Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care
2007; Elsevier BV; Volume: 33; Issue: 2 Linguagem: Inglês
10.1016/j.jen.2006.11.017
ISSN1527-2966
Autores Tópico(s)Nursing Roles and Practices
ResumoThe Manager's Forum is an integral part of our Journal of Emergency Nursing. During the past years, Section Editor Polly Zimmermann has tapped into our creative potential, connected managers across the country, and provided us with a high-quality, informative, and insightful column. As time marches forward, the baton has been passed to us. First and foremost we want to thank Polly for her wisdom and expertise, and we wish her the best in her new ventures. We will do our best to maintain the high standards that our members have come to expect. This is an exciting opportunity and we invite you to help us keep the flames of nursing management and leadership burning brightly. Please feel free to E-mail us with ideas, questions and/or creative solutions to current ED management and leadership issues. Your contributions are what make this column successful. We are looking forward to working with you, and thank you for your support.—Jeff Solheim, RN, CEN, and AnnMarie Papa, MSN, RN, CEN, CNA, FAEN With more than 135 staff to accommodate, we offer 4 different staff meetings monthly at a variety of times to meet everyone's schedule. Our first meeting is held on Tuesday mornings at 9:00 am. This is our “kid friendly” meeting, which is geared toward mothers with children. Several of our nurses bring their kids every month, and while we conduct business, the kids get to play with one another. The remaining meetings are held throughout the day on Wednesday to accommodate everyone's schedule. There is a 7:00 am meeting for the night shift, a 1:15 pm meeting for the evening shift, and a meeting at 3:30 pm in the afternoon to accommodate the day shift.—Cathy C. Fox, RN, CEN, Clinical Nurse II Educator, Sentara Virginia Beach General Hospital, Virginia Beach, Va; E-mail: Recognizing that staff's time is precious, not to mention having to drive in to work on a day off, we offer a “paper staff meeting” 1 month, which alternates with a “live staff meeting” the next month. All of the concerns, comments, and normal agenda items that are covered in the live staff meetings are distributed to all of the staff during the month of the “paper staff meeting.” The staff are given a deadline date to return them with their comments and votes. After all of the responses are received, the comments and votes are tallied up and redistributed with the comments highlighted. We have had 100% return rate by the deadline, with many positive comments about this format. In fact, we find a better response on our “paper staff meetings” than our live staff meetings, perhaps because people feel they can be more open and honest using this format.—Geneva Sides, RN, BSN, Emergency Department Nurse Manager, Redington-Fairview General Hospital, Skowhegan, Maine In a profession of constantly evolving technology and improvement in the standard of care, we are committed to providing the highest quality patient care possible. To do that, we require members of our staff to attend our annual skills fair. The process begins 3 months in advance, when a sign-up sheet is posted to allow interested members to volunteer to be on the planning committee. Every effort is made to make it a fun and informative event while at the same time fulfilling our education requirements. The committee picks a theme for the event and we decorate accordingly. Some of the past themes were:•The Wild, Wild ER•Survivor•Fiesta•Tropical•Game Show Two days are offered for nurses and 2 days for our technicians and phlebotomists. The average time for a nurse to complete the process is 4 to 5 hours. Each staff member must complete and be signed off on several stations, including cardiac, QC documentation, trauma, stroke, pediatrics, airway, hazmat, intravenous medications, TLC (helping us take care of each other), and violence/drug abuse. We also add a “rotating” station each year that might be of interest to us, such as forensic medicine, orthopedic update, or something going on in our community that may affect us.—Tracy Stark, RN, Assistant Education Coordinator, Emergency Trauma Center, St John's, Springfield, Mo; E-mail: The process starts by choosing which competencies will be measured. This changes from year to year based on an assessment done using “The ultimate guide to competency assessment in healthcare” by Donna Wright.1 Four areas are reviewed when choosing competencies to measure. These include the following:1.New policies, procedures, equipment, and initiatives2.Changed policies, procedures, equipment, and initiatives3.High-risk aspects of a job (things that carry a significant risk of harm, death, or legal action)4.Problematic areas identified through quality management data, incident report trends, patient surveys, and staff surveys Once potential competencies have been identified using these criteria, they are ranked in priority from high to low. The top 10 priorities are then selected as areas of competency measurement for the year. (To minimize overwhelming staff and leadership, no more than 10 areas of competency measurement are chosen annually.) Woven into these competencies are any appropriate age-specific or cultural-specific aspects. Department preceptors, educators, and experts from other departments (for example, NICU nurses for neonatal resuscitation, laboratory personnel for Point of Care testing, etc.) are then recruited to prepare study materials and man skill stations. Staff members are provided with preparation packets ahead of time that review the skills that will be measured. Multiple competency days are then scheduled, and staff must visit each skill station during that day to demonstrate the specific skills that have been chosen.—Penny Edwards, RN, BScN, CEN, Clinical Educator, Salem Hospital, Salem Ore; E-mail: 1.Wright D. The ultimate guide to competency assessment in healthcare. 2nd ed. Eau Claire (WI): PESI HealthCare LLC Publishing Inc; 1998. We set up a competency day that includes the following stations: Triage—A station that includes a scenario with a list of different presenting complaints, signs and symptoms, and a review of the triage classification. To be signed off, the participant must correctly classify each patient and report the order patients will be taken back. Trauma—This station includes a review of roles of the primary, secondary and recorder role. A trauma scenario is presented, and participants must demonstrate trauma assessment using a SIM man in the simulation laboratory. Implanted device—Participants are asked to demonstrate accessing an implanted catheter on a mannequin. Peritoneal dialysis—Participants demonstrate the proper way to collect peritoneal dialysis cultures, as well as a complete exchange and dwell prior to collection. Stroke assessment—The family nurse practitioner in our neurological services area sets up a skill station where National Institute of Health Stroke Scale is reviewed and a neurologic examination is performed by participants on the SIM mannequin using the stroke scale. Staff members who are unable to attend the established competency day are responsible to request a designated “reviewer” to monitor them performing these specific tasks in the clinical area. “Reviewers” are staff members who have been predesignated as verifiers for competency completion.—Kim Morgan, RN, MSN, CEN, Dayshift Charge Nurse, CAMC General Emergency Department, Charleston, WV; E-mail: In the absence of inpatient beds, direct admissions are assessed by the bed control nurse for stability. If a bed will not be available for 2 or more hours and the patient is deemed stable, the admitting physician is notified to inquire about the appropriateness of allowing the patient to return home to wait for an available bed. The patient is then given the choice of waiting at home or staying in the outpatient area. They may be provided with meal tickets as appropriate. If the patient is not deemed stable, he or she is referred to the emergency department for initiation of treatment. Admitting orders, such as laboratory and radiologic examinations, as well as medications, are initiated. All medications administered are recorded on an inpatient MARS record. Patients who will be held in the emergency department for an extended period are placed in a hospital bed, and regular meals are ordered. If the anticipated ED stay exceeds 24 hours, a nursing admission assessment also is performed.—Ingrid Steinbach, RN, CEN, Director of Emergency and Trauma Services, Valley Baptist Health System, Brownsville, Tex; E-mail: When our hospital is full, patients awaiting admission are sent to the emergency department. We staff one area of our ED with inpatient nurses when we are holding patients and, if possible, all admission holds will be placed in that area. If all else fails, the ED staff will give direct care to those waiting for admission.—Barbara Taubenberger, RN, BSN, CEN, Nurse Manager, Frankford Hospital, Torresdale Division, Philadelphia, Pa; E-mail: “Left without being seen” (LWBS) is used for patients who have not been seen by a physician. “Against medical advice” (AMA) is used for patients who have been seen initially by a physician but have not completed treatment. If the staff are aware that the patient wishes to leave and can get them to sign the AMA form, then they are AMA. We use “eloped” for patients who have been seen by a physician but not discharged by a physician and have left without informing the staff. All of these terms are documented in the medical record.—Carole L. Mennell, BSc, RN, MICN, Director of Emergency Services, Mercy San Juan Medical Center, Carmichael, Ca We use “left prior to triage” (LPT) (any patient who did not have a triage assessment); “left prior to medical screening examination” (LPMSE) (patient who has been triaged but left before seeing the doctor); and “against medical advice” (AMA) (any patient who had triage assessment and had an examination by a doctor but left before completing testing or treatment). We use the back of our sign-in sheet to document the LPT and LPMSE. This form has risks and benefits. It also has the time the patient signed in and the time that we called them for triage or treatment. If the patient does not notify staff, we still document what time we called them and this, in turn, becomes their medical record. We also have an AMA form that documents risk and benefits with release of liability. The form is completed even if the patient does not sign or does not notify staff that they are leaving.—Kevin Manning, RN, CEN, Manager of Emergency Services and Trauma, Medical Center of Arlington, Arlington, Tex The Emergency Department Performance Measurement Summit convened in February of 2006 with the intent of creating operational definitions for performance measures frequently utilized in United States–based emergency departments. The group—which included representatives from a variety of alliances and associations that have demonstrated an interest in performance data and quality improvement in emergency departments—was tasked with defining a set of ED benchmarking terms that could be used to monitor ED operations. The group chose a global definition for the group of people commonly referred to as AMA, LWBS, LBMSE, or more simply stated, “People who left before they were supposed to.” It was the consensus of the group that this population needed to be tied to a specific, predictable event that occurs in every patient encounter across the industry. EMTALA has defined the Medical Screening Examination (MSE) as a defining event in emergency care. The causes of a patient's unofficial departure and actions taken vary according to when in the patient's experience they depart and warrant monitoring. Therefore, the key performance indicators for this group were recommended as follows: Patients Leaving Before the Medical Screening Examination (PLBM): This term refers to any patient who leaves the emergency department before initiation of the MSE and should be expressed as a rate of occurrence per 100 visits. The interval should be calculated from the time of arrival to the emergency department to the time (or best determined time) that the patient departed, up to the initiation of the MSE. Patients Leaving After the Medical Screening Examination (PLAM): Refers to any patient who leaves the emergency department after their MSE but before the provider deemed treatment complete. It should be expressed as a rate of occurrences per 100 visits. Calculate the interval from the time of initiation of the MSE to the time (or best determined time) that the patient departed. Patients who Leave Against Medical Advice (LAMA): Any patient recognized by the institution and leaving after interaction with the ED staff but before the ED encounter is officially ended. This differs from PLAM in that it includes documentation of patient competence, discussion about risks and benefits, and completion or refusal to complete documentation confirming the intent to leave against the recommendation of medical care staff. Documentation for each measurement should be supported by individual hospital policy. By measuring this and other parameters of ED performance using the same criteria nationwide, we begin to move toward standardization of metrics for benchmarking purposes. ED Performance Measures and Benchmarking Summit: The Consensus Statement was retrieved on November 11, 2006, from www.qualityindicators.ahrq.gov/news/EDPerformanceMeasures-ConsensusStatement.pdf.—India J. Taylor Owens, RN, MSN, Manager, Clinical Operations, Indiana University Emergency Department, Clarian Health, Indianapolis, Ind; E-mail: Hospitals normally divide patients who leave prior to completion of medical care into 2 categories: LWBS (or left without being treated) and AMA. LWBS is typically applied to patients who have not seen the physician regardless of whether the patient is in an examination bed or the waiting room. AMA is applied to patients who have been seen by the physician and choose to leave prior to completion of the full plan of care. Documentation can vary based on your legal team's instructions. For LWBS, if possible you would want to include the time left, any salient conversation that occurred (eg, an encouragement to stay for care), and documentation of the condition of the patient as they were witnessed leaving (eg, walked out of emergency department in no apparent distress). For AMA, a discussion and documentation related to risks and benefits of leaving AMA and a signed release form is optimal. Both of these categories of patients must be recorded on your ED log and should be key operational metrics monitored by hospital leadership.—Fred Neis, RN, MS, CHE, CEN, Director, The Advisory Board Company, H*Works, Washington, DC; E-mail: Nothing is a substitute for good clinical judgment. That said, we must recognize that clinicians have variations in their practice, and thus a policy must be created to better standardize expected care. In my experience, hospitals vary based on route of administration rather than differentiating between narcotic and non-narcotic. If a patient is given a medication orally, 20 minutes should be enough time elapsed to uncover possible unexpected adverse effects. This may be waived if the medication is one the patient normally receives or has received in the past without incident. Medications via intravenous or intramuscular route should declare themselves more quickly, but 30 minutes appears to be the standard for time elapsed before discharge. Patients who receive medications that may alter decision making or motor skills should have a ride home.—Fred Neis, RN, MS, CHE, CEN, Director, The Advisory Board Company, H⁎Works, Washington, DC; E-mail: Our current policy is to hold patients for 20 minutes after any injection (intramuscular or intravenous). It is the same for all medications.—Pam Kvas, RN, Director of Emergency Services, Newman Regional Health, Emporia, Kan; E-mail: The protocol at our facility states that all patients receiving any medication must be observed for 30 minutes prior to discharge. Some medications require a longer observation time, as in the case of racemic epinephrine. After administering a narcotic, the patient still requires the 30-minute observation period in order to observe for any adverse or allergic reactions, in addition to re-assessing the patient for efficacy and pain control. Prior to administering any narcotic, however, we assess the patient for transportation home and make other arrangements if they drove themselves to the emergency department.—Ingrid Steinbach, RN, CEN, Director of Emergency and Trauma Services, Valley Baptist Health System, Brownsville, Tex; E-mail: In general, our registrars ask for a picture form of identification in conjunction with any coverage or insurance information, which is usually in the form of a driver's license. However, we do not refuse treatment or delay treatment if the patient can not produce a picture identification. In the event that we suspect a patient is using a fraudulent identification, our risk management department is contacted. They conduct an investigation and collect documentation and if the suspicions are substantiated the appropriate authorities are contacted.—Ingrid Steinbach, RN, CEN, Director of Emergency and Trauma Services, Valley Baptist Health System, Brownsville, Tex; E-mail: We do not require a photo identification, although we have been entertaining the thought because of a lot of fraud lately. If we suspect the patient is using a false name, maybe because someone recognizes the patient, we try to verify through records, then we call the police. We have had several arrested in the emergency department for this lately, and it is usually because they are trying to obtain narcotics illegally.—Geneva Sides, RN, BSN, Emergency Department Nurse Manager, Redington-Fairview General Hospital, Skowhegan, Maine At our hospital, the registration clerks request a Federal Issued ID or a Medicare/Medicaid number or card. They then make a copy of it and will run the Medicare/Medicaid number through a system. If the system denies the number, then they are registered as self-pays. If it is a repeat offender, then it is marked in the computer that the address or numbers given were inaccurate and they are registered as self-pays also. Now, the unfortunate issue is that even though they are labeled self-pay, the hospital probably is not going to be reimbursed. We will be meeting with the Business Office soon to better utilize our checkout area for this patient population. We have no policy in place to pursue criminal charges in these cases. We ensure that the patient has received the appropriate MSE before these issues are addressed, which is the primary purpose of the checkout area staffed by a person from the Business Office. More than fraud, our patients have a tendency just to give a fictitious phone number or address.—G. Lee Ladner, RN, BSN, BSB, Lake Charles Memorial Hospital, Lake Charles, La; E-mail:
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