENR reflect the current scientific and clinical knowledge at the time of publication, are only current as of their publication date, and are subject to change without notice as advances emerge.

Emergency Nursing Resource: Difficult Intravenous Access

Authors: 2011 ENA Emergency Nursing Resources Development Committee: Melanie Crowley, MSN, RN, CEN, MICN, Carla Brim, MN, RN, CEN, CNS, Jean Proehl, MN, RN, CEN, CPEN, FAEN, Susan Barnason, PhD, RN, APRN, CEN, CCRN, CNS, CS, Sherry Leviner, MSN, RN, CEN, Cathleen Lindauer, MSN, RN, CEN, Mary Naccarato, MSN, RN, CEN, CCNS, Andrew Storer, DNP, RN, ACNP, CRNP, FNP, Jennifer Williams, MSN, RN, CEN, CCRN, CNS 2011 ENA Board of Directors Liaison: AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN

Emergency Nursing Resource: Non-invasive Temperature Measurement in the Emergency Department

Authored by the 2011 ENA Emergency Nursing Resources Development Committee: Susan Barnason, PhD, RN, APRN, CEN, CCRN, CNS, CS Jennifer Williams, MSN, RN, CEN, CCRN, CNS Jean Proehl, MN, RN, CEN, CPEN, FAEN Carla Brim, MN, RN, CEN, CNS Melanie Crowley, MSN, RN, CEN, MICN Sherry Leviner, MSN, RN, CEN Cathleen Lindauer, MSN, RN, CEN Mary Naccarato, MSN, RN, CEN, CCNS Andrew Storer, DNP, RN, ACNP, CRNP, FNP

Emergency Nursing Resource: The Use of Capnography During Procedural Sedation/Analgesia in the Emergency Department

ENA’s Emergency Nursing Resources (“ENR”) are developed by ENA members to provide emergency nurses with evidence-based information to utilize and implement in their care of emergency patients and families. Each ENR focuses on a clinical or practice-based issue, and is the result of a review and analysis of current information believed to be reliable. As such, information and recommendations within a particular ENR reflect the current scientific and clinical knowledge at the time of publication, are only current as of their publication date, and are subject to change without notice as advances emerge.

Emergency Nursing Resource: orthostatic vital signs.

Summary of Literature Review Summary of Definitions The definition of orthostatic vital signs warrants further research despite its common use in clinical practice, textbooks, guidelines and research studies. A review of definitions from the literature indicates that the assessment parameter labeled as orthostatic vital signs can be summarized by its: physiological variables, measurement method, and purpose. The physiological variables include blood pressure, heart rate, and stroke index (Durukan et al., 2009; Fuchs & Jaffe, 1987; Horam & Roscelli, 1992; Koziol-McLain et al., 1991; Levitt et al., 1992; Witting & Gallagher, 2003), as well as symptoms of dizziness or lightheadedness (Lance et al., 2009; Sarasin et al., 2002). Stated purposes of orthostatic vital signs assessment include identification of hypovolemia (both dehydration and blood loss) and treatment efficacy of pharmacological agents for neurological conditions. Assessment for hypovolemia is the purpose of orthostatic vital signs for this review. The most common variables measured to assess orthostatic vital signs in potentially hypovolemic patients include blood pressure and heart rate, measured with the patient in different positions (supine, sitting, standing). Equipment used to obtain orthostatic vital signs, as well as the feasibility of obtaining orthostatic vital signs in the clinical setting will be described. For the purposes of this document, orthostatic vital signs are defined as a change in blood pressure, heart rate, or onset of symptoms after a change in position in individuals (adult, child, and adolescent) with a decrease in intravascular volume (Durukan et al., 2009; Fuchs & Jaffe, 1987; Horam & Roscelli, 1992; Koziol-McLain et al., 1991; Levitt et al., 1992; Witting & Gallagher, 2003).

Transforming Care in a Large Inner City University Hospital Emergency Department

Sadly, arriving to an emergency department in 2012, a patient and his or her family’s initial encounter can bewith a secretary or a registration staff memberwho is less interested in the chief complaint and more concerned with capturing basic demographic information and establishing the method of payment. Patients’ expectations regarding a visit to the emergency department include being greeted, having their complaint or injury assessed, and receiving care in a timely manner. A crowded waiting room can be a dangerous place in the emergency department. On a busy evening, high nurse-patient ratios can result when patients with various chief complaints, of various ages, and often with children and elderly patients present to the emergency department, with one triage nurse being responsible for over 30 to 40 waiting patients. The waiting room is full of potentially or actual critically ill patients who are often unmonitored, often not reassessed, and left without any conduit for communication if they are able to verbalize a change in their presenting condition. If you or your loved one arrives to the emergency department, your expectations are that you are greeted, your complaint or injury is assessed, and you are taken care of in a timely manner. This quality-improvement project was designed to place a triage nurse in the waiting room to greet each patient on arrival, determine the reason for the ED visit, perform an initial evaluation and an across-the-room assessment, and assign triage acuity. Revising the upfront arrival and triage process and moving patients directly from triage to a bed (ie, immediate bedding), when a bed is available, with bedside registration, reduces the door-to-doctor time and can increase overall throughput. The Institute ofMedicine (IOM) indicated in the title of a 2006 report that the emergency care system in the United States is reaching its “breaking point.” The framework the IOM proposed to examine ED crowding was based on the IOM’s 2001 report The Quality Chasm, in which the IOM identified the 6 dimensions of quality—safety, effectiveness, patient centeredness, efficiency, timeliness, and equity—all of which can be compromised when patients experience long delays in seeing a physician or when the number of boarding patients limits the ED staff’s ability to provide effective care. In addition, patients’ perception of care and their overall level of satisfaction with the entire visit may be determined early in the visit if they experience lengthy delays. The goal of the waiting room nurse is “GRASP-ED,” that is, greet-reassure-assess-sort-prioritize in the emergency department: greet each arriving patient and assure him or her that a registered nurse understands his or her reason for arrival; reassure each arriving patient and his or her family or support persons; assess using essential nursing assessment skills and history-taking questions, chief complaint, medical history, and currentmedications; sort in a certain place or ranking, to arrange according to illness; and prioritize by being the eyes and ears of the triage nurse who is behind closed doors performing full assessments, vital signs, and protocols on already sorted patients, allowing the triage nurse to treat patients by acuity versus time of arrival. In addition, the goals for the GRASP-ED nurse are to identify critically ill patients and expedite their care, ensure early isolation of patients with communicable diseases, ensure early reverse isolation for patients who are immunocompromised, assist in facilitating the triage process and throughput, and immediately initiate first aid on arrival, while enhancing the patient experience and changing the perception of patient care, starting immediately upon arrival, while accomplishing this with excellent customer service skills. Jeanne J. Venella,Member, South Jersey Chapter, is Project Manager, Emergency Department, Hospital of the University of Pennsylvania, Philadelphia, PA.

It’s Electric!

I n 1752, when Ben Franklin first flew his kite with an attached key to demonstrate that lightening was electricity, he likely did not realize that 251 years later, this event would meld with tobacco, laying the groundwork for the development of the electronic cigarette. This year the electronic cigarette turns 10 years old. First used in China, “e-cigarettes” eventually spread to Europe and the United States, creating an industry that projected to generate revenues of one billion dollars in product sales. The growth of this industry has now infiltrated emergency departments as electronic cigarettes are showing up in our waiting areas and even patient rooms. Several months ago, a question regarding how emergency departments were handling electronic cigarette usage showed up on the ENA listserv. Electronic cigarette usage raises several concerns ranging from how emergency departments are handling this type of tobaccoless “smoking” to the impact of exhaled vapors on family members, other patients, and staff. Electronic cigarettes, referred to as ENDS (electronic nicotine delivery systems) by the World Health Organization, are devices that use electricity to convert nicotine into a vapor that is inhaled and then exhaled by the user. 5 Although ENDS lack tobacco, a variety of chemicals mixed with the nicotine have led to claims that the exhaled vapor may contain toxic carcinogens. Thirdhand smoke—the nicotine residue from smoking—has been found to stick to and linger for years in various surfaces in our homes, workplaces, and cars. This “lingering” sets up the potential for the third-hand smoke to interact with other chemicals, producing

Emergency Nursing Resource: Wound Preparation

Authors: 2011 ENA Emergency Nursing Resources Development Committee: Andrew Storer, DNP, RN, ACNP, CRNP, FNP, Cathleen Lindauer, MSN, RN, CEN, Jean Proehl, MN, RN, CEN, CPEN, FAEN, Susan Barnason, PhD, RN, APRN, CEN, CCRN, CNS, CS, Carla Brim, MN, RN, CEN, CNS, Melanie Crowley, MSN, RN, CEN, MICN, Sherry Leviner, MSN, RN, CEN, Mary Naccarato, MSN, RN, CEN, CCNS, and Jennifer Williams, MSN, RN, CEN, CCRN, CNS 2011 ENA Board of Directors Liaison: AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN

Welcome New Nurses to the Wonderful World of Emergency Nursing

Thirty-eight years ago, I entered the world of emergency nursing as a new graduate. I remember the many mixed emotions I experienced. Back then, it was not popular to hire a new graduate into the emergency department—especially one with a bachelor of science in nursing (BSN)! There was a belief that a nurse needed at least 2 years in medical/surgical nursing. That same debate exists today, but necessity has provided us with the opportunity to re-examine our previous beliefs and practices. Whatever your thoughts on the topic, everyone agrees that to ensure the success of the newly graduated registered nurse (RN) in an emergency department, it takes time, patience, planning, and precepting. As we are approaching the season for newly graduated nurses to come through your doors, we asked a few of your colleagues to share their thoughts and ideas on the subject. Let us see what they have to say!

Rub a Dub Dub: Best Practices for Stretcher Cleaning

Community hospital, stand-alone facility, rural facility, or academic medical center—ED nurses working in different settings all rely heavily on stretchers. We might even go so far as to claim that the stretcher is the ED nurse’s best friend, for without these 4-wheeled metal objects our practice would be much different, as “pushing around” patients in beds would greatly decrease the life span of our backs. With such a heavy reliance on these 4-wheeled friends, Audra Ford, MSN, RN, CEN, Director of the Emergency Department at Marshall Medical Center North in Guntersville, AL, reached out to ED nurse colleagues across the United States to ascertain how others were cleaning and disinfecting their stretchers. The feedback ranged from using a variety of commercial products, wipes, and even vinegar (yes, there was an issue with the smell) to clean stretchers. This array of “cleaning tips” led us to contact 2 ENA Corporate Sponsors, Stryker Medical (Kalamazoo, MI) and Hill-Rom (Batesville, IN), for their recommendations and expertise regarding how to properly clean, disinfect, and care for stretchers. At Stryker Medical, Don Payerle, Vice President and General Manager of Patient Handling and EMS, and Kevin Patmore, Chief Engineer, were happy to share a few pointers regarding stretcher cleaning. They began, “Most important to stretcher cleaning and disinfecting is ensuring that blood and/or other bacteria-transferring fluids are removed—and, of course, getting rid of those dust bunnies [that get caught in the casters] helps keep the stretcher in good condition.” Although each stretcher comes with an operation manual detailing proper cleaning and disinfecting, these booklets often reside in the facilities management or ED administrative offices and may not