Jennifer Wilbeck

Unexpected birth in the emergency department: the role of the advanced practice nurse.

Emergency department (ED) births are relatively uncommon, but when they occur, the advanced practice nurse is in a unique position to assist the mother through unexpected vaginal delivery in the ED. The purpose of this article is to guide the advanced practice nurse through the process of care for a woman giving birth in the emergency department. Anticipation, preparation, “the catch,” the newborn, the placenta, stabilization, and transport are the individual steps reviewed in this article. The focus of this manuscript is also to discuss the management of a mother and neonate during and following an unexpected vaginal birth.

Standards of Practice for Emergency Nurse Practitioners.

ENPs are specialized licensed practitioners, who possess the necessary clinical competencies to provide optimal care to patients in ambulatory, urgent, and emergent care settings. ENP specialization builds upon NP entryinto-practice knowledge and skills and requires a minimum of a master’s level preparation or specialized preparation at the post-master’s or doctoral level. ENPs demonstrate competencies by applying standardized care guidelines in their clinical practice. Other ways of continuing competencies include participation in maintaining continuing education, quality improvement processes and peer reviewsincluding the systematic periodic review of records and treatment planswhile maintaining specialty and population-focused certification in compliance with current laws and regulations.

Teaching management of the unexpected birth: application of multimodal techniques.

The ability to safely manage birth in the emergency department is a competency for emergency nurse practitioner practice. However, it is difficult to ensure that students receive enough practice with this low-frequency event. To meet this need, we created a learning environment combining readings, skills videos, lecture, practice with models, simulation, and debriefing to assist students in providing safe care to women giving birth in the emergency department. This program, which includes a high-fidelity, low-technology simulation, has been successfully implemented with excellent results. The realistic nature of the simulations, use of recently graduated nurse–midwives as the simulated patients, and group interactions during the births were keys to this successful simulation experience. When paired with appropriate preparation, simulation of an unexpected birth in the emergency department promotes confidence and safe practice among advanced practice nursing students.

North American Snake and Scorpion Envenomations

Envenomations by snakes and scorpions in North America, although uncommon, do occur, and the victims may seek medical treatment. Combined, snake and scorpion encounters result in more than 25,000 calls a year to poison centers. Although some similarities exist with respect to general signs of envenomation and treatment, specific nuances distinguish the medical care to be anticipated and therapies available. Regardless of geographic practice area, exposures will occur that may result in a significant envenomation. This article provides critical care nurses with fundamental knowledge of varied snake and scorpion envenomation presentations and treatments to assist in optimizing patient outcomes.

Emergency Nurse Practitioner Core Educational Content

Increasing numbers of patients are presenting to national emergency departments (EDs). This is occurring simultaneously with reductions in providers along with ED closures, creating a significant gap in emergency care. According to the advanced practice registered nurse consensus model, specialty-specific knowledge and practice build upon generalist nurse practitioner (NP) population foci. Although the National Organization of Nurse Practitioner Faculties provides guidelines for educational programs at the NP population level, determination of core specialty knowledge lies with specialty organizations. Emergency nurse practitioners (ENPs) require additional specialty-specific education to manage patients spanning age and acuity continuums. Although certification mechanisms are now in place to recognize NP specialty knowledge, a nationally standardized curriculum remains to be proposed. This article proposes core educational content for ENP specialty education; the utility of this content may serve as the foundation for the development of standardized ENP academic and postgraduate fellowship programs.

Toxicology in the emergency department: a review for the advanced practice nurse.

General assessment, resuscitation strategies, and risk assessment of the poisoned patient are explored in this article, including specific interventions for unresponsive patients and seizures. Sympathomimetic and anticholinergic toxidromes are described in terms of clinical presentation and treatment strategies and are compared with other common toxidromes. Controversies in gastric decontamination are also outlined, including consensus panel and national organizational recommendations. Despite available methods for toxin elimination, advances in medicine, and pharmacotherapy options, the cornerstone of toxicology remains supportive care. The purpose of this article is to equip the advanced practice nurse in the emergency setting with baseline knowledge to provide initial care of the poisoned patient.

Postgraduate Emergency Nurse Practitioner Fellowships: Opportunities for Specialty Education

Specialty trained emergency nurse practitioners (ENPs) can meet the demands of an unpredictable emergency care environment within an overburdened health care system. Although existing literature supports fellowship training as a method for bridging academic knowledge with clinical experiences for the novice nurse practitioner, the currently available emergency care postgraduate fellowship programs are inconsistent in approach. Building upon descriptive data provided by the existing 9 postgraduate ENP fellowship programs, a comparison and gap analysis of program content was conducted to identify perceived standards for ENP specialty education and the congruence with published ENP competencies. Standards to curricula, didactics, clinical rotations, and measures of competency were identified in the currently established ENP fellowships. A national ENP fellowship curriculum has the potential to afford consistency among programs, support attainment of competency, and provide clarity to the role and general education of advanced practice registered nurses seeking employment in emergency care.

Strategies to Enhance Success Among Dual-Specialty Students in Advanced Practice Nursing Programs.

BACKGROUND In attempts to simultaneously address the 2008 Consensus model and meet the growing need for advanced practice nurses with a robust scope of practice, some schools of nursing offer dual advanced practice nursing (APN) programs. METHOD Built on the successes of multiple dual programs at two universities, this article provides specific practice strategies to enhance academic success among students and faculty in dual-specialty APN programs. RESULTS Faculty- and student-led strategies are outlined, addressing the academic and professional aspects of the dual APN role. With implementation of these strategies, graduation and subsequent dual certification rates in these programs remains extremely high. CONCLUSION Adaptation of these strategies to support student and faculty efforts can potentiate additional opportunities for successful dual APN programs. [J Nurs Educ. 2016;55(8):463-466.

Delivery of babies in the emergency department.

Dear Editor: It was with interest that we read the article “‘Did You Just Say...The Baby’s Coming!!??’: A Nurse’s Guide to Prepare for a Safe Precipitous Delivery in the Emergency Department.” We agree that managing unexpected births in the emergency department is a low-frequency, high-risk occurrence that requires preparation. However, we believe several areas of the article warrant clarification and updating to most current evidence-based practice. First, the author states that precipitous deliveries commonly result from various obstetrical or medical complications. Although several medical complications can result in a truly precipitous birth, the ED nurse should find reassurance in the fact that the majority of precipitous births are rarely associated with serious maternal complications. Additionally, the management of several components of the birth itself must be updated. Routine use of bulb suction and third stage management have newer guidelines than those mentioned in the article. Recent recommendations are that the use of the bulb syringe to clear the mouth and nose should be reserved for babies who have an obvious obstruction or require positive pressure ventilation. Routine use of the bulb syringe has been found to cause harm and should not be practiced. Except in rare cases, the baby routinely should be placed in a skin-to-skin position on the mother immediately after the birth. Assessment and care of the newborn can be done while the skin-to-skin position is maintained. It is not necessary to clamp and cut the umbilical cord unless the baby must be separated from the mother. In fact, delayed clamping and cutting is beneficial to the newborn and is recommended. It is not harmful for the placenta to be expelled while still attached to the newborn. Cord pulsations stop spontaneously, and remaining blood in the cord is contained within a closed circuit, meaning that any blood loss noted with placental expulsion is not from the baby. Cutting of the cord should not occur until at least 2 minutes after the birth, but it can then be cut at any point, even after the placenta is expelled. After the placenta is expelled, the mother should receive either 10 units of Pitocin administered intramuscularly or, preferably, 20 units of Pitocin administered intravenously mixed with 500 to 1000 mL of lactated Ringers or normal saline solution. Waiting to determine the amount of bleeding before treatment is not recommended because proactive treatment decreases the risk of postpartum hemorrhage. As the author stated, a strategic and rehearsed plan for unexpected births in the emergency department will increase team communication and patient safety and enhance what is usually a normal, healthy event.—Jennifer Wilbeck, DNP, ACNP-BC, FNP-BC, Member, Middle Tennessee ENA Chapter, Associate Professor of Nursing and Program Coordinator, Emergency Nurse Practitioner Program, Vanderbilt University School of Nursing, Nashville, TN; E-mail: Jennifer. wilbeck@vanderbilt.edu, and Mavis N. Schorn, PhD, CNM, Associate Professor of Nursing, Nurse-Midwifery Program and Assistant Dean for Academics, Vanderbilt University School of Nursing, Nashville, TN http://dx.doi.org/10.1016/j.jen.2012.08.007

Noninvasive ventilation in emergency care.

The use of noninvasive ventilation (including bilevel positive airway pressure and continuous positive airway pressure modalities) has become increasingly more widespread in emergency care, offering an alternative to traditional ventilation using an endotracheal tube. This article provides an overview of the types and potential uses of noninvasive ventilation, the risks and benefits of its use, and current evidence to support its use in specific patient populations. Guidelines for appropriate selection of patients for noninvasive ventilation therapy are provided. Management considerations, assessment techniques, troubleshooting, and transportation of patients receiving noninvasive ventilation are also discussed. Advanced practice nurses in the emergency department can provide leadership and advocacy for its use in appropriate patients, and this article provides the foundational knowledge to do so.