ENA Connection December 2013 by ENA Connection

the Official Magazine of the Emergency Nurses Association

connection Soul Purpose

December 2013 Volume 37, Issue 11

2013 Annual Conference

Nurturing Our Spirits in Nashville By Filling Our Heads and Refueling Our Tanks

38 PAGES OF COVERAGE INSIDE! PLUS . . . Profiling the Lantern Award Recipients 6 - 10 ♦ Code You: Beware the Holiday Blues 14 ♦

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Dates to Remember Dec. 2, 2013 Deadline to apply for the Academy of Emergency Nursing 2014 Class of Fellows. Dec. 6, 2013 Deadline to apply for Leadership Tapestry Scholarship to attend Leadership Conference 2014 in Phoenix, March 5 - 9. Jan. 15, 2014 Deadline to submit poster/paper abstracts for 2014 Annual Conference.

ENA Exclusive Content PAGES 6 -10 Lantern Award Recipient Profiles PAGE 14 Blue Season: With Holidays Comes the Risk of Feeling Less Than Merry PAGES 16 -53 2013 Annual Conference Section 16 - 21 General Assembly 23 Anita Dorr Lecture and Luncheon 24 Presessions 25 Ultrasound Labs 26 Poster Winners 28 TNCC Pilot 30 Opening Session 32 Ready or Not: General Session 34 - 42 Concurrent Sessions 44 Closing Session 46 - 47 ENA Foundation Events 48 - 51 2nd Annual Awards Gala and Award Recipients

Regular Features PAGE 4 Free CE of the Month NEW! Letters to the Editor PAGE 12 ENA Foundation PAGE 54 Board Writes PAGE 56 Academy of Emergency Nursing

LETTER FROM THE PRESIDENT | JoAnn Lazarus, MSN, RN, CEN

Thank You, Everyday Heroes

t has been my honor to serve as your ENA president, and I am grateful to the membership for the opportunity to have served you. I am a bit sad to be finishing my term; however, I know that next year’s leadership is anxiously awaiting their time. My passion and focus this year have been leadership development, association mentoring and board/member communication. I believe these are important ingredients not only for the success of ENA but for your individual professional success. I have tried to weave this into all of my communications to you.

In January, I spoke about advocatism. This was my word for what we do for our patients, our profession and the specialty of emergency nursing. Whether it is bringing a potential medication error to the physician’s attention, helping others hear a patient’s voice or shaping policy by speaking to our legislative representatives, advocating for our profession and our patients is our role as emergency nurses. February’s focus was about professional ism. I expect that we treat everyone with respect and dignity — not just our patients and families, but our peers and colleagues, even when we do not agree with their philosophies or opinions. Professionalism comes from behavior, attitude, appearance and education. As emergency nurses, we must first respect one another before we earn the respect of others. That comes by doing the right thing, speaking to each other as professionals, honoring promises and having integrity in everything we do. Mentoring, lateral violence and servant leadership were my column topics for March, April and May. Mentoring is one of the most powerful methods by which we can shape the future of our profession and of our organization. Lateral violence, or bullying, is creating a toxic work environment. The first step in stopping lateral violence is recognition. The second step is to respond to it. Respond by not tolerating the behavior. Most important, I believe, is promoting positive, professional behaviors. As nurses we should tolerate nothing less. All nursing professionals have an obligation to practice servant leadership. We can do this by helping others to

advance in their careers by sharing our own experiences and ideas with them and by reaching out to newer nurses and providing them with mentorship and encouragement. In June and July, I reflected on the support of our peers who were still dealing with the crisis of the Boston Marathon bombings and the explosions in West, Texas. We know these are the days we all train for, with the hope that the day never arrives. For Boston and for West, that day did come, and everyone was ready. We all came together like a family, providing what support we could through pizza, e-mails, flowers and prayers. The nurses, firefighters, physicians and other health care providers who responded to these events are all heroes. Thank you for all you did. I finished up the year by focusing on the topics of influence and control, the importance of saying thank you, heroes and teamwork. Each and every one of you has the ability to influence health care decisions every day. You do this by the care you provide, the conversations you have with others and by working together as a team. Teamwork is critical to the success of ENA, and all of you are a part of this team. Each of you has unique talents that you share at the local, state or national level. I would like to thank each and every one of you for being heroes every day. The last 12 months have been an amazing journey. I thank all of you for your support. I especially would like to thank my family; my employer, Blue Jay Consulting; the ENA staff and the ENA Board of Directors.

Official Magazine of the Emergency Nurses Association

Be inspired by an example of longdistance collaboration when you dig into the latest free continuing education course from ENA!

NEW

Available to you starting Dec. 1 . . . “Crossing Over: A Critical Access Hospital and an Academic Medical Center Collaborating and Building Evidence for a 600-Mile Relationship,’’ presented by Christina A. Costello, BS, RN, CEN, and Leigh Anne Schmidt, MSN, RN. (Credit: 1.0 contact hour.) Costello (Mount Desert Island Hospital, Bar Harbor, Maine) and Schmidt (formerly Hospital of the University of Pennsylvania, Philadelphia) talk about the cooperative relationship between those organizations. In this eLearning course recorded at Leadership Conference 2013, they • Compare resources between a critical access hospital and an academic medical center • Uncover the collaborative opportunities to enrich staffs, departments and facilities • Discuss ways to do an RN exchange between separate hospital entities in different states • Share the experiences and growth of RNs involved in the exchange To take these and other CE courses free as an ENA member: • Go to www.ena.org/freeCE, where you’ll log in as a member (or create an account). • Add desired courses to your cart and ‘‘check out.’’ • Proceed to your Personal Learning Page to start or complete any course for which you have registered or to print a final certificate. • To return to your Personal Learning Page later, go to www.ena. org and find ‘‘Personal Learning Page’’ under the Education tab. Please be sure you are using the e-mail address associated with your membership when logging in. If you have questions about any free eLearning course or the checkout process, e-mail elearning@ena.org.

ENA Connection is published 11 times per year from January to December by: The Emergency Nurses Association 915 Lee Street Des Plaines, IL 60016-6569 and is distributed to members of the association as a direct benefit of membership. Copyright© 2013 by the Emergency Nurses Association. Printed in the U.S.A. Periodicals postage paid at the Des Plaines, IL, Post Office and additional mailing offices.

POSTMASTER: Send address changes to ENA Connection 915 Lee Street Des Plaines, IL 60016-6569 ISSN: 1534-2565 Fax: 847-460-4002 Website: www.ena.org E-mail: connection@ena.org

Member Services: 800-900-9659 Non-member subscriptions are available for $50 (USA) and $60 (foreign).

ENA Connection welcomes letters from members. Letters should address content previously published in the magazine. Letters may be edited for space and clarity. Submission does not guarantee publication. Please include your name, credentials and contact information for verification. Send letters to connection@ena.org.

just finished reading Kathy Clarke’s article, “Don’t Wait for a New ED Design: Top 5 Operational Considerations You Can Tackle Today” [October ENA Connection, p. 26], and I have a few comments. I recently started working in a ‘‘no wait’’ ER where triage-to-bed time is practically zero. The patients absolutely love it! I found myself also liking the process, as the patients come in happier and we both start off ‘‘on a good foot.’’ The one downside that I see is that the nursing assessment is nonexistent. Nurses are relegated to being clinical task

Do you have a recent professional or educational success story you want to share about yourself or an ENA member colleague? E-mail the information to connection@ena.org with the subject line “Members in Motion.”

Use ‘‘Ask ENA’’ to ask about the organization and emergency nursing in general. Questions will be referred to the appropriate ENA staff or department. E-mail questions to connection@ena.org.

Editor-in-Chief: Amy Carpenter Aquino Associate Editor: Josh Gaby Senior Writer: Kendra Y. Mims Editorial Assistant: Renée Herrmann BOARD OF DIRECTORS Officers: President: JoAnn Lazarus, MSN, RN, CEN President-elect: Deena Brecher, MSN, RN, APRN, ACNS-BC, CEN, CPEN

Secretary/Treasurer: Matthew F. Powers, MS, BSN, RN, MICP, CEN Immediate Past President: Gail Lenehan, EdD, MSN, RN, FAEN, FAAN Directors: Kathleen E. Carlson, MSN, RN, CEN, FAEN Ellen (Ellie) H. Encapera, RN, CEN Marylou Killian, DNP, RN, FNP-BC, CEN Michael D. Moon, PhD, MSN, RN, CNS-CC, CEN, FAEN Sally K. Snow, BSN, RN, CPEN, FAEN Joan Somes, PhD, MSN, RN, CEN, CPEN, FAEN Karen K. Wiley, MSN, RN, CEN Executive Director: Susan M. Hohenhaus, LPD, RN, CEN, FAEN

performers, and the crucial critical thinking process is nearly forgotten. I figured this problem was unique to this particular hospital, so I was upset to read in Ms. Clarke’s article that this is actually part of the expedited patient throughput model! The patients ‘‘no longer will have nursing assessments completed as they do in current traditional triage models . . . helping clinical staff prioritize nursing tasks.’’ I find this so upsetting. In an age where we are pushing for higher nursing education, eliminating the important nursing assessment seems like a step backwards. I would like to know from Ms. Clarke if she meant nursing assessments entirely, or did she mean just in the initial triage process? There has to be a way to quick triage, expedite care and maintain the nursing assessment at least by the primary nurse. Thanks for your time. Lynne Cerullo, BSN

ear Lynne, Thank you so much for your comments regarding my article. They clearly demonstrate your passion for emergency nursing and your commitment to providing quality care to

ED patients. I applaud the efforts of your department in support of expediting patients through triage or intake, and clearly, if nursing assessments were performed at triage/ intake, that would only impede the forward-moving process of getting patients to the right place for the right treatment. As you noted, my comment is not meant to eliminate the nursing assessment from the ED patient care process altogether but not to perform the assessment at triage/intake. Triage is to ‘‘sort’’ expediting the patient to the medical provider as quickly as possible. Adding unnecessary delays to perform a nursing assessment is counterproductive. Like you, I find absolute value in the primary RN performing the nursing assessment bedside instead of at triage/intake by a nurse who more than likely will not provide continuous nursing care for the patient. I hope this clarifies my position of performing nursing assessments during the triage/intake process. Sincerely, Kathy Clarke, RN, BSN, CEN FreemanWhite ED Design Team ED Clinical Expert

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Official Magazine of the Emergency Nurses Association

2013 Lantern Award Recipients

Sharing Innovation and Best Practices By the 2013 ENA Lantern Award Committee: Andi Foley, MSN, RN, CEN, Chairperson Jennifer M. Davis, MSN, MPH, RN, EMT-P, CEN, NE-BC Susan K. Ebaugh, MSN, APRN, CEN, ACNS-BC Tami L. Morin, MS, BS, RN, CPEN India J. Owens, MSN, RN, CEN, NE-BC, FAEN Cheryl Rourke, MSN, RN, NE-BC Barbara A. Weintraub, MSN, MPH, RN, APRN, CEN, CPEN, ACNP-BC, FAEN Marylou Killian, DNP, RN, FNP-BC, CEN, ENA Board of Directors Liaison

hat distinguishes an ENA Lantern Award emergency department? Demonstration of innovative and evidencebased practices, leading to improved and sustained outcomes and metrics for patients, staff and the community. Since 2011, ENA Lantern Awards have recognized exemplary EDs. Applications are evaluated against predetermined, evidence-based criteria during a systematic, blinded review by multiple trained reviewers. Based on the results, ENA recognizes EDs exemplifying exceptional practice and innovative performance in the core areas of leadership, practice, education, advocacy and research. An additional goal of the Lantern Award is to identify and share outstanding, innovative practices from EDs achieving Lantern Award designation. Each application illustrates novel implementation of evidence and best practice driven by stretcherside staff leading to optimal patient outcomes. Here are some of the initiatives that made 2013 recipients exemplary:

Akron General Medical Center– Akron, Ohio Akron General Medical Center is a 511-bed, not-for profit, designated chest pain and stroke, non-academic teaching hospital and Level I trauma center. The ED serves more than 56,000 patients annually. Exemplary throughput process is accomplished through implementation of the hospital’s Operations Center. OC nurses assign beds after contacting and obtaining admission orders from physicians — eliminating this task for emergency nurses — and notify the inpatient units using a ‘‘one-call rule.’’ OC nurses continuously

Akron General Medical Center Emergency Department monitor organizational activities including the ED, OR, housekeeping, transportation, electronic medical records, bed availability and

organizational dashboard in order to provide timely and appropriate bed assignments. When an automatic paging system alerts the ED charge nurse of the

December 2013

inpatient bed assignment, a Situation, Background, Assessment and Recom mendation report is sent to the receiving unit. An administration-supported ‘‘45-minute rule’’ enables the ED to take stable patients to the admission unit, placing them near the nurses’ station until housekeeping completes room cleaning, when necessary. Improvements have been shown in the overall time from decision-to-admit to having the patient physically in an inpatient bed from 125 minutes in 2011 to an average of 78 minutes in 2012, along with increased nurse and overall patient satisfaction. Dramatic progress was shown in the bed-ordered to assigned time from 91 minutes to the current average of 20 minutes.

Bethesda North Hospital – Cincinnati Bethesda North Hospital has a 44-bed ED and sees 56,000 patients annually. Front-line staff contributes to innovation and enhancements in care via the Shared Leadership Council. One example of innovation driven by a staff nurse in this ED, which has a low volume of pediatric visits, is the implementation of intranasal medication for the pediatric patient. With support from ED leadership, the stretcherside nurse conducted a literature review, collaborated with the ED pharmacist and

the regional tertiary-care pediatric hospital to ensure consistency across the region and also worked with the ED medical director to expand opportunities for intranasal medication delivery in other populations. Changes to the EMR were made to ensure intranasal as a delivery type for appropriate drugs. Education was facilitated by nurse/ physician collaboration, and this best practice was extended to regional ambulance services.

Bon Secours Richmond Community Hospital Emergency Department

Bon Secours Richmond Community Hospital – Richmond, Va. The Bon Secours Richmond Community Hospital ED is a 13-bed unit seeing approximately 33,700 adult and pediatric patients visits per year, priding itself in providing quality care and support to the inner-city community it

Bethesda North Hospital Emergency Department

Official Magazine of the Emergency Nurses Association

serves. Like many EDs, Bon Secours has its share of challenges, including a number of recurrent patients with non-urgent complaints. After further investigation, it was found that many insured patients did not have a primary care provider and used the ED instead. ED nursing, leadership, registration and medical staff developed a plan in collaboration with area physicians called the PCP Initiative. When the insured patient without a PCP was identified in the ED through a series of triggers, a few questions were asked of the patient to make a match with a participating physician. The unit secretary then made an appointment for the patient. Over an 18-month period, more than 500 individuals found PCPs and medical homes through this effort.

Egleston Emergency Department at the Children’s Hospital of Atlanta The Egleston ED at the Children’s Hospital of Atlanta is part of an academic medical center and a Level I trauma center that cares for more than 60,000 children each year. The institution promotes collaboration across disciplines and departments to improve patient outcomes. CHOICE councils were implemented to involve nurses in the decision-making processes that impact the delivery of patient care and their families. The term CHOICE stands for Choosing How Outcomes Impact Clinical Excellence. Councils are unit-based and have representation on interdepartmental and interdisciplinary councils. Through these councils, standing-order sets have been developed for selected patient populations, including high-risk groups such as febrile oncology patients, diabetic ketoacidosis patients and patients in sickle cell crisis. These interdisciplinary protocols have

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2013 Lantern Awards Continued from previous page supported the team-based approach to patient care. Staff are encouraged to recognize their peers on an ongoing basis through a program in which nurses receive a FISH card when they are seen displaying a great attitude. These cards are placed in a fishbowl, and at the end of the month one winner receives a FISH T-shirt that reads, ‘‘I Made Their Day.’’

St. Anthony Hospital – Lakewood, Colo. St. Anthony Hospital is a 224-bed community hospital and Level I trauma center with 46,500 ED visits per year. Sixty-four percent of the nurses are certified. Patient satisfaction scores at St. Anthony’s are in the 96th percentile, door-to-provider times are less than 10 minutes and the left-without-treatment rate is .014 percent. Before these improvements, the department ‘‘languished with throughput, poor quality metrics and patient satisfaction issues for years,’’ the director wrote. These achievements are a result of dedication to excellence and mutual respect by the physicians, nurses and the leadership team, which fostered a

St. Anthony Hospital Emergency Department

Egleston Emergency Department at the Children’s Hospital of Atlanta strong collaborative culture. Stretcherside staff is engaged in innovative practice and contributing to the profession of emergency nursing in meaningful ways, such as the 2012 implementation of a patient callback program. ED staff report not only improved patient satisfaction but also examples of callbacks that rescued patients who had gotten sicker or who could not afford medications prescribed

at discharge. The program and its optimal outcomes have been presented at both local and national conferences.

Children’s Hospital Los Angeles Children’s Hospital Los Angeles is a Level I trauma center with an emergency department that annually sees more than 64,000 children. Its patient care services governance structure was redesigned in 2010 to increase direct-care nurse participation. This structure cascaded to the ED unit-based councils. The benefit of this structure is demonstrated in superb care and dedication to providing the most dynamic care for pediatric patients. One of many best practices is the improved care and outcomes for the 3,000 pediatric asthma patients seen every year. The ED Practice Council wanted to ensure that the most current recommendations were reflected in the ED asthma protocols. Because 97 percent of ED asthma patients are discharged, the ED team also focused on home management

December 2013

stretcherside nurses. Participants receive education and training, enhancing leadership skills and improving nursing practice by focusing on critical thinking, problem solving, communication, delegation and mentoring.

The Medical Center of Aurora â&#x20AC;&#x201C; Aurora, Colo.

Childrenâ&#x20AC;&#x2122;s Hospital Los Angeles Emergency Department

The Medical Center of Aurora is a for-profit community Magnet hospital with trauma, stroke and chest pain center designations, and the ED serves more than 62,000 adult and pediatric patients per year. Dedication to process improvement using Lean methodology and communication, including an interdisciplinary, monthly EMS education conference, are apparent in its Lantern exemplars. Another clear example of commitment to communication is the ED SAFE program. ED SAFE is a stoplight-type visual cue system designed to raise awareness of the ED threat level. ED charge nurses collaborate with providers

Continued on next page

OSF Saint Francis Medical Center Emergency Departtment education and referral. Caring for an asthma patient is very complex; this ED knows there are more facets to consider. Its next step is to form a community partnership with the Breathmobile service for follow-up at local public schools.

As a designated trauma, stroke and

OSF Saint Francis Medical Center Emergency Department â&#x20AC;&#x201C; Peoria, Ill.

nursing staff. The Frontline Nursing

This Midwestern Magnet-recognized academic medical center sees 86,341 adult and pediatric ED visits annually.

providing direct patient care by

chest pain facility, almost 55 percent of the hospitals admissions come through the ED. The ED and medical center have demonstrated a commitment to the educational and professional advancement of their stretcherside Leadership Program is an example of an innovative idea that can drive change in nursing practice. The four-semester course program is designed for nurses identifying potential leaders and investing in the future of selected

Official Magazine of the Emergency Nurses Association

The Medical Center of Aurora Emergency Department

2013 Lantern Awards

Continued from previous page

and hospital security to determine normal, elevated and high risk within the department using not only behavioral risk but also ED volume, acuity and boarding elements. The increase in communication, collaboration and awareness has reduced incidents of workplace violence and increased staff and patient safety.

Virginia Hospital Center – Arlington, Va. Virginia Hospital Center’s ED is a 36-bed designated stroke center seeing 65,000 patients per year. The ED knew it had to up its game, as a survey of new graduate nurses revealed that none felt prepared to practice independently following orientation. Making use of their robust shared governance structures, the staff created an ED fellowship program. The program includes multiple modalities, including

Virginia Hospital Center Emergency Department the ENA Orientation modules, 24 hours of lectures and weekly review of feedback and goals with their preceptor. Following this revision, 100 percent of 16 new graduates felt prepared to practice independently. That is how Virginia Hospital Center lights the way to helping new graduates succeed with their Lantern Award.

Congratulations to each ED for its dedication to providing quality care to the community it serves and for earning the distinction of being a 2013 Lantern Award recipient. For more information about the Lantern Award program, visit www.ena.org/LanternAward.

The ENA Lantern Award Celebrates Outstanding Emergency Departments.

cipie

nt 2014-20

We recognize exceptional performance and innovative practice in the following areas: ª ª ª ª ª

Advocacy Education Leadership Practice Research

We invite your Emergency Department to apply for this distinguished award. Applications accepted through February 26, 2014. Please follow the application guidelines on the website

www.ena.org/lanternaward

Development of the Lantern Award program criteria funded in part by

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December 2013

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ENA FOUNDATION | Julie Jones, BS, RN, CEN, 2013 ENA Foundation Chairperson

A Year of Successes to Sing and Shout About I

cannot believe this year is coming to an end. I am pleased as punch about the successes of the ENA Foundation in 2013. ENA members, our corporate sponsors, friends and family have helped to make this year one of the best yet in ENA Foundation history. I happily leave the ENA Foundation in the wonderful hands of Seleem Choudhury, MSN, MBA, RN, CEN, who will have a fun time breaking all the records. The State Challenge is our biggest annual fundraiser, and this year was no exception. We ‘‘Shouted Out for Emergency Nursing’’ across the country and broke our previous record and our goal. Every penny of the $121,500 raised will support 2014 scholarships and research grants. A congratulatory shout-out to the 12 state councils and chapters that raised more than $5,000 — they each will receive the privilege of naming a scholarship for 2014. Contributions poured in for the Judith Kelleher Memorial Endowment. ENA graciously offered to match donations up to $25,000. The endowment raised enough money to offer a scholarship in 2013. Thank you, ENA members! Who can forget the great conferences we attended this year? In Fort Lauderdale, Fla., we hosted the Backyard Barbecue at Leadership Conference. There was nothing better for this Southern girl than to eat barbecue and mingle with 410 of my best ENA friends. Annual Conference in Nashville was the highlight of my year, as well as a mark on my bucket list, with our Grand Ole Opry event attended by a

The fun rained down at the ENA Foundation’s Backyard Barbecue fundraiser at Leadership Conference 2013 in Fort Lauderdale, Fla., on March 1. record 1,200 ENA Foundation friends. We let the world know we were there when they announced our attendance during the live broadcast. Our hooting and hollering could be heard around the world, and I’m not sure you even needed to turn on your radio to hear it! Thank you to all who attended these events. Annual Conference is not complete without the ENA Foundation jewelry auction. It was fabulous to see more than 210 beautiful pieces. Thank you to

all of the state councils, chapters and individuals who donated these lovely items, and to the bidders. My favorite part was the last five minutes and the scrambles to get in the winning bids. That could be considered an event in itself. We raised an incredible amount of more than $23,700. The ENA Foundation was also busy giving out scholarships in 2013. We awarded 43 individual academic scholarships totaling $192,000, as well as 10 continuing education scholarships to attend Leadership Conference and 20 to attend Annual Conference for an additional $40,000.

December 2013

Emergency nurses place their bids at the ENA Foundation jewelry auction in Nashville in September. More than $23,000 was raised from 210 jewelry items. We also have been quite busy with research grants. We teamed up with the Emergency Medicine Foundation to award one $50,000 team grant and with Sigma Theta Tau International to award a $6,000 research grant. Stryker and FreemanWhite ED Design each supported a $5,000 research grant. We also launched the ENA Foundation Seed

Grants this year. Ten researchers each received these $500 grants. Please go to www.enafoundation.org for more information regarding available scholarships and research grants. The ENA Foundation is busy giving away your donations in the form of scholarships and grants in the discipline of emergency nursing. All of your

support helps us to advance the future of emergency nursing. We are here to advance emergency nursing, but we could not do what we do without you supporting us every step of the way. I also would like to thank our corporate supporters — Blue Jay Consulting, the Board of Certification for Emergency Nursing, BSN Medical, Elsevier, ENA, Hill-Rom, Physio-Control, Pinpoint, Stryker and Vidacare — for their generous support as corporate and event partners. We sincerely thank them for their commitment to the ENA Foundation. I have had a wonderful time as chair of the ENA Foundation and could not have done it without some wonderful folks behind me: the great South Carolina ENA State Council, the fabulous Management Board and Board of Trustees and the truly spectacular staff of Pierre Désy, Terri Bruce and Oksana Kurylak. Thank you for the best 2013. Cheers!

A New, Updated Online Learning Geriatric Emergency Nursing Educational Course

Coming Soon! For additional details please visit: www.ena.org

The Emergency Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

GENE Coming Soon_Connection_half_10 2013.indd 1

Official Magazine of the Emergency Nurses Association

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BLUE SEASON With Holidays Comes the Risk of Feeling Less Than Merry

By Kendra Y. Mims, ENA Connection

hile many people look forward to festivities, shopping, exchanging gifts, decorating and spending time with loved ones during the holidays, there are others who feel lonely or depressed and suffer from the ‘‘holiday blues.’’ Whether the person going through a difficult time is a family member, friend, colleague, patient or you, here are ways to recognize the signs of the holiday blues and how to manage them.

Defining the Holiday Blues The holiday blues are defined as feelings of sadness, loneliness, depression and anxiety that often occur around the holiday season. They can develop from reflecting on lifechanging moments in the past or having anxiety about the upcoming year. Here are some reasons people lose their joy and become blue around the holiday season: • Loss of a loved one • Separation from loved ones due to work, military obligations, moving, etc. • Financial difficulties • Divorce • Dealing with a sickness or an ill loved one • Life-altering changes (e.g., new job, loss of job, moving, retiring) • Stress Symptoms often associated with the holiday blues include the following:

• Headaches • Insomnia or excessive sleeping • Irritation, restlessness or anxiety • Loss of appetite or overeating • Isolation • Constant sadness • Fatigue • Loss of interest in work, hanging out with friends, hobbies and in the holidays • Difficulty concentrating

that give you peace, whether it’s prayer, volunteering to help others or reading motivational books.

Ways to Handle the Holiday Blues

Journey of Hearts encourages people to get their R-E-S-T for the holidays:

According to the Journey of Hearts, the holiday blues can be intense and emotional but short-term, lasting up to two weeks. If you or someone you know is experiencing them, here are several things you can do to help yourself or others cope: 1. Talk to a trusted loved one and avoid isolation by staying connected to others. Surround yourself with supportive people who care about you. 2. Exercise is a proven way to decrease sadness and depression. Incorporating even a 20-minute walk into your day can lift your spirits. 3. Avoid overwhelming yourself by creating a list of priorities. Tackle them one day at a time. 4. Take time to recharge and engage in activities that you love. 5. Find time to draw from the things

6. Keep a journal throughout the holidays and write down your feelings as well as everything for which you are thankful. 7. Reduce financial stress and avoid overspending by setting a budget. 8. Create a new holiday tradition.

• Reasonable expectations and goals. Be realistic about what you can and cannot do. Get plenty of rest and relaxation. • Exercise, even walking daily. Eat and drink in moderation. Enjoy free activities. • Simplify to relieve stress. Set a budget for social obligations and gifts. Give your time to others — volunteer, donate to charity, call or visit a friend or someone who is homebound. • Take time to relax and remember. Spend time with caring, supportive people. Keep in mind that traditions can be changed. Reference Dyer, K. (2007). The holiday blues brochure. Retrieved from http://www. journeyofhearts.org/squidoo/holiday_ blues_brochure.pdf

December 2013

LEADERSHIP CONFERENCE

2014

March 5-9, 2014 Phoenix, AZ

Phoenix Convention Center

For the latest news on Leadership Conference 2014, visit www.ena.org/lc Follow the action

#ENALC14

*Accreditation statement: The Emergency Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centerâ&#x20AC;&#x2122;s Commission on Accreditation.

Emergency nurses at the 2013 General Assembly filled vases with roses to remember ENA co-founder Judith C. Kelleher.

BACK TO BEGINNINGS General Assembly Comes Into Bloom With Emotional Rose Tribute to Kelleher By Amy Carpenter Aquino, ENA Connection

eneral Assembly participants honored ENA co-founder Judith C. Kelleher in a warm and touching tribute Sept. 18. As the rich sound of bagpipes filled the room, ENA’s Board of Directors, past presidents and state council leaders placed yellow, white and red roses in two large vases at the front of the room.

Charlene Wilson, Kelleher’s granddaughter, speaks to ENA leaders and more than 600 delegrates.

ENA President JoAnn Lazarus, MSN, RN, CEN, said the roses represented friendship, remembrance, sincere love, courage and respect and that the white and red roses together signified unity. A glass case containing Kelleher’s nursing cap and cape stood on display and soon will have a permanent home at ENA headquarters in Des Plaines, Ill. ‘‘ENA lost an exemplary leader when Judy passed away this year,’’ Lazarus said. ‘‘She was a part of our family, and as her family, I know that we will continue to make Judy proud as we work to move her dream forward.’’ Kelleher’s granddaughter Charlene Wilson described attending her first ENA conference with her grandmother 15 years ago. ‘‘I offered to listen to her practice her speech, and she looked at me like I was crazy,’’ Wilson said. ‘‘She had no cards, she needed no rehearsal, because she spoke from her heart. She spoke of caring and of community and of change. She spoke of vision. It was easy for her

because she spoke to a group of like-minded people she considered her family.’’ Wilson said it was at that conference that a special group of members ‘‘strongly encouraged’’ her to become an emergency nurse, which she did. ‘‘Like I had a choice,’’ she quipped. ‘‘I am proud and I am grateful for this opportunity to speak on Judy’s behalf and to thank all of you for the love and the friendship, for all the cards and the notes; she kept them all,’’ Wilson said. ‘‘Thank you for being kind and caring and as strong and as spirited as she was. Thank you for continuing her legacy.’’ State leaders felt honored by the opportunity to pay tribute to a visionary and much admired leader. ‘‘Someone stepped up 40 years ago and recognized that emergency nursing is a separate specialty,’’ said Nebraska ENA State Council President Cindy Slone, RN, CEN, who soon will celebrate her 40th year in nursing. ‘‘She organized us and made us what we are and put us on the map.’’

December 2013

President’s Address

Feeding Relationships For Our Future

f all the places she has traveled this year, ENA’s 2013 president, JoAnn Lazarus, MS, RN, CEN, said the highlight was Charlotte, N.C., where she spoke to more than 700 student nurses at the National Student Nurses’ Association annual conference. ‘‘I have no doubt our future is in good hands,’’ Lazarus said. ENA’s future looks equally bright, as Lazarus reported an increase in membership and the fact that 10,000 members are under age 34. The average age of new members in the last year was 36.6 — a positive trend that shows ENA is meeting the needs of nurses entering the profession, she said. As she embarked on her presidential year, Lazarus said, she employed leadership lessons according to Abraham Lincoln. In addition to ‘‘getting out of the office and circulating among the troops’’ by traveling to conferences around the country and the world, she has focused on building strong alliances with such organizations as the American College of Emergency Physicians, the American Academy of Emergency Medicine and The Joint Commission. Two other lessons — influencing people through conversation and storytelling and preaching a vision and continuing to confirm it — are being achieved through the continuation of the vision of Judith C. Kelleher, ENA’s co-founder. Kelleher ‘‘was able to see the difference she made in our organization . . . to the thousands who are receiving better care in EDs around the country because of her passion to improve emergency care for everyone,’’ Lazarus said. The last lesson — how to have the courage to handle unjust criticism — is one that Lazarus employed as she followed through on her president-elect vision that ENA had to become more innovative and take risks. ‘‘Everything we have done has been in the best interest of the member and the association at heart,’’ she said. ‘‘Leaving a legacy is not about one person. It is about what we do collectively. It is about all the members who have come before us and those who will come after us.’’ Amy Carpenter Aquino

President-Elect: We Must Discuss the Mistakes We Make

‘I

f you think you have made a mistake in the ED this week, you are most likely correct’’ — but rather than be ashamed of mistakes, emergency nurses should recognize them, share them and celebrate the great catches that happen every day in the ED, said Deena Brecher, MSN, RN, APRN, ACNS-BC, CEN, CPEN, 2013 president-elect. Brecher shared a story of a medication error she made two years ago with a pediatric patient, which, while having no negative outcomes, changed her outlook on errors in the ED. ‘‘Why do you care about someone else’s mistake that didn’t maim or kill anyone?’’ Brecher said. ‘‘I stand before you as a human, and as humans we make mistakes. As nurses, we make lots of mistakes. Each mistake we make in the ED has the potential to hurt or kill a patient.’’ Medical errors are the cause of death for 98,000 hospital patients every year, she said. ‘‘It’s the big secret we don’t like to talk about,’’ she said. ‘‘It’s time we started talking about them.’’ Communication errors, system failures and intricate workarounds that fail to address the root causes of the problems all contribute toward catastrophic events, she said. Add in constant distractions, short staffing, nonexistent breaks and lack of teamwork and there is a veritable recipe for errors. Nurses often do not speak up because they feel powerless to enact change, Brecher said. That silence can be dangerous. ‘‘The only way we are going to stop this epidemic of preventable death in our EDs is to start talking about what went wrong, what happened and how we can decrease the likelihood it happens again,’’ she said. ‘‘I am challenging all of you to change . . . I want you to believe you have the most important role in keeping our patients safe in the ED. I want you to speak up when you see something that negatively impacts patient safety, whether that something is a computer issue, a medication system issue, or how a person treats another teammate.’’ Amy Carpenter Aquino

Official Magazine of the Emergency Nurses Association

Resolutions and Bylaws

Executive Director Addresses ‘Year of Change,’ Healthy Finances

‘I

bring you greetings from the more than 80 ENA staff members,’’ ENA Executive Director Susan M. Hohenhaus, LPD, RN, CEN, FAEN, told leaders and delegates at General Assembly. ‘‘We wish you a time of excitement, inquiry, education and fun.’’ She shared photos of the staff from the ENA headquarters in Des Plaines, Ill., as she explained that the ENA 2012-2014 Strategic Plan was the staff’s roadmap provided by the ENA Board of Directors. Hohenhaus described 2012 as a ‘‘year of change’’ for ENA. She directed delegates to the ENA and ENA Foundation 2012 Annual Report, available on the home page at www.ena.org, for details about the healthy financial year. ‘‘We’ve come a long way since the vision of Anita Dorr and Judy Kelleher,’’ she said. Amy Carpenter Aquino

Delegates Get Down to Business By Amy Carpenter Aquino, ENA Connection

early 700 General Assembly delegates considered 13 proposed amendments to the ENA bylaws and one proposed resolution at the annual business meeting of the association on Sept. 18-19. Delegates from all 50 states and five international delegates debated such issues as military membership, amendment submission deadlines and background checks and eligibility requirements for the ENA Board of Directors. The lone resolution addressed evidence-based standards for life-long learning. Delegates voted overwhelmingly in favor of the bylaws amendment titled

Military Membership, with amended language, which aimed to ensure that members from all branches of the U.S. military clearly qualify for ENA’s military membership discount. Authored by Amanda M. Cook, MSN, APN, FNP-C, and Jacob M. Cook, BSN, RN, EMT-P, the amendment sought to also ensure that this membership category does not penalize members who have retired early from service due to injuries received in combat. Delegates did not support a proposed bylaws amendment titled Eligibility RequirementsBackground Checks, which would have eliminated background checks for all candidates for the ENA Board of

Directors and the Nominations Committee. The proposal aimed to streamline and reduce the timeline for the ENA election process, said Louise Hummel, MSN, RN, CEN, CNS, FAEN, chairwoman of the 2013-2014 Nominations Committee. A review of best practices found that none of 26 other nursing organizations required background checks of election candidates, Hummel said. Delegates opposed to eliminating the background checks pointed out that ENA is a multimillion-dollar organization and that background checks, which cost about $3,000 per election, are a relatively inexpensive way to protect association interests. Delegates did not support the bylaws amendment Past President on Executive Committee, which would have made the immediate past president a member of the ENA Board of Directors executive committee. The voting members of the commitee include the president, president-elect and secretary/ treasurer. Authored by the board, the goal of the proposal was to provide

‘‘guidance to the president as well as experience and wisdom to the Executive Committee in making necessary decisions of the association between board meetings.’’ Delegates who spoke in opposition said that while the experience of the immediate past president was appreciated, he or she should not serve as a voting member of the committee. ‘‘I will oppose this amendment and encourage others to do the same,’’ said Matt Choate, MBA, RN, CEN, of the Vermont ENA State Council. ‘‘I can think of no other example where a past administrator remains part of the core executive group. You can call for advice or guidance, but I don’t believe we need to put the past administrator on the core group.’’ The General Assembly adopted the bylaws amendment Suspension and Termination, with changes, which added the option of membership suspension for members who are found to have failed to adhere to the ENA bylaws or for cause. The former bylaw allowed

only for termination of membership. Authored by the ENA Board of Directors, the amendment ‘‘will allow the board to set a lesser penalty, if appropriate.’’ Delegates spoke in support of the proposed amendment. Delegates did not support the proposed Amendment Submission Deadline, which would have changed the due date for proposed bylaws amendments and resolutions to March 1. After March 1, bylaws amendments only would be allowed by the ENA Board of Directors or five members of an ENA standing committee. The current submission deadline for bylaws amendments is 90 days before General Assembly. The proposal was authored by the ENA Board of Directors to ‘‘provide consistency with the bylaws submission process by allowing sufficient time for processing, reviewing and preparing the proposals for presentation to the General Assembly.’’ ‘‘I think this [amendment] is much

Continued on next page

BOARD MEMBERS HEAR CONCERNS OF MEMBERS AT GENERAL ASSEMBLY

he following letter was sent by e-mail to all members Oct. 29 in response to a memorandum of concern received by the ENA Board of Directors and discussed at General Assembly: Dear ENA Member, We are pleased to share with you the first ‘‘State of the Association Update.’’ Delivered quarterly, these updates will provide an overview of ENA initiatives, happenings and enhancements. This has been a busy year and we’ve been able to accomplish many successes and reach new milestones. However, with growth come growing pains. We’ve identified opportunities for improvement, specifically within the Emergency Nursing Pediatric Course (ENPC) and our Continuing Nursing

Education (CNE) provider unit. We are also focusing on advancing our government relations agenda and preparing for the rollout of Trauma Nurse Core Course (TNCC) 7th Edition. Below is an outline of specific strategies and milestones for each: Emergency Nursing Pediatric Course 1. Incorporated corrections to the ENPC Provider Manual and Instructor Supplement with help from our members and many other experts in emergency nursing. The updated ENPC Provider Manual will be available by the end of the year. 2. Engaged an external course administration subject-matter expert to assist in the final review of ENPC’s course instructional design and logistics. 3. Will complete final review and

revision of test questions by the end of October. Continuing Nursing Education 1. All CNE application forms have been revised and posted on the ENA website at www.ena.org/ education/CNE. 2. ENA staff has processed all pending CNE applications. Priority was given to those who submitted a CNE application for an educational event to be held in October and November 2013, followed by those who submitted an application after July 1, 2013. All applications were processed at no additional cost to applicants. 3. ENA remains a provider and approver of CNE with ANCC. That has not changed. 4. ENA is developing a CNE toolkit to assist applicants in navigating the application process. It will be available by the end of 2013. Trauma Nursing Core Course 1. ENA learned a great deal from the most recent revision of ENPC,

Resolutions and Bylaws Continued from previous page too limiting,’’ said Jim Hoelz, MS, RN, CEN, FAEN, of the New Jersey ENA State Council. ‘‘Any five members of any committee, state or chapter who happen to meet for coffee should be able to propose a bylaws amendment.’’ ‘‘This is a member-driven organ ization,” said Leora Wile, BSN, RN, CEN, of the Pennsylvania ENA State Council. If there is a late, pressing issue that needs to be addressed by the General Assembly, members should have the opportunity to work with the Resolutions Committee to ensure that a proposal is constructed correctly, she said. Delegates overwhelmingly supported the resolution Evidence-Based Standards for Lifelong Learning, authored by Janet Kaminsky, MSN, RN, CEN, ANP-BC, and Nancy Barr, MSN, RN. The resolution, which was

approved with language rewrites, calls for ENA to ‘‘work collaboratively with other nursing and health care organizations, regulatory agencies and academic institutions to promote lifelong learning and to investigate its association with patient safety and nursing practice.’’

December 2013

and the TNCC 7th Edition has benefited. 2. The 7th Edition TNCC work team has been led by an independent contractor who is an external subject-matter expert and an excellent project manager. The project has been managed in a very collaborative way, has been process-oriented, and stakeholders such as course administration faculty and international members outside of the work team have been engaged and informed. Both a pilot course and a pilot examination were conducted at ENAâ&#x20AC;&#x2122;s 2013 Annual Conference in Nashville, Tenn. The pilots were very well received and the feedback, both positive and critical, will be used to finalize content and design. Government Relations 1. In 2013, ENA established an ENA advocacy office with two full-time staff in office space shared with ACEP in Washington DC. In the past year, our two new government relations experts have

developed strategic initiatives and partnerships that have resulted in numerous successes, including maintaining funding for nursing education and training programs, continuing the nationâ&#x20AC;&#x2122;s 57 poison control centers operating, maintaining federal support for the Emergency Medical Services for Children program and the appointment of a permanent director for the Office of Emergency Care Research. 2. ENA advocacy staff is implementing a robust communication plan for the 2014 government relations initiatives. This will be in addition to the monthly reports sent to state leaders which are tailored for each state with information on newly introduced bills or changes in bills as they relate to emergency nursing. 3. The ENA Government Relations staff has created a dedicated webpage for its EN411 Legislative Network (cqrcengage. com/ena/tool). On this site is a new Advocacy Tool Kit which

contains significant advocacy information ranging from how to get prepared for meetings to how a bill becomes law to information on legislative terms. The EN411 program now has 3,300 ENA members enrolled. This reflects an increase of almost 20 percent in the past month. 4. In 2014, ENA will be consolidating government relations events. Content will be incorporated into the ENA 2014 State Leaders Conference in March and the Day on the Hill events in late April or early May 2014. We continue to work on ways to improve and enhance association initiatives and education to best meet the needs of all of our members and the profession of emergency nursing. We will keep you apprised of our progress and, as always, we appreciate your suggestions for enhancing the services we provide Sincerely, JoAnn Lazarus, MSN, RN, CEN 2013 ENA President

Official Magazine of the Emergency Nurses Association

‘PARTY WITH A PURPOSE’ A

social gathering with substance kicked off the networking portion of this year’s ENA Annual Conference. The reception for ENA past presidents and state council and chapter leaders, traditionally held the evening before General Assembly, was named the ‘‘Party With a Purpose.’’ ENA President JoAnn Lazarus, MSN, RN, CEN, welcomed representatives of Friends Life, a Nashville-based nonprofit organization that helps adults with intellectual and developmental disabilities, to the Sept. 17 gathering. ‘‘We provide programming Monday through Friday that helps our adults grow and develop personally and socially and live productive and fulfilling lives as part of the Nashville community,’’ program director Waverly HarrisChristopher said. Friends Michael Scott and Jimmy Clark shared how Friends Life provided them with opportunities to learn job skills and perform community service projects. Donations to the organization were accepted throughout

Left: ENA President JoAnn Lazarus laughs with singer/songwriter Rivers Rutherford. Above: Jimmy Clark, a beneficiary of the Nashville-based Friends Life nonprofit group, shares his story. the event. Nashville singer/songwriter Rivers Rutherford, who has written No. 1 songs for such artists as Brooks & Dunn, Tim McGraw and Gretchen Wilson, performed an entertaining set to round out the evening. Lazarus later shared that the Party With a Purpose raised $910 for Friends Life. Amy Carpenter Aquino

Topics Discussed at Town Hall Meeting T wo primary themes emerged at the ENA town hall meeting in Nashville on Sept. 17: requests for the ENA Board of Directors to address a member-signed memorandum of concern regarding recent changes within ENA and requests to reinstate processing and approval of online continuing education applications. ENA President JoAnn Lazarus, MSN, RN, CEN, acknowledged that she and other board members had been forwarded an e-mail containing a memorandum of concern. The e-mail was written by ENA past presidents and distributed to several ENA members via e-mail before the conference. It asked for greater

transparency within the organization and expressed concerns regarding a number of changes within the organization and the board. Lazarus noted that although the board did not receive the memorandum directly from the authors, she initiated a meeting while in Nashville with the original 14 authors. Lazarus also said the board takes the concerns of the members seriously and would provide a response at a future date. Other members at the town hall shared concerns about ENA approving continuing education programs. Many asked ENA to reinstate processing of continuing education applications online, which had

been suspended through November. ‘‘We rely on you for our contact hours,’’ one member said, ‘‘and we need to know that you will support us on this issue.’’ Pierre Désy, ENA chief development officer, assured members the CNE issue would be addressed within 24 hours. Additional updates were released to members the next day, and a plan of action was implemented to address all outstanding applications. More information on ENA CNE application guidelines can be found at www.ena. org/Education/CNE. Margo Schafer

December 2013

Anita Dorr Lecture and Luncheon

Where the Past Meets the Presence By Renée Herrmann, ENA Connection

ttendees gathered Sept. 18 for the Anita Dorr Memorial Lecture and Luncheon, where ENA President JoAnn Lazarus, MSN, RN, CEN, began the program by presenting the Judith C. Kelleher Award to AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN. According to those who nominated her, Papa demonstrates knowledge and expertise in emergency nursing practice, education and research. She is active in numerous nursing associations and is an ENA past president. ‘‘Her passion for emergency nursing leadership is apparent in her interactions with colleagues and her undying willingness to help others achieve their own goals,’’ Lazarus said. Upon receiving her award, Papa asked previous recipients to stand and be recognized. ‘‘This is about Judy’s legacy,’’ she said, referring to ENA co-founder Judith C. Kelleher, who passed away in January. After lunch, Lazarus introduced the ‘‘wind beneath my wings’’ — her husband, Richard Lazarus, who focused on the importance of family and began his address by providing a history of family presence during resuscitation and ENA’s efforts to promote this practice. He next discussed the second kind of family presence, among those in the workplace. ‘‘Colleagues are like family. Some you get along with, some you’d rather not see, but they are there every day,’’ he said. Citing several studies, he noted that camaraderie is a key to job satisfaction. Finally, he described the third kind of family presence through the story of his and JoAnn’s marriage. He recounted struggles and joys but noted that the biggest lessons he learned were while he was along for the ride, traveling with his wife during her ENA and work engagements. ‘‘I imagine your co-founder brought her family along with her,’’ he said.

AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, the 2011 ENA president, receives the Judith C. Kelleher Award.

ENA 2013 President JoAnn Lazarus, MSN, RN, CEN, shares a tender moment with husband Richard, who spoke about the various types of family presence.

Official Magazine of the Emergency Nurses Association

Presessions

Nurses try stitching methods on cow tongues under the direction of Andrew Galvin, MSN, RN, ACNP-BC, CEN (right).

STARTING OUT BY CLOSING

Education Seekers Dig In Immediately With Lessons in Advanced Suturing Techniques

hands-on advanced wound closure workshop Sept. 18 allowed Annual Conference participants to practice advanced stitching techniques using beef tongue models and three types of woundclosure materials. ‘‘If you sew anything other than people, you may be familiar with this first technique,’’ said Andrew Galvin, MSN, RN, ACNP-BC, CEN, about a running percutaneous suture. The stitch can work for children or

intoxicated patients, Galvin noted, because it’s fast, easy and does not require staples. ‘‘It’s basically a hem stitch,’’ he noted. All that is required is a needle driver and a sharp pair of scissors. Participants practiced the same stitch with a ‘‘lock’’ for extra strength. Galvin cautioned about stitch alignment in lip and facial lacerations: ‘‘These are devastating lacerations, and meticulous care is required. If you wouldn’t close this on a family

IT’S NOT A SPIDER BITE: MRSA ABSCESSES AND TREATMENT

‘T

he CDC says one in three people are carriers, and one in two health care providers are carriers,” Andrew Galvin, MSN, RN, ACNP-BC, CEN, said at the start of his presession on methicillin-resistant Staphylococcus aureus on Sept. 19. Galvin led participants through the presentations of true spider bites and other skin infections and conditions that patients may assume are caused by pesky arachnids such as black widows and brown recluse spiders. Galvin described risk factors for and differences between common types of MRSA, including community-acquired and hospital-acquired. The prevalence of S. aureus has led to resistance to many treatments, but incision and drainage alone can be particularly effective, he said.

member, don’t do it on a stranger. Get help.’’ Sydney Gay, MSPA, PA, was on hand to help participants refine their techniques in constructing deep or buried sutures. ‘‘Parents love these stitches because you can’t see them,’’ Galvin said. Participants practiced running percutaneous sutures, running subcuticular sutures and vermilion border sutures in the session. Margo Schafer

Participants also learned techniques for eradication, such as hand-washing regimens and use of antibiotic soaps and nasal medications. Patient education was also highlighted. Galvin ended the didactic portion of the session by reviewing common conditions that can result in soft tissue and skin abscesses and discussing the treatment recommendations. The session ended with a hands-on skill lab to practice incision and drainage of an abscess and decompression of a paronychia on the cuticle. ‘‘I thought it was really interesting. I enjoyed the hands-on portion,’’ said Claire Guthrie, BSN, RN, of Michigan. ‘‘What was really useful for me was the information on the abscesses because of their prevalence,’’ said John Stedman, BSN, RN, of Alaska. ‘‘It reinforced [my knowledge] and expanded it a bit, including what to look for and how to differentiate between lesions.’’ Renée Herrmann

December 2013

Lounge Leads Researchers in New Directions

onference attendees brought resuscitation in her their burning questions to emergency department. the experts at the IENR Research Denise Edge, MSN, RN, a Lounge on Sept. 21. Doctorally doctoral student, spoke with prepared emergency nurses from Diane Salentiny-Wrobleski, the Academy of Emergency PhD, RN, CEN, about her Nursing, the Institute for capstone project on blood Emergency Nursing Research’s culture contamination. Advisory Council and the general ‘‘She was pointing me in membership came to help other directions I didn’t even nurses participate in the research think about,’’ Edge said. Doctorate-level nurses and those process. Salentiny-Wrobleski said newer to research put their heads together at the IENR Lounge. The six-hour format was new a key part of research is to this year’s conference, said ensuring the key players are ENA senior research associate Altair Delao, MPH. Within the at the table at the beginning of any project. She also noted first hour, 30 people had signed up to talk to an expert that the library is a researcher’s most important resource. researcher, and traffic was steady throughout the day. ‘‘I don’t think most people know how much our librarians Walk-ins and appointments were accepted. can do for us,’’ she said. She encouraged Edge to speak with Kris Corwin, MSN, RN, CEN, CPEN, came to the lounge to her librarian to establish a personal relationship. find resources and assistance for a research project on Renée Herrmann

Coming in Early 2014 SEVENTH EDITION Highlights Include: § Initial Assessment § New Chapters Teamwork and Trauma Care, Pain, The Bariatric Trauma Patient, Interpersonal Violence, and Post Resuscitation Care in the ED § Evidence into Practice Balanced fluid resuscitation, blood component transfusion, and tourniquet use

The Emergency Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

TNCC Coming Soon_Connection_half_12 2013.indd 1

Official Magazine of the Emergency Nurses Association

11/8/13 10:47 AM

IENR PRESENTS . . .

POSTER AWARD WINNERS By Amy Carpenter Aquino, ENA Connection

he Institute for Emergency Nursing Research presented the research and evidence-based practice poster awards on Sept. 20 at the 2013 Annual Conference. Recipients were chosen from 15 research topic submissions and 45 evidence-based practice topic submissions.

BEST RESEARCH POSTER The IENR presented the research poster award to ‘‘Social Behavioral Needs of Patients With Sickle Cell Disease,’’ authored by Paula Tanabe, PhD, MSN, RN, MPH; Carlton D. M. Rutherford, M.Div., MSW, LCSW; David M. Cline, MD; Laura M. De Castro, MD; Susan G. Silva, PhD; Dori Taylor Sullivan, PhD, RN, NE-BC, CPHQ, FAAN; Victoria L. Thornton, MD, MBA, FACEP; Caroline Freiermuth, MD; and Jontue’ Hinnant, BSN, BA, RN, of Duke University Hospital in Durham, N.C. ‘‘The goal is to start a pilot program that can be used nationwide eventually,’’ Hinnant said about her facility’s poster project, which involved research on how to improve care of ED patients with sickle cell disease. ‘‘We began by doing an attitude survey,’’ said Hinnant, the on-site presenter. ‘‘We did an anonymous survey of physicians and nurses to see how attitudes may affect the care of patients, because patients weren’t pleased with care. We were trying to see how that correlates to how somebody perceives the patient, how they feel about that patient population and how that affects direct care to the patient. We wanted to validate clinical attitudes toward this type of patient.’’ She pointed to results showing significant negative attitudes by clinicians toward ED patients with sickle cell disease. ‘‘Any time you have negativity, it’s going to reflect on the team as a whole,’’ she said.

Presenter Jontue' Hinnant, BSN, BA, RN (left), joins one of her research poster co-authors, Paula Tanabe, PhD, MSN, RN, MPH. The team’s research identified seven key issues related to clinician attitudes toward sickle cell disease patients. They selected four to highlight in the poster, including pain management. ‘‘One of the things we found was that people may have felt these patients were drug-seeking and they come in all the time, so that affects how people perceive them,’’ Hinnant said. The amount of narcotic pain medication necessary to relieve patients’ pain also made some clinicians uncomfortable. ‘‘What we found out was clinicians lack knowledge about the disease process in order to adequately treat these types of patients,” Hinnant said. ‘‘We also found that more initiatives needed to be set into place to improve how we care for the patients.’’

One of the most significant outcomes of the team’s research has been instituting monthly quality improvement meetings which include input from patient representatives. ‘‘This has probably been the most profound part of this,’’ Hinnant said, ‘‘because we get the actual patient’s input on how they feel things are going, how they felt at the beginning of this, how they felt like they’ve been treated and how they feel things have changed. ‘‘So even though it may not have seemed very positive at the beginning, we have quality improvement interventions that have been done in our department to make those necessary changes. It’s not, ‘Let’s get all the negative and not do anything about it.’ We’ve gathered the information, we’ve talked about

December 2013

THE JUDGES The IENR gratefully acknowledges the following individuals for serving as poster judges for the 2013 ENA Annual Conference poster awards program: Nikki Austin, PhD, RN, CEN Margaret Carman, DNP, RN, CEN Jessica Castner, PhD, RN, CEN Garrett Chan, PhD, RN, CNS, CEN, FAEN Mary Kamienski, PhD, RN, APRN, FAEN

Brenda Luchs, MSN, RN, CEN, answers questions about the winning poster she co-authored. how we can improve it and now we’re doing things to improve it.’’ The most profound result of the team’s research has been the ability to educate clinicians about treatment of patients with sickle cell disease, which has contributed to improvement in care. ‘‘I’m a clinical nurse, not an educator,’’ Hinnant said. ‘‘I work on the floor with everyone else, and you can see the difference.’’

BEST EVIDENCE-BASED PRACTICE POSTER The IENR presented the evidence-based practice poster award to ‘‘An Emergency Department’s Journey: Implementation of Evidence-Based Tools Reduce Restraint Usage,’’ authored by Brenda Luchs, MSN, RN, CEN; Mary Bigowsky, MSN, RN, NEA-BC; Michelle George, BSN, RN, CEN; and Senka Pavetic, RN, of St. Elizabeth Health Center in Youngstown, Ohio. ‘‘This is actually phase two of our focus on behavioral health patient problems and trying to address them,’’ Luchs said about her team’s winning poster project. The first phase focused on dedicating a five-bed behavioral health patient area in the ED. The poster focused on the implementation of a form with definitions of behaviors that could

be used by staff to identity potential violence from behavioral health patients. ‘‘We were seeing a large volume of patients coming in who were violent, and we had many instances where staff was injured,’’ Luchs said. ‘‘We were introduced to the Broset Violence Checklist by our corporate sponsors, and we decided we would go ahead and try it out because it seemed very simple.’’ The team developed a straightforward form for staff to use with their behavioral health patients. After using the form for 2 1/2 months, the ED saw an immediate decrease in restraint usage and calls to security for assistance. ‘‘We went ahead and put the form into our electronic medical record, and we’ve been using it ever since,’’ Luchs said. ‘‘Despite our volume remaining the same, our calls for disruptive patients to security have tremendously decreased, and our use of restraints has tremendously decreased.” ‘‘It’s a patient safety issue and a staff safety issue as well,’’ Bigowsky said. Using the tool has simplified the process of addressing potential violence in behavioral health patients. ‘‘It’s a very simple, objective tool that makes you proactive instead of reactive to your violent patients,’’ Luchs said. ‘‘It seems like most of the people we’ve talked to here this [conference] week are

Official Magazine of the Emergency Nurses Association

Vicki Keough, PhD, RN, APRN-BC, FAAN Jodie Lane, EdD, MSN, RN Anne Manton, PhD, RN, APRN, FAEN, FAAN Elizabeth Mizerek, MSN, RN, CEN, CPEN Andrea Novak, PhD, RN-BC, FAEN Vicki Patrick, MS, RN, ACNP, CEN, FAEN Ruthie Rea, PhD, RN Kathleen Richardson, DNP, ARNP, NP-C Sonny Ruff, DNP, RN, CEN Diane Salentiny Wrobleski, PhD, RN, CEN Deborah Schwytzer, DNP, RN, CEN Sheila Silver, DNP, RN Cynthia Slone, EdD, RN, CEN Nancy Stevens, DNP, MSN, MS, RN, APRN, CEN, ACNP-BC, FAEN

having a lot more behavioral health patients coming in to their EDs because so many other facilities have closed. They need tools. They need help.’’ Said Bigowsky: ‘‘We’ve worked very hard in our facility to improve the care that we provide our behavioral health patients, such as segregating them in a specific area and giving the staff additional tools. I think what we feel the most is that this is good for our patients and good for our staff.’’

‘Kicking the Tires’ of Revised TNCC By Renée Herrmann, ENA Connection

ashville is known as Music City, but on Tuesday and Wednesday of Annual Conference week, it was pilot season. Seventeen individuals attended the full two-day pilot of the new edition of Trauma Nursing Core Course, or TNCC. A team of instructors were selected to teach the course, led by Ray Bennett, BSN, RN, CEN, CFRN, CTRN, NREMT-P, chairperson of the Course Administration Faculty. Members of TNCC Revision Work Team, headed by Diane Gurney, MS, RN, CEN, FAEN, oversaw the program. ‘‘The purpose of the pilot was to take the car out of the garage, kick the tires and make sure all of the parts were working,’’ Bennett said. ‘‘We tried to use the new material under real course structure and conditions, just as they will be used [when the course is launched].’’ The participants went through all of the components of the revised course, including the provider manual, lectures, hands-on skill stations and testing, so that the work team could get a sense for the flow and feel of the new course. The group represented nurses ranging in experience from novice to expert. In addition to the two-day course, more than 100 participants sat for a test validation session. Each was asked to review a draft of the provider manual and provide feedback on content and test questions. ‘‘Overall, the two days were a success,’’ Bennett said. Gurney expressed the work team’s gratitude to ENA for the opportunity to convene a pilot of the new edition. ‘‘We received valuable feedback, thoughtful comments and suggestions and were able to see firsthand how the material would be used,’’ Gurney said. After the conference, feedback — handwritten, typed and verbal — was compiled by ENA staff and considered by the work team. Members met in October and made their final recommendations. ‘‘Based on your feedback, we have designed a new

schedule to reduce class lecture time and add time to skill stations for interactive, personalized, small-group learning,’’ Gurney said. ‘‘One thing we feel important to let members know is that we have had your interests in mind for every decision we have made. Hopefully this new edition will meet your needs and continue to grow with you during the next four years.’’ She added, ‘‘We appreciate the opportunity to have been a part of this very special process and thank everyone at ENA who had a part in making this course come to life.’’

GUIDING THE TNCC PILOT

• Jami Blackwell, BN, RN, CEN

• Sandy Waak, RN, CEN

• Joseph Blansfield, MS, RN, NP

• Beth Broering, MSN, RN, CEN,

WORK TEAM

• Melanie Crowley, MSN, RN, CEN

• Kathleen Carlson, MSN, RN, CEN,

• Dawn McKeown, RN, CEN, CPEN

FAEN

• Vicki Patrick, MS, RN, CEN, FAEN

CPEN, CCNS, CCRN, FAEN • Judy Leverette, MSN, RN, APRN, FNP, EMT-B, CEN, NP-C

• Diane Gurney, MS, RN, CEN, FAEN

INSTRUCTORS

• Rhonda Manor-Coombes, RN

• Ray Bennett, BSN, RN, CEN,

• Gail Dodge, MSN, RN, CEN

• Sean Varricchio, MSN, BS, RN, CEN

• Jan Elliott, RN

• Rachel Schumate, RN, CEN, CPEN

NREMT-P

Instructor Sean Varricchio, MSN, BS, RN, CEN, demonstrates pelvic binding during the TNCC pilot.

December 2013

A Little Lab Work Ultrasound Exercises Address Difficult Access

hether your patient is obese, elderly or an infant, hypovolemic, fragile veins and varying depth can make difficult access a real challenge. For the first time at an ENA conference, attendees had the opportunity to try ultrasound-guided IV access at several labs Sept. 20, following a didactic lecture in which instructors reviewed the physical anatomy of the body via ultrasound, focusing on the kidneys, liver, eyes, gallbladder and spleen. During 30-minute lab sessions, attendees were able to see the vein, measure the depth, view volume and see whether the vein was obstructed. During the lab, attendees saw how the ultrasound guides selection of catheter size, both length and gauge. The screen shows the moment the catheter enters the vein, limiting risk of puncture of the distal vein wall, and then

calculates the length of the catheter inside the vein. Several attendees said the lab provided a good overview of ultrasound-guided IV access. ‘‘The application of the ultrasound, where it can be used, kind of extends your practice a little bit more,’’ said Erma Kinzie, BSN, RN, CEN, of Mercy Hospital in Chicago. Cherry Tanjapatkul, BSN, RN, CEN, MICN, of Newport Beach, Calif., tried the ultrasound for the first time. ‘‘To get the actual hands-on was very helpful,’’ she said. ‘‘It was a good orientation.’’ ‘‘I thought it was great,’’ said Cassie Richard, RN, CEN, of Oregon Health and Science University in Portland. ‘‘It was hands-on — we got an opportunity to practice what they taught us in the lecture to get a feel for it to take it home with us.’’ In-kind support for ultrasound equipment and supplies was provided by Bard Access Systems Inc. Marlene Bokholdt, MS, RN, CPEN, Nursing Education Editor, Institute for Emergency Nursing Education, and Amy Carpenter Aquino, ENA Connection

Official Magazine of the Emergency Nurses Association

Opening Session

Chef Jeff and the Recipes of Success His Message: ‘To Become the Best, You Have to Be Among the Best’ By Amy Carpenter Aquino, ENA Connection

‘M

y life journey has taken me to the darkest places.’’ Jeff Henderson, known as Chef Jeff, was the first African-American executive chef at Café Bellagio in Las Vegas, has appeared on the Oprah Winfrey show, hung out with Will Smith and is the author of the New York Times best-selling memoir Cooked. But as a small boy growing up poor and fatherless in South Central Los Angeles, Henderson was told he would not live past age 18. He seemed on a trajectory to fulfill that prediction when at 16 he arrived in the emergency department with a stab wound to the chest after a gang-related dispute. ‘‘It was the ER nurses who told my mother that I was going to be OK,’’ Henderson said during the Sept. 19 opening session keynote. ‘‘It was a nurse in a shopping mall who came to my aid, using her sweater to apply pressure to the stab wound in my chest.’’ Henderson shared his story of how he discovered his potential and gift during a 10-year incarceration for selling drugs. His addictions were not the drugs he sold but the money and status they earned him. In addition to putting food on his mother’s table, Henderson saw drug-selling as

a way to climb out of the intergenerational poverty that plagued his family and community. ‘‘I was running a very successful business with a bad product,’’ he said. Prison is where he made the connection between education and the American dream, earning his GED and reading his first book. Henderson was drawn to books about black architects, engineers and geniuses. ‘‘At that moment I began to see my life differently,’’ he said. After being assigned to the kitchen crew, Henderson

Live-Streamed Clinical Simulation Lab F

or the first time, opening session attendees witnessed a live-streamed clinical simulation lab. Faculty Kathleen Flarity, DNP, PhD, CEN, CFRN, FAEN; Kevin High, MPH, RN, CEN, CFRN; and Elda Ramirez, PhD, RN, FNP-BC, FAANP, FAEN, began the simulation with a moment of silence to honor the deceased patient, his family and the medical institution that donated his body.

High presented the victim as a 42-year-old male who suffered a single gunshot wound to the chest and was tachycardic, hypotensive and acutely short of breath. The three faculty took turns performing and explaining the patient care procedures, including intubation, achieving vascular access via intraosseous infusion and inserting a chest tube. Vidacare, an ENA strategic sponsor, and Vanderbilt Emergency Medicine provided in-kind support for the clinical simulation. Amy Carpenter Aquino

December 2013

discovered his talent for cooking. ‘‘It was the first time in my life I was praised for something good,’’ he said. ‘‘My chicken and biscuits and my meatballs were really good.’’ He read an article on top African-American chefs and began to believe he could follow that path. ‘‘Oprah Winfrey told me many years ago, ‘Jeff, it’s never too late. It’s never too late until you take your last breath to find your power.’ ’’ Upon his release, Henderson sought out acclaimed chef Robert Gadsby, who ‘‘saw beyond the felony’’ and gave him his first kitchen job and taught him how to cook fine California cuisine. ‘‘I knew that in order to become the best, you have to be among the best,’’ he said. ‘‘That’s why you guys are here. I did the same thing in my career.’’ Henderson extolled the importance of mind-set and vision in achieving your professional goals. At the end of the day, it’s about execution, he said. ‘‘It takes about 10,000 hours to become a master at what you do, so don’t call in sick,’’ he said to thunderous applause. What’s most important to Henderson now is that his six children see him as a man of integrity and character. ‘‘When I walked out of prison, I never looked back,’’ he said. ‘‘I saw myself as successful. And here I am today, before you folks. God bless you all.’’

TIP OF THE HAT FROM THE ENA FOUNDATION ‘I

t has been an absolutely fantastic year with many outstanding fundraising and program accomplishments,’’ said Julie Jones, BS, RN, CEN, chairperson of the ENA Foundation Board of Trustees. Speaking at the Opening Session on Sept. 19, Jones invited attendees to visit the ENA Foundation booth to see the wall of names of members who have received academic scholarships and research grants this year thanks to donations from groups, individuals and industry partners. ‘‘In the audience are 20 members who received assistance to attend this conference,’’ Jones said to loud applause. Ten others received scholarships to attend Leadership Conference 2013, while 43 ENA Foundation academic scholarships and three research grants were also awarded this year. ‘‘All these scholarships and grants are made possible by donations from state councils, chapters, our industry partners and individuals like you,’’ Jones said. The 2013 ENA Foundation State Challenge campaign broke all previous records, raising $121,500. ‘‘Because we raised more money, we will have more scholarships and grants to give back to you next year,’’ Jones said. Donning a sparkly tiara, Jones invited attendees to visit the ENA Foundation’s jewelry auction in the Exhibit Hall; proceeds support 2014 scholarships and research grants. Changing to a pink cowboy hat, Jones gave a shout-out to everyone who bought a ticket to the sold-out ENA Foundation Event at the Grand Ole Opry. ‘‘There are many ways to support the ENA Foundation,’’ Jones said, ‘‘and it all adds up.’’ Amy Carpenter Aquino

Official Magazine of the Emergency Nurses Association

READY OR NOT? |

Knox Andress, BA, RN, AD, FAEN

A Thread of Preparation General Session Speaker Sounds Bell on Community Disaster Planning

ommunity emergencies and disasters frequently require many emergency department and health care resources and capabilities for surge management. However, financial priorities are frequently at odds with emergency surge capacity concepts and requirements. Under these circumstances, we must ask the question: Who and what will lead the nation in building hospital and health system preparedness? The 2013 ENA Annual Conference in Nashville, Tenn., included an energetic and thought-provoking address by David ‘‘Marco’’ Marcozzi, MD, FACEP, director of the National Healthcare Preparedness Programs, under the Assistant Secretary of Preparedness and Response, U.S. Department of Health and Human Services. Marcozzi highlighted features and benefits of the Hospital Preparedness Program, an initiative that begins to answer the question of who and what will build national health care preparedness.

Federal Organization Marcozzi provided an overview of the federal structure, specifically the Office of the Assistant Secretary for Preparedness and Response (www.phe. General Session speaker David Marcozzi, MD, FACEP, talks preparedness with conference attendees in Nashville. gov), which supports state and local health care response to disasters. This work is conducted via the Doing More With Less constructs of the National Response Framework and its annex, Emergency Support Function No. 8 (Public Since 2002, the Hospital Preparedness Program has Health and Medical Services). Federal medical response provided leadership, evaluation, technical support and resources include the National Disaster Medical System, funding through cooperative agreements to 62 awardees, and elements such as Disaster Medical Assistance Teams including all 50 states, U.S. territories and eligible frequently present at large-scale disasters. metropolitan areas. These cooperative agreements

Situation Status – Marginalized Many factors hamper health care system capacity and the ability to ‘‘medically surge.’’ Potential disaster response is marginalized by limited and/or diminishing resources of hospital space, supplies and staff in the national health care system. Marcozzi noted that ED crowding exacerbates this problem. In an American Hospital Association survey from 1991 to 2011, the number of annual patient ED visits increased annually as the number of EDs decreased. Today’s economics drive hospitals to maintain a just-in-time inventory and staffing model, limiting resources that could be used in a disaster response. Additionally, some parts of the country report physician and nurse shortages.

enhance community and hospital preparedness for public health emergencies and improve surge capacity. In 2002, the Hospital Preparedness Program provided $125 million to public health and health care systems within the U.S. In 2003, the amount rose to $498 million, but unfortunately, funds have decreased annually for the last decade. In 2012, the budgeted amount for HPP is $347 million, representing 0.0001 percent of total national health expenditures. The president’s budget for fiscal year 2013 allocates $255 million for HPP.

The Foundation Community emergencies and disasters impact more than the hospital and its ED — they affect community medical

December 2013

resources, including hospitals without EDs, rehabilitation facilities, long-term acute care facilities, psychiatric hospitals, public health entities, EMS providers, dialysis centers, primary care and urgent care centers, nursing homes, pharmacies, home health agencies, academia and others. Marcozzi explained that all community medical resources ‘‘have skin in the game’’ and are potential partners for surge planning. Increasing health care system capacity requires engaging hospitals and health care-related agencies to develop health care preparedness coalitions based on the national health care preparedness program capabilities (tinyurl.com/pcn42bj). Capabilities include health care system preparedness, emergency operations coordination, fatality management, information sharing and medical surge, among others. The combination of health care coalitions and their capability development will grow health system capacity and medical capability in disaster response.

Making Room Previous events such as the Madrid train bombing, Hurricane Sandy, the West (Texas) fertilizer explosion and the Boston Marathon bombing have demonstrated the need for disasterrelated medical surge planning. A new concept in medical surge is emerging in academic and practical settings. Immediate bed availability is an evidence-informed, population-based, ethically grounded concept. The goal of IBA is to provide a higher level of care to more seriously injured patients within a short period of time with no additional health care system assets. IBA requires leveraging hospital and health care coalition partnerships to meet incident needs. IBA strives to make available 20 percent of staffed hospital beds within four hours of an event. To prepare a community for IBA, coalitions develop during normal operating conditions and establish partnerships and protocols based on local risk assessments. Marcozzi related IBA to the Institute of Medicine’s ‘‘Crisis Standards of Care’’ (tinyurl.com/7zphjvl). Crisis Standards of Care provide a way for health care systems to move from normal operations to contingency and crisis and back again. IBA is initiated before a move into the contingency or crisis standards of care and response. Marcozzi recognized that we are all busy but asked emergency nurses as the ‘‘tip of the spear’’ in a disaster response to start asking questions within our institutions so our communities can better care for patients during mass casualty events: • • • • •

Is our hospital part of a HPP coalition? Are we ready for a no-notice event? Are we ready for a slow-evolving event like a pandemic? Can our coalition execute IBA? What other partners should we include in our coalition?

Additional information about the HPP can be found at www. phe.gov/preparedness.

Thank you to the following organizations for their generous support. STRATEGIC SPONSORS

STRATEGIC SUPPORTERS

The ENA Strategic Sponsorship Program was designed to create partnerships with leading organizations whose objectives include supporting the emergency nursing profession.

CONCURRENT SESSIONS Peds Needs Playing tic-tac-toe while triaging a crying child is probably the last thing most nurses would think to do, but Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPEN, CPN, CTRN, CCRN, SANE-A, AFN-BC, EMT-P, recommends it. ‘‘Play is the work of the child,’’ she told a packed room at this fast track session. ‘‘Develop diversion techniques and keep tools and toys nearby. You’ll win over both the child and the parent while getting your work done.’’ Because children are literal, Foresman-Capuzzi advised members to use the child’s language, not clinical terms, when possible. For example, use ‘‘tummy,’’ ‘‘owie’’ and ‘‘ouchie.’’ Call a catheter ‘‘a little straw.’’ Remember that a child may think of a cat — the animal — if you use the term ‘‘CAT scan’’ or poison ivy if you use the term ‘‘IV.’’ Some diversion techniques: • Draw on a paper bag to create

a puppet; use the puppet to assess eye movement • Make a scrapbook of tests and procedures to help calm fears and educate parents and children • Use stickers and squirt toys; put scratch ’n’ sniff stickers in oxygen masks • Numb taste buds with a popsicle or ice before giving medicines, if pharmacy approves • Use silly straws and have a ‘‘tea party’’ or a contest to see how fast a child can drink something if contrast or a liquid must be ingested ‘‘Children are like cement,’’ Foresman-Capuzzi said. ‘‘Everything you do makes an impression.’’ Margo Schafer

Human Trafficking: What Emergency Nurses Need to Know During her work as a mental health specialist in a local emergency department, Donna Sabella, PhD,

MEd, MSN, RN, came to realize that some of her patients were victims of human trafficking. She recounted the story of one patient, Mimi, who was forced into prostitution; she was not able to get the resources she needed and eventually killed herself. Certain telltale injuries of human trafficking include bald spots from hair pulling, bites, vaginal bruising, hearing problems from getting hit on the head, sexually transmitted infections, burn marks and slap marks. Other signs are poor hygiene, bad nutrition and being unable to name the patient’s location. Helpful questions that may reveal a trafficking victim’s situation include the following: • Where do you live? • Where do you eat and sleep? • What do you do all day? • When you are not working, can you come and go as you please? • Has anyone threatened you or your family? • Do you have identification?

December 2013

Seballa cautioned attendees to not ask these questions in front of a patient’s companion, who could be the one holding her captive. If the patient’s companion refuses to leave her side, the nurse could state that the hospital’s policy dictates that patients are questioned alone or that the patient needs to have lab work done. ‘‘You might be the only person who makes a difference in that patient’s life,’’ Sabella said. Amy Carpenter Aquino

Fatigue in Health Care Michael Frakes, MS, APRN, CCNS, CEN, CFRN, reviewed the causes of fatigue and sleeplessness, especially among shift workers. A quarter of people in the United States say their work schedule does not permit sleep, leading to most

Americans having only 7.5 hours of sleep per night rather than the 8.25 hours that studies report are needed. This debt is cumulative, Frakes said, but two nights of optimal sleep should help restore a person’s normal activity. Sleeplessness and fatigue can have neurobehavioral effects, including irritability, decreased on-the-job alertness and loss in cognitive function, fine motor skills and language skills. For health care workers, this can lead to increased blood-borne pathogen exposure and medication errors. Night shift workers are also more likely to be involved in a collision on their way home, Frakes said. Additional consequences include chronic GI and cardiovascular disease, obesity and depression. Fatigue also can cause a nurse to be unable to notice ‘‘significant but subtle cues’’ that are essential in their practice, Frakes said.

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Official Magazine of the Emergency Nurses Association

Suggestions for combating fatigue include making sure to sleep before a shift, taking naps or activity breaks during the shift, rotating shifts only once per week and limiting long shifts to two on, two off. Recognizing the signs of fatigue in yourself and coworkers is also key. ‘‘I thoroughly enjoyed [the presentation],’’ said Cindy St. Andre, MSN, RN, CEN, of Austin, Texas. ‘‘I think it provides a lot of information for me and how I can improve my part of the sleep cycle.’’ Renée Herrmann

Munchausen Syndrome By Proxy Munchausen syndrome by proxy is an often baffling form of child abuse in

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Concurrent Sessions Continued from previous page which a parent or caregiver abuses a child to seek attention for him- or herself. The child’s symptoms often send staff on a wild goose chase to diagnose what appears to be a rare disease. MSBP is often overlooked as a cause of the child’s symptoms. ‘‘When you hear hooves, think horses, not zebras,’’ advised presenter Laura M. Criddle, PhD, RN, CEN, CPEN, CFRN, FAEN. Criddle explained commonalities found in MSBP cases: Abuser • Premeditates abuse; displays caring attitude when others are present but abuses privately • Enjoys and seeks attention; quickly develops relationship with hospital staff • Provides vague details but highly specific symptom information; can become irate when challenged or questioned • Continues abuse in the hospital (70 percent) to create symptoms, especially if the child’s condition is improving or news of discharge is mentioned • May adopt martyr or ‘‘parent of sick child’’ identity to extreme degree to get attention Victim • Abuser is only witness to symptoms (seizures, apnea, rare neurological conditions) • Child does not respond to typical treatments; medical history is difficult to disprove • Condition improves when hospitalized or disappears entirely when removed from abuser • Child is likely to have dead siblings What to Do if MSBP Is Suspected • Share concerns and develop a plan to rule out MSBP • Remove the child from the

abuser if possible • Use covert video surveillance to detect abuse Margo Schafer

Victims of Violence: Emergency Department Staff Are Victims, Too ‘‘Security became a deep-down passion of ours over the years,” said Denise Abernethy, MSN, RN, CEN, unit director at University of Pittsburgh Medical Center, Shadyside Hospital. A recent shooting at a UPMC psychiatric hospital that left two people dead has prompted other facilities to follow Shadyside’s lead in workplace violence prevention. ‘‘We all know what workplace

violence is. The problem with emergency nursing is that we’ve always been told that’s an expectation,’’ Abernethy said. ‘‘Yeah, you get sworn at, you get spit at, people throw objects, you get punched, and it was all part of the job. People just tolerated it.’’ Attitudes have changed in recent years, with influential research and work being done by ENA and other national organizations, including the Occupational Health and Safety Administration. Abernethy cited a 2005-2009 U.S. Department of Justice survey that ranked health care workers third among workers who were victims of violence while on the job, behind only police officers and retail workers. ‘‘Some of the estimates now are

December 2013

box cutters and 48 guns. ‘‘It gave some good pointers,’’ said attendee Luba James, RN, an ED staff nurse from San Francisco. ‘‘We are a small hospital and we have no police. . . . I still feel unsafe at work because our security is not supposed to touch the patient unless we get assaulted, which I find very disturbing. Because of what she said, I need to ask security to wand more people. We have found things in our ER.’’ Amy Carpenter Aquino

that 500,000 health care workers are injured a year, which is staggering,’’ she said. Abernethy showed attendees how to adapt their own workplace violence prevention program based on ENA’s Workplace Violence Toolkit and Shadyside’s own program. Some of the violence prevention measures her facility has implemented are a coding system for security alerts; metal detectors; cameras placed at each entrance and hallway, with screens at the charge nurse desk; and a tagging system for visitors. Abernethy shared a slide from the first month after the metal detectors were installed that showed security secured 257 weapons from ED patients and visitors, including 159 knives, 44 mace dispensers, eight

Hand and Wrist Injuries and Radiology Review Hand and wrist injuries are important to identify because they can lead to malpractice cases against emergency practitioners, said Denise Ramponi, DNP, NP-BC, CEN, FAEN, who highlighted clinical pearls for hand and wrist injuries and interpretation on radiographs. Ramponi gave an overview of common and high-risk hand and wrist injuries. She reviewed keys for radiograph interpretation, including identifying factors such as location, degree of offset, shortening, impaction and angulation. Ramponi provided other tips, such as referring to fingers using words, not numbers. She also described

techniques for a simple sensory and motor examination for the hand, such as having the patient make the OK sign. Attendees were able to review some of the fractures and injuries that were discussed and put some of these techniques to use. Ramponi ended the session with tips for risk management. As missed fractures and wound care account for many malpractice claims, referral to a hand surgeon is key, along with good documentation. ‘‘The session was excellent,’’ said Julian Good, MS, RN, CEN, a nurse practitioner from Wyoming. ‘‘I frequently see hand and wrist fractures in practice, and I received the information I was looking for.’’ Renée Herrmann

Boston Bombings: Insight Into Crisis Best Practices and Lessons Learned The Boston Marathon is considered a ‘‘planned’’ mass casualty incident each year. Five local trauma centers surround the marathon route, and the city’s first responders, health department and elected officials work together annually to plan for all

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possible marathon outcomes and scenarios. Throughout the year, they conduct extensive drills. ‘‘We were ready,’’ Dan Nadworny, BSN, RN, ED clinical manager at Beth Israel Deaconess Medical Center, told attendees at the ‘‘Boston Strong’’ educational session. The 54-bed ED beefs up staff and reconfigures its layout to prepare for a surge in patients experiencing heat exhaustion, aches, pains, heart attacks and sprains. Historical data have shown that a typical marathon surge might bring in anywhere from 10 to 54 patients. Still, on April 15, when two pressure-cooker bombs exploded near the marathon’s finish line, the city’s

double amputations. A hazmat tent was set up within

emergency response system was challenged to an extreme

minutes, and all patients were screened with a Geiger

level. Within 10 minutes of the first explosion, BIDMC

counter and X-rayed for shrapnel and nails. Triage was moved outside the hospital.

received its first two patients.

‘‘In the early stages, we didn’t have a good understanding

‘‘People who make bombs don’t make bombs out of nice

of who had done this,’’ Nadworny said. ‘‘We needed to keep a

things,’’ Nadworny said. The staff received 10 patients in 39 minutes; 14 more arrived, all requiring immediate surgery. Many were single or

sterile environment in the ED. We needed a fast turnaround because of the seriousness of the incident. Changing the triage traffic flow allowed us to screen patients more quickly.’’ Lessons Learned, Surprises and Takeaways • Blast injuries can be unique, causing head injuries, temporary deafness, disorientation, severe burns, bleeding and dirty wounds. ‘‘You can’t always see the entry wound,’’ said Nadworny,

Call for Paper and Poster Abstracts

who showed radiographs of patients who reportedly felt fine but had nails and shrapnel in the neck or skull. Additionally,

Research and Evidence-based Practice Projects

tourniquets were in short supply. ‘‘Use bed sheets if you

Don’t Miss this Opportunity to Showcase Your Work on Emergency Department Management, Leadership and Research

have to,’’ he said.

Submission Deadline: January 15, 2014

• The high volume of staff members, physicians, media members, family members and the general public who self-deployed to the hospital created crowding issues. ‘‘The only e-mail I sent that day was asking staff and others to please stay home,’’ Nadworny said. Additionally, a special call center had to be set up to handle the influx of phone calls. • Never underestimate the power of permanent markers for tracking patients, even if you have an EMR. ‘‘We wrote names and other information on patient chests,’’ Nadworny said. ‘‘We knew that chest was staying put.’’ Staff also wrote their roles in large letters on their incident command vests for faster identification. Technology is not always faster, Nadworny said. • Notify support functions of your needs as early as

For questions or to submit your paper and poster abstract please visit:

www.ena.org/abstracts

possible. The blood bank, pharmacy, social workers, environmental services and pastoral care all play important roles in mass casualty incidents. Margo Schafer

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10/3/13 2:56 PM

December 2013

Autism Is Speaking; Are We Listening? Understanding the unique characteristics and situations of patients with autism spectrum disorder can help emergency nurses better care for this population, said presenter Elizabeth Mizerek, MSN, RN, CEN, CPEN. There is no defined cause for ASD, and diagnosis is typically done through clinical and parental observation and comprehensive evaluation. Treatment is most effective if done early and requires a team approach. ‘‘It is early, intensive treatment,’’ Mizerek said. ‘‘It is 25 hours per week, year-round. There are no summer vacations.’’ Patients with ASD can have medical issues, including gastrointestinal problems, seizures, tics and sleep disorders, along with behavioral issues. Patients also might be on restricted diets and take dietary supplements. ‘‘Make no assumptions on what the medications are being taken for,’’ Mizerek said. Additional factors in the care of patients with ASD

include increased parental stress and unique family dynamics and high cost of treatment. Emergency nurses may also see older patients, including adolescents and adults, with ASD, but many of the interventions used can be applied to this group. Mizerek reviewed characteristics of ASD, including a lack of communication skills, obsessions, repetitive behaviors and hypo- and hypersensitivity. Techniques for caring for this population included using a patient’s obsession as an entryway into conversation and building a relationship, such as when dealing with a child who has a favorite cartoon character. Another example is allowing patients to remain in their own clothing as much as possible if they have a sensitivity to touch and texture. Providing patients with ASD clear expectations for the examination and allowing them time to adjust for transitions was another key technique Mizerek provided. She also stressed the importance of positive reinforcement and anticipatory guidance. She encouraged nurses to work with the caregiver, adding, ‘‘The only expert in the room is the caregiver who lives with that patient.’’ Renée Herrmann

Prescribing for the Older Adult in the ED Adults 65 years and older account for 12 percent of the U.S. population, but they take 31 percent of the prescribed medications. Nancy Denke, MSN, FNP-BC, ACNP-BC, CEN, CCRN, FAEN, discussed age-related changes and factors that can make medication administration challenging in

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Concurrent Sessions Continued from previous page this patient population. Older adults are at risk for medication interactions because of age-related physiologic changes in absorption, distribution, metabolism and excretion. Other factors include poor adherence due to financial issues or trouble understanding dosing instructions. When prescribing for older adults, Denke said to ‘‘start low and go slow.’’ An incorrect medication or dose of a medication can lead to adverse effects that may mimic other conditions, which can begin a ‘‘prescribing cascade’’ — patients are prescribed more medication for the new condition, which may spark another reaction, requiring another medication and so on. Denke noted that older adults may have multiple providers, so gaining an accurate medication list is key. She said nurses should clarify what is meant by ‘‘medications’’ so that patients include supplements and over-the-counter medications. Denke also included tools that providers can use to determine if a medication is appropriate, such as the Beers Criteria List, STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). While these tools are not a substitute for clinical judgment, she said, they can be used to help make better decisions regarding prescribing for the older adult. Renée Herrmann

Social Media Isn’t Evil ‘‘Turn on your phones!’’ Landon James, MA, BSN, RN, CEN, PCP, encouraged session attendees to do what most presenters discourage. The fast track session provided a quick overview of some common social media applications and

implications for future use in health care. James encouraged emergency nurses to know their laws regarding what can and cannot be posted on social media. According to the presentation, more than 50 percent of patients had used Twitter and/or Facebook to obtain information related to their health care. Barriers to social media use among patients included privacy and reliability. Health care providers cited their personal inefficiency and lack of skills as barriers.

James provided demonstrations of common social media tools, including RSS feeds and Twitter. He also reviewed the ‘‘Academic Sketchiness Score’’ and ‘‘Real World Applicability Score’’ to each. ‘‘Be smart and know where you are going for your information,’’ he said. Implications for future use were strongest in emergency management. Using an alert provided by a government affairs channel in Japan, James showed how social media was

December 2013

able to alert residents of a coming earthquake and save hundreds of lives. Using hashtags on Twitter, James also showed how providers can obtain instantaneous information regarding events such as plane crashes so they can be informed of a situation as it develops — even before prehospital personnel. Renée Herrmann

Pediatric Head Injury Triage Most children who present with traumatic brain injury will be asymptomatic and have normal vital signs, making triaging this population difficult for emergency nurses, said presenter Elizabeth Stone Griffin, BSN, RN, CPEN. She shared some of the available tools and research to help nurses with this process. The region most often associated with TBI at every age is the meningeal artery/temporal parietal region, Griffin said. This area starts at the temporal region and forms a band around the top part of the skull. Other triage and prioritization tools, such as Emergency Severity Index and the pediatric assessment triangle, can assist in the decisionmaking process, but knowing recent research is crucial. Knowing the patient’s mechanism of injury, the region of the skull injured and symptoms can help determine if a patient is urgent or nonurgent. Griffin reviewed two tools that can provide clarity in pediatric head injury triage. The PECARN algorithm determines who does and does not need radiologic imaging and can be used in children 0 to 17 years old. The SCALP system looks at the patient’s risk of skull fracture and is useful in assessing infants. Before reviewing some pediatric head injury case studies, Griffin provided some takeaway points for the audience. Both major and minor falls can cause head trauma.

‘‘Falling out of shopping of carts . . . was the way most toddlers had fractures and bleeds,’’ she said. Discharge planning and follow-up care are essential in this group. Children with concussive symptoms need to ‘‘rest their brains’’ before returning to play or they can risk additional injury. Renée Herrmann

Using the Haddon’s Matrix to Identify Critical Events for Emergency Nurses Assaulted at Work ‘‘Nurses are not confident in their ability to protect themselves,’’ said presenter Lisa Wolf, PhD, RN, CEN, FAEN, director of ENA’s Institute for Emergency Nursing Research. Zero-tolerance policies are posted in many EDs, but they are not enforced, which has led many nurses to feel that the risk of violence at the workplace is part of the job. Recounting narratives submitted to the IENR, Wolf shared concerns and common themes among nurses assaulted on the job. The idea that these incidents of violence happen ‘‘without provocation’’ raises interesting questions, Wolf said, as there are

often clear predictors and antecedents of violence. This is why cue recognition, both personal and institutional, is key. The Haddon’s Matrix, originally developed for traffic incidents, is one tool that can be used to plan for safety issues and to identify these issues, Wolf said. The matrix looks at the pre-event, event and post-event phases. It also identifies areas for intervention, including the host (or nurse), agent (or perpetrator), physical factors and social factors. Looking at some case studies, Wolf led the group through how to use the matrix to identify issues and make suggestions for prevention tactics. The presentation led to a lively discussion of what some participants’ hospitals are doing and shared experiences when it comes to workplace violence. Renée Herrmann

WATCH: Workplace Awareness for Terrorism and Crimes in Hospitals Emergency departments are prime targets for terrorist attacks. In his work as the CEO of a company specializing in threat consulting and

Official Magazine of the Emergency Nurses Association

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Concurrent Sessions

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as an employee of the Department of Homeland Security, Mike D. Clumpner, MBA, CHS, NREMT-P, CCEMT-P, PNCCT, EMT-T, FP-C, has studied major terrorist attacks to hospitals, both domestic and international. ‘‘When we planned for the Democratic National Convention, our two top worries were emergency departments,’’ he said. Clumpner showed slides of several terrorist events that targeted hospitals, including the 1995 Budyonnovsk hospital attack, which ended with the killing of more than 100 hostages. Domestically, gangs present severe threats to hospitals. Newer gangs are less structured than more established gangs and reward irrational behavior by moving the most violent members higher up the hierarchy. EDs can deter gang activity by keeping police vehicles parked out front and by giving officers a substation in the ED. ‘‘Give them a them a place to work, and design it with a one-way mirror so they can look over the lobby,’’ he said. Low security is present in many U.S. hospitals. Clumpner described how easy it is to get access to any area of a

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hospital if you look and act like you belong there. Clumpner urged attendees to defend themselves by any means possible if they are physically attacked in the hospital. ‘‘There are times when you’re in the fight or your life and you need to act like it,’’ he said. ‘‘If you’re being choked or strangled, you are in the fight of your life.’’ Other personal security tips included not having last names on identification badges because disgruntled patients or family members can easily use social media to track down where employees live. ‘‘You all put your life on Facebook,’’ he said. Even if you think your Facebook profile is secure, ‘‘I’ll make you a friend request in five minutes that you will not turn down.’’ ‘‘I want you to walk out of here with a mind-set of preparation,’’ Clumpner said. Amy Carpenter Aquino

Toxins, Tablets and Drugs: What’s New on the Streets? Attendees eager to learn about the latest street drugs and how to treat patients who have taken them packed this concurrent session. Michael D. Gooch, MSN, RN, ACNP-BC, FNP-BC, CFRN, CEN, EMT-P, discussed popular street drugs that are showing up in EDs across the United States, including bath salts, molly (also known as Molly’s Plant Food), ketamine and salvia. He reviewed the symptoms exhibited by patients who ingest these substances, along with care considerations. Patients who take bath salts, known under such street names as Vanilla Sky and Bliss, can exhibit signs of dehydration (which can be severe enough to have an impact on the renal system if not treated), as well as superior strength. Other symptoms include paranoia, hallucinations and violent behavior. ‘‘This is the new PCP,’’ Gooch said, adding that these patients experience severe overstimulation. Molly has the opposite effect on patients, Gooch said. The release of serotonin often makes these patients exhibit signs of affection and empathy toward others. Physical symptoms include tachycardia and hypertension. Treatment for both drugs is supportive. Gooch advised attendees to focus on treating patients’ dehydration and to ‘‘stock up on the Ativan and the Versed.’’ Salvia is an herb that can be chewed, smoked or brewed as a tea and can be obtained legally in most states. It causes hallucinations, euphoria and detachment and can leave patients in a catatonic state. There are no known long-term effects so far. Gooch covered several other drugs and toxins, including GHB, Jimson weed, botulinum and ginko. Amy Carpenter Aquino

10/17/13 4:58 PM

December 2013

NEVADA TAKES TOP TURTLE State councils and chapters created and decorated toy or ornamental turtles with an ENA flair — a theme inspired by 2013 ENA President JoAnn Lazarus’ use of the inspirational message, ‘‘Behold the turtle — he makes progress only when he sticks his neck out.’’ Lazarus will make donations to the 2014 ENA Foundation State Challenge campaign in honor of the top three winners: • First place – Nevada ENA State Council (pictured at left) • Second place – Greater Twin Cities ENA Chapter • Third place – Nebraska ENA State Council Turtles were judged by representatives of Friends Life, a Nashville organization that provides services for adults with intellectual and developmental disabilities.

GETTING REAL

Two procedural cadaver labs sponsored by Vidacare on Sept. 20 let attendees enhance the educational experience with even more hands-on learning.

ENA Strategic Sponsor

Official Magazine of the Emergency Nurses Association

Closing Session

‘We Are So Grateful You Are There’ Woodruff Forever Bonded With Nurses After Husband’s Injuries From Bomb in Iraq By Amy Carpenter Aquino, ENA Connection

‘T

his is not going to be a sad conversation. I am that person at the end of the conference who reminds you how wonderful you are,’’ Lee Woodruff told attendees at the Sept. 21 closing session. ‘‘You see the worst of us; you see us when we’re angry, scared, still processing what happened to a loved one or ourselves. ‘‘Even though we may not always act that way, we are so grateful that you are there.’’ In 2006, Woodruff’s husband, Bob, was seriously injured by a roadside bomb in Iraq shortly after being named co-anchor of ABC’s ‘‘World News Tonight.’’ Packed with rocks and dirt, the bomb exploded 25 feet from the correspondent’s tank, she said, leaving Bob with a traumatic brain injury. Rocks shattered his scapula and the left side of his skull and tore a hole through his neck. ‘‘He still has a number of rocks buried in his face. It is so incredible to me that he wasn’t blinded,’’ she said. Woodruff shared the story of her husband’s recovery, which was ‘‘nothing short of miraculous,’’ and praised the health care professionals who helped him and her family heal. ‘‘You don’t always see the back end,’’ she said. ‘‘You don’t get to see that patient walk through the door and say, ‘Look how well I turned out.’ ’’ Woodruff said there were four equally important legs supporting the stool that she leaned on during her

husband’s recovery: family, friends, faith and funny. ‘‘You cannot get through a difficult situation without a sense of humor,’’ she said. ‘‘The ability to laugh and let the good stuff out was absolutely a part of our healing.’’ During the early days of her husband’s treatment, which included being in a medically induced coma, Woodruff said she came to rely on the stories her husband’s nurses would share about patients who had made remarkable recoveries. ‘‘Those stories knit together in my heart like a braid,’’ she said. ‘‘My nurses knew little ways to insert hope with just a story or a word.’’ Woodruff choked up when she relayed the story of the two medical personnel of the military helicopter crew who picked up Bob Woodruff from the bombing site and brought him to safety, ignoring orders to turn around when fighting become too intense to land. ‘‘They heard the order to turn around, looked at each other and said, ‘Did you hear anything? I didn’t hear anything,’ turned the radio down and landed that helicopter,’’ she said. ‘‘You do a form of that every single day. . . . That’s what those two young men did that day for Bob.’’

December 2013

E m e r g e n c y N u r s e s A s s o c i a t i o n a n d G e n e n t e c h

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A NIGHT AT THE GRAND OLE OPRY — AN ENA FOUNDATION EVENT

™

Friends of the ENA Foundation who supported the foundation by attending the Sept. 20 Grand Ole Opry performance represented the second largest contingent from one organization in the history of the Opry. Performing that Friday night in Nashville were country music stars Kristen Kelly, Jimmy C. Newman, Wade Hayes, The Henningsens, Jesse McReynolds, The Willis Clan, Jim Lauderdale, Jeannie Seely, The Whites, George Hamilton IV and John Conlee.

Kristen Kelly

Chris Hollo, Grand Ole Opry

Jim Lauderdale

Chris Hollo, Grand Ole Opry

December 2013

AUCTION-PACKED! Bids were pouring in at the ENA Foundation jewelry auction, which ran from Sept. 19 - 21 and raised more than $23,000 to support 2014 ENA Foundation scholarships and research grants.

Official Magazine of the Emergency Nurses Association

STARS WITH STRIPES

Second Annual Awards Gala Toasts Emergency Nurses at the Forefront

NA President JoAnn Lazarus, MSN, RN, CEN, and master of ceremonies Terry M. Foster, MSN, RN, CEN, CCRN, FAEN, celebrated the ‘‘best of the best’’ on Sept. 21, at the second annual ENA Awards Gala. Recipients of the 2013 ENA Annual Recognition Awards and the Lantern Awards, along with nine Academy of Emergency Nursing inductees, received red-carpet treatment at the Gaylord Opryland Resort and Convention Center. Awards gala attendees enjoyed an elegant reception

and dinner during the three-hour ceremony. All award recipients were brought on stage to receive their awards and pose for a picture with Lazarus, whose cowboy hat and boots added some Nashville flavor to her awards ensemble. Some line-dancing demonstrations with Foster and a live local band completed the country music theme, but the evening was clearly focused on the recipients and inductees as they were recognized for their contributions to ENA and the practice of emergency nursing. Amy Carpenter Aquino

The nine new inductees of the Academy of Emergency Nursing (holding award certificates) are honored in front of their peers at the gala.

December 2013

Official Magazine of the Emergency Nurses Association

THE A-LISTERS

Individual award recipients recognized at the ENA Awards Gala on Sept. 21. Honorees are pictured with 2013 ENA President JoAnn Lazarus, MSN, RN, CEN.

Barbara A. Foley Quality, Safety and Injury Prevention Award

Behind the Scenes Award

Clinical Nurse Specialist Award

Robin Walsh, BSN, RN

Pamela Bucaro, MS, RN, PCNS-BC, CPNP, CPEN

Frank L. Cole Practitioner Award

Judith C. Kelleher Award

Nurse Researcher Award

Andrew Galvin, MSN, RN, ACNP-BC, CEN

AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN

Kathleen Flarity, DNP, PhD, CEN, CFRN, FAEN

Nursing Education Award

Nursing Practice and Professionalism Award

Rising Star Award

Kimberly Wright, BSN, RN

Leah Davis, BSN, RN, CEN

Rhonda Holmstrom, BSN, RN, CEN

Nicholas Nelson, MS, RN, CEN, CPEN, CPN, NRP

Team Award

• Erica Dempsey, BSN, RN, CEN • Amy Drejka, MS, BSN, RN, SANE-A • Meghan Ellis, BSN, RN, CEN • Mary Kathleen Fillingame, BS, RN • Jennifer Henry, BSN, RN, CEN • Amy Hensel, BSN, RN, SANE-A, CEN • Donna Lougheed, BSN, RN • Angela McNulty, BSN, RN, SANE-A • Christi Mench, RN, SANE-A • Beth Miller, BA, RN

Anita Symonds (left) and Angela McNulty (right), representing the Forensic Nurse Examiner Team of Christiana Care Health System, Newark, Del.

• Noemi Miranda, RN • Jennifer Oldham, BS, RN, CEN • Kelly Green O’Shaughnessy, BSN, RN, CEN • Christine Parks, BSN, RN • Nicole Possenti, BSN, RN • Amy Stier, RN, CEN, SANE-A • Anita Symonds, MS, BSN, RN, SANE-A, SANE-P • Steaphine Taggart, BSN, BA, RN • Erin Vaughn, BSN, RN, SANE-A

ENA Foundation State Challenge Awards Congratulations to the New Jersey ENA State Council for raising the highest amount for the fifth consecutive year. Jackie Taylor-Wynkoop, MSN, RN, accepted the award on behalf of the New Jersey State Council.

Nurse Manager Award

Media Award

Suszanne Deyke, MSN, RN, CEN

Cheryl Tan

Congratulations to the Maine ENA State Council for raising the highest amount per capita. Donna Hovey, BSN, RN, CEN, accepted the award on behalf of the Maine State Council.

2013 Academy of Emergency Nursing Inductees

Linda Arapian, MSN, RN, EMT-B, CEN, CPEN, FAEN

Susan Barnason, PhD, RN, APRN, CNS, CEN, FAHA, FAAN, FAEN

Nancy Stephens Donatelli, MS, RN, CEN, FAEN, NE-BC

Cathy Fox, RN, CEN, CPEN, FAEN

Lynne Gagnon, MS, BSN, RN, FAEN, CPHQ, NEA-BC

Louise Hummel, MSN, RN, CNS, CEN, FAEN

Elizabeth Nolan, MA, BSN, RN, CEN, FAEN

Elda Ramirez, PhD, RN, FNP-BC, FAEN, FAANP

Joyce Foresman-Capuzzi, MSN, RN, APRN, CCNS, EMT-P, CEN, CPEN, CTRN, CPN, CCRN, FAEN, SANE-A, AFN-BC

BUSINESS OR PLEASURE? Emergency nurses took in plenty of both, from sampling the latest cutting-edge products and services from more than 200 exhibitors in the Exhibit Hall to unwinding under the lights at the Welcome to Nashville Party.

December 2013

2013 Annual Conference photography by Jules Clifford

BOARD WRITES |

Michael D. Moon, PhD, MSN, RN, CNS-CC, CEN, FAEN

Practice What We Preach Safe Practice, Safe Care Regarding Medication Administration

recently received my quarterly copy of the Texas Board of Nursing bulletin and was amazed at the number of nurses who had disciplinary action taken against their licenses: seven full pages of names, at least half of them registered nurses.1 A large number of these disciplinary actions dealt with medication errors. Unfortunately, this is not an unusual occurrence in the United States. The Institute of Medicine concluded that 1.5 million preventable medication errors occur annually, costing around $3.5 billion.2 The emergency department is a dynamic, high-volume, high-acuity practice setting. As emergency nurses, we are the last safety check in preventing medication errors. Yet the ED practice environment is prone to medication errors since three-fourths of all ED visits result in a form of medication administration.3 While there are numerous areas where medication administration can go awry, this article focuses on medication administration. Scalise4 notes that 52 percent of all ED medication errors occur during the administration phase. As RNs, we all have been trained to look up medications we are unfamiliar with before administration. Once we have looked up a medication several times, it is not unusual to no longer routinely review the information. How well did you really review the information in the first place? Think about the last time you looked up a medication in your drug reference. Did you actually read all of the information or did you just check the action, dosage and compatibility of the medication? What about the rate of administration? Did you get that

information from the drug reference or did you ask another RN? If you asked another RN about the rate of administration for an intravenous push medication, I would suspect that you were told you could administer the medication slowly or over two minutes, which is a common response that I hear RNs give to each other. Let’s test your knowledge about three commonly administered medications in the ED: morphine sulfate, ceftriaxone4 and fentanyl. The physician orders morphine sulfate 4 mg IV push. How fast would you administer this dose? One, two, five or 10 minutes? The correct answer is five minutes. Administration of intravenous morphine sulfate 2.5 - 15 mg faster than five minutes leads to increased respiratory depression, hypotension and circulatory collapse.5 Let’s try another. You need to

administer 2 g of ceftriaxone IV. How would you administer this medication — IV as an infusion over 30 minutes or IV push over two to three minutes? The correct answer is IV over 30 minutes, avoiding the use of Lactated Ringers since the calcium in Lactated Ringers can cause ceftriaxone to precipitate.5 Interestingly enough, there are numerous accounts of RNs administering this large dose of ceftriaxone IV push despite the lack of supporting evidence that this method of administration is safe and despite the fact that this is contradictory to the manufacturer’s recommendations. The physician has ordered fentanyl 100 mcg IV push for a 125-kg patient who sustained a shoulder dislocation. How fast would you administer the fentanyl? One, two, three or five minutes? The correct answer is all of the above. Since the dose of fentanyl

December 2013

is less than 5 mcg/kg you can administer it safely over one to three minutes. However, slow IV administration reduces the incidence and severity of muscle rigidity.5 So in this case, you may actually want to give the medication over five minutes to help avoid any muscle rigidity. It is easy to get into a hurry in the emergency department and not consider all of the factors that go into medication administration. As professional RNs, we have a responsibility to ensure that we are knowledgeable about medication administration. We must be comfortable using resources in the clinical setting that are current, easily accessible and help to prevent medication errors. There are numerous medication reference applications that are available for smartphones, allowing emergency RNs immediate access to medication information. The U.S. Food and Drug Administration6 has

developed guidelines regarding mobile medical applications which can help RNs determine which medical applications are appropriate for the clinical setting. Current medication references should be available in the department, either in electronic or text format. Emergency nurses should have contact information of the hospital pharmacist readily available to seek clarification when drug references are incomplete or confusing. Make sure to take time to ensure the safety of your patient. Your license and the patient’s life can depend on it.

Erickson, A., Munz, K., Schuur, J.,

References

Medicine. [Mobile application]

1. Texas Board of Nursing (2013, October). Texas Board of Nursing bulletin. Austin, TX: Author.

6. U.S. Food and Drug Administration

2. Aspden, P., Wolcott, J., Bootman, J. L., & Cronenwett, L. R. (Eds.) (2006). Preventing medication errors: Quality chasm series. National Academy Press.

administration staff. Retrieved from

3. Rothschild, J. M., Churchill, W.,

UCM263366.pdf

Salzberg, C.A., … Bates, D. W. (2010). Medication errors recovered by emergency department pharmacists. Annals of Emergency Medicine, 5(6), 513-521. 4. Scalise, D. (2006, May). Patient safety in the ED: A guide to identifying and reducing errors in the emergency department. Chicago, IL: Health Forum. 5. Vallerand, A. H., & Sanoski, C. A. (2012). Davis’s drug guide for nurses (13th ed.). Media, PA: Unbound

(2013). Mobile medical applications: Guidance for industry and drug http://www.fda.gov/downloads/ MedicalDevices/DeviceRegulation andGuidance/GuidanceDocuments/

Everyone wanted a piece of the jewelry auction! § Thank You from the ENA Foundation § 210 jewelry pieces donated § $23,700 dollars raised Because of your support, every year thousands of dollars are given to emergency nurses for research grants and scholarships. The ENA Foundation continues to advance the future of emergency nursing.

Visit www.enafoundation.org

ENA Foundation Jewelry Auction Thank You Ad_Connection_half_12 2013.indd 1

Official Magazine of the Emergency Nurses Association

10/18/13 9:03 AM

Lessons Learned and a Treasure Appreciated By Nancy Bonalumi, MS, RN, CEN, FAEN, AEN Board of Directors and 2006 ENA President

ooking back on my first year on the Academy of Emergency Nursing Board, I’ve learned several valuable lessons: 1. Size does not matter. The five-member AEN board is small by non-profit board definitions; however, small does not imply lack of strength or responsibility. Regardless of its composition, a board is accountable to the members it represents. The Academy is composed of 110 accomplished fellows, and the duty of its board is to honor nurses who have made enduring, substantial contributions to emergency nursing and who continue to advance the profession of emergency nursing, including the health care system in which emergency nursing is delivered. That is no small assignment. The AEN board oversees the mentoring of future fellows through its EMINENCE program and conducts a very thorough review process of each candidate for fellowship. These two activities comprise the majority of work done by this small, committed board. Diversity of the board membership is something to celebrate as well. While we all come from the common denominator of emergency nursing, our board members have functioned as clinicians, educators and prehospital and clinical specialists both in civilian and military settings. We may share different thoughts, but we respect each other’s opinions. Our unified vision of what is in the best interest of the

Academy remains our guiding principle, and we speak with one voice when representing the Academy. 2. Personal commitment is required. I have had the privilege of serving on many non-profit boards during my career. Being a board member requires time and energy. At all times, you are representing that group, and your behavior and actions are subject to scrutiny by other board members and the public. My commit ment to being a board member means I live up to the standards of that group and adhere to its rules of conduct. It also means donating my time for phone calls, travel and meetings. Making a decision to serve on a board is not to be done lightly. Board service allows you to work on something you are passionate about and to build and expand the mission, vision and direction of the entity. It provides a venue to use skills you already may have acquired in previous board experiences as well as transferring skills from the workplace to the board room. Key traits of an effective board member include honoring the commitment to serve, asking informed questions and offering and receiving constructive feedback. 3. The Academy of Emergency Nursing is a treasure. Describing the talent, expertise and accomplishments of each of the fellows would require pages and pages, but in simple terms, AEN fellows represent thousands of years of emergency nursing experience! Where else is there such a repository of emergency nursing knowledge and achievement?

he Academy of Emergency Nursing was established by the Emergency Nurses Association on Sept. 28, 2004, to: • Honor emergency nurses who have made enduring, substantial contributions to emergency nursing • Advance the profession of emergency nursing, including the health care system in which emergency nursing is delivered • Provide visionary leadership to ENA and AEN The body of work left by AEN fellows goes well beyond being an outstanding nurse and a devoted ENA member. Amazingly, it doesn’t end with induction into the Academy, as fellows continue to contribute to the advancement of emergency nursing. At the AEN business meeting held during the 2013 ENA Annual Conference in September, fellows were asked to complete an inventory of their expertise. The intention is to tap into this pool of knowledge to support activities of AEN and ENA. Health care reform, academic nursing preparation, clinical practice of emergency care in any setting and administrative, leadership and quality activities are a small example of the capabilities and interests of fellows. There is a world out there that needs our knowledge; matching that need with the usefulness of a fellow’s understanding of these issues is a goal of the Academy. I look forward to 2014 and embarking on a new year of learning as a member of the AEN Board of Directors.

Intraosseous Vascular Access

Our Specialty Societies Agree, So Why Can’t We? By Jean Proehl, RN, MN, CEN, CPEN, FAEN, and John J. Rogers, MD, CPHQ, CPE, FACS, FACEP

NA and the American College of Emergency Physicians both have positions that support the use of intraosseous vascular access to include insertion by nurses. Yet IO remains an underused technique in most emergency departments. Nurses say doctors are unfamiliar, uncomfortable and resistant to using IO. Doctors say nurses are unfamiliar, uncomfortable and resistant to using IO. The time is now for us to stop pointing fingers at each other and move toward overcoming the barriers to IO that exist in our EDs. It appears the barriers to IO are rooted in misunderstanding, unfamiliarity, misplaced fears and our natural desire to cling to the comfort we find with the technologies of the past. We accept common myths as fact and thus rationalize our opposition to IO. The truth is that inserting an IO needle is safe, fast, effective, easy and no more painful than insertion of a peripheral intravenous catheter or other common ED procedures. The technique of IO insertion can be easily and quickly taught, even to novices. In one study, medical students unfamiliar with the technique were instructed and became comfortable and competent within hours. It is not uncommon for paramedics and nurses to insert IOs,

Emergency nurses practiced intraosseuous vascular access during Vidacare cadaver labs at the 2013 Annual Conference in Nashville. unlike central lines that are usually inserted by a physician, nurse practitioner or physician’s assistant. Serious complications are virtually nil. Osteomyelitis from an IO approaches one case per million insertions. Extravasation is the most common problem and affects up to 5 percent of patients but is usually of no clinical concern. Compartment syndrome is a more serious compli cation from unrecognized extravasation, yet remains rare and is usually limited to small children and due to inadequate monitoring of the site. Flow rates are generally more than adequate. Research has shown the average flow rate for the proximal humerus to be 5 L per hour and as high as 9 L per hour when infused under 300 mm Hg of pressure. Other studies have shown IO access to be suitable for contrast administration for CT scans The medications that can be given IO are virtually no different than those that can be given via any peripheral intravenous line. Numerous studies have shown pharmacologic equivalence of medications administered IO and IV.

Official Magazine of the Emergency Nurses Association

Intraosseous access costs less than a central line. Central lines require ultrasound guidance or X-ray confirmation, and full sterile technique to avoid the high mortality and expense in both dollars and pain and suffering associated with central line infections. These precautions add hundreds of dollars to the cost of central vascular access, whereas the cost of an IO is approximately what would be spent on three attempts at inserting a peripheral line. With benefits that far outweigh the disadvantages, we wonder why resistance to IO persists. We wonder why we don’t have the courage to step out of our comfort zones. We wonder how we can continue to justify not using IO when indicated. Clearly our professional ethics demand that we adjust to new technologies despite our comfort with the old. Our patients deserve the best from us and we can and should deliver it to them. We call upon emergency nurses and physicians alike to work together to implement IO as a standard method of vascular access in EDs across the

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connection

Recruitment & Professional Opportunities

s s e n l l e W

Career Center enacareercenter.ena.org

For ad rates and information, contact ENA Sales Representative Maureen Nolimal at 847-460-4076 or Maureen.Nolimal@ena.org. Intraosseous Vascular Access

Medicine, 18(2), 126–129.

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American College of Emergency Physicians. (2011, June). Alternative methods to vascular access in the emergency department. Retrieved from http://www.acep.org/Clinical---PracticeManagement/Alternative-Methods-toVascular-Access-in-the-EmergencyDepartment/

country. We call upon them to dispel the myths of IO and promulgate the truths. We call upon them to educate and teach their peers. We call upon them to become the local champions and lead their facilities toward the improved safety and outcomes that IO offers. We call upon the deans of nursing and medical schools to include IO in the curricula for their students. And we call upon the residency program directors in emergency medicine, pediatrics, internal medicine, family practice and other disciplines to include IO in the training of their residents. Our patients deserve the benefits IO access can deliver and we owe it to them to become knowledgeable, familiar and competent with the technique. Let’s agree to agree for the benefit of our patients and start down that path together. Jean Proehl and John J. Rogers are consultants for Vidacare Corp. References Abe, K. K, Blum, G. T., & Yamamoto, L. (2000). Intraosseous is faster and easier than umbilical venous catheterization in newborn emergency vascular access models. American Journal of Emergency

Crowley, M., Brim, C., Proehl, J., Barnason, S., Leviner, S., Lindauer, C., …Williams, J. (2011, December). Clinical practice guideline: Difficult intravenous access. Retrieved from http://www.ena.org/practice-research/ research/CPG/Documents/ DifficultIVAccessCPG.pdf Ong, M. E., Chan, Y. H, Oh, J. J., & Ngo, A. S. (2009). An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO. American Journal of Emergency Medicine, 27(1), 8–15. Levitan, R. M., Bortle, C. D., Snyder, T. A., Nitsch, D. A., Pisaturo, J. T., & Butler, K. H. (2009). Use of a batteryoperated needle driver for intraosseous access by novice users: Skill acquisition with cadavers. Annals of Emergency Medicine, 54(5), 692–694. Rogers, J. (2012, October 17). Safety of intraosseous vascular access in the 21st

century. Abstract presented at the 2012 World Congress of Vascular Access, San Antonio, TX. Santolucito, J. B. (2001). A retrospective evaluation of the timeliness of physician initiated PICC referrals: a continuous quality assurance/performance improvement study. Journal of Vascular Access Devices, 6, 20–26. Stein, J., George, B., River, G., Hebig, A., & McDermott, D. (2009). Ultrasonograhically guided peripheral intravenous cannulation in emergency department patients with difficult intravenous access: a randomized trial. Annals of Emergency Medicine, 54(1), 33–40. Stouffer, J. A.. Acebo, J., & Hawks, R. W. (2007). The Portland IO experience: results of an adult intraosseous infusion protocol. Journal of Emergency Medical Services, 32(10), S27–S28. Vidacare Corp (2012). Hospital Value Analysis. Vizcarra, C,, & Clum, S. (2010). Intraosseous route as alternative access for infusion therapy. Journal of Infusion Nursing, 33(3), 162–174. Von Hoff, D. D., Kuhn, J. G., Burris, H. A., & Miller, L. J. (2008). Does intraosseous equal intravenous? A pharmacokinetic study. American Journal of Emergency Medicine, 26(1), 31–38.

December 2013

Nursing

Elevate your career. Discover more at our website: www.sentaracareers.com

Explore our Emergency Opportunities in Leadership, Advanced Practice, Staff Nursing, and Education. At Sentara, we view each day as another opportunity to be better. To provide patient care that is unmatched, every time. And to improve the level of satisfaction our careers deliver. Our goal is to make you feel more excited to be here every day. Sentara is 26,000 strong with a unified objective. Creating an environment of health and healing for our patients with our high standards of care and patient safety. Questions, please contact our Recruitment Hotline at: 800-237-4822 x. 87433 or e-mail: ejcreath@sentara.com.

• Locations in Virginia and North Carolina • Acute Care Hospitals • Advanced Imaging Centers • Home Health and Hospice • Medical Group Practices • Senior Services and Long Term Care

To apply online, visit: www.sentaracareers.com

• Outpatient Care Centers • Emergency and Urgent Care Centers • Physical Therapy and Rehab Services • Flexible Schedules • Family Friendly Environment • Excellent Beneﬁts, including 401(k) / 403(b)

EOE, M/F/D/V A Drug Free/Tobacco Free Workplace.

ENA CONNECTION JOURNAL 12/1/2013 There’s no place like 3048894-WA24780 JPS HEALTH SENHEA NETWORK. 7.125” x 4.75” JPS Health Network values highly motivated Veta Ifito ll-Martinez v.2 nurses who want make a difference in people’s lives. Every team member fills a vital role in providing compassionate care for the patients we serve. A major employer in the Fort Worth area, JPS is a teaching hospital and Level I Trauma Center.

Please visit our website for additional information. Contact Mekka Livingston, mlivings@jpshealth.org or 817-702-3836, to learn more about current nursing opportunities. If you’re interested in joining our team, please visit

www.JPSNursing.org

Official Magazine of the Emergency Nurses Association

28 41 55 68 %

Average improvement in throughput for admitted and discharged patients

Average improvement in time from arrival to seeing a physician.

Typical improvement in patient satisfaction scores and likelihood to recommend

Improve emergency care, improve your career You know us as recognized ED leaders who guide hospitals toward real and effective change. Now we would like to get to know you. Blue Jay Consulting is looking for professionals with the leadership insight and clinical experience to bring process improvements to our clients, and the passion and commitment to enhance the overall quality of emergency care. If you consider yourself among the best in your field, you’ll find yourself in good company at Blue Jay Consulting. Join the strongest team in the industry and improve your career. Contact Jim Hoelz or Mark Feinberg at 407-210-6570 to discuss how we can capitalize on one another’s strengths.

www.bluejayconsulting.com

Average improvement in LWBS rates, resulting in an additional $1.6 million in collected revenue

“As a Blue Jay consultant, I bring my 30 years of emergency department leadership experience to each client. Every assignment brings a unique set of challenges, but the tools to solve them are similar. We can often shorten the improvement process from years to months and create an environment that is better for patients, families and staff. I leave each assignment with a good feeling that I have left it better than when I arrived. I love being a Blue Jay consultant.” —

B I L L B R I G G S , M S N , R N , C E N , FA E N

Senior Consultant Blue Jay Consulting, LLC