ENA Connection August 2014 by ENA Connection

the Official Magazine of the Emergency Nurses Association

connection

August 2014 Volume 38, Issue 7

COMMON LANGUAGE

ENA’s Influence Spreads With a Seventh-Edition TNCC Dissemination in Abu Dhabi PAGES 14-17

PLUS . . . ♦ ENA Election Results

♦ Member’s Video Geared to Stop ‘Hill Hopping’ 10

WORKPLACE VIOLENCE VIOLENCE PREVENTION PREVENTION WORKPLACE KNOWYOUR YOUR WAY WAYOUT: OUT: KNOW

RECOGNIZE,AVOID, AVOID,PREVENT, PREVENT AND AND MITIGATE MITIGATE EMERGENCY EMERGENCY DEPARTMENT DEPARTMENTVIOLENCE VIOLENCE RECOGNIZE,

Interactive, online course designed to mitigate violence in the emergency department. Nurses, managers, and staff who work in emergency care settings will learn to:    

Recognize risk factors Apply prompt and appropriate responses Implement organizational prevention strategies Report and analyze patterns of violence

2 Hour Course  Video Demonstrations  1.13 Contact Hours Interactive Quizzes  Developed by ENA with a grant from OSHA

Violence is not part of the job—Protect Yourself! Go to www.ena.org/workplaceviolence

The Emergency Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credential Center’s Commission on Accreditation. This material was produced under grant number SH-23534-12-60-F-17 from the Occupational Safety and Health Administration, U.S. Department of Labor. It does not necessarily reflect the views or policies of the U.S. Department of Labor, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.

Dates to Remember Oct. 5-11, 2014 Emergency Nurses Week (Emergency Nurses Day is Oct. 8) Oct. 7-11, 2014 ENA 2014 Annual Conference, Indianapolis

ENA Exclusives PAGE 6 2014 ENA Election Results PAGE 9 ENA Can Approve CNE Into 2018 PAGE 10 Oregon Member to Be Honored For Video Against ‘Hill Hopping’ PAGE 14 Worlds Come Together During TNCC Dissemination in Abu Dhabi PAGE 18 Ramping Up Pedestrian Safety PAGE 25 CODE YOU: How Strong Is Your Emotional Intelligence? PAGE 30 The Ethics of Nursing for Your Family PAGE 32 Legislators Listening After ENA’s Record Day on the Hill PAGE 36 Flu Vaccinations: Best Shot at Safety PAGE 38 Work Team Tackles ED Technology PAGE 40 ENA Archives: The Roadrunner PAGE 42 Faster Care With Video Interpretation

Regular Features PAGE 4 Free CE of the Month Members in Motion PAGE 26 ENA Foundation PAGE 28 Academy of Emergency Nursing PAGE 34 Board Writes

FROM THE PRESIDENT | Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN

At-Risk Behaviors Can Lead to Errors I

t’s halfway through your shift and you finally feel caught up. You offer to help your teammate give a dose of morphine to a patient with a left lower-leg deformity. You checked the order, removed the medication from the medication dispensing cabinet and went to the patient’s bedside. While you were able to scan the patient’s barcode ID band, you were unable to scan the medication. After a few unsuccessful attempts, you just gave the medication to the patient. In an effort to report the difficulty, you share your frustration with the charge nurse, who validates that, yes, there is an issue with the morphine currently stocked and it does not scan. She assures you that everyone is not scanning the medication since the scan doesn’t work and not to worry about it. You go back to your patient assignment. You are walking down the hallway and you hear a pulse oximeter alarm sounding. The patient is not on your team, but you stop, reposition the patient and walk away, getting back to your mission at hand. A co-worker calls you to a computer to sign off on a dose of insulin. The dose already has been administered. You have worked with this person for years and trust her with your life. You sign off the insulin. All of your patients are tucked in and stable. It’s a good time to go and grab lunch. You find your teammate in the medication room, pulling medication for procedural sedation. You poke your head in and say, ‘‘My patients are fine — I’m going to grab lunch. I’ll be back in 15 minutes.’’ He nods, and you leave the unit. In the ED, we are in a constant state of busy. Distractions, interruptions, volume, crowding and pressure to decrease length of stay, increase patient satisfaction and provide safe and timely care can drive our behavior in the ED. There are times we engage in at-risk behavior. In the first example, working around the system issue and not following the proper reporting channels has the potential to lead to an error. In the second example, the patient’s

Continued on page 8

Official Magazine of the Emergency Nurses Association

Boost your CE credits this summer by learning more about two important topics — veterans with PTSD and how the Affordable Care Act is affecting you — in the latest free continuing education sessions from ENA.

Available as of July 1 . . . ‘‘Wounded Warriors: PTSD and Suicide in Returning Veterans,’’ presented by Cheryl Randolph, MSN, RN, CCRN, CEN, CPEN, FPN-BC. (Credit: 0.87 contact hours.) Randolph leads a review of the psychology in warfare that can lead to post-traumatic stress disorder and suicidal intent. Learn to recognize PTSD and suicidal intent in veterans coming through your ED and familiarize yourself with available treatments and therapies.

Available beginning Aug. 1 . . . ‘‘What’s Happening in Washington That Affects EDs,’’ presented by Richard Mereu, JD, MBA. (Credit: 1.0 contact hour.) This session explores the implementation of the Affordable Care Act, including Medicaid expansion, state health care exchanges and coverage for young adults. Mereu outlines the budget situation in Washington and its impact on key programs and other legislation that could impact emergency nurses. To take these and other eLearning courses free as an ENA member: •G o 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 later, go to www.ena.org and find ‘‘Go to 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 is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

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 ©2014 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: membership@ena.org

Member Services: 800-900-9659 Non-member subscriptions are available for $50 (USA) and $60 (foreign). For editorial inquiries, e-mail connection@ena.org

Sizing Up ATV Safety in Arkansas Arkansas ENA recognized ATV Safety Month in April by putting on an education event at a minor-league baseball game in Springfield, Ark., in partnership with the Northwest Arkansas Trauma Regional Advisory Council and Fayetteville Kawasaki. More than 1,200 people attended. Children between ages 8 and 18 — the key target group — received free fitted helmets in exchange for participation in a survey on helmet safety. State council members distributed brochures and shared ATV safety tips.

New Jersey Recognizes Its Own New Jersey ENA announces the following winners from its annual Emergency Care Conference: • Innovations in Nursing Education: Mary Kamienski, PhD, APRN-C, CEN, FAEN, FAAN • Spirit Award: Bill Miller, BS, RN, PHRN, NREMT-P • Advanced Practice Award: Gwyn Parris-Atwell, MSN, RN, NP-C, CEN, FAEN • Behind the Scenes Award: Karen Halupke, MEd, BSN, RN • Nursing Education Award: Ray Bennett, BSN, RN, CEN, CFRN, CTRN, NREMT-P • Rising Star Award: Sean Varricchio, MSN, RN, CEN, CPEN • Quality and Safety Award: New Jersey Hospital Association, Institute for Quality and Patient Safety • President’s Award: Pat Nierstedt, MS, RN, CEN • President’s Award: Beth McFarland, RN, CEN

Publisher: Kathy Szumanski, MSN, RN, NE-BC Editor-in-Chief: Amy Carpenter Aquino Associate Editor: Josh Gaby Senior Writer: Kendra Y. Mims BOARD OF DIRECTORS Officers: President: Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN President-elect: Matthew F. Powers, MS, BSN, RN, MICP, CEN

Secretary/Treasurer: Kathleen E. Carlson, MSN, RN, CEN, FAEN Immediate Past President: JoAnn Lazarus, MSN, RN, CEN Directors: Ellen (Ellie) H. Encapera, RN, CEN Mitch Jewett, RN, CEN, CPEN Michael D. Moon, PhD, MSN, RN, CNS-CC, CEN, FAEN Sally K. Snow, BSN, RN, CPEN, FAEN Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN Joan Somes, PhD, MSN, RN-BC, CEN, CPEN, FAEN, NREMT-P Karen K. Wiley, MSN, RN, CEN Executive Director: Susan M. Hohenhaus, LPD, RN, CEN, FAEN

ED Staff Among Top Innovators in Minnesota A team led by front-line staff at the Fairview Ridges Emergency Department in Burnsville, Minn., received the 2014 Innovation of the Year (Patient Care) Award from the Minnesota Hospital Association. Because of a series of staff-owned initiatives, including best-practice research and visits to other EDs, Fairview Ridges implemented an “open rooming” system for physicians that eliminated assigned exam rooms and later a “pull until full” system of bringing patients directly to ED rooms, bypassing a stop at triage. This resulted in an average time of 17 minutes from

From left (front row): Shawnda Braun, RN, CEN; Anne Sherman, MS, ACNS-BC, CEN**; co-leader Peggy Heppner, MA, RN, CEN, CPEN**; Becky Daily, RN; (back row) ED director Jamie Hornibrook**; John Houghland, MD, FAAEM; Tammy Digirolamo, RN, CEN; co-leader Tanda Tavakley, RN; Jessica Bents, RN**; and Mike Rock, MD, FACEP, FAAEM. ** Denotes ENA member Do you have a recent professional patient arrival to physician examination in 2013, down from 37 minutes in 2012 and 54 minutes in 2011.

or educational success story about yourself or an ENA member colleague? E-mail it to ‘‘Members in Motion’’ at connection@ena.org.

It’s summer. Take a breath. Earn your certification.

It’s OK with us if you study at the beach or in a lawn chair. Board of Certification for Emergency Nursing (BCEN®) certifications demonstrate your commitment to excellence in nursing care and professional advancement. You have the confidence and expertise, now make the decision to join the 35,000+ emergency nurses who have earned their mark of distinction!

Official Magazine of the Emergency Nurses Association

Learn more… www.BCENcertifications.org

THE VOTES ARE IN ... By Amy Carpenter Aquino, ENA Connection

NA is pleased to announce the results of the 2014 election for the ENA Board of Directors and the Nominations Committee. Voting concluded June 11.

Voter participation was down slightly from 2013, with 6.17

percent of 41,161 eligible members casting votes. The Vermont ENA State Council had the highest voter turnout at 13.07 percent participation, followed by the North Dakota ENA State Council with 12.24 percent. Other state councils with double-digit voter turnouts were Nebraska and Utah.

Board Officers 2015 President-Elect Members elected Kathleen E. Carlson, MSN, RN, CEN, FAEN, as the 2015 president-elect. Carlson is an ED staff nurse at Kathleen E. Sentara Virginia Carlson Beach General Hospital in Virginia Beach, Va. Carlson is the 2014 secretary/ treasurer of the ENA Board of Directors and has been a board member since 2011. She is a 2008 recipient of the Judith C. Kelleher Award and was inducted into the Academy of Emergency Nursing in 2009. She has contributed to several ENA projects, including serving as co-editor of the Emergency Nursing Certification Review and as a longtime contributing editor of the Journal of Emergency Nursing. She is a past president of the Connecticut ENA State Council. ‘‘I am so humbled,’’ said Carlson, an ENA member since 1976. ‘‘ENA has

Members can view the official election results in the members-only section of www.ena.org. ENA commends all of the candidates for their involvement in the 2014 election, as well as all of the members who voted. The official installation of the 2015 board and committee members will be held Oct. 8 at the JW Marriott Indianapolis during the 2014 General Assembly. Newly elected members of the ENA Board of Directors will take office Jan. 1, 2015. Nominations Committee members will begin their terms in October.

become my second family. ‘‘This was a close election with another very capable candidate. I am honored and will continue to listen, weigh all options, be objective and make decisions based on what is best for our organization. I will keep you informed and look forward to hearing your ideas and concerns.’’

2015 Secretary/ Treasurer Members elected Karen K. Wiley, MSN, RN, CEN, as the 2015 secretary/ treasurer. Wiley is an ED staff nurse at Alegent Creighton Karen K. Wiley Immanuel Medical Center in Omaha, Neb. This is Wiley’s third year as a member of the ENA Board of Directors. She was president of the Nebraska ENA State Council in 2001 and 2010 and served as the Nebraska ENA Government Affairs chairperson from 2000 to 2013. Wiley has been a passionate advocate for emergency

nurses. In 2012, she received the Nebraska Nurses Association’s Outstanding Achievement in Nursing Award for successfully fighting to pass legislation making assaulting a health care provider a felony in her state. ‘‘No organization has the depth and talent found within ENA’s membership,’’ said Wiley, an ENA member since 1997. ‘‘The tremendous respect I have for ENA members makes me appreciate the great honor of serving as secretary/treasurer all the more. I’ll work diligently to serve and represent all members.’’

Directors The following candidates were elected to three-year terms (Jan. 1, 2015-Dec. 31, 2017) on the ENA Board of Directors: Jean A. Proehl, MN, RN, CEN, CPEN, FAEN, is principal and clinical nurse specialist at Proehl PRN, LLC, in Cornish, N.H; a Jean A. Proehl per diem emergency nurse and life support

August 2014

instructor at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and a per diem emergency nurse at Gifford Medical Center in Randolph, Vt. Proehl served on the ENA Board of Directors from 1993 to 2000 and was the 1999 president. She served on the ENA Foundation Board of Trustees and as chair of the Academy of Emergency Nursing Board and several national ENA committees and workgroups. She has received several national ENA awards, including the ENA Foundation Pillar Award, the President’s Award, the Judith C. Kelleher Award and the Education Award. She was inducted into AEN in 2005. ‘‘I thank the members for placing their trust in me,’’ said Proehl, an ENA member since 1982. ‘‘I look forward to promoting transparent decision-making processes driven by the members’ values and desires. I will do my best to ensure that ENA’s reputation for high-quality products and intellectual property is maintained and enhanced.’’ Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN, is the director of emergency services for UK Patricia Kunz HealthCare in Howard Lexington, Ky. Howard served on the ENA Board of Directors from 2000 to 2006 and was the 2005 president. She was the 2010 chairperson of the ENA Foundation Board of Trustees and has served as chairperson of several national ENA committees and workgroups. She is the 2013-14 chairperson of the ENA Trauma Committee. Howard was inducted into the Academy of Emergency Nursing in 2008 and the

American Academy of Nursing in 2012 and was the 2011 recipient of the Judith C. Kelleher Award. ‘‘I am deeply honored that the members trust me to represent their views and interests,’’ said Howard, who joined ENA in 1989. ‘‘Transparency, integrity and commitment to the profession are the values that will guide my member-driven decisions while serving as a director.’’

Nominations Committee The following candidates were elected to the Nominations Committee: Robyn R. Larkin, BSN, RN, CEN, was elected to represent Region 1. Larkin is an ED charge nurse/educator at Davis Hospital Robyn R. Larkin and Medical Center in Layton, Utah. ‘‘I am so excited to be part of ENA by serving on the Nominations Committee,” Larkin said. ‘‘It really takes my commitment to ENA to a higher level. I will try to work diligently with other committee members while learning my new position. Thank you for the opportunity to serve you.’’ Terry M. Foster, MSN, RN, CCRN, CEN, CPEN, FAEN, was elected to represent Region 3. Foster is an ED critical-care clinical nurse Terry M. Foster specialist at St. Elizabeth Medical Center in Edgewood, Ky. He has represented Region 3 on the Nominations Committee since 2012

Official Magazine of the Emergency Nurses Association

and is a recipient of the ENA Lifetime Achievement Award and the Judith C. Kelleher Award. ‘‘I consider it an important responsibility to be able to represent my colleagues in emergency nursing,’’ Foster said. ‘‘I am also honored that the membership has re-elected me to this committee. During the past two years that I have served on the Nominations Committee, I have learned an incredible amount of information regarding the election process at the national level. One of my main goals will be to continue to work on increasing our voter participation in our national election. Every vote truly does count.’’ Lucinda W. Rossoll, MSN, RN, CEN, CPEN, CCRN, was elected to represent Region 5. Rossoll Lucinda W. Rossoll is a bedside RN at Alice Peck Day Memorial Hospital in Lebanon, N.H. She has represented Region 5 on the Nominations Committee since 2012. ‘‘I am very honored to have been re-elected to the Nominations Committee,’’ Rossoll said. ‘‘The next several years in ENA will be challenging to all of us as we proceed from two meetings to one. This change process presents a large challenge to the Nominations Committee and the work it needs to do. We want to ensure that candidate information gets out to our members in a timely fashion, that we have an increase in member voting participation, and to have a smooth election process. Thank you to all who participated in this election, as it is an integral part of our organization now and in the future.’’

From the President

we engage in at-risk behaviors because we don’t understand the relationship between these behaviors and errors in health care. In a just culture, we recognize that humans make mistakes. We need to do a better job of understanding how our at-risk behaviors impact patient safety. We cannot afford to take shortcuts, nor can we work around existing processes that are designed to improve safety and decrease the risk of error. Each of us has a responsibility to take the time we need to keep our patients and each other safe in the ED. We need to work within the systems that are designed to keep us safe, not around them. We need to speak up when there is an issue that impacts safety, and we need to commit to doing everything we can to create a safe environment in our departments. Just being a human being sets us up to make a mistake. Don’t let your at-risk behaviors in the ED make these errors inevitable.

Continued from Page 3 desaturation could be related to poor patient positioning, or it could be a sign of deteriorating patient condition. The alarm was addressed; however, the care team was not notified. In the next example, signing off on a high-risk, double-check medication without actually doublechecking the medication could easily lead to a medication error. Interrupting a co-worker while she is preparing medications is a recipe for an error. Ineffective and incomplete handoffs are the root cause of many sentinel events. Why do we engage in at-risk behaviors? The list of reasons is long. Perhaps we are just helping a colleague. Maybe we think, ‘‘I have taken this shortcut before and nothing bad has happened.’’ It’s possible we trust our teammates to not make a mistake, so we don’t feel the need to complete independent double-checks. Sometimes,

Call for Memorial Requests at 2014 ENA General Assembly Deadline: Wednesday, Aug. 20, 5 p.m. CDT ENA will honor members who have died in the last year during a special memorial presentation at the 2014 General Assembly in Indianapolis. If you would like to recognize a member who has died, please complete the request form in the General Assembly area (members only) at www. ena.org. All requests must be submitted electronically to membership@ena.org.

ENA Foundation State Fundraising Challenge Thank You for Building a Strong Foundation The results are in...$113,000 raised! How did your state stack up?

þ þ þ

Largest percentage increase per capita - Montana Largest number of individual donations per state - South Carolina Can your state raise more than $5000? - Yes! California, Colorado, Georgia, Illinois, Kentucky, Maryland, New Jersey, New York, South Carolina, Tennessee, Texas

For more information,

visit www.enafoundation.org

ENA Foundation State Challenge_Connection_half_08 2014.indd 1

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August 2014

ACCREDITATION

APPROVED TO THE MAX

ANCC Recognizes ENA as CNE Approver Into 2018

WITH THEIR HELP The members of the Peer Review Education Committee were instrumental in ANCC’s recognition of ENA as a CNE approver through July 31, 2018. • Joan S. Eberhardt, MA, RN, CCRN, FAEN, Chairperson • Lisa M. Eckenrode, MSN, MBA, RN, EMT-P • LTC Sandra F. Fonkert, MSN, RN, CEN, CPEN • Marie E. Garrison, MSN, RN, EMT-I, CEN

By Amy Carpenter Aquino, ENA Connection

• Trisha A. Iacobucci, DNP, RN, CPEN

• Colleen Marie Martella, MS, RN, NP, NP-C

NA received notice this spring that the American Nurses Credentialing Center's Commission on Accreditation recognized it as an approver of continuing nursing education through July 31, 2018. The four-year approval period is the maximum certification time that ANCC gives to approver units. ‘‘We demonstrated that we are able to approve programs, and we got the maximum four-year period,’’ said Janet Crawford, MSN, ACNS-BC, DNC, the ANCC lead nurse planner and nurse peer-review leader for ENA. She noted that fulfilling the requirements and report for ANCC by the deadline ‘‘was a lot to do in short period of time.’’ Crawford dedicated the end of 2013, including over the holidays, to completing the report and says the result was worth it. ‘‘The outcome makes me happy,’’ she said. ‘‘The review process was very extensive. ANCC reviewed everything to make sure that things were perfect, and then there was a qualitative component.’’ Effort and cooperation from ENA members and staff, plus the clear expectations set by ANCC, helped ENA attain the approver unit recognition. ‘‘The membership component was wonderful,’’ said Crawford, citing extraordinary effort across the organization, from volunteer peer reviewers to the ENA Board of Directors. ‘‘The peer reviewers were wonderful. They were very helpful because when we had to change, and all the forms . . . they had to learn the entire new process. We had orientation and education the first week in January, and it was a 100 percent turnout — 100 percent! That’s how everybody was: People just cooperated with this in such a wonderful way.’’ Members of ENA chapters and state councils helped by adapting seamlessly to the newly implemented process, and the board of directors made necessary changes to the peer reviewer requirements, even changing the name of the Education Committee to the Peer Review Education Committee. Crawford credited the ENA WebUpdates team for showcasing ENA’s commitment to green technology by

• Elizabeth Ann Mizerek, MSN, RN, CEN, CPEN • Geraldine F. Muller, MSN, RN, CEN • John T. Schmidt, DNP, MSN, RN, EMT-P, CEN • Rebecca L. Zumbo, BSN, RN, CEN, CCRN • Joan Somes, PhD, MSN, RN, CEN, CPEN, FAEN, 2014 ENA Board Liaison housing all required documents at www.ena.org, which allowed ANCC appraisers to view everything online. ‘‘WebUpdates are our partners in making sure that all of our forms are fluid, so that whenever ANCC makes a change, they’re ready to help us make that change,’’ she said. Other ENA departments, including teams that support conferences, research and practice poster sessions, have been very active in updating procedures, Crawford said. Now that ENA has ANCC approver unit certification, the organization can work toward the next goal of attaining provider unit certification and even achieving ANCC premier recognition, which Crawford estimates should take about two years. ‘‘Ultimately, I want to make sure that when it comes to nursing education, a member or an emergency room nurse only needs to come here and get all of their credentialing needs for licensure, for continuing education, as well as for any certification,’’ she said. ‘‘We need to meet all their needs, so this is where we’re going.’’ The beneficiaries of all this work are ENA members, who will be able to plan educational programs through ENA chapters and state councils and know they are covered by ANCC for the next four years. ‘‘As long as we have that stamp of approval of ANCC and being accredited, that certificate is recognized worldwide because ANCC is international,’’ Crawford said. ‘‘All they have to do is see ANCC and ENA and they’re covered. They know that when they come here, they can maintain those contact hours. It’s a big value.’’

Official Magazine of the Emergency Nurses Association

HOP-STOPPING VIDEO ENA Honoring Member Who Put a Camera on Dangerous Teen Trend

By Kendra Y. Mims, ENA Connection

peeding down a narrow country road in Salem, Ore., almost turned deadly for Josh Martinson and his friends last year when he lost control of the car at more than 125 mph. The four 16-year-old Sprague High School students had decided to go ‘‘hill hopping,’’ a dangerous activity in which the driver speeds down a rural road and accelerates before the top of a hill to make the car go airborne. Though Martinson was impaled through the shoulder by a fence post, he and his friends survived without any permanent injuries and were

treated at Salem Hospital. When another hill-hopping accident

coordinator. ‘‘These are good kids who are making bad choices. It’s just tragic

occurred in the same area three weeks

when we’re losing young lives

later, killing the 19-year-old driver and

needlessly. And these events are 100

leaving the other two teen passengers

percent preventable. They don’t have

in serious condition, trauma nurse Kelly

to happen.’’

Owen, RN, ADN, CEN, knew something

Owen said hill hopping is common

had to be done to decrease the number

in Salem among teenagers because of

of teens presenting to her emergency

the rolling hills in the area. With more

department because of hill hopping.

than 10 years of experience in injury

‘‘As an emergency room nurse, these

prevention, Owen actively searches for

are some of the things I get to see, and

ways to educate students on safety

I see the impact it has on their families,

issues. She encourages emergency

on the community and their fellow

nurses to keep their eyes open for

students,’’ said Owen, Salem Health’s

educational opportunities.

trauma services and injury prevention

‘‘There are opportunities out there,

August 2014

SEE FOR YOURSELF Kelly Owen’s video, which will be honored with this year’s ENA Media Award, can be viewed on YouTube by visiting tinyurl.com/ hillhopping or scanning the QR code here. WARNING: This video contains graphic images.

especially in the ED. We see a lot,’’ she said. ‘‘I have a dual role as an emergency room nurse and an injury prevention nurse, so I think differently. I see through two sets of glasses. I see tragic things in the emergency room, but then I am always looking for ways to prevent those things. I’m always looking for stories to tell and ways to use those stories as education.’’ Martinson’s hill-hopping accident inspired Owen to interview him and his passengers and create a video that would allow them to share their story with other teens, including why they decided to engage in the dangerous activity. ‘‘I suspect their choice was probably the same as ones other kids make,’’ Owen said. ‘‘But I wanted to go further and have them share what it felt like to be in a car crash. Was it painful? Was it scary? What did it feel like to be a trauma patient and have a pole go through your shoulder? What lessons did you learn? Was it really worth it? What advice would you give to other kids who are thinking about doing the same thing?’’ The teens and their parents were

Driver Josh Martinson, now 17, bears ghastly scars where a pole impaled him through the back and shoulder in a high-speed crash in Salem, Ore. (top and opposite page). excited about the idea, as they were looking for an opportunity to raise awareness about the dangers of hill hopping. During the interview process, Owen, video producer Mark Glyzewski and Vicki Kimpton, Owen’s injury

Official Magazine of the Emergency Nurses Association

prevention partner, separated the teens from each other and their parents to get authentic responses. ‘‘We got consent from both the kids and parents to interview them

Continued on next page

‘‘I wanted to go further and have them share what it felt like to be in a car crash. Was it painful? Was it scary? What did it feel like to be a trauma patient and have a pole go through your shoulder? What lessons did you learn? Was it really worth it? What advice would you give to other kids who are thinking about doing the same thing?” KELLY OWEN, RN, ADN, CEN (left) with video producer Mark Glyzewski

Hill Hopping Continued from previous page separately,’’ Owen said. ‘‘We wanted them to be honest because it’s important. I feel they gave really honest answers, and I really appreciate that about them. It’s tough for teenagers to admit that they made a bad choice, especially on camera.’’ The six-minute video, featuring the four teens talking about their close call with death and the dangers and consequences of hill hopping, shows graphic photos of their injuries from the accident scene and the hospital. It also includes interviews from the Salem firefighter/paramedic who cut Martinson out of the car and the Salem Hospital trauma surgeon who treated Martinson’s soft-tissue injury. The surgeon explains how Martinson’s injury could have been fatal if the fence post had struck him a few inches lower. The video is shown at schools in the Northwest as a part of the injuryprevention program Trauma Nurses Talk Tough, which originated in Oregon. Owen said she has numerous opportunities to show the video to teens in driver’s education classes throughout the area and health classes at local high schools. ‘‘I’m constantly looking for educational opportunities to teach kids something,’’ Owen said. ‘‘This video is a great injury-prevention tool, and anyone who teaches injury prevention

can use it. It’s a great video because it’s coming directly from the kids who have experienced this, and they are talking to other kids about the dangers of it. It’s a peer-to-peer thing, and I think that holds a lot of credibility. And that was the vision, intent and purpose behind the video.’’ Since its release in July 2013, Owen said the video has been shown to about 3,800 students in 27 classes and has almost 60,000 views on YouTube. KGW-TV in Portland featured the story and video on its website last July. During her presentations, Owen has received positive feedback from students who have viewed the video. She believes the messages, such as the importance of wearing a seat belt and the dangers of speeding and distracted driving with other teenage passengers, are resonating with students. ‘‘This is a great story to tell, and it has a lot of important messages,’’ she said. ‘‘It’s interesting that since we’ve debuted the video last summer, we haven’t had any more hill-hopping crashes. They are getting the information.’’ Owen will receive this year’s ENA Media Award on Oct. 11 during the Awards Gala at the ENA Annual Conference in Indianapolis. The award recognizes a media presentation (television, radio, Internet or print) that portrays emergency nursing in a positive, accurate and professional manner and may have been created to

Josh Martinson and his mother, Shonna, will attend the ENA Awards Gala, where Kelly will receive her award Oct. 11. educate the consumer about emergency nursing/emergency care issues or advocate for issues in emergency nursing/emergency care. Owen is excited that Martinson and his parents, Kimpton and Glyzewski will be joining her at the gala. ‘‘A media award is not an individual award,’’ she said. ‘‘It was my vision, but it was a team effort and would have never happened without Mark Glyzewski, Vicki Kimpton or the teens agreeing to do it. ‘‘We’re very excited about this award. Hopefully this will be another way to get this video out there to other nurses who could use this video in their area of education. The more people that can see this video, the more it can be used, and the better the outcome.’’

August 2014

Details Matter.

When it comes to the equipment you use every day, with every patient, details matter. That is why we spent so much of our attention during the design of the Prime TC Transport Chair on the Flip-Up Footrests with Swing Away. Flip-Up Footrests remain in an upright position until pressure is applied to reduce trip hazards. A lip at the edge allows caregivers to flip the footrest down for the patient, which reduces the need to bend over and touch dirty footrests. Simply stepping on the yellow button swings the footrest back, and completely out of the way for access to the patient, and to provide clearance during lateral transfers. Contact your local Stryker Account Manager, or stop by Stryker booth #301 at the ENA Annual Conference in Indianapolis to experience the footrests on the Prime TC Transport Chair.

COURSES

Health care workers (at table, clockwise from left) Imelda Oao, Rani James, Kristina Mae Cabato and Terry Sumahit follow along with instructor Ahmad Aldizdar (right, face not pictured) as they practice with a pediatric mannequin during their TNCC course in Abu Dhabi, United Arab Emirates, in May. ENA faculty member Margot Daugherty looks in on the background.

TNCC TRAVELS WELL Worlds Come Together During Seventh-Edition Dissemination in Abu Dhabi

By Tim Murphy, MSN, RN, ACNP-BC, CEN; Margot Daugherty, MSN, MEd., RN, CEN; Sandy Waak, RN, CEN; and Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN

he United Arab Emirates, situated near the end of the Arabian Peninsula on the Persian Gulf, was the location of ENA’s most recent dissemination of Trauma Nursing Core Course on May 19-30. The UAE is comprised of seven emirates: Ajman, Dubai, Fujairah, Ras al-Khaimah, Sharjah, Umm al-Quwain

and Abu Dhabi, which is the largest emirate as well as the capital. The courses were conducted at Al Rahba Hospital in Abu Dhabi. The dissemination team included ENA members Tim Murphy, MSN, RN, ACNP-BC, CEN, course director; Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN, 2014 ENA president; Margot Daugherty, MSN, MEd., RN, CEN; and Sandy Waak, RN, CEN. Al Rahba Hospital is a Joint Commission International-accredited facility affiliated with Johns Hopkins Medicine International. Al Rahba is also a member of the Abu Dhabi

Health Services Company, or SEHA, which is owned by the Abu Dhabi government. SEHA, the Arabic word for health, includes 12 hospitals, many of which were represented by nurses attending the inaugural courses. ENA made a previous TNCC dissemination to the UAE nearly a decade ago. The original UAE instructors’ status had expired after the sixth-edition update, and the contract with the original organization was no longer active. Al Rahba expressed the desire to assume the contract to teach

Continued on page 16

August 2014

ENA COURSES AROUND THE WORLD

NA sets the standard for international nursing trauma care. Emergency nurses around the world have seen the value in becoming verified in ENA’s courses, including Trauma

Nursing Core Course, Emergency Nursing Pediatric Course and Course in Advanced Trauma Nursing-II. ENA developed and implemented TNCC for national and international dissemination as a means of identifying a standardized body of trauma nursing knowledge. The purpose of TNCC is to present core-level knowledge, refine skills and build a firm foundation in trauma nursing. ENA developed ENPC to improve the care of the pediatric patient by increasing the knowledge, skill and confidence of the emergency nurse.

This two-day course provides core-level pediatric knowledge and psychomotor skills needed to care for pediatric patients in the emergency care setting. ENPC is the only pediatric emergency nursing course written by pediatric nurse experts. A new, Web-based version of CATN is expected to be released in early 2015, replacing the retired CATN-II course. Below is a list of countries and the years when they began hosting ENA course instruction: TNCC Aruba – 2007 Australia – 1993 Canada – 1993

Greece – 2008 Hong Kong – 1999 Netherlands - 1996 Norway – 2001 Portugal – 2001 Sweden – 1996 South Africa – 2006 South Korea – 2010 United Arab Emirates – 2005; 2014 United Kingdom – 1998 ENPC Australia – 1995 Canada – 1997 Netherlands – 2001 Portugal – 2005 Sweden – 2001 CATN-II Australia – 2004 Canada – 2003 Netherlands – 2006 United Kingdom – 2006

SEVENTH EDITION

The Premier Course for Trauma Care TNCC, widely recognized as the premier course for hospitals and trauma centers worldwide, empowers nurses with the knowledge, critical thinking skills, and hands-on training to provide expert care for trauma patients. § Rapid identification of life-threatening injury § Comprehensive patient assessment § Enhanced intervention for better patient outcomes 2 Day Intensive Course § 24 Chapter Comprehensive Manual § Hands-on Skill Stations 5 Online Modules § Special Population Chapters § 17.65 Contact Hours

Available Now

Visit www.ena.org/TNCC to find a course near you. The Emergency Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

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Official Magazine of the Emergency Nurses Association

6/25/14 4:02 PM

ENA 2014 President Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN, presents a certificate of completion to TNCC instructor candidate Iman Yassin.

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Continued from previous page

TNCC in the UAE. Murphy was also a member of the original dissemination team and appreciated the significant growth throughout the country since his last visit. In 2008, there was a multiple-casualty incident involving more than 250 injured patients who were transported to Al Rahba Hospital after a multi-vehicle pileup during which a petroleum tanker caught fire and exploded. There were eight deaths and little warning before the transport of the patients to Al Rahba. As a result of this experience, Al Rahba, with the support of SEHA, has assumed a leadership role in the development of a trauma system. The American College of Surgeons Committee on Trauma conducted a trauma consultation at Al Rahba to begin preparations for trauma center verification. Providing TNCC verification for nurses is a central component of the quest for designation. Elijah Gilreath Jr., MSN, RN, CS, CMCN, chief nursing officer, along with John Britton Beatty, RN, assistant director of nursing, advocated to SEHA and secured support to bring the TNCC dissemination team to Al Rahba. Gilreath and Beatty are strong supporters and advocates of TNCC. Norman Avila, RN, the trauma program manager Instructor candidate Rahma and one of the previous Warsama at a skill station. TNCC instructors, worked

August 2014

PROVIDER COURSE: Front row (from left): Margot Daugherty, Deena Brecher, Sandy Waak, Tim Murphy. Middle row: Samer Awad, Ivy Mendoza, Iman Yassin, Lity John, Ma-Teresa Laude, Maysoon Enouz, Amna Darwish, Helen Caulfield. Back row: Bindu Anthony, Rahma Warsama, Nazir Ahmad, Yehia AlBuhaisi, Ahmad Aldizdar, Norman Avila, Vinod Hareendrannair, Adrian Dobson.

INSTRUCTOR COURSE: Front row (from left): Margot Daugherty, Deena Brecher, Sandy Waak, Tim Murphy. Back row: Iman Yassin, Bindu Anthony, Nazir Ahmad, Norman Avila, Vinod Hareendrannair, Ahmad Aldizdar, Lity John, Rahma Warsama, Amna Darwish. tirelessly to facilitate resources necessary to host the dissemination. Al Rahba has a culturally diverse group of employees representing more than 60 countries. The TNCC students were representative of this cultural diversity. Although Arabic is the official language of the UAE, teaching occurred in English. The ENA team was warmly welcomed by the hospital leadership on arrival. A tour of the

hospital revealed a well-equipped and staffed facility, similar to any U.S. facility. The team was particularly impressed with a ‘‘homegrown’’ ED dashboard that displayed unit-based metrics measuring physician-to-patient time and length-of-stay information on a large-screen monitor with color coding, which was visible to the entire staff. During the visit, a paperless documentation system was being

Official Magazine of the Emergency Nurses Association

implemented. The nurses selected to participate in the inaugural provider courses were truly exceptional. Each came to class prepared and thoroughly engaged. The team was humbled and excited to work with such a fine group of nurses. As in all TNCC courses, learning is a two-way street, with instructors benefiting from student experiences as much as students learn from the instructors. This course was no exception. The ENA team encountered several practice differences. One medical/legal issue was the lack of advance directives, which changed considerations for one of the teaching scenarios. From a clinical standpoint, there is almost no penetrating trauma because guns are not legal in the UAE. In addition to motor vehicle collisions, falls account for a significant amount of trauma because of the large number of construction projects throughout the region. At the conclusion of the first provider course, the ENA team identified a number of instructor candidates who attended the first instructor course. After the second provider course, the team identified four of the new instructors as course directors and faculty. It will be their responsibility to develop a trauma committee in the UAE and promulgate further courses. They have a very aggressive plan supported by the hospital leadership to start teaching; there is no doubt they will be successful. The support of the entire leadership team at Al Rahba and SEHA is unparalleled, and the ENA team wishes them the best. The team found that the work with its UAE colleagues was the most rewarding part of the trip and has every confidence that TNCC will flourish under their leadership. Team members would enjoy seeing their UAE colleagues again, perhaps at an ENA conference. The team members found themselves both personally and professionally enriched through this experience.

WELLNESS AND SAFETY

EFFORTS ARE AFOOT Steps Being Taken to Ramp Up Pedestrian Safety

tatistics show the percentage of pedestrian fatalities has increased over the last several years. According to the U.S. Department of Transportation’s National Highway Traffic Safety Administration, 4,743 pedestrians were killed and about 76,000 were injured in traffic accidents in 2012, accounting for 14 percent of all traffic fatalities in the United States, which is a 6 percent increase from 2011.1

♦ By Kendra Y. Mims, ENA Connection

Whether people walk as a means of transportation or for leisure, NHTSA considers everyone a pedestrian and defines a pedestrian as any person on foot walking, running, jogging, hiking, in a wheelchair, sitting or lying down.2 Because of the increase in pedestrian fatalities and injuries, the following efforts are being made nationally and globally to improve safety for pedestrians.

Pedestrian Safety Act of 2014

signals and highway crossing islands. 3. Increase federal funding for state and local pedestrian safety campaigns.

With more than 100 fatalities and thousands of injuries involving pedestrians recently occurring on Long Island and Hudson Valley’s main roads 3, U.S. Sen. Kirsten Gillibrand (D-N.Y.) proposed a bill that would allow localities to use federal highway safety funds for pedestrian safety projects. Currently, the federal government fully funds specific highway safety projects for states, primarily centered on vehicles and motorists. The Senate Environmental and Public Works Committee endorsed Gillibrand’s Pedestrian Safety Act of 2014 in May. The act seeks to improve the safety of pedestrians, particularly children and older adults, by updating automotive design standards, incentivizing additional pedestrian roadway improvements and providing more federal assistance for public awareness and educational campaigns. ENA supports the Pedestrian Safety Act of 2014, which would increase pedestrian safety in the following three ways: 1. Raise safety standards on motor vehicles to reduce pedestrian injury. 2. Increase federal funding to improve pedestrian-safety-related roadway conditions, such as crosswalk

Everyone is a Pedestrian The U.S. Department of Transportation launched the ‘‘Everyone is a Pedestrian’’ campaign last year to help communities decrease the number of pedestrian fatalities and injuries and reduce dangers. NHTSA and the Federal Highway Administration launched www.nhtsa.gov/ everyoneisapedestrian to provide road users and communities with safety tips, research and educational resources to raise awareness and increase pedestrian safety. In an effort to help cities that have some of the highest rates of pedestrian deaths nationwide, NHTSA also awarded three grants totaling about $1.6 million to Louisville, Philadelphia and New York to raise awareness, provide education and implement enforcement initiatives.4

Decade of Action Pedestrians were one of the few groups of U.S. road users to experience an increase in fatalities in 2012. The World Health Organization has created a 10-year goal for its global campaign to improve

pedestrian safety. The WHO designated 2011-2020 as the ‘‘Decade of Action for Road Safety to save 5 million lives.’’ It reported that 46 percent of fatalities on the world’s roads are ‘‘vulnerable road users’’: pedestrians, cyclists and motorcyclists. Part of the global plan includes safer roads and mobility for pedestrians, such as improving the safety-conscious planning, design, construction and operation of roads and making sure roads are frequently evaluated for safety.5

New Vehicle Technology Engineers are working on improvements to vehicles that could protect pedestrians and decrease the extent of their injuries in traffic accidents. The Insurance Institute for Highway Safety reports that although deaths in all other types of passenger vehicle collisions have decreased significantly during the last decade, pedestrian fatalities account for an increasing percentage of accident fatalities. Most pedestrian crashes involve a single-passenger vehicle and are frontal crashes; the most common entails a person crossing the road and a vehicle driving straight.6 To decrease pedestrian deaths and injuries, IIHS recommends modifying the fronts of vehicles. Technology

August 2014

being explored includes plastic hood mounts, crushable hoods and fenders, padding in bumpers, headlights that break away on impact, pedestrian airbags and crash avoidance technology such as radar systems designed to recognize pedestrians entering a vehicle’s path and warn the driver. Brian Ericson, BSN, RN, CEN, clinical lead nurse at the Mercy Hospital Emergency Department in Portland, Maine and an ENA Emergency Nurses Wellness Committee member, encourages emergency nurses to use the following resources to engage their local community: ♦ www.nhtsa.gov/ Pedestrians ♦ www.cdc.gov/ MotorVehicleSafety/Pedestrian_ Safety/pedestrian.html

♦ www.safekids.org/ walkingsafelytips ♦ safety.fhwa.dot.gov/ped_bike/ ‘‘I don’t think people realize that pedestrian fatalities have been on an upward swing for the last three years,’’ Ericson said. ‘‘Statistics indicate that someone is dying every two hours and getting injured every 15 minutes. There are a number of efforts being made to reverse this trend, but one that I think emergency nurses need to focus on is education. This would be a super topic to engage your community with, and there are lots of resources available to make it happen.’’

References 1. National Highway Traffic Safety Administration. (n.d.). Everyone is a pedestrian. Retrieved from www.nhtsa.gov/nhtsa/everyoneisapedestrian/ index.html 2. National Highway Traffic Safety Administration. (2013). Safety in numbers. Retrieved from www. nhtsa.gov/nhtsa/Safety1nNum3ers/august2013/ SafetyInNumbersAugust2013.html 3. Office of Sen. (NY) Kirsten Gillibrand. Key Senate committee passes Gillibrand measure to improve pedestrian safety on New York roadways, reduce fatalities and injuries. (2014, May 15). Retrieved from www.gillibrand.senate.gov/newsroom/press/ release/key-senate-committee-passes-gillibrandmeasure-to-improve-pedestrian-safety-on-new-yorkroadways-reduce-fatalities-and-injuries 4. National Highway Traffic Safety Administration. U.S. Department of Transportation announces winners of pedestrian safety grants. (2014, April 25). Retrieved from www.nhtsa.gov/ About+NHTSA/Press+Releases/2014/U.S.+ Department+of+Transportation+Announces+ Winners+of+Pedestrian+Safety+Grants 5. World Health Organization. (2011). Decade of action for road safety 2011–2020: Saving millions of lives. Retrieved from www.who.int/violence_ injury_prevention/publications/road_traffic/ saving_millions_lives_en.pdf 6. Insurance Institute for Highway Safety. (2013). Softer vehicle fronts and pedestrian detection systems could reduce pedestrian deaths, injuries. Retrieved from www.iihs.org/iihs/sr/statusreport/article/48/10/3

AGGRESSIVE BEHAVIOR...

...towards staff at work is dramatically on the increase, especially in our Hospitals. Verbal abuse, threats with weapons, cuts, punches, even serious injuries are becoming everyday occurrences. The impact on the confidence and morale of staff is damaging and costly and has a serious impact on the caring and commitment that lies at the heart of the staff/patient relationship. Installing an INSTANTalarm 5000

Staff Personal Alarm System will make a dramatic difference INSTANTalarm does NOT • track you around the hospital • use radio-frequency • rely on unreliable wi-fi • have a computer controlling it

INSTANTalarm, however, DOES

• let you decide when you need help • pinpoint your location, to a room • work instantaneously • make you and your patients feel safer • reduce the frequency and impact of violent incidents Which is why, over 20 years, INSTANTalarm 5000 has been probably the most widely-installed, staff duress alarm system in the world. ®

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Official Magazine of the Emergency Nurses Association

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Serious or amoxapine. skin Serious reactions skin Serious reactions have skin occurred reactions have occurred with have oraloccurred with oral with oral 2. loxapine loxapine and amoxapine loxapine and amoxapine and amoxapine • ADASUVE • ADASUVE must•be ADASUVE must administered be administered mustonly be administered by aonly healthcare by aonly healthcare professional by a healthcare professional professional Pl • Prior to•administration, Prior to•administration, Prior to alladministration, patients all patients must be all must patients screened be screened must for abe history screened for aofhistory pulmonary for aofhistory pulmonary disease of pulmonary and disease examined and disease examined and examined in (including (including chest auscultation) (including chest auscultation) chest for respiratory auscultation) for respiratory abnormalities for respiratory abnormalities (eg,abnormalities wheezing) (eg, wheezing) (eg, wheezing) • Administer • Administer only •a Administer single only 10 a single mg only dose 10 a single mg of ADASUVE dose 10 mg of ADASUVE dose within of a ADASUVE 24-hour within a period 24-hour within by a period 24-hour oral inhalation byperiod oral inhalation by using oralthe inhalation using theusing the single-use single-use inhalersingle-use inhaler inhaler

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HELP DEFUSE HELP HELP THE DEFUSE DEFUSE SITUATION THE THE SITUATION SITUATION BEFORE BEFORE BEFORE AGITATION AGITATION ESCALATES AGITATION ESCALATES ESCALATES FURTHERFURTHER FURTHER ORAL INHALATION ORAL ORAL INHALATION INHALATION

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IMPORTANT IMPORTANT IMPORTANT SAFETY SAFETY INFORMATION SAFETY INFORMATION INFORMATION (continued) (continued) (continued) • After ADASUVE • After • After ADASUVE administration, ADASUVE administration, administration, patients must patients patients be monitored must must bebe monitored for monitored signs for and for signs symptoms signs and and symptoms of symptoms bronchospasm of bronchospasm of bronchospasm at at at least every least 15 least minutes every every 15for 15 minutes minutes at least for1for at hour least at least 1 hour 1 hour • ADASUVE • ADASUVE •can ADASUVE cause can sedation, can cause cause sedation, which sedation, can which mask which can the can mask symptoms mask thethe symptoms of symptoms bronchospasm of bronchospasm of bronchospasm • Antipsychotic • Antipsychotic • Antipsychotic drugs candrugs cause drugs can acan potentially cause cause a potentially afatal potentially symptom fatal fatal symptom complex symptom complex called complex Neuroleptic called called Neuroleptic Neuroleptic MalignantMalignant Malignant Syndrome Syndrome (NMS), Syndrome manifested (NMS), (NMS), manifested manifested by hyperpyrexia, by by hyperpyrexia, hyperpyrexia, muscle rigidity, muscle muscle altered rigidity, rigidity, mental altered altered state, mental mental irregular state, state, pulse irregular irregular or pulse pulse or or blood pressure, blood blood pressure, tachycardia, pressure, tachycardia, tachycardia, diaphoresis, diaphoresis, diaphoresis, and cardiac and and dysrhythmia. cardiac cardiac dysrhythmia. dysrhythmia. Associated Associated Associated features can features features include cancan include include escalatedescalated serum escalated creatine serum serum phosphokinase creatine creatine phosphokinase phosphokinase (CPK) concentration, (CPK) (CPK) concentration, concentration, rhabdomyolysis, rhabdomyolysis, rhabdomyolysis, elevated serum elevated elevated and serum urine serum and and urine urine myoglobin myoglobin concentration, myoglobin concentration, concentration, and renaland failure. and renal renal If failure. NMS failure. occurs, If NMS If NMS immediately occurs, occurs, immediately immediately discontinue discontinue discontinue antipsychotic antipsychotic antipsychotic drugs drugs drugs and otherand drugs and other other that drugs may drugs that contribute that may may contribute tocontribute the underlying to the to the underlying disorder, underlying disorder, monitor disorder, and monitor monitor treat and symptoms, and treat treat symptoms, symptoms, and treat and any and treat treat anyany concomitant concomitant concomitant serious medical serious serious problems medical medical problems problems • ADASUVE • ADASUVE •can ADASUVE causecan hypotension, can cause cause hypotension, hypotension, orthostatic orthostatic hypotension, orthostatic hypotension, hypotension, and syncope. andand syncope. Use syncope. with caution Use Use with with incaution patients caution inwith patients in patients with with known cardiovascular known known cardiovascular cardiovascular disease, cerebrovascular disease, disease, cerebrovascular cerebrovascular disease, or disease, conditions disease, or conditions orthat conditions wouldthat predispose that would would predispose patients predispose topatients patients to to hypotension. hypotension. hypotension. In the presence In the In the presence of presence severe of hypotension severe of severe hypotension hypotension requiring vasopressor requiring requiring vasopressor vasopressor therapy, epinephrine therapy, therapy, epinephrine epinephrine should should should not be used notnot be be used used • Use ADASUVE • Use • Use ADASUVE with ADASUVE caution with with incaution patients caution inwith patients in patients a history with with of a history seizures a history of or seizures of with seizures conditions or with or with conditions that conditions lowerthat the that lower seizure lower thethe seizure seizure threshold.threshold. ADASUVE threshold. ADASUVE lowers ADASUVE the lowers seizure lowers thethreshold. the seizure seizure threshold. Seizures threshold. have Seizures Seizures occurred have have occurred in occurred patients intreated patients in patients with treated treated oral with with oraloral loxapine and loxapine loxapine can also and and occur cancan also inalso epileptic occur occur in patients epileptic in epileptic patients patients • Use caution • Use • Use when caution caution driving when when ordriving operating driving or or operating machinery. operating machinery. ADASUVE machinery. ADASUVE can ADASUVE impair can judgment, can impair impair judgment, thinking, judgment, thinking, and thinking, motor and skills and motor motor skills skills • The potential • The • The potential forpotential cognitive forfor cognitive and cognitive motor and impairment and motor motor impairment impairment is increased is increased iswhen increased ADASUVE when when ADASUVE isADASUVE administered is administered is administered concurrently concurrently concurrently with otherwith CNS with other depressants other CNS CNS depressants depressants • Treatment • Treatment •with Treatment antipsychotic with with antipsychotic antipsychotic drugs caused drugs drugs an caused increased caused an an increased incidence increased incidence ofincidence stroke of and stroke of transient stroke and and transient ischemic transient ischemic ischemic attack in attack elderly attack inpatients elderly in elderly with patients patients dementia-related with with dementia-related dementia-related psychosis; psychosis; ADASUVE psychosis; ADASUVE isADASUVE not approved is not is not approved for approved the treatment forfor thethe treatment oftreatment of of patients with patients patients dementia-related with with dementia-related dementia-related psychosis psychosis psychosis • Use of ADASUVE • Use • Use of ADASUVE ofmay ADASUVE exacerbate may may exacerbate exacerbate glaucomaglaucoma orglaucoma cause or urinary or cause cause retention urinary urinary retention retention • The most • The •common The most most common adverse common reactions adverse adverse reactions (incidence reactions (incidence ≥2% (incidence and≥2% greater ≥2% and and than greater greater placebo) than than placebo) in clinical placebo) instudies clinical in clinical instudies studies in in patients with patients patients agitation with with agitation treated agitation with treated treated ADASUVE with with ADASUVE were ADASUVE dysgeusia, were were dysgeusia, dysgeusia, sedation,sedation, and sedation, throat and irritation and throat throat irritation irritation • Pregnancy • Pregnancy • Category Pregnancy Category C.Category Neonates C. C. Neonates exposed Neonates exposed to exposed antipsychotic to to antipsychotic antipsychotic drugs during drugs drugs the during third during the trimester the third third trimester oftrimester pregnancy of pregnancy of pregnancy are at riskare ofare at extrapyramidal risk at risk of extrapyramidal of extrapyramidal and/or withdrawal and/or and/or withdrawal symptoms withdrawal symptoms after symptoms delivery. after after delivery. ADASUVE delivery. ADASUVE should ADASUVE beshould used should during bebe used used during during pregnancy pregnancy only pregnancy if theonly potential only if the if the potential benefi potential t justifi benefi benefi estthe justifi t justifi potential es es thethe potential risk potential to therisk fetus risk to to thethe fetus fetus • Nursing•mothers: Nursing • Nursing mothers: Discontinue mothers: Discontinue Discontinue drug or nursing, drug drug or taking or nursing, nursing, into taking account taking intointo the account account importance thethe importance importance of the drug of to the of the drug mother drug to the to the mother mother • The safety • The •and The safety effectiveness safety andand effectiveness effectiveness of ADASUVE of ADASUVE ofinADASUVE pediatric in pediatric patients in pediatric have patients patients not been have have not established not been been established established References: 1.References: ADASUVE References: [package 1. ADASUVE 1. ADASUVE insert]. [package Horsham, [package insert]. PA: insert]. Teva Horsham, Horsham, SelectPA: Brands, Teva PA: Teva Select a division Select Brands, ofBrands, Teva a division Pharmaceuticals a division of Teva of Teva Pharmaceuticals USA, Pharmaceuticals Inc; December USA,USA, Inc; 2013. December Inc; December 2013. 2013. 2. Data on file. Clinical 2. Data 2. Data Study on file. onReport Clinical file. Clinical 004-301. Study Study Report Teva Report Pharmaceuticals. 004-301. 004-301. TevaTeva Pharmaceuticals. 3.Pharmaceuticals. Data on file. Clinical 3. Data 3. Data Study on file. onReport Clinical file. Clinical 004-302. Study Study Report Teva Report 004-302. Pharmaceuticals. 004-302. TevaTeva Pharmaceuticals. Pharmaceuticals.

Please see Please Please Briefsee Summary see Brief Brief Summary of Summary Prescribing of of Prescribing Prescribing Information, Information, Information, includingincluding Boxed including Warnings, Boxed Boxed Warnings, Warnings, on following onon following following pages. pages. pages. ©2014 Teva Pharmaceuticals ©2014 ©2014 TevaTeva Pharmaceuticals USA, Pharmaceuticals Inc. USA,USA, Inc. Inc. All rights reserved. All rights All April rights reserved. 2014 reserved. Printed Aprilin April 2014 USA. 2014 Printed ADA-40010 Printed in USA. in USA. ADA-40010 ADA-40010

BRIEF SUMMARY ADASUVE® (loxapine) inhalation powder, for oral inhalation use The following is a brief summary only; see full prescribing information, included Boxed Warnings for complete product information. WARNING: BRONCHOSPASM and INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS Bronchospasm ADASUVE can cause bronchospasm that has the potential to lead to respiratory distress and respiratory arrest. Administer ADASUVE only in an enrolled healthcare facility that has immediate access on-site to equipment and personnel trained to manage acute bronchospasm, including advanced airway management (intubation and mechanical ventilation) [see Warnings and Precautions (5.1, 5.2)]. Prior to administering ADASUVE, screen patients regarding a current diagnosis, history, or symptoms of asthma, COPD and other lung diseases, and examine (including chest auscultation) patients for respiratory signs. Monitor for signs and symptoms of bronchospasm following treatment with ADASUVE [see Dosage and Administration (2.2, 2.4) and Contraindications (4)]. Because of the risk of bronchospasm, ADASUVE is available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS) called the ADASUVE REMS [see Warnings and Precautions (5.2)]. Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. ADASUVE is not approved for the treatment of patients with dementia-related psychosis [see Warnings and Precautions (5.3)]. 1 INDICATIONS AND USAGE ADASUVE is a typical antipsychotic indicated for the acute treatment of agitation associated with schizophrenia or bipolar I disorder in adults. “Psychomotor agitation” is defined in DSM-IV as “excessive motor activity associated with a feeling of inner tension.” Patients experiencing agitation often manifest behaviors that interfere with their care (e.g., threatening behaviors, escalating or urgently distressing behavior, self-exhausting behavior), leading clinicians to the use of rapidly absorbed antipsychotic medications to achieve immediate control of the agitation [see Clinical Studies (14)]. The efficacy of ADASUVE was established in one study of acute agitation in patients with schizophrenia and one study of acute agitation in patients with bipolar I disorder [see Clinical Studies (14)]. Limitations of Use: As part of the ADASUVE REMS Program to mitigate the risk of bronchospasm, ADASUVE must be administered only in an enrolled healthcare facility [see Warnings and Precautions (5.2)]. 4 CONTRAINDICATIONS ADASUVE is contraindicated in patients with the following: • Current diagnosis or history of asthma, COPD, or other lung disease associated with bronchospasm [see Warnings and Precautions (5.1)] • Acute respiratory symptoms or signs (e.g., wheezing) [see Warnings and Precautions (5.1)] • Current use of medications to treat airways disease, such as asthma or COPD [see Warnings and Precautions (5.1)] • History of bronchospasm following ADASUVE treatment [see Warnings and Precautions (5.1)] • Known hypersensitivity to loxapine or amoxapine. Serious skin reactions have occurred with oral loxapine and amoxapine. 5 WARNINGS AND PRECAUTIONS 5.1 Bronchospasm ADASUVE can cause bronchospasm that has the potential to lead to respiratory distress and respiratory arrest [see Adverse Reactions (6.1)]. Administer ADASUVE only in an enrolled healthcare facility that has immediate access on-site to equipment and personnel trained to manage acute bronchospasm, including advanced airway management (intubation and mechanical ventilation) [see Boxed Warning and Warnings and Precautions (5.2)]. Prior to administering ADASUVE, screen patients regarding a current diagnosis or history of asthma, COPD, and other lung disease associated with bronchospasm, acute respiratory symptoms or signs, current use of medications to treat airways disease, such as asthma or COPD; and examine patients (including chest auscultation) for respiratory abnormalities (e.g., wheezing) [See Dosage and Administration (2.2) and Contraindications (4)]. Monitor patients for symptoms and signs of bronchospasm (i.e., vital signs and chest auscultation) at least every 15 minutes for a minimum of one hour following treatment with ADASUVE [see Dosage and Administration (2.4)]. ADASUVE can cause sedation, which can mask the symptoms of bronchospasm.

Because clinical trials in patients with asthma or COPD demonstrated that the degree of bronchospasm, as indicated by changes in forced expiratory volume in 1 second (FEV1), was greater following a second dose of ADASUVE, limit ADASUVE use to a single dose within a 24 hour period. Advise all patients of the risk of bronchospasm. Advise them to inform the healthcare professional if they develop any breathing problems such as wheezing, shortness of breath, chest tightness, or cough following treatment with ADASUVE. 5.2 ADASUVE REMS to Mitigate Bronchospasm Because of the risk of bronchospasm, ADASUVE is available only through a restricted program under a REMS called the ADASUVE REMS. [see Boxed Warning and Warnings and Precautions (5.1)] Required components of the ADASUVE REMS are: • Healthcare facilities that dispense and administer ADASUVE must be enrolled and comply with the REMS requirements. Certified healthcare facilities must have on-site access to equipment and personnel trained to provide advance airway management, including intubation and mechanical ventilation. • Wholesalers and distributors that distribute ADASUVE must enroll in the program and distribute only to enrolled healthcare facilities. Further information is available at www.adasuverems.com or 1-855-7550492. 5.3 Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at increased risk of death. Analyses of 17 placebocontrolled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the cases of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies can be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. ADASUVE is not approved for the treatment of elderly patients with dementia-related psychosis [see Boxed Warning]. 5.4 Neuroleptic Malignant Syndrome Antipsychotic drugs can cause a potentially fatal symptom complex termed Neuroleptic Malignant Syndrome (NMS). Clinical manifestations of NMS include hyperpyrexia, muscle rigidity, altered mental status, and autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmia). Associated features can include elevated serum creatine phosphokinase (CPK) concentration, rhabdomyolysis, elevated serum and urine myoglobin concentration, and renal failure. NMS did not occur in the ADASUVE clinical program. The diagnostic evaluation of patients with this syndrome is complicated. It is important to consider the presence of other serious medical conditions (e.g., pneumonia, systemic infection, heat stroke, primary CNS pathology, central anticholinergic toxicity, extrapyramidal symptoms, or drug fever). The management of NMS should include: 1) immediate discontinuation of antipsychotic drugs and other drugs that may contribute to the underlying disorder, 2) intensive symptomatic treatment and medical monitoring, and 3) treatment of any concomitant serious medical problems. There is no general agreement about specific pharmacological treatment regimens for NMS. If a patient requires antipsychotic drug treatment after recovery from NMS, the potential reintroduction of drug therapy should be carefully considered. The patient should be carefully monitored, since recurrences of NMS have been reported. 5.5 Hypotension and Syncope ADASUVE can cause hypotension, orthostatic hypotension, and syncope. Use ADASUVE with caution in patients with known cardiovascular disease (history of myocardial infarction or ischemic heart disease, heart failure or conduction abnormalities), cerebrovascular disease, or conditions that would predispose patients to hypotension (dehydration, hypovolemia, or treatment with antihypertensive medications or other drugs that affect blood pressure or reduce heart rate). In the presence of severe hypotension requiring vasopressor therapy, the preferred drugs may be norepinephrine or phenylephrine. Epinephrine should not be used, because beta stimulation may worsen hypotension in the setting of ADASUVE-induced partial alpha blockade. In short-term (24-hour) placebo-controlled trials of patients with agitation associated with schizophrenia or bipolar I disorder, hypotension occurred in 0.4% and 0.8% in the ADASUVE 10 mg and placebo groups, respectively. There were no cases of orthostatic hypotension, postural symptoms,

presync decreas 10 mg ≤ 50 mm of the A In 5 Pha was 3% tively. Th 2.3% an mal volu ≥ 20 mm groups, decreas placebo 5.6 Seiz ADASUV treated during a placebo 5.7 Pote ADASUV placebo 12% an patients The pot ADASUV Drug In machine therapy 5.8 Cere Dement In place with dem brovasc includin not appr sis [see 5.9 Anti Urinary ADASUV antichol or urina (e.g., an 6 ADVER The foll sections • Hyper • Bronc • Increa sis [s • Neuro • Hypot • Seizur • Poten cautio • Cereb Deme • Antich nary R 6.1 Clin Because adverse directly not refle The follo (24-hou (Studies with acu In the 3 placebo Commo tion, the throat ir ADASUV to Table

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antipsyplaceboents takg-treated patients. death in out 2.6% most of ure, sudnal student with extent to s can be eristic(s) reatment Warning].

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presyncope or syncope. A systolic blood pressure ≤ 90 mm Hg with a decrease of ≥ 20 mm Hg occurred in 1.5% and 0.8% of the ADASUVE 10 mg and placebo groups, respectively. A diastolic blood pressure ≤ 50 mm Hg with a decrease of ≥15 mm Hg occurred in 0.8% and 0.4% of the ADASUVE 10 mg and placebo groups, respectively. In 5 Phase 1 studies in normal volunteers, the incidence of hypotension was 3% and 0% in ADASUVE 10 mg and the placebo groups, respectively. The incidence of syncope or presyncope in normal volunteers was 2.3% and 0% in the ADASUVE and placebo groups, respectively. In normal volunteers, a systolic blood pressure ≤ 90 mm Hg with a decrease of ≥ 20 mm Hg occurred in 5.3% and 1.1% in the ADASUVE and placebo groups, respectively. A diastolic blood pressure ≤ 50 mm Hg with a decrease of ≥ 15 mm Hg occurred in 7.5% and 3.3% in the ADASUVE and placebo groups, respectively. 5.6 Seizures ADASUVE lowers the seizure threshold. Seizures have occurred in patients treated with oral loxapine. Seizures can occur in epileptic patients even during antiepileptic drug maintenance therapy. In short term (24 hour), placebo-controlled trials of ADASUVE, there were no reports of seizures. 5.7 Potential for Cognitive and Motor Impairment ADASUVE can impair judgment, thinking, and motor skills. In short-term, placebo-controlled trials, sedation and/or somnolence were reported in 12% and 10% in the ADASUVE and placebo groups, respectively. No patients discontinued treatment because of sedation or somnolence. The potential for cognitive and motor impairment is increased when ADASUVE is administered concurrently with other CNS depressants [see Drug Interactions (7.1)]. Caution patients about operating hazardous machinery, including automobiles, until they are reasonably certain that therapy with ADASUVE does not affect them adversely. 5.8 Cerebrovascular Reactions, Including Stroke, in Elderly Patients with Dementia-Related Psychosis In placebo-controlled trials with atypical antipsychotics in elderly patients with dementia-related psychosis, there was a higher incidence of cerebrovascular adverse reactions (stroke and transient ischemic attacks), including fatalities, compared to placebo-treated patients. ADASUVE is not approved for the treatment of patients with dementia-related psychosis [see Boxed Warning and Warnings and Precautions (5.3)]. 5.9 Anticholinergic Reactions Including Exacerbation of Glaucoma and Urinary Retention ADASUVE has anticholinergic activity, and it has the potential to cause anticholinergic adverse reactions including exacerbation of glaucoma or urinary retention. The concomitant use of other anticholinergic drugs (e.g., antiparkinson drugs) with ADASUVE could have additive effects. 6 ADVERSE REACTIONS The following adverse reactions are discussed in more detail in other sections of the labeling: • Hypersensitivity (serious skin reactions) [see Contraindications (4)] • Bronchospasm [see Warnings and Precautions (5.1)] • Increased Mortality in Elderly Patients with Dementia-Related Psychosis [see Warnings and Precautions (5.3)] • Neuroleptic Malignant Syndrome [see Warnings and Precautions (5.4)] • Hypotension and syncope [see Warnings and Precautions (5.5)] • Seizure [see Warnings and Precautions (5.6)] • Potential for Cognitive and Motor Impairment [see Warnings and Precautions (5.7)] • Cerebrovascular Reactions, Including Stroke, in Elderly Patients with Dementia-Related Psychosis [see Warnings and Precautions (5.8)] • Anticholinergic Reactions Including Exacerbation of Glaucoma and Urinary Retention [see Warnings and Precautions (5.9)] 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. The following findings are based on pooled data from three short-term (24-hour), randomized, double-blind, placebo-controlled clinical trials (Studies 1, 2, and 3) of ADASUVE 10 mg in the treatment of patients with acute agitation associated with schizophrenia or bipolar I disorder. In the 3 trials, 259 patients received ADASUVE 10 mg, and 263 received placebo [see Clinical Studies (14)]. Commonly Observed Adverse Reactions: In the 3 trials in acute agitation, the most common adverse reactions were dysgeusia, sedation, and throat irritation. These reactions occurred at a rate of at least 2% of the ADASUVE group and at a rate greater than in the placebo group. (Refer to Table 1).

Table 1. Adverse Reactions in 3 Pooled Short-Term, Placebo-Controlled Trials (Studies 1, 2, and 3) in Patients with Schizophrenia or Bipolar Disorder Placebo ADASUVE Adverse Reaction (n = 263) (n = 259) Dysgeusia 5% 14% Sedation 10% 12% Throat Irritation 0% 3% Airway Adverse Reactions in the 3 Trials in Acute Agitation Agitated patients with Schizophrenia or Bipolar Disorder: In the 3 shortterm (24-hour), placebo-controlled trials in patients with agitation associated with schizophrenia or bipolar disorder (Studies 1, 2, and 3), bronchospasm (which includes reports of wheezing, shortness of breath and cough) occurred more frequently in the ADASUVE group, compared to the placebo group: 0% (0/263) in the placebo group and 0.8% (2/259) in the ADASUVE 10 mg group. One patient with schizophrenia, without a history of pulmonary disease, had significant bronchospasm requiring rescue treatment with a bronchodilator and oxygen. Bronchospasm and Airway Adverse Reactions in Pulmonary Safety Trials Clinical pulmonary safety trials demonstrated that ADASUVE can cause bronchospasm as measured by FEV1, and as indicated by respiratory signs and symptoms in the trials. In addition, the trials demonstrated that patients with asthma or other pulmonary diseases, such as COPD are at increased risk of bronchospasm. The effect of ADASUVE on pulmonary function was evaluated in 3 randomized, double-blind, placebo-controlled clinical pulmonary safety trials in healthy volunteers, patients with asthma, and patients with COPD. Pulmonary function was assessed by serial FEV1 tests, and respiratory signs and symptoms were assessed. In the asthma and COPD trials, patients with respiratory symptoms or FEV1 decrease of ≥ 20% were administered rescue treatment with albuterol (metered dose inhaler or nebulizer) as required. These patients were not eligible for a second dose; however, they had continued FEV1 monitoring in the trial. Healthy Volunteers: In the healthy volunteer crossover trial, 30 subjects received 2 doses of either ADASUVE or placebo 8 hours apart, and 2 doses of the alternate treatment at least 4 days later. The results for maximum decrease in FEV1 are presented in Table 2. No subjects in this trial developed airway related adverse reactions (cough, wheezing, chest tightness, or dyspnea). Asthma Patients: In the asthma trial, 52 patients with mild-moderate persistent asthma (with FEV1 ≥ 60% of predicted) were randomized to treatment with 2 doses of ADASUVE 10 mg or placebo. The second dose was to be administered 10 hours after the first dose. Approximately 67% of these patients had a baseline FEV1 ≥ 80% of predicted. The remaining patients had an FEV1 60-80% of predicted. Nine patients (17%) were former smokers. As shown in Table 2 and Figure 7, there was a marked decrease in FEV1 immediately following the first dose (maximum mean decreases in FEV1 and % predicted FEV1 were 303 mL and 9.1%, respectively). Furthermore, the effect on FEV1 was greater following the second dose (maximum mean decreases in FEV1 and % predicted FEV1 were 537 mL and 14.7 %, respectively). Respiratory-related adverse reactions (bronchospasm, chest discomfort, cough, dyspnea, throat tightness, and wheezing) occurred in 54% of ADASUVE-treated patients and 12% of placebo-treated patients. There were no serious adverse events. Nine of 26 (35%) patients in the ADASUVE group, compared to one of 26 (4%) in the placebo group, did not receive a second dose of study medication, because they had a ≥ 20% decrease in FEV1 or they developed respiratory symptoms after the first dose. Rescue medication (albuterol via metered dose inhaler or nebulizer) was administered to 54% of patients in the ADASUVE group [7 patients (27%) after the first dose and 7 of the remaining 17 patients (41%) after the second dose] and 12% in the placebo group (1 patient after the first dose and 2 patients after the second dose). COPD Patients: In the COPD trial, 53 patients with mild to severe COPD (with FEV1 ≥ 40% of predicted) were randomized to treatment with 2 doses of ADASUVE 10 mg or placebo. The second dose was to be administered 10 hours after the first dose. Approximately 57% of these patients had moderate COPD [Global Initiative for Chronic Obstructive Lung Disease (GOLD) Stage II]; 32% had severe disease (GOLD Stage III); and 11% had mild disease (GOLD Stage I). As illustrated in Table 2 there was a decrease in FEV1 soon after the first dose (maximum mean decreases in FEV1 and % predicted FEV1 were 96 mL and 3.5%, respectively), and the effect on FEV1 was greater following the second dose (maximum mean decreases in FEV1 and % predicted FEV1 were 125 mL and 4.5%, respectively). Respiratory adverse reactions occurred more frequently in the ADASUVE group (19%) than in the placebo group (11%). There were no serious adverse events. Seven of 25 (28%) patients in the ADASUVE group and 1of 27 (4%) in the placebo group did not receive a second dose of study medication because of a ≥ 20% decrease in FEV1 or the development of respiratory symptoms after the first dose. Rescue medication (albuterol via MDI or

nebulizer) was administered to 23% of patients in the ADASUVE group: 8% of patients after the first dose and 21% of patients after the second dose, and to 15% of patients in the placebo group. Table 2: Maximum Decrease in FEV1 from Baseline in the Healthy Volunteer, Asthma, and COPD Trials Healthy Volunteer Asthma COPD Maximum Placebo ADASUVE Placebo ADASUVE Placebo ADASUVE n (%) 10 mg n (%) 10 mg % FEV ↓ n (%) 10 mg n (%) n (%) n (%) N=26

N=26

N=27

N=25

≥10

7 (27)

3 (12)

22 (85)

18 (67)

20 (80)

≥15

1 (4)

5 (19)

1 (4)

16 (62)

9 (33)

14 (56)

≥20

1 (4)

11 (42)

3 (11)

10 (40)

N=26

N=27

N=25

≥10

4 (15)

5 (19)

2 (8)

16 (62)

8 (30)

16 (64)

≥15

1 (4)

2 (8)

1 (4)

8 (31)

4 (15)

10 (40)

After any Dose

After Dose 1

1 (4)

6 (23)

2 (7)

9 (36)

N=26

N=25

N=17

N=26

N=19

≥10

5 (19)

6 (24)

3 (12)

12 (71)

15 (58)

12 (63)

≥15

5 (20)

1 (4)

9 (53)

6 (23)

10 (53)

≥20

1 (4)

5 (30)

1 (4)

5 (26)

≥20 After Dose 2

FEV1 categories are cumulative; i.e. a subject with a maximum decrease of 21% is included in all 3 categories. Patients with a ≥ 20% decrease in FEV1 did not receive a second dose of study drug. Figure 7: LS Mean Change from Baseline in FEV1 in Patients with Asthma

Patients with a ≥ 20% decrease in FEV1 did not receive a second dose of study drug and are not included in the curves beyond hour 10. Extrapyramidal Symptoms (EPS): Extrapyramidal reactions have occurred during the administration of oral loxapine. In most patients, these reactions involved parkinsonian symptoms such as tremor, rigidity, and masked facies. Akathisia (motor restlessness) has also occurred. In the 3 short-term (24-hour), placebo-controlled trials of ADASUVE in 259 patients with agitation associated with schizophrenia or bipolar disorder, extrapyramidal reactions occurred. One patient (0.4%) treated with ADASUVE developed neck dystonia and oculogyration. The incidence of akathisia was 0% and 0.4% in the placebo and ADASUVE groups, respectively. Dystonia (Antipsychotic Class Effect): Symptoms of dystonia, prolonged abnormal contractions of muscle groups, may occur in susceptible individuals during treatment with ADASUVE. Dystonic symptoms include spasm of the neck muscles, sometimes progressing to tightness of the throat, difficulty swallowing or breathing, and/or protrusion of the tongue. Acute dystonia tends to be dose-related, but can occur at low doses, and occurs more frequently with first generation antipsychotic drugs such as ADASUVE. The risk is greater in males and younger age groups. Cardiovascular Reactions: Tachycardia, hypotension, hypertension, orthostatic hypotension, lightheadedness, and syncope have been reported with oral administration of loxapine. 7 DRUG INTERACTIONS 7.1 CNS Depressants ADASUVE is a central nervous system (CNS) depressant. The concurrent use of ADASUVE with other CNS depressants (e.g., alcohol, opioid analgesics, benzodiazepines, tricyclic antidepressants, general anesthetics, phenothiazines, sedative/hypnotics, muscle relaxants, and/or illicit CNS depressants) can increase the risk of respiratory depression, hypotension, profound sedation, and syncope. Therefore, consider reducing the dose of CNS depressants if used concomitantly with ADASUVE.

7.2 Anticholinergic Drugs ADASUVE has anticholinergic activity. The concomitant use of ADASUVE and other anticholinergic drugs can increase the risk of anticholinergic adverse reactions including exacerbation of glaucoma and urinary retention. 8 USE IN SPECIFIC POPULATIONS In general, no dose adjustment for ADASUVE is required on the basis of a patient’s age, gender, race, smoking status, hepatic function, or renal function. 8.1 Pregnancy Pregnancy Category C Risk Summary There are no adequate and well-controlled studies of ADASUVE use in pregnant women. Neonates exposed to antipsychotic drugs during the third trimester of pregnancy are at risk for extrapyramidal and/or withdrawal symptoms following delivery. Loxapine, the active ingredient in ADASUVE, has demonstrated increased embryofetal toxicity and death in rat fetuses and offspring exposed to doses approximately 0.5-fold the maximum recommended human dose (MRHD) on a mg/m2 basis. ADASUVE should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Human Data Neonates exposed to antipsychotic drugs during the third trimester of pregnancy are at risk for extrapyramidal and/or withdrawal symptoms following delivery. There have been reports of agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, and feeding disorders in these neonates. These complications have varied in severity; in some cases symptoms have been self-limited, but in other cases neonates have required intensive care unit support and prolonged hospitalization. Animal Data In rats, embryofetal toxicity (increased fetal resorptions, reduced weights, and hydronephrosis with hydroureter) was observed following oral administration of loxapine during the period of organogenesis at a dose of 1 mg/kg/day. This dose is equivalent to the MRHD of 10 mg/day on a mg/m2 basis. In addition, fetal toxicity (increased prenatal death, decreased postnatal survival, reduced fetal weights, delayed ossification, and/or distended renal pelvis with reduced or absent papillae) was observed following oral administration of loxapine from mid-pregnancy through weaning at doses of 0.6 mg/kg and higher. This dose is approximately half the MRHD of 10 mg/day on a mg/m2 basis. No teratogenicity was observed following oral administration of loxapine during the period of organogenesis in the rat, rabbit, or dog at doses up to 12, 60, and 10 mg/kg, respectively. These doses are approximately 12-, 120-, and 32-fold the MRHD of 10 mg/day on a mg/m2 basis, respectively. 8.3 Nursing Mothers It is not known whether ADASUVE is present in human milk. Loxapine and its metabolites are present in the milk of lactating dogs. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from ADASUVE, a decision should be made whether to discontinue nursing or discontinue ADASUVE, taking into account the importance of the drug to the mother. 8.4 Pediatric Use The safety and effectiveness of ADASUVE in pediatric patients have not been established. 8.5 Geriatric Use Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death [see Boxed Warning and Warnings and Precautions (5.3)]. ADASUVE is not approved for the treatment of dementia-related psychosis. Placebo-controlled studies of ADASUVE in patients with agitation associated with schizophrenia or bipolar disorder did not include patients over 65 years of age. 10 OVERDOSAGE Signs and Symptoms of Overdosage As would be expected from the pharmacologic actions of loxapine, the clinical findings may include CNS depression, unconsciousness, profound hypotension, respiratory depression, extrapyramidal symptoms, and seizure. Management of Overdosage For the most up to date information on the management of ADASUVE overdosage, contact a certified poison control center (1-800-222-1222 or www.poison.org). Provide supportive care including close medical supervision and monitoring. Treatment should consist of general measures employed in the management of overdosage with any drug. Consider the possibility of multiple drug overdosage. Ensure an adequate airway, oxygenation, and ventilation. Monitor cardiac rhythm and vital signs. Use supportive and symptomatic measures. Manufactured by: Alexza Pharmaceuticals, Inc., Mountain View, CA 94043 Manufactured for: Teva Select Brands, Horsham, PA 19044, Division of Teva Pharmaceuticals USA, Inc. Iss.12/2013 ADA-40059

THE OTHER INTELLIGENCE Do You Have a Strong EI? Your Success Could Depend On It By Yvonne Prowant, MM, BSN, CEN, Emergency Nurses Wellness Committee Member

t has been said that emergency nursing and teaching kindergarten are the professions that require the widest variety of attributes to be successful. Emergency nurses certainly use various skills and abilities at all times. Beyond specific clinical skills, perhaps one of the most important skills is a well-developed EI, or emotional intelligence. EI, sometimes referred to as EQ, has been identified as the factor that determines success more than education, experience or IQ. Think of those with whom you have worked. We all know people who have high IQs, advanced degrees and breadth of experience but are not very effective in their bedside skills or as a team member. They are not considered to be on the ‘‘A’’ team. Why is this, and why is it so important, especially for emergency nurses? Emotional intelligence is comprised of five elements in two dimensions: intrapersonal (self-awareness, selfregulation, motivation) and interpersonal (empathy, social skills). These sound like requirements for any emergency nurse. While we typically do not screen new candidates in these areas, a high level of proficiency in each of these EI components is needed for success. Here is the success formula:

IQ + Education + Experience (opens door to an emergency nursing job) + EI Proficiency (self-awareness, self-regulation, motivation,

plus empathy, social skills)

= Success! Self-awareness is the first step in being able to handle a situation effectively. As emergency nurses, we need to be aware of several areas that impact our self: emotions, values, prejudices and personal stress. Our perspective in each of these areas may, at times, create a problem or conflict in dealing with others. Often, we need to self-regulate our

natural response. Can you imagine a situation when an ED staff member did not practice self-regulation? We likely all remember a time when that happened. It probably was not pretty and created even more stress. Motivation is essential not only for teamwork but also for personal growth. The team depends on everyone taking the initiative to pick up patients, help others and be knowledgeable and capable in all aspects of emergency nursing. These three intrapersonal aspects of EI are crucial to who we are as emergency nurses. The two interpersonal aspects of EI are also essential. Empathy, the ability to understand the emotions of others, is important as we need to provide care in a way that makes patients feel cared for. The final aspect of EI, social skills, is necessary in working effectively with teammates and with patients and families. ED teams are unique, and the unique combinations of assignments and roles require astute, adaptable social skills. Add physicians, ancillary staff, emergency medical services and inpatient units and you have even more challenges. In addition, emergency nurses interact with patients of all ages and families from every spectrum of society at a moment’s notice, without time to prepare. This requires a high level of comfort and ease with meeting and talking with unfamiliar people. Emergency nursing can be stressful and requires each of us to be our best. It requires a complex skill set, so much more than book knowledge and clinical know-how. To be highly effective, we also have to show great intrapersonal and interpersonal EI skills. When this is done, the team feels privileged to work with you, and your patients and families are thankful that you are their nurse. Resources Freshman, B. (2002). Emotional intelligence: A core competency for health care administrators. The Health Care Manager, 20(4), 1-9. Target Training International, Ltd. (2013). TTI Emotional Quotient™ debriefing guide. Scottsdale, AZ: TTI Success Insights.

Official Magazine of the Emergency Nurses Association

ENA FOUNDATION

ASKING FOR OURSELVES Member Puts Seed Grant Funds Toward Keeping CAUTI Out of the ED By Kendra Y. Mims, ENA Connection

hen Elizabeth Mizerek, MSN, RN, CEN, CPEN, FN-CSA, realized the majority of prevention efforts for catheter-associated urinary tract infections weren’t focused on the emergency department, she decided to conduct her own research to address CAUTI from the emergency nurse’s perspective. ‘‘Catheter-acquired urinary tract infections are a never event and a Joint Commission national patient safety goal,’’ said Mizerek, ED educator at the Robert Wood Johnson University Hospital Hamilton in Hamilton, N.J. ‘‘There’s been a lot of work done around CAUTI prevention efforts with the Surgical Care Improvement Project, but no one’s really talked to the ED.’’ Mizerek wanted to explore the emergency nurse’s decision-making process when considering Foley catheter insertion. She was a 2013 recipient of an ENA Foundation seed grant, which gave her an opportunity to conduct a qualitative study. ‘‘I think there was an assumption that a physician writes an order to have a Foley catheter inserted and the nurse places it,’’ she said. ‘‘By doing the qualitative research, we found that the catheter insertion decision was really nurse-driven more than provider-driven. And that turned the whole paradigm on its head.’’ For her research project, ‘‘Foley or No Foley: Factors Influencing Emergency Nurse’s Decision to Insert an Indwelling Urinary Catheter,’’ Mizerek and her colleagues from the New Jersey ENA State Council conducted three focus-group sessions

with a total of 23 participants at the annual New Jersey ENA Emergency Care Conference in March. After analyzing the data, she discovered emergency nurses were driving the decision-making based on their clinical judgment, and the majority did not have a demonstrated competency. She also found a wide variability in the frequency of catheter insertions. Mizerek said there’s definitely a lack of communication and understanding about the impact of CAUTI on the patient. She believes this research can help raise awareness and educate emergency nurses. ‘‘We need to have a better approach to our CAUTI prevention efforts to prevent patient harm,’’ she said. ‘‘Hopefully this research will help to inform the CAUTI prevention programs going on across the country to really spend time looking at their processes, education and how they are communicating to people providing direct patient care. Part of our study shows that the bedside nurse is not receiving information to understand the impact of the preventable patient harm of CAUTI.’’ Mizerek recently submitted her research manuscript to the Journal of Emergency Nursing. She said one of the most exciting aspects of the project was receiving the $500 ENA

Foundation seed grant, which was enough to get her foot in the door. ‘‘For those of us who work in a community hospital and don’t have an affiliation with an academic institute, it’s really exciting to have that support from the ENA Foundation and to know that every time I bought a flash drive or attended an ENA Foundation fundraiser, I ended up funding research for myself and others,’’ she said. ‘‘If this is what we can do with a $500 grant, imagine what we can do with a $2,500 grant.’’ Mizerek said the project has helped her as an ENA mentor for Project Protect: Infection Prevention Fellowship, presented by the On the CUSP: Stop CAUTI program. She hopes her research will create a discussion about CAUTI prevention strategies that is inclusive of the nurse’s perspective and that emergency nurses will continue to give back to the ENA Foundation to support future research projects. ‘‘It’s our foundation,’’ she said. ‘‘It’s who we are. If ENA wants to be the global leader in emergency nursing, it has to start with education and research, and that’s what the ENA Foundation is all about. It supports those of us in the field, whether it’s through the educational scholarships or through research grants. The ENA Foundation helps advance the practice of emergency nursing in a very concrete way.’’

“If this is what we can do with a $500 grant, imagine what we can do with a $2,500 grant.’’ ELIZABETH MIZEREK, MSN, RN, CEN, CPEN, FN-CSE, 2013 ENA Foundation Seed Grant Recipient

August 2014

ENA Foundation Event

THE POWER OF ONE

“A single person can do incredible things when they set their heart to it. That’s the power of one.” - Jeff Solheim

The Power of One: Engaging Generations of Nurses to Give Back and Do Incredible Things Friday, October 10 6 – 8:30 pm

2014 ANNUAL CONFERENCE INDIANA CONVENTION CENTER

1.30 CONTACT HOURS Join the ENA Foundation and Jeff Solheim, Internationally Recognized Motivational Speaker, for an evening of exploring the Power of One— Inspiring stories of our heroes—100% of your ticket value goes to the Emergency Nursing 2015 Conference scholarship fund. The goal of the Foundation Event is to raise money to send 10 emerging professionals to the Emergency Nursing 2015 Conference. Empowering young nurses with education, networking, and advocacy skills will give them the tools to do incredible things. $50 (tax deductible) Dinner, dessert bar, and beverages following the program.

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

Becoming a Fellow: Which Type Are You? By Gordon Lee Gillespie, PhD, RN, PHCNS-BC, CEN, CPEN, CCRN, FAEN

ellows offer many reasons for what motivated them to seek induction into the Academy of Emergency Nursing. You may identify among these reasons why you would apply to become a fellow of the Academy of Emergency Nursing. Fellows’ motivators can be categorized as intrinsic and extrinsic. Two types of intrinsic motivators are motivation toward accomplishments and motivation to experience stimulation.1 Three types of extrinsic motivators are external regulation, introjected regulation and identification.1 External regulation is modeled by current fellows and other colleagues recommending others to apply to become a fellow. Introjected regulation can be exhibited by people with a professional responsibility to role-model to others; they apply to become a fellow so that their colleagues are more likely to apply to the Academy as well. Identification is a reason for those applicants seeking

personal recognition by others as having achieved a legacy in emergency nursing. Applicants still need to address their potential for sustained contributions after induction. The Institute of Medicine, in consort with the Robert Wood Johnson Foundation, called for nursing leaders and mentors enabled to ‘‘lead change to advance health.’’2 Fellows of the Academy of Emergency Nursing are ideally situated to lead changes in emergency care reflecting the induction criterion for sustained contributions, which can be demonstrated as increased leadership opportunities through mentorship and advisement. Mentoring opportunities are formalized through the Academy’s EMINENCE program and informal networking with ENA members. AnnMarie Papa, DNP, MSN, RN, CEN, NE-BC, FAEN, an ENA past president, said a benefit of being a fellow is being ‘‘recognized as an expert in the profession of emergency nursing when serving on committees and advisory

2014 Academy Candidates for Induction ENA and the Academy of Emergency Nursing are pleased to announce the 2014 academy candidates for induction: • Roger Casey, MSN, RN, CEN (Washington) • Rita Celmer, RN, CRNA, CEN (Pennsylvania) - Posthumous • Nicholas Chmielewski, MSN, RN, CEN, CNML, NE-BC (Ohio) • Seleem Choudhury, MSN, MBA, RN, CEN (Vermont) • Ruth E. Rea, PhD, RN (Washington) • Robert Ready, MN, RN-C, CPEN, NEA-BC (Rhode Island) • Stephen J. Stapleton, PhD, MS, RN, CEN (Illinois) • Tiffiny Strever, BSN, RN, CEN (Arizona) • Mary Alice Vanhoy, MSN, RN, CEN, CPEN, NR-P (Maryland) • Cheryl Wraa, MSN, RN (California) The candidates will be inducted as fellows on Oct. 11 at the 2014 Annual Conference in Indianapolis. We extend our congratulations and appreciation to the candidates for their outstanding contributions to emergency nursing and ENA.

boards to shape and influence the future’’ of emergency nursing. Papa’s statement reflects the advisement occurring when Academy members are solicited by the ENA Board of Directors, ENA committees and

August 2014

external advisory boards to provide views, advice and appraisal for decisionmaking and health policy. Nancy Bonalumi, MS, RN, CEN, FAEN, an ENA past president and the AEN chairperson-elect said, ‘‘Being a fellow means making a contribution, not just making accomplishments.’’ This means that whether you apply to become a fellow for intrinsic or extrinsic reasons, your opportunity to meet the IOM challenge as a leader in emergency nursing and your future positive impact to the profession can be actualized. The Academy board looks forward to reviewing members’ future applications.

Vial Alert from CDC, Joint Commission

References 1. Vallerand, R. J., Pelletier, L. G., Blais, M. R., Brière, N. M., Senécal, C., & Vallières, E. F. (1992). The academic motivation scale: A measure of intrinsic, extrinsic, and amotivation in education. Educational and Psychological Measurement, 52, 1003-1017. 2. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Gala 2014 2014_print.pdf Washington, DC: The AD_CONN_Half_08 National Academies Press.

he Centers for Disease Control and Prevention and The Joint Commission are warning health care providers to follow precautions when administering single-dose/single-use and multiple-use vials. On June 16, The Joint Commission released Sentinel Event Alert Issue 52: Preventing infection from the misuse of vials. The CDC has reported that the improper use of medication vials during routine health care procedures, such as administering injections, has resulted in the transmission of bloodborne viruses to patients. It further warns that adverse events have been caused by misuse and urges basic infection control practices to ensure patient safety. Failure to follow simple precautions can result in the spread of the hepatitis C and B viruses. Single-dose/single-use vial medications do not have preservatives and are at greater risk of spreading infection when used improperly. The following precautions are urged: • Use a single-dose/single-use vial for one patient during one procedure. • Do not keep used single-dose/single-use vials or combine the contents for later use. • Only vials labeled for multiple-dose use can be used more than once. The full text of the alert can be found at tinyurl.com/tjcalert or by scanning the QR code at the top of this box. 1

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ACelebration of Ínductees to the Academy of Emergency Nursing, Lantern Awards, and Annual Achievement Awards Saturday, October 11 7:30 pm JW Marriott Indianapolis to register visit www.ena.org/ac

Official Magazine of the Emergency Nurses Association

NEMSAC Update: A Look at Community Paramedicine By Michael Hastings, MSN, RN, CEN

t the April meeting of the National EMS Advisory Council, we looked at the issue of community paramedicine, which was also a topic at the town hall meeting held at ENA Leadership Conference 2014 in Phoenix. In response to member concerns, the ENA Board of Directors voted this spring to create an EMS advisory council this year. The American Nurses Association also has come out with the statement ‘‘ANA Essential Principles for Utilization of Community Paramedics,’’ which can be found at tinyurl.com/ anaprinciples or by scanning the QR code here. We also received an update from the U.S. Department of Health and Human Services that the Association of State and Territorial Health Officials was scheduled to release a white paper about community paramedicine, which looked at the legality and policy issues affecting community paramedicine. A U.S. Department of Transportation Federal Highway Administration Safety Performance Measures notice of proposed rulemaking soon will require all states to report serious-crash injury data to USDOT. This will be a phased-in project in which the details from a motor-vehicle crash will be collected in a systematic way, regardless of where the crash occurs. These are just some of the topics discussed. Any ENA member with an interest in EMS can sign up for NEMSAC meeting updates at www.ems.gov. All Office of EMS updates and NEMSAC meeting materials are available here. Any members with questions may contact the author at mahastings @seton.org.

ETHICS

IT’S NOT EASY IN THE MIDDLE Applying Your Nursing Know - How to Family Can Get Complicated By Vicki C. Sweet, MSN, RN, CEN, CCRN, FAEN, 2014 Chairperson, Emergency Nurses Wellness Committee

any emergency nurses are finding themselves in the ‘‘sandwich generation.’’ If you haven’t heard this term, it describes those who are providing health care of some sort to their own dependents as well as to an older family member, friend or neighbor.1 While there is much in current literature about this stage in our lives, there is not much written about what ethical and moral dilemmas arise when a nurse finds himself or herself in the middle of conflict between what we know is best and family members’ wishes. We all have been in the situation where, as the nurse in the family, we are asked to facilitate health care decisions or provide advice to our loved ones. We draw upon our nursing expertise to counsel our families on what we think might be best for them. In the sandwich generation, we may be increasingly called upon as we become more involved with health care decisions for our aging parents, or even for our siblings or close friends. After dealing with moral and ethical dilemmas in the workplace, we find that we are now facing similar dilemmas within our own families or circles of friends. We find ourselves in the situation of being ‘‘double-duty caregivers,’’ meaning we care for patients in the workplace and then must continue that role within our own families or circle of friends.2 Being identified as a health care decision-maker seems at first to be an easy choice. We learn what the patient, our friend or family member wants and then we implement their wishes when the time comes. We tell ourselves, ‘‘We are the nurse — we can do this.’’ The reality is, when we are actually faced with making an end-of-life decision for someone we love and have cared for, it may be more emotionally taxing than we anticipate. We intervene with patients and families in our jobs and then must come home to do the same with those who are dependent on us for health care within our families or friends. Fear of making the wrong decision may lead to guilt

and second-guessing, especially if our family/friend/ patient takes a turn for the worse. It can cause us to doubt our identity as a nursing professional.3 It also may be a cause of moral distress, especially when the wishes of the patient or other family members might be contrary to what we believe to be best.4 Moral distress is a term that has been used to define this sense of doubt in the context of workplace decisions; it may also be applicable in the decisions we are asked to make for family or friends. Without support or self-fulfillment, compassion fatigue may be inevitable. What resources are there for us to be able to fill our own cups of compassion? While the topic of compassion fatigue has been around since 1992, it is in recent years that it has gained attention. We are getting better at understanding the importance of self-care and compassion satisfaction. In 2013, the Wellness Committee published a white paper on nurse fatigue (tinyurl.com/ nursefatigue, QR code at left) after recognizing the effects of physical fatigue on patient safety as well as our own quality of life. This year, we are tackling the subject of compassion fatigue and are finding the need for more research in this area. A topic brief soon will be available and will outline current progress as well as challenges for the future. Compassion satisfaction is a crucial component of nurse wellness. ENA is well-positioned to address the issue for the benefit of our members, our patients and the entire health care community.

Thank you to the following organizations for their generous support.

STRATEGIC SPONSORS

This article is dedicated to the memory of Christine Dimitrakopoulos, PhD (c.), MSN, RN, CEN. Dimitrakopoulos was appointed to the first Wellness Committee by Benjamin E. Marett, MSN, RN, CEN, CNA, COHN-CS, 2000 ENA president, and her ultimate goal was to help emergency nurses care for themselves and for one another in body, mind and spirit. She died in October 2013, knowing ENA was carrying on her dream.

STRATEGIC SUPPORTER

References 1. Do, E., Cohen, S., & Brown, M. (2014). Socioeconomic and demographic factors modify the association between informal caregiving and health in the sandwich generation. BMC Public Health 14, 362. 2. Ward-Griffin, C., St. Amant O., & Brown, J.B. (2011). Compassion fatigue within double duty caregiving: Nurse-daughters caring for elderly patients. Online Journal of Issues in Nursing, 16(1), 14. 3. Ward-Griffin, C. (2013). Blurred boundaries: Double duty caregiving. The Canadian Nurse, 109(6),15.

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

4. Fernandez-Parsons, R., Rodriguez, L., & Goyal, D. (2013). Moral distress in emergency nurses. Journal of Emergency Nursing, 39,547-552.

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Official Magazine of the Emergency Nurses Association

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ENA ADVOCACY | Ken Steinhardt, Director of Government Relations

Our In-Person Impact Record ‘Day on the Hill’ Group Has Legislators Listening

n May 6-7, a record-breaking 99 ENA members attended ‘‘Day on the Hill’’ to advocate on behalf of ENA’s federal legislative priorities. This year’s event included sessions with senior congressional staff and issue experts, a networking reception, morning coffee on Capitol Hill and visits with members of Congress. The program began with a panel comprised of Capitol Hill staffers J.P. Paluskiewicz, deputy chief of staff for Rep. Michael Burgess, MD (R-Texas), and Stanley Watkins, chief of staff for Rep. Bobby Rush (D-Ill.). These Hill veterans explained the ins and outs of life in a congressional office and advised ENA members on how to make the most of their Hill visits and convince their elected officials to take action on their requests. The experts also discussed the importance of follow-up. Attendees also were briefed by experts on ENA’s two congressional ‘‘asks’’: H.R. 4080, the Trauma Care Systems and Regionalization of Emergency Care Reauthorization Act, and H.R. 274.S. 153, the Mental Health First Aid Act. Lisa Tofil, who represents the Trauma Center Association of America, explained the federal government’s role in regulating and funding our nation’s trauma centers and systems. Tofil kept the audience engaged as she thoroughly explained H.R. 4080 and what the trauma grants within the bill accomplish. She gave attendees all the tools they needed to make the case as to why our nation’s trauma care system is in dire need of federal support. This included highlighting that 45 million Americans live without access to a major trauma center within the critical golden hour after a serious injury. On the topic of mental health, ENA members heard from Al Guida, president and CEO of Guide Consulting Services. He represents several organizations, including the National Mental Health Association and the National Mental Health Awareness Campaign. Guida emphasized the importance of recognizing mental health issues in individuals early, before the condition develops into something more serious. This need for early recognition was the impetus behind the Mental Health First Aid Act, which would offer grants to teach people how to spot signs of mental health problems and how to offer help. Mental Health First Aid is the CPR of mental health disorders. May 7 kicked off with a Coffee with Congress event in the Rayburn House Office Building on Capitol Hill. ENA

ENA advocates at Day on the Hill got some motivating face time with two congresswomen with nursing backgrounds: Rep. Lois Capps (D-Calif., top photo) and Rep. Diane Black (R-Tenn., bottom photo, left, with ENA 2014 President Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN). members heard from multiple members of the House of Representatives, including Rep. Michael Burgess, MD (R-Texas). Burgess is the lead sponsor of H.R. 4080. He provided a status update on his legislation and thanked ENA members for supporting his legislation and traveling to D.C. to advocate for the bill. He entertained the audience with

August 2014

stories from his days as a practicing obstetrician in Texas — before the existence of emergency physicians — and said emergency nurses were always there to provide vital care to patients. Burgess was followed by Rep. Lois Capps (D-Calif.), co-chair and founder of the House Nursing Caucus. A former school nurse, Capps spoke about the importance of the nursing profession and how she has dedicated much of her congressional career to legislation impacting all nurses. These efforts have included legislation addressing the national Texas ENA members Michael Moon, PhD, MSN, RN, CNS-CC, CEN, FAEN (left) of nursing shortage, improving mental health services, providing emergency defibrillators to the ENA Board of Directors and Cam Brandt, MS, RN, CEN (right) talk about emergency nursing concerns with Rep. Joe Barton (R-Texas). local communities and bringing CPR After this encouraging event, attendees met with their instruction to schools. members of Congress — more than 120 senators, The final speaker of the morning was the only former representatives and their staff. Based on the increase in emergency nurse serving in Congress, Rep. Diane Black (R-Tenn.). Black explained how she still has a distinct co-sponsors to both the trauma care and mental health bills, it connection to emergency nurses and showed authentic is obvious the time and effort put in by these members had an excitement for addressing a group of emergency nurses. She immediate and positive impact. More important, the relationtold the group how she became an emergency nurse, how ships formed with the offices of senators and representatives much of an impact that has had on her life and how she is will pay dividends in the future as ENA members advocate on still an actively licensed registered nurse in Tennessee. issues critical to emergency nurses.

Celebrate

Emergency Nurses Week

This year's theme is Life Saving Hands. Emergency Nurses WeekTM October 5 – 11, 2014 Emergency Nurses Day® Wednesday, October 8, 2014 Here are some fun ways to celebrate: ¡ Participate in community events such as health & wellness fairs ¡ Promote team building through scavenger hunts and staff picnics ¡ Shop Marketplace for EN Week gifts to share with your colleagues! For more ideas on EN Week activities visit www.ena.org/ENweek Images from 2013 Emergency Nurses Week Instagram photo contest winner, Washington Regional Medical Center, Fayetteville, AR.

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Official Magazine of the Emergency Nurses Association

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BOARD WRITES |

Sally K. Snow, BSN, RN, CPEN, FAEN

Join Our Collaboration on Behalf of Children E

NA is very pleased to have multiple opportunities to collaborate on behalf of children with our colleagues in emergency medical services, pediatrics and emergency medicine. It has been my honor to be a participant in these collaborative projects for many years. Most recently, ENA worked with the American Academy of Pediatrics and the American College of Emergency Physicians to co-author a joint policy statement and technical report titled ‘‘Death of a Child in the Emergency Department.’’ Last month, for the first time ever, the Journal of Emergency Nursing, Annals of Emergency Medicine and Pediatrics simultaneously published both of these collaborative documents. Our first joint policy statement, ‘‘Care of Children in the Emergency Department,’’ was a groundbreaking opportunity for emergency nursing and emergency medicine to come together to produce a comprehensive plan for improving ED preparedness. Already in the works are additional collaborative documents addressing patient- and family-centered care, best practices in patient flow for pediatric patients in the ED, and transition of care in the ED. This important collaboration aims to provide all hospitals with comprehensive resources that can establish best practices for providing care to children in the ED. In addition, many of you heard from me or one of the ENA Pediatric Committee members in 2013 requesting your participation in the National Pediatric Readiness Project. If you were the nurse leader in your

organization who completed the assessment, you are aware of your hospital’s readiness score and know where the gaps are. Both represent instant feedback that was part of this comprehensive quality-improvement project. As a staff nurse, you may not know your hospital’s readiness score. Make a point to ask if you are interested. While more than 4,100 EDs participated in the assessment and median readiness scores improved from 55 in 2003 to 69 in 2013, we still have some work to do. We must ensure that all EDs are prepared to care for children with the right equipment, competent staff, necessary policies and procedures in place, and a quality-improvement plan that includes pediatric patients. What we know about readiness is that having a designated nurse who champions pediatric preparedness improves the chances that a hospital is prepared.1 Hospitals should use the gap analysis to prioritize improving their readiness score. The EMS for Children program supports the

www.pediatricreadiness.org website, which allows emergency nurses to look at the recommendations of the joint policy statement— the basis for the NPRP assessment. Our next step is to improve our collaboration with EMSC state partnership managers. These dedicated individuals primarily have a background in EMS or state government and need the assistance of emergency nurses to open doors and facilitate dialogue. ENA members are uniquely positioned to help bridge the gap and enable EMSC managers to mobilize available resources to improve emergency preparedness. If you don’t know your EMSC state partnership manager, I strongly urge you to make a point to get acquainted. Visit tinyurl.com/ emscstate or scan the QR code at left. Together, ENA, EMSC and your state chapters of ACEP and AAP are a powerful force with the resources to move those state and hospital preparedness scores even higher in the near future. Your efforts will improve care for the children in your communities. They may be one-third of our population, but they are all of our future. Reference 1. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, American College of Emergency Physicians, & Emergency Nurses Association Pediatric Committee. (2009). Joint policy statement — Guidelines for care of children in the emergency department. Pediatrics, 124(4):1233-1243. doi:10.1542/ peds.2009-1807

August 2014

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FLU VACCINATIONS

BEST SHOT AT SAFETY By Josh Gaby, ENA Connection

‘A

re you up to date on your immunizations?” Staff nurse Linda Ebbeler, BS, RN, CEN, working triage in the University of Michigan’s adult emergency department, asks the question of any patient with possible flu exposure during flu season. It’s not just students and their families. Ebbeler’s ED serves the surrounding Ann Arbor community, international visitors via the nearby airport, sports fans in town for big games and, far more than you’d expect, groups passing through who have religious or cultural objections to vaccines. On the immunization question, the latter aren’t engaged. ‘‘I am obligated to ask, and I can’t do any more when they say no,’’ Ebbeler said. ‘‘[I say to them], ‘You need to think about this.’ They seem to stop listening.’’ August is National Immunization Awareness Month, and Ebbeler is the sort of emergency nurse who wants to keep others from glazing over, including fellow nurses. The Centers for Disease Control and Prevention calls for any healthy person age 6 months or older to get a flu vaccine every year — ideally as soon as they become available, around October. ENA stands solidly behind that recommendation. The ENA topic brief Adult Immuni zations (tinyurl.com/ENAimm or QR code at left) includes detailed administration guidelines for the flu vaccine and 11 others as determined

SETTING THE MISCONCEPTIONS STRAIGHT • I can’t get a flu vaccine. I hate needles. Flu vaccines can also be given intranasally and transdermally. • The flu shot will give me the flu. The flu in vaccines is weakened or inactivated, is not infectious and cannot cause flu. There can be mild side effects, including low fever, headache and tenderness where a shot was given. • You’re better off getting the actual flu than getting the vaccine. Flu is a serious illness that can mean hospitalization or death for healthy adults and children. Those under age 2 or older than 65 or with existing health complications are especially at risk. • The flu vaccine doesn’t work because you can get the flu anyway. Each year’s vaccine is tailored to three or four strains of flu that experts expect to circulate. It is possible to get a very different strain outside the protection of the vaccine, or to come down with flu you were exposed to before getting the vaccine or while you were still building immunity. Respiratory viruses with flu-like symptoms also can be mistaken for the flu. Source: CDC by the CDC’s Advisory Committee on Immunization Practices. All are evidencebased and reviewed annually. Some of Ebbeler’s triage patients will have gotten their flu vaccines. She said a similar number who aren’t vaccinated aren’t so much resistant as uninformed about why vaccines are needed and where to get them. ‘‘The partially informed are just my challenge,’’ Ebbeler said. ‘‘I don’t understand it. I understand that factually and objectively, that’s your choice, but you’re affecting everybody else.’’ It works like this: Exposure to a disease or getting a vaccine with a dead or weakened version of virus (imitating a full-blown infection) triggers the body to create antibodies

to ward off the disease in the future — the natural immune response that can come with normal, minor symptoms such as fever. The higher the public vaccination rate for a disease, the less likely that those who aren’t or can’t be vaccinated will be exposed (‘‘herd immunity’’). History is clear on flu as a killer, with the 1918-1919 ‘‘Spanish Flu’’ standing as the grimmest example. Between 20 and 40 million people around the world died in that pandemic, including 675,000 in the United States, which lost only a tenth of that number in World War I. The etiological cause of flu was pinpointed in 1933, with vaccinations beginning in the 1940s. Seventy-plus

August 2014

years later, vaccinations are well below what they ought to be, according to the CDC, which received reports of 9,632 lab-confirmed flu hospitalizations between Oct. 1, 2013, and May 17, 2014, including an increase among patients ages 18-64 and more than 90 pediatric deaths (flu-related death reporting is not required for patients older than 18). Not getting vaccinated is a real threat to health care workers and those they come in contact with, said Monica Escalante, MSN, RN, senior associate for the ENA Institute of Quality Safety and Injury Prevention. ‘‘If you are caring for someone who’s immunocompromised and you choose not to get vaccinated, you are putting that patient at risk,’’ Escalante said. ‘‘Influenza can be spread in the 24 hours before symptoms develop to 5-7 days after actual symptoms begin.’’ Consider these case studies provided by the ENA Institute for Emergency Nursing Research:

♦ Hank, a long-distance truck driver two days from home, presented to the ED complaining of a cough with blood-tinged sputum, myalgias and fever. He gave a medical history significant for diabetes mellitus type 2 and asthma. He reported he hadn’t felt well before leaving home, and his fever now felt higher. The triage nurse obtained the following vital signs: oral temperature of 104.2 F, respiratory rate of 40, SaO2 of 85 percent, blood pressure of 85/40 and a heart rate of 125. Hank was immediately brought to a treatment room, where he was intubated and placed on mechanical ventilation. Chest radiography showed bilateral infiltrates. His dropping blood pressure required the use of vasopressors, and he was moved to the intensive care unit. Despite aggressive therapy, he died 48 hours later. A viral culture was positive for Influenza A; his wife noted he had not received an influenza vaccine.

♦ Mallory, a 7-year-old with cerebral palsy, was sent home from her public school because of a fever and sore throat. By evening, her temperature was 102.0 F and she was having prolonged coughing episodes. Her mother gave her fluids and cold medicine and planned to take her to her pediatrician in the morning. By morning, Mallory was experiencing shaking chills, clammy skin and prolonged coughing episodes, during which she could not take a deep breath. She became less responsive, and her mother decided to bypass the pediatrician’s office and take her to the ED. Chest radiography showed bilateral pneumonia; her rapid antigen test was positive for Influenza A. Despite aggressive treatment, Mallory was in respiratory arrest and could not be resuscitated. Her mother had not vaccinated Mallory against influenza.

Continued on next page

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Official Magazine of the Emergency Nurses Association

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Flu Vaccinations Continued from previous page For an ENA member committed to safe practice, safe care, flu is a glaring patient hazard. Briana Quinn, MPH, BSN, RN, senior associate for wellness and injury prevention for IQSIP, said the best approach is to consider the flu vaccine a necessary medication, with rare adverse effects like any other medication. ‘‘The myths about vaccinations are just rampant,’’ Quinn said. ‘‘You cannot get the flu from a flu shot. If you do get a slight fever after the flu shot or feel crummy after it, that’s expected because it means your immune system is reacting appropriately. It takes your immune system approximately two weeks after a vaccination for antibodies to develop with protective effects. If you come down with the flu in that two-week period, it was not from the flu shot — it probably was because you already had a virus and you didn’t have the immunity.’’ Do your homework and rely on the CDC evidence, Quinn said. Back in Ann Arbor, Ebbeler continues sounding the horn. Pamphlets and fliers are a conduit to consider, she said. So is the idea of embedding the immunization question in discharge paperwork. ‘‘My response to ‘How do you deal with the public and the pushback?’ is exactly how it’s been done: a constant barrage of encouragement,’’ Ebbeler said. ‘‘ ‘These are the 24-hour places you can get it,’ with the free accessibility, the community programs if there’s funding for it. That’s the only way I see it being tackled.’’ Resources Misconceptions About Seasonal Flu and Flu Vaccines, CDC.gov Situation Update: Summary of Weekly FluView, www.cdc.gov/flu/weekly/summary.htm The Influenza Pandemic of 1918, virus. stanford.edu/uda/ Understanding How Vaccines Work, CDC.gov.

COMMITTEES AND WORK TEAMS

Meet the Team That Took on ED Technology By Amy Carpenter Aquino, ENA Connection

NA has several national committees and work teams comprised of skilled and dedicated members eager to share their expertise with the membership. One very productive group has been the Emergency Nursing Technology and Informatics Work Team, whose members have produced a position statement, a topic brief and a handbook in less than three years. Chairperson Michael Seaver, BA, RN, an ENA lifetime member, said he The Emergency Nursing Technology and Informatics jumped at the chance to Work Team. Front row, from left: Dagny S. Scofield, chair the work team in 2012 RN, CEN, CPEN; Monica Escalante, MSN, RN, senior after a few years as facilitator associate, IQSIP. Middle row: Jeannette Jefferies, MS, RN, CCRN; Debra Esse, MHA, BS, RN, CEN. Back row: of the ED Informatics Special Mitch Jewett, RN, CEN, ENA Board of Directors liaison; Interest Group. David G. Holman, MNSc, RN; Michael Seaver, BA, RN, While the work team had chairperson; and Leslie Talbert, senior administrative a number of charges in the assistant, IQSIP. beginning, Seaver said the members — some who have rotated off the work team since 2012 — chose to focus on technology issues related to emergency nursing practice. The team’s biggest undertaking was writing a book on electronic medical record implementation, which fulfilled its charge of developing key performance indicators for an evaluation of clinical systems and technology application, Seaver said. ‘‘That, to me, was the highlight of our whole time,’’ he said. ‘‘We took our combined various knowledge and expertise and tried to put all of that in an organized fashion to provide the membership with some guidance . . . when they were implementing an electronic medical records system, whether it be standalone or part of an integrated enterprise.’’ The work team also developed one of ENA’s first topic briefs in 2012, ‘‘Health Information Technology in the Emergency Department’’ (tinyurl.com/ENAedtech or QR code at left). Seaver said the goal in creating it was to provide members easily accessible educational material. ‘‘For a lot of people, EMRs are a lot of computer stuff, a lot of acronyms, a lot of things that people have to learn to work with, but maybe they don’t understand all

August 2014

ENA CONNECTED

Annual Conference, Emergency Nurses Week Sync Up By Thomas Barbee, ENA Digital Marking Manager

he 2014 ENA Annual Conference in October will be particularly special as both Emergency Nurses Week and Emergency Nurses Day occur during conference this year. We will have daily activities to

celebrate with our attendees and emergency nurses worldwide. This presents a wonderfully unique opportunity for ENA’s social media channels. Last year, we asked members to use Instagram to submit entries for this year’s Emergency Nurses Week poster. This year, we will use social media to help connect all members to our celebration, so that even if you aren’t able to join us in Indianapolis Oct. 7-11, you can

the implications,’’ he said. ‘‘So this was a unique opportunity to be able to put that together for the membership.’’ A position statement, Mobile Electronic Device Use in the Emergency Department (tinyurl.com/ ENAedmobile or QR code at left) was approved by the ENA Board of Directors in September 2013. In the position statement, the work group outlined ENA’s support for emergency nurses’ access to mobile devices, partially as a matter of patient safety. A mobile device provides instant access to the Internet for evidence-based clinical information, drug references, best practices and more. The work team tackled the issue of social media in the ED by presenting a concurrent session titled ‘‘The Good, the Bad and the Ugly: Social Media and Social Networking’’ at the 2013 ENA Annual Conference in Nashville, Tenn. 2013 ENA President JoAnn Lazarus, MSN, RN, CEN, suggested the topic, which intrigued the rest of the work team. ‘‘It was something we had never considered,’’ said Seaver, one of four work team members who presented the session. ‘‘We covered a lot of the do’s and don’ts and cautions, as well as some of the very positive aspects of using social networking and social media. I think we probably took a bit more of a precautionary stance, just because the potential for not-so-good things happening is very high, and the consequences of those not-so-good things.’’ The work team has been investigating several other topics, including wrong-chart documentation, work-arounds and workstation security. Alert fatigue was of particular interest to Deb Esse, MHA, BS, RN, CEN, who joined the team in January. ‘‘Technology affects everyday practice because we are documenting electronically now and we are getting more dependent upon the electronic documentation and alerts,’’ Esse said. Alert fatigue arises when clinicians grow immune to the constant alerts that pop up on their computer screens when they are documenting in an EMR and they choose to bypass

still be a part of the Annual Conference fun. Look for more exciting announcements as the time for conference draws near. Join the conversation using the hashtag #ENWeek, whether you are on-site or elsewhere. If you are attending, stop by @ENA Wired to get the latest information on activities for the week. We look forward to celebrating with you!

the alerts without reading them. A recent study on drug alerts showed that more than 50 percent of drug alerts were bypassed, and the majority of those were for possible allergies or drug interactions, Esse said. ‘‘What the literature suggests is that we look at the amount of alerts that we are putting up and only put up the most necessary ones,’’ she said. ‘‘Otherwise it just becomes white noise.’’ The other related issue the work team is exploring is alert overdependence, which occurs when clinicians wait for an alert to send a cue that a mistake was being made without thinking independently. ‘‘It’s a huge safety issue,’’ Esse said. Esse said she joined the work team after working for years as an ED staff nurse and then in her current position with a technology company, where she helps implement coding software for EDs and helps clients use collected data to make improvements. ‘‘It just made sense for me to join this, because I have experience with every kind of electronic health record . . . . I’m aware of the different styles and different types of documentation, and it fascinates me,’’ she said. She said her experience so far on the work team has been ‘‘really fun. They’re a great group of people, really knowledgeable.’’ The work team is being sunsetted at the end of this year, with the ED Operations Committee absorbing its purpose. Seaver said the conclusion of the work team’s composition is bittersweet, but members are proud of their work and the resources they’ve created for the membership. When he was invited to be the chairperson, Seaver said, he was thrilled at the opportunity to collaborate with talented work team members and ENA staff. ‘‘We had the pleasure of working with a number of staff members, and it has always been an absolute delight,’’ said Seaver, who wished to send ‘‘a big thank-you to everybody involved with the work team.’’

Official Magazine of the Emergency Nurses Association

ENA ARCHIVES

Remembering the Roadrunner

Joanne Fadale, BSN, RN, FAEN, displays T-shirts and a pin depicting ENA’s early mascot, the roadrunner.

By Kendra Y. Mims, ENA Connection

oanne Fadale, BSN, RN, FAEN, the 1990 ENA president, remembers how much ENA meant to co-founder Anita Dorr. Fadale worked for Dorr, RN, FAEN, at the Edward J. Meyer Hospital in Buffalo, N.Y., from 1970 to 1972 and witnessed how Dorr encouraged every nurse in the emergency department to join the association. ‘‘She told me you had to belong to the association to work in the emergency department. She really believed in it, and so did I, as well as everyone else who joined,’’ Fadale said. Dorr and co-founder Judith C. Kelleher, MSN, RN, CEN, formed the Emergency Department Nurses Association in 1970 and selected the roadrunner to be EDNA’s mascot. Dorr designed the original pin featuring a roadrunner with a nurse’s cap (see photos). During her visit to ENA

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headquarters in May, Fadale recalled the significance of the roadrunner symbol and what it meant to Dorr and Kelleher. ‘‘The roadrunner is a bird that doesn’t stop,’’ she said while holding an EDNA T-shirt with the roadrunner symbol. ‘‘It goes after what it needs to do, fixes it and continues. That’s why they chose it as their logo. They thought emergency nurses were like roadrunners because they persist and do what they need to do. It was developed because they really thought roadrunners were tenacious and represented what emergency nurses did.’’ ‘‘The Roadrunner’’ also was the name of EDNA’s first newsletter. The mascot was used until the late 1970s. As ENA’s volunteer historian, Fadale understands the importance of preserving ENA’s history, especially because she has been involved in ENA since its formation. During her visit, she met with the ENA staff archivist to continue the work of the Historical Perspectives Work Team, which was active from 2011 through 2013. Fadale will work with the staff archivist on developing a sustainable system to retain important ENA documents and other historical materials in the appropriate ENA or ENA-affiliated repositories. To learn more about the roadrunner and ENA’s early history, documents are now available for viewing online at the University of Virginia School of Nursing, Eleanor Crowder Bjoring Center for Nursing Historical Inquiry. A link to the ENA Collection is accessible from ENA’s History page, www.ena.org/about.

August 2014

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PRACTICE INNOVATIONS

COMING TO A SCREEN NEAR YOU?

Video Interpretation System Means Faster Care for Those With Barriers By Amy Carpenter Aquino, ENA Connection roviding care to patients who speak a language other than English or who are hearing-impaired can be difficult in the best of circumstances. Add the urgency of providing care in an emergency department, and barriers due to language differences can be frustrating for both patient and caregiver. ENA member Michelle Parish, RN, recalled how the previous interpretation systems used at her ED at Saline Memorial Hospital in Benton, Ark., did not allow nurses to provide the most efficient patient care for the hearingimpaired or those who spoke another language. The ED used a telephone interpreter service when caring for patients who spoke another language and had to call in an interpreter for the hearing-impaired. ‘‘With the prior methods, there was a delay in patient care for our hearing-impaired,’’ she said. ‘‘We had to wait for somebody to come in and provide the interpretation.’’ If there was no time to wait, ED staff had to rely on communicating by pointing to body parts to indicate they had to draw blood, for example. ‘‘We were doing the best communication we could do with the patient,’’ Parish said. Even the phone interpretation system method was lacking, since it was impossible for the interpreter to pick up on patients’ body language, she said. ‘‘You’re just limited to what information you could gather through a phone call, and so it was hard to tell if there was understanding of what the discharge instructions were or anything like that,’’ she said. For more complicated cases, such as when a patient had to go into surgery, the ED had to call in an interpreter. Parish’s experiences are in line with the findings from a 2012 study by Elizabeth A. Jacobs, Paul C. Fu Jr. and Paul J. Rathouz, ‘‘Does a Video-Interpreting Network Improve Delivery of Care in the Emergency Department?’’ The authors said face-to-face interpretation is useful ‘‘but inefficient because time interpreting is lost in transit between clinical sites and waiting for providers and patients. Telephonic interpretation increases efficiency of service delivery, but it has the disadvantage of loss of interpreter visual clues and rapport development with patient and provider.’’ Six months ago, Saline Memorial adopted a video interpretation system for non-English-speaking and hearing-

Photo courtesy of Rebecca Jones, Saline Memorial Hospital

Laura Gotcher, RN, an ED team leader at Saline Memorial Hospital in Benton, Ark., demonstrates the facility’s video interpretation system with staff nurse Dianne Koopmann, RN. impaired patients. The results have been better communication, less stress and more timely delivery of care, Parish said. The system works via an iPad. A nurse taps an icon to choose either a language interpretation service or a hearingimpaired interpretation service. There are about 30 languages available, and more are added each year. In 20 to 30 seconds, an interpreter is visible on the iPad screen and can begin communication with the patient while the nurse holds the iPad. ‘‘It’s very simple, very easy, and there is no delay in care,’’ Parish said. ‘‘[Patients are] able to communicate through the person on the iPad what their presenting problem is, associated symptoms and all the medical questions that we need to know to provide better care for the patient. We’re able to communicate back to them what we’re going to do, why we’re doing it, what the physician recommends.’’ ‘‘I think it’s a great technology,” she added. ‘‘It’s certainly helped us break down that communication barrier, being more effective in the way we’re able to deliver care for those patients.’’

August 2014

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Official Magazine of the Emergency Nurses Association

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