ENA Connection October 2014 by ENA Connection

the Official Magazine of the Emergency Nurses Association

connection

October 2014 Volume 38, Issue 9

Safekeeping EXPANDING THE WAYS WE CAN PROTECT PATIENTS YOUNG AND OLD — AND OURSELVES ♦ Day of Dialogue on ED Violence

♦ Looking Out For Child Passengers

♦ Rethinking Elderly Transitions of Care

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. 7-11, 2014 ENA 2014 Annual Conference, Indianapolis

ENA Exclusives PAGE 6 Update From the Executive Director PAGE 8 ENA, AONE Hold a Day of Dialogue on Workplace Violence PAGE 10 A Trip Through the ENA Archives PAGE 12 Your Role in Child Passenger Safety PAGE 14 Medical Errors Are on Senate’s Radar PAGE 16 ED Getting a Helping Hand From a Suicide Crisis Center PAGE 23 Focused State and Chapter Leaders Orientation Coming to Las Vegas PAGES 24 - 29 ENA Foundation Scholarship and Research Grant Award Recipients PAGE 32 The Wisdom in Nursing Stories PAGE 34 Game-Changing Votes Are Out There For ENA Elections PAGE 36 Michigan ED Plugs the Gaps in Transitions of Care for the Elderly PAGES 38 - 43 Committee Reports: ENA Lantern Award, Past Presidents and Technology

Regular Features PAGE 4 Free CE of the Month Members in Motion PAGE 9 Letters to the Editor PAGE 30 Board Writes PAGE 35 Future of Your Nursing

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

‘Hey, Can I Grab You For a Second?’ Y

ou are at the bedside caring for a patient with abdominal pain. This patient has a history of colon cancer, diabetes and hypertension. The patient has questions about the plan of care, and you need to speak to the physician to get the answers. The patient is also hyperglycemic and needs insulin coverage. You walk out of the room with a list of questions, tasks and interventions to accomplish. As you are walking toward the team station, you are stopped by a peer asking what time you would like to go to lunch. You are in the medication room, making an insulin drip for a 12-yearold patient in diabetic ketoacidosis. The charge nurse comes into the room to let you know the OR is ready for your patient with appendicitis. You are reviewing a medication order for a patient. You need some clarity about the order, as you are not sure the dose is correct for the patient. You walk toward the physician, who is getting sign-out from a resident, saying, ‘‘Hey, can I ask you a question?’’ In the ED, we are constantly balancing a need for information and communication with tasks and responsibilities. Have you ever considered that the where, when and how of seeking out that information impacts patient safety? Take the patient with abdominal pain. You have made your mental task list before walking out of the room. Within 45 seconds, your thoughts are interrupted when you are asked about lunch. Now, trust me, making sure you get to lunch is incredibly important, not only to maintain adequate glucose levels to the brain but to take a much-needed break. However, how easy is it for you to recover from that interruption? Is it possible you forgot what questions you need to ask? Is it possible one thing might have fallen off your list of things to do? Is it possible you forgot what your patient’s blood glucose result was? By not doing what you forgot to do, is it possible the patient can be harmed? There is much evidence that identifies the ED as a place where distractions and

Congratulations and appreciation to all emergency nurses from the ENA Board of Directors in celebration of

Emergency Nurses Week Oct. 5 - 11

Emergency Nurses Day Oct. 8 interruptions are prevalent. There is also evidence to show that interruptions during the medication preparation and delivery processes can lead to serious errors. How is your emergency department working to limit distractions and interruptions? Do you have ‘‘distraction-free’’ zones in your department? Can you create ‘‘sterile cockpit’’ environments where interruptions are unacceptable? Medication rooms are one place that should be interruption-free. What about where we are discussing important patient information? How many times have you interrupted a conversation about patient care to ask a noncritical question? Do we need to

Continued on page 9

Official Magazine of the Emergency Nurses Association

In celebration of Emergency Nurses Week and Emergency Nurses Day this month, ENA is giving you not one but two new free continuing education courses as part of our catalog of offerings.

Available to you starting Oct. 1 . . . ‘‘Shift Work Disorder: Are You At Risk?’’, presented by Mary Alice Vanhoy, MSN, RN, CEN, CPEN, NREMT-P. This session explores shift work disorder, its impact on practice and strategies for mitigating it. ‘‘Difficult Airway Response Teams (DARTs) in the Hospital Setting,’’ presented by Michael J. Chicarelli, MSN, RN, CEN. Learn about the basics of DARTs and DART alerts, along with the benefits, equipment costs and challenges that come with implementing DARTs. 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 select ‘‘check out.’’ • Proceed to your Personal Learning Page to start or complete any course for which you have registered or to print a final certificate. • To return to your Personal Learning Page later, go to www.ena.org and find ‘‘Go to Personal Learning Page’’ under the Education tab. Be sure you are using the e-mail address associated with your membership when logging in. If you have questions about any free eLearning course or the checkout process, e-mail elearning@ena.org.

ENA Connection is published 11 times per year from January to December by: The Emergency Nurses Association 915 Lee Street Des Plaines, IL 60016-6569 and is distributed to members of the association as a direct benefit of membership. Copyright ©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

Do you have a recent professional or educational success story you want to share about yourself or an ENA member colleague? Have you won an award or earned a promotion? Has another member you know been recognized for outstanding work? Tell us! Send an e-mail to connection@ena.org with the subject line “Members in Motion.” Be sure to include names, credentials and, if applicable, photos of the nurse(s) being recognized. ENA staff may follow up with you for additional details.

Kentucky ENA Names 2014 Emergency Nurse of the Year The Kentucky ENA State Council honored Meg Candage, BSN, RN, CFRN, as its emergency nurse of the year, presenting her with the second annual Cheryl L. Westbay Award for Emergency Nursing Excellence at its annual educational conference in London, Ky., in May. Candage, the current Kentucky ENA treasurer and 2012 president of the Bluegrass Chapter, works in the education department at Georgetown Meg Candage Community Hospital in Georgetown, Ky., and as a flight nurse for Air Care at the University of Cincinnati. The first Cheryl L. Westbay Award was presented in 2013 to Linda J. Murray, RN, CEN, CPEN, a staff development instructor in the University of Kentucky HealthCare emergency Candage receives the Award for Emergency Nursing Excellence from Cheryl L. Westbay. department.

More Members in Motion, page 7 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, AA, 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

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UPDATE FROM THE EXECUTIVE DIRECTOR | Susan M. Hohenhaus, LPD, RN, CEN, FAEN

Strength in the 2nd Quarter D

ear ENA Members, As always, ENA staff remains focused on the work that supports its members. Here is an overview of the health and well-being of ENA at the end of the second quarter of 2014: ♦ ENA’s Government Relations staff focused on the following federal issues in the second quarter of 2014: trauma care legislation, EMS for Children, the Pedestrian Safety Act and support for nurses in the VA system. At the state level, ENA GR staff assisted Louisiana in becoming the 31st state to make assault against an emergency nurse a felony, assisted the California ENA State Council with finding a sponsor for a similar bill that is expected to be introduced in 2015 and assisted the Illinois ENA State Council in preventing poison centers from closing. ENA’s EN411 program increased by 66 members in Q2; 145 members took action to 445 offices on Capitol Hill for EMSC — the largest response to an action alert. Ninety-nine ENA members attended Day on the Hill, up from 77 in 2013. GR staff also worked with the National Association of EMTs and the American Academy of Critical-Care Nurses on air medical safety rules being recommended by the Federal Aviation Administration. ♦ ENA’s marketing team has been extremely busy, evidenced by the fact that our social media presence continues to grow. Our largest presence is on Facebook, where we achieved more than 29,000 ‘‘likes’’ on our main ENA page in the first half of 2014. Web Presence • • • • •

Web traffic increased by about 30,000 unique visitors. Time spent per visit increased slightly. New visitors increased by approximately 4 percent. Mobile usage increased by 6 percent. While e-mail open rates are down approximately 6 percent, the click-through rates are up by almost 1 percent, which we believe means content is relevant.

Social Media • Our number of followers has increased by approximately 2,400 (Q1: 30,132; Q2: 32,520). • Impressions for Q2 have more than doubled since Q1 (Q1: 267,000; Q2: 429,750). This shows our message is resonating and expanding to a wider audience by spreading virally.

♦ ENA’s Market Research staff has completed several studies, including surveys of Academy of Emergency Nursing members, election candidates and conference and Day on the Hill attendees. ♦ ENA’s Institute for Emergency Nursing Education (IENE) continues to monitor our courses, manage the ANCC Continuing Nursing Education units and maintain the free CE process for our members’ benefit. Three courses were deployed in Q2 2014. ♦ ENA’s Institute for Emergency Nursing Research (IENR) has several studies on target, including studies on discharge criteria for patients receiving narcotics; acuity assignment; fatigue and cognitive ability; and moral distress in emergency nurses. ♦ ENA’s Institute for Quality, Safety and Injury Prevention (IQSIP) completed the fourth cycle of the Lantern Award program. Staff has been assisting member work teams and committees in the creation of several products, including topic briefs and position statements. ♦ Course Operations: Trauma Nursing Core Course 7th edition is on target with 2,410 provider courses and 138 instructor courses in Q2. There were 7,731 attendees at provider courses and 248 attendees at instructor courses. Emergency Nursing Pediatric Course had 911 provider courses with 2,334 attendees and 67 instructor courses with 78 attendees. ♦ Membership: ENA’s membership at the end of Q2 2014 was 40,443, compared to 40,059 at the end of Q2 2013. ♦ Finances: The second quarter continued to yield healthy, vibrant financial results. Revenue is up 10 percent from 2013, and while expenses are 7 percent higher than in 2013, we are managing them well at 8 percent better than budget. Total investment income as of June 30 was $754,000. As always, we thank our members for their support, encouragement and thoughtful feedback of ENA’s processes and programs and look forward to a productive second half of 2014.

October 2014

Continued from page 4

Minneapolis ED Determined to Drop Pounds Together Emergency department staff at the University of Minnesota Medical Center–East Bank in Minneapolis recently took part in an ‘‘en masse’’ weight-loss challenge organized by ENA member Erica Myking, RN, CEN, CPEN, to see who could lose the highest BMI percentage over 12 weeks. Each participant contributed $5 into a pot to be awarded to the first-place winner. Weights were reported on the honor system every other Monday and communicated via e-mail. Along the way, Myking provided tips, recipes and motivating quotes. Among 15 other participants who finished the challenge were ENA members Pete Benolken, MSN, CEN, CPEN; Molly Delaney, PhD, RN, CEN, CPEN; Lisa Wright, MA, RN, CEN; and Sandra Fonkert, MSN, CEN, CPEN, a member of ENA’s Peer Review Education Committee, who took second place. Participants lost 116.5 pounds combined. A second challenge began Sept. 2 because the first was so well-received. ‘‘This was a great activity for our department to do together because everyone could participate,’’ Myking said. ‘‘When you work in a department that runs 24/7, it can be difficult to get people together for any sort of extracurricular activities because everybody’s schedules are so crazy. Having the challenge be ‘on your honor’ so nobody had to ever drive in to do a weigh-in made it easy for everyone to participate.’’ Christina M. Weaver, MSN, RN, CEN, of the Cardinal Chapter of North Carolina, was elected to a four-year term on the North Carolina Board of Nursing from January 2015 to December 2018. ‘‘I am looking forward to my service and am proud to say I am also a member of ENA,” Weaver wrote. Kathy Lebowitz, MSN, RN, CEN, is the 2014 recipient of the Alumni Nurse Leader Award from Mount St. Joseph University near Cincinnati. Lebowitz, the emergency department manager at Bethesda Butler Hospital Emergency Department in Hamilton, Ohio, also recently became certified as an advanced nurse executive. Debora La Torre, BSN, RN, received the Clinical Excellence Award at New Jersey ENA’s annual Emergency Care Conference. Other award winners from the conference were listed in the August issue of ENA Connection.

Official Magazine of the Emergency Nurses Association

PARTNERSHIPS

PUTTING OUR HEADS TOGETHER ENA, Nursing Execs Meet For Day of Dialogue on Workplace Violence By Amy Carpenter Aquino, ENA Connection

mergency nurses cannot solve the problem of violence in the emergency department by themselves. On July 14-15, members of ENA and the American Organization of Nurse Executives held a day of dialogue in Chicago to discuss workplace violence and how the organizations can partner to provide solutions. The following ENA members and staff represented the association: Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN, 2014 president; JoAnn Lazarus, MSN, RN, CEN, immediate past president; Susan M. Hohenhaus, LPD, RN, CEN, FAEN, executive director; Kathy Szumanski, MSN, RN, NE-BC, deputy executive director for nursing; Lisa Wolf, PhD, RN, CEN, FAEN, director of the Institute for Emergency Nursing Research; Kristine Powell, MSN, RN, CEN, NEA-BC, corporate director of emergency services for Baylor, Scott & White Emergency Services-North Texas; and Sean Elwell, MSN, RN, EMT-B, trauma program manager and interim ED manager at the Alfred I. DuPont Hospital for Children in Wilmington, Del. AONE was represented by Pamela Thompson, MS, RN, CENP, FAAN, chief executive officer of AONE and senior vice president for nursing for the American Hospital Association; Karen Wray, MSN, RN-BC, NEA-BC, nursing director, acute care, at the University of Kansas Hospital; Reynaldo R. Rivera, DNP, RN, NEA-BC, FAAN, director of nursing, New York Presbyterian Hospital; and Erik Martin, MSN, RN, clinical director for the Pediatric

“I think there needs to be buy-in on this from all different levels. It’s definitely important for emergency nurses, but it’s important from a leadership standpoint, too, that there is support for this moving forward.’’ Sean Elwell, MSN, RN, EMT-B, ENA Representative at meeting with AONE Intensive Care Unit at Cincinnati Children’s Hospital Medical Center. ‘‘I thought it was an exciting idea to bring together the nurse executives with the emergency nurses,’’ said Powell, who was invited to the day of dialogue by Brecher. ‘‘I believe that when the nurse executive is actively involved and aware of the issue of workplace violence, we can be more proactive and more effective in dealing with the issue itself.’’ Powell said the meeting began with a session in which the two groups met separately to discuss what they would say to the other group. ‘‘If you could tell the nurse executives whatever you want about workplace violence, what would those things be from the perspective of a clinical staff nurse in the emergency department?’’ Powell said. ‘‘And alternately, the nurse executives were responsible for doing the same thing.’’ Powell said that session was “very insightful’’ because when the two groups shared their results, the importance of other expected issues such as lateral violence came to the forefront. While lateral violence, or

Kristine Powell Sean Elwell violence between colleagues, is usually not physical, it is no less harmful. ‘‘Violence is violence, regardless of who the perpetrator is,’’ Powell said. Elwell said he appreciated the format for the two-day meeting because it offered a platform not only for discussing the problems but for formulating a plan to move forward and establishing priorities for the two groups in managing workplace violence. ‘‘I think there needs to be buy-in on this from all different levels,’’ he said. ‘‘It’s definitely important for emergency nurses, but it’s important from a leadership standpoint, too, that there is support for this moving forward. I think that’s a big piece.’’ ENA continues to reach out to new partners. On Aug. 21, members of the International Association of Healthcare Security and Safety visited ENA headquarters in Des Plaines, Ill., to share their perspective on the issue of violence in the ED. Brecher wrote about the meeting in the Aug. 26 edition of her ENA President’s Blog (enapresident.wordpress.com). Additional coverage will appear in next month’s issue of ENA Connection. ‘‘Workplace violence is not just a staff safety issue,’’ said Powell, who also attended the Aug. 21 meeting. ‘‘It’s a patient safety issue. The shared goal for all of us is to make the environment safer for our patients and ourselves.’’

October 2014

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

n recognition of Emergency Nurses Week, I felt compelled to submit a letter as a celebration of all emergency nurses and the job we all do daily without a second thought about the impact we make on the lives of others. A short time ago, I was moved by the circumstances that resulted in my elementary-school-age daughter bringing home a 30-minute video for her ‘‘Hero Classic Assignment,’’ and I wanted to share my thoughts with gratitude. The assignment was to watch the video and reflect on the central idea of ‘‘experiencing risk is part of being human.’’ By complete coincidence, my daughter chose the Florence Nightingale video. When her teacher (a nurse) questioned her choice, she stated that she liked Florence’s name, having no idea that she was the nurse who shaped her mother’s professional life. That evening found the entire family viewing the video about this hero, Florence Nightingale, and her life as the founder of modern nursing. The amazement in my child’s eyes as she saw the care that Florence provided to the soldiers and how she herself became ill created feelings of pride in my heart. As I reflected on my years in nursing and the patients who had been in my care, I thought of those close to me who were choosing nursing as their profession and found myself with tears in my eyes in appreciation for the legacy that we all continue to uphold. As emergency nurses, we all see more in our career than most people see in a lifetime. But despite the critical and dying patients, sick children, verbally inappropriate patients and others who touch us emotionally, we continue to perform our job without hesitation. All too often, we do not hear words of thanks. As we celebrate Emergency Nurses Week, it is important to take a moment to reflect on our work and to say thank you for the care you provide, and for being a true risk-taker. You make our specialty profession outstanding, and there is nothing trivial about your impact on the lives of others. As Florence Nightingale once said, ‘‘Live life when you have it. Life is a splendid gift — there is nothing small about it.’’ Mary Cain, BSN, RN, CEN, Emergency Department Staff Nurse, St. Anthony Hospital, Lakewood, Colo.

From the President

Continued from page 3

interrupt patient handoff to ask a question? If the patient’s life depends on it right now, the answer is yes. If it’s a question that needs to be asked but not critical in this moment in time, should you be interrupting a patient care conversation to ask it? How do we partner with the interdisciplinary team to limit unnecessary distractions and still engage in critical communication? First, we need to change our own behavior. The next time you are heading out to ask a question of a colleague, pay attention to the task that person is engaged in. If your colleague is obviously engaged in a critical patient task, such as handoff or medication preparation, hold your question until the task is complete. Then ask if it’s a good time for a question. If you are engaged in a task and someone approaches with a question, say, ‘‘I need to focus on this critical task. I am happy to answer your question when I am finished.’’ By recognizing unsafe clinical behavior in ourselves, we can change that behavior and move closer to an error-free ED. Read more from Deena Brecher on the ENA President’s Blog (enapresident.wordpress.com or QR code at left).

JEN Editor-in-Chief Named

n Aug. 26, ENA announced the appointment of Anne Manton, PhD, PMHNP-BC, FAEN, FAAN, as editor-inchief of the association’s Journal of Emergency Nursing. She had been interim editor-in-chief since September 2013. Manton, who specializes in psychiatric and mental health care, brings extensive emergency nursing experience to this role, as well as decades of involvement with ENA. She was ENA president in 1998 and previously was a contributing editor to JEN. ‘‘As the editorial board looked at the future of JEN and how it fits into ENA’s strategic plan, it was evident that Dr. Manton not only has the expertise to elevate the journal but has already made substantial contributions since she began serving as interim editor,’’ said ENA president Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN. ‘‘Her clinical expertise, leadership skills and involvement with ENA provide a solid foundation for producing a journal with the highest level of editorial excellence.’’ JEN is the official peer-reviewed journal of ENA and reaches more emergency nurses, emergency/trauma departments and ED managers than any other journal. Marie Grimaldi

Look for more information about Manton’s new role in an upcoming issue of ENA Connection.

Official Magazine of the Emergency Nurses Association

ENA ARCHIVES

Seeing What’s in Store Trip to Review Collection Confirms ENA Treasures By Kendra Y. Mims, ENA Connection

he ENA Collection is a comprehensive history of the association that consists of seven boxes containing original correspondence from ENA founders Anita Dorr, RN, FAEN, and Judith C. Kelleher, RN, MSN, CEN, FAEN, along with other donated historical items. It’s housed at the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry, which was established at the University of Virginia School of Nursing in 1991 to acquire nursing materials and preserve nursing history. ENA’s volunteer historian, Joanne Fadale, BSN, RN, FAEN, and ENA staff archivist Laura Peter took their first visit to the Bjoring Center in August. The primary purpose was to verify the materials donated to the collection and confirm how many of the documents were original as opposed to copies. After a full day of examining the contents of the boxes — archived in the Claude Moore Health Sciences Library — Fadale found an estimated 80 percent of the documents were originals. Archived items included letters, minutes, reports, a cloth patch displaying ENA’s first mascot and logo (the Roadrunner), the first Emergency Department Nurses Association national conference program and volumes of ENA Connection and ENA Daily News.

ENA volunteer historian Joanne Fadale, BSN, RN, FAEN, and staff archivist Laura Peter stand with the seven-box ENA Collection they went through in August at the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry in Charlottesville, Va.

How the Archiving Project Came to Be At its July 2004 meeting, the ENA Board of Directors approved a proposal to donate records related to the foundation and formation of ENA to the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry at the University of Virginia School of Nursing. The initial donation was made at a dedication ceremony on Sept. 28, 2005. Fadale said she didn’t realize how many people were involved in forming ENA until she went through the collection. She discovered numerous letters between Dorr and ENA past president Marion Dover, RN, and would like to see original correspondence from other past presidents included, as well as the history of the first Trauma Nursing Core Course and Emergency Nursing Pediatric Course. ‘‘I don’t think we need to send

everything, but I think we need to include how we got funding for the first TNCC and ENPC,’’ Fadale said. ‘‘Those things are significant because when you do a project like that, there are people involved and funding.’’ The library where the collection is housed has historical nursing books and artifacts on display, including a nursing student uniform similar to the one Fadale wore more than 40 years ago. ‘‘They had just about every book on nursing history and nursing from all parts of the world — you could just sit there for hours and read,’’ Fadale said. ‘‘They have a nice collection of their own historical artifacts. They also have a window display, currently of the year 1906. They have appropriate newspaper articles on the diseases of that time, like influenza. The display shows a child going to the hospital with their mother, and it shows a nurse. It was all done in appropriate clothing for that time.’’ Fadale said she was impressed with the care the University of Virginia took with the ENA Collection. ‘‘They organized the collection so

October 2014

Among other nursing items on display at the Bjoring Center’s Claude Moore Health Sciences Library: a quilt honoring the profession and an old uniform of the type once worn by student nurses. well that we didn’t have to dig through,’’ she said. A meeting with the center’s director, Arlene W. Keeling, PhD, RN, FAAN, provided insight into what ENA actually should be saving. Fadale’s favorite part of the trip was reviewing old documents that she had seen at one point in her life.

‘‘Most of those documents came from my chapter,’’ she said. ‘‘In 1985, we found all of these documents after one of our former state presidents passed away. She had all Anita’s old documentation, and we gave it to the national president in a binder. Those are the only copies that we have of

those. It tickled my heart knowing that I had put my fingers on these pieces of paper before.’’ For more on the ENA Collection and to view a list of the contents, visit tinyurl.com/ ENACollection or scan the QR code at left.

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Official Magazine of the Emergency Nurses Association

TECH SUPPORT Emergency Nurses Encouraged to Take the Wheel on Child Passenger Safety as Certified Technicians By Kendra Y. Mims, ENA Connection

larming statistics show that preventable injuries are the No. 1 killer of children in the United States and that U.S. emergency departments treat almost 9 million pediatric patients for injuries every year. The National Child Passenger Safety Certification Training program attempts to reduce that by raising awareness and educating communities and families about child safety on the road. The State Farm-sponsored program certifies child passenger safety technicians and instructors. More than 131,000 people have completed the certification course since 1997, including 36,000 currently certified CPS

technicians. CPS technicians contribute to improving children’s safety by conducting child car seat checks, providing families with hands-on instructions on how to install seats and safety belts properly and educating parents on what they can do to prevent injuries. Meanwhile, Safe Kids Worldwide is an organization committed to protecting children from unintentional injuries through advocacy, research, education and awareness programs. As the CPS certification specialist for Safe Kids Worldwide, Kim Herrmann travels nationally, developing continuing education opportunities to help CPS technicians maintain their certification. ‘‘It’s a two-year certification,’’

GET CERTIFIED, EARN CE CREDIT Upon successful completion of the National Child Passenger Safety Certification Training course, ENA will provide 23.75 contact hours. In order for nurses attending a certification course to receive 23.75 nursing contact hours (6.91 Pediatric designation), the lead instructor must follow the requirements detailed in the checklist (tinyurl.com/ LeadInstructorChecklist or QR code below). Course documentation must be maintained for six years. ENA is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. For questions regarding any details for contact hours, please email the CNE unit with your questions at CNE@ena.org.

October 2014

INJURY PREVENTION Herrmann said. ‘‘We’ve been able to really increase the quality, as well as the numbers of certified technicians. They come from a background of not only hospital-based programs, but also firefighters, EMS personnel, law enforcement and public health. Many people who want to be advocates for children come from a lot of different walks of life. Many people, like first responders, are frustrated when there is a crash-related injury and it could have been prevented had the child been properly secured in an appropriate car seat.’’ Herrmann said almost half of the 36,000 certified CPS technicians are from the health field (hospital/medical personnel make up 19 percent and rescue/EMS personnel 28 percent). She actively searches for ways to promote the importance of CPS certification. ‘‘Children really do not have the capability of protecting themselves,’’ she said. ‘‘We treat them, we try to help them recuperate, but it takes the family to do that. If we had a way of connecting emergency nurses to families to help them understand that there is more that can be done to protect their children and keep them safer, I think the emergency nurse would have a big role in that.’’ ENA member and National Child Passenger Safety Board member Thelma Kuska, BSN,

STATISTIC Safe Kids Worldwide reports that child safety seats can reduce fatal injury by up to 71 percent for infants and 54 percent for toddlers. In 2011, restraint use saved 263 lives, according to the organization.

RN, CEN, FAEN, has position to educate long been a proponent parents and caregivers of emergency nurses on how to keep Motor vehicle crashes becoming certified CPS children safe while are the No. 1 cause of technicians. traveling in motor death for people ages 1 ‘‘Should all vehicles. Routine to 19 years, according emergency nurses be encounters in the to Safe Kids Worldwide. certified technicians? It emergency department would be nice, but the provide a perfect setting reality is they do not all have to be for this educational opportunity.’’ certified,’’ said Kuska, who has been The CPS Technician Certification involved in child passenger safety for Course is three to four days of more than 15 years. ‘‘But all of them classroom instruction with hands-on should have the correct information so skill assessments, written quizzes and a that they can provide the correct community safety seat checkup event. discharge instructions to parents and Highlights of the course include caregivers.’’ learning about the different parts of the “Emergency nurses are in a very car seat, how to read instructions, how unique position to influence the to install car seats in different vehicles parents because of the teachable and the basics of injury prevention. moments in the ED,’’ Kuska added. Nurses can earn contact hours for ‘‘We see the victims of car crashes and completing the national course. know their injuries. Routine encounters ‘‘Nurses would also learn about with young children and their parents some of the technology involved in the provide excellent opportunities for vehicles and car seats, so we can point assessing car seat and booster seat use. those out to families and provide Emergency nurses are also in a unique guidance to families,’’ Kuska said. ‘‘We can also make sure their current data is appropriate for the age and weight of their child, and it fits them properly.’’ Safe Kids Worldwide continues to raise awareness and promote CPS technician certification through initiatives such as the nationally recognized Child Passenger Safety Week in September and partnering with advocacy agencies to help families protect their children. ‘‘It’s a big responsibility, and there’s a real passion for people who want to help children,’’ Herrmann said. ‘‘We would just like to be able to let more people know about child passenger safety as a potential to fit in with their current job responsibilities to protect and advocate for children.’’

STATISTIC

Official Magazine of the Emergency Nurses Association

WASHINGTON WATCH | Ken Steinhardt, ENA Director of Government Relations

Medical Errors on Senate’s Radar ‘M

edical harm is a major cause of suffering, disability and death — as well as a huge financial cost to our nation,’’ Sen. Bernie Sanders (I-Vt.) said at the outset of the July 17 hearing of the Senate Subcommittee on Primary Health and Aging. At this subcommittee hearing, hospital quality and patient safety experts urged lawmakers to establish measures to minimize the number of medical errors in hospitals. According to one of the witnesses at the hearing, more than 220,000 deaths occur each year because of preventable medical mistakes. Another witness cited the figure of 440,000 preventable deaths due to errors committed by the health care system. In addition to deaths and injuries, medical errors also cost the United States billions of dollars. The health policy journal Health Affairs published a study that put the figure at $17 billion a year. Counting indirect costs such as lost productivity due to missed work days, medical errors cost nearly $1 trillion each year, according to a 2012 report in the Journal of Health Care Finance. One of the witnesses at the congressional hearing was Joanne Disch, PhD, RN, FAAN, clinical professor at the University of Minnesota School of Nursing. Disch testified there are many factors that lead to medical errors, including the ‘‘complexity of health care, the rapid generation of new knowledge and interventions, the patchwork nature of our health care system, the incentives to do too many interventions and not enough assessment and prevention, and the use of new technology (both too much and little).’’ Disch also highlighted several recommendations based on her 46 years of experience as a nurse that she believes will lead to a measurable improvement in patient safety. These include (1) ensuring a sufficient supply of highly educated nurses, (2) actively engaging patients and families as partners in their care and (3) convincing hospitals and other healthcare settings to embrace a culture of safety. Another witness, Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins University, testified that though progress has been made, thousands of patients are still dying unnecessarily from infections, preventable blood clots, adverse drug events, falls, overexposure to medical radiation and diagnostic errors. ‘‘We need to declare right now that preventable harm is unacceptable and work to prevent all types of harm,’’ Pronovost said. Ashish Jha, MD, MPH, a Harvard School of Public Health professor, testified that American hospital patients are no

safer today than they were in 1999, when the Institute of Medicine released its report ‘‘To Err is Human.’’ ‘‘We have not moved the needle in any demonstrable way overall,’’ he said. ‘‘No one is getting it right consistently.’’ In addition to the recommendations set forth by Disch, witnesses offered a wide array of initiatives for reducing medical errors, such as expanding the role of the Centers for Disease Control and Prevention to compile and report patient safety data, establishing a national patient safety board or increasing the oversight responsibilities of Centers for Medicare and Medicaid Services and the Joint Commission. Witnesses also called on providers to improve information technology systems and create incentives to enhance safety throughout the entire health care system. The hearing by the Primary Health and Aging Subcommittee wasn’t the only activity in Washington focused on patient safety. In April, Sen. Barbara Boxer (D-Calif.) released a new report detailing the most common and harmful errors at our nation’s hospitals and what hospitals in California are doing to prevent them. Boxer wrote to 283 California acute-care hospitals asking them to respond with the actions they are taking to improve patient safety. As of July, 87 percent of the hospitals had responded. Notably, the survey found that all the hospitals are taking at least some steps to address the most common medical errors, while others were pursuing unique approaches to enhance patient safety. For example, UCLA Medical Center reported that it disinfects hospital rooms using ultraviolet technology, prohibits the use of home-laundered scrubs and bans healthcare professionals with open wounds, bandages or casts from scrubbing into surgeries. Desert Valley Hospital in Victorville reported that it reduced the number of surgical site infections from 16 in 2009 to 2 in 2013 after starting an innovative program that rewards medical staff who are observed practicing good hand hygiene. The hearing held by the Senate Subcommittee on Primary Health and Aging and the important report produced by Boxer’s office show an increased focus by our federal representatives on the issue of medical errors and patient safety. Given the opportunity to save countless lives, it is our hope that this work will lead to meaningful legislation.

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Potential complications may include local or systemic infection, hematoma, extravasations or other complications associated with percutaneous insertion of sterile devices. References: 1. Rogers JJ, Fox M, Miller LJ, Philbeck TE. Safety of intraosseous vascular access in the 21st century [WoCoVA abstract O-079]. J Vasc Access. 2012;13(2): 1A-40A. 2. Paxton JH, Knuth TE, Klausner HA. Proximal humerus intraosseous infusion: a preferred emergency venous access. J Trauma. 2009;67(3):1-7. 3. Cooper BR, Mahoney PF, Hodgetts TJ, Mellor A. Intra-osseous access (Ez-IO ® ) for resuscitation: UK military combat experience. J R Army Med Corps. 2007; 153(4):314-316. 4. Dolister M, Miller S, Borron S, et al. Intraosseous vascular access is safe, effective and costs less than central venous catheters for patients in the hospital setting [published online ahead of print January 3, 2013]. J Vasc Access. doi:10.5301/jva.5000130. *Research sponsored by the Vidacare Corporation. Teleflex and EZ-IO are trademarks or registered trademarks of Teleflex Incorporated or its affiliates. © 2014 Teleflex Incorporated. 2014-2673

BEHAVIORAL HEALTH

A Friend to Call On Grant Program for Suicide Crisis Lifelines Allows Wisconsin Center to Give Local ED a Helping Hand By Kendra Y. Mims, ENA Connection

he U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) and the Mental Health Association of New York City (MHA of NYC) launched the National Suicide Prevention Lifeline in 2005 to provide confidential, free support to those in a suicidal crisis via a network of 24/7 crisis intervention centers. Through the National Suicide Prevention Lifeline Crisis Center Follow-Up grant program, funded by SAMHSA, a subdivision of crisiscenter grantees also provides follow-up services and continuity of care for patients discharged from emergency departments. With the patient’s consent, these centers contact the patients to help them receive the appropriate behavioral health services. One of these centers, the Acute Care Services lifeline crisis center in West Bend, Wis., is partnered with Froedtert & the Medical College of Wisconsin St. Joseph’s Hospital and handles 1,000 to 1,200 contacts per month, consisting of walk-ins, mobile crisis interventions, calls coming into the center and follow-ups. Lori Landy, the behavioral health care coordinator at St. Joseph’s Hospital, says partnering with a 24/7 mobile crisis team that responds to the ED has been an invaluable resource. ‘‘It’s been five years [that we’ve] worked cooperatively trying to meet the needs of patients with behavioral health issues or concerns in the ER while focusing on the least restrictive interventions whenever possible,’’ Landy said. ‘‘In return, they [ACS] connect the patient to the lifeline and follow up with them.’’ Although St. Joseph’s does not have a behavioral health unit onsite, Landy says her position allows her to complete consultations in the ED and assess suicidal patients. ‘‘St. Joseph’s recognizes that just because we don’t have a behavioral health unit, it doesn’t mean that we are not going to have a behavioral health crisis in the ED. We might have them more frequently,’’ she said. When an ED nurse recently called her about a suicidal patient who had relapsed, she was able to assess the patient instead, allowing the nurse to get back to bedside patient care. ‘‘St. Joseph’s recognizes the need for a specialized role in the ER,’’ Landy said. ‘‘One of the nurses’ frustrations, often, in our ER is that they spend more time on the phone calling for services for patients with behavioral health needs and the

Lori Landy

Ginger Knapp

amount of time it takes to get a person referred to appropriate services. That’s where I come in. It can take hours to find beds and find treatments, and that’s not always the best use of the ER nurse’s skill. I think the biggest benefit for the ED nurses is having a crisis partnership like this that gets them back to bedside where they are needed and away from the role of trying to be a nurse case manager on the phone. It’s out of their scope and takes them away from patients and critical health issues.’’ St. Joseph’s staff nurse Ginger Knapp, RN, CEN, considers Acute Care Services another part of her ED team. ‘‘ACS comes to the patient’s bedside and spends time talking to our suicidal patients and then determines the best plan for these patients,’’ Knapp said. ‘‘For some patients, ACS can ‘safety plan to home.’ ACS coordinates the safety plan based on the patient’s needs and also coordinates the follow-up for this. A safety plan to home is a great option for people. It saves money by preventing a hospitalization. It also prevents the patient from having to appear before a judge, as they would if they were chaptered. Also, these patients do not need the added stress of missing work for a hospitalization.’’ After ACS interviews the patient, a determination may be made on inpatient care, which can be voluntary or involuntary. ‘‘ACS can facilitate these transfers a lot faster than I can,’’ Knapp said. ‘‘A transfer requires a lot of sitting on the phone, calling different mental health facilities to find openings. ACS takes care of all of this. They provide the nurse with the name of the hospital and the phone number to intake. Sometimes you go through the intake process, only to find out the patient is declined at a certain facility. We just let ACS know, and they do the legwork and provide us with another facility.’’ The partnership with ACS gives patients an opportunity to talk openly. ‘‘Patients really appreciate the ability to talk,’’ Knapp said. ‘‘The ER staff frequently does not have time to do this. These patients are often accompanied by the police. For the most part, when ACS does their interview with the patient, the police step out of the room. ACS can really get to the root of the problem. This can really diffuse a situation.’’ Patients who consult with ACS typically move through the department faster, Knapp said. ‘‘This helps overall throughput,’’ she said. ‘‘If the department keeps moving, all of our patients are happy.’’

October 2014

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ENA Trauma Committee Develops Tourniquet-Use TIP

ongratulations to ENA’s Trauma Committee on the development of a Translation Into Practice document regarding the use of tourniquets. This evidence-based document includes recommendations for the use of tourniquets, along with supporting rationale as it relates to extremity trauma to reduce blood loss, thus decreasing morbidity and mortality. Committee members include Ellie Encapera, RN, CEN, board liaison; Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN, chairperson; Pete Benolken, MSN, RN, EMT-B, CEN, CPEN; Stacey Hill, BSN, RN; Kimberly Murphy, MSN, RN, CEN, ACNP-BC, MICN, PHN; Maria Tackett, EdD, MSN, RN, CEN, CCRN; Leslie Gates, senior administrative assistant; and Dale Wallerich, MBA, BSN, RN, CEN, staff liaison. This and other TIPs may be found at tinyurl.com/ENA-TIPS or by scanning the QR code here.

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Chamberlain College of Nursing | National Management Offices 3005 Highland Parkway | Downers Grove, IL 60515 | 888.556.8CCN (8226) | chamberlain.edu Comprehensive program-specific consumer information: chamberlain.edu/studentconsumerinfo. Program/program option availability varies by state/location. The Bachelor of Science in Nursing degree program and the Master of Science in Nursing degree program are accredited by the Commission on Collegiate Nursing Education (CCNE, One Dupont Circle, NW, Suite 530, Washington, DC 20036, 202.887.6791). Chamberlain College of Nursing, 2450 Crystal Drive, Arlington, VA 22202 is certified to operate by the State Council of Higher Education for Virginia, 101 N. 14th Street, 10th Floor, James Monroe Building, Richmond, VA 23219, 804.225.2600. Chamberlain College of Nursing has provisional approval from the Virginia Board of Nursing, Perimeter Center, 9960 Mayland Drive, Suite 300, Henrico, VA 23233-1463, 804.367.4515. ©2013 Chamberlain College of Nursing, LLC. All rights reserved.

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Official Magazine of the Emergency Nurses Association

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INITIALS

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ADASUVE Administer ADASUVE only inADASUVE an only enrolled in an only enrolled healthcare in an enrolled healthcare facility healthcare that facility hasthat immediate facility has that immediate has immediate n access on-site access to on-site access equipment to on-site equipment and topersonnel equipment and personnel trained and personnel to trained manage to trained manage acuteto bronchospasm, manage acute bronchospasm, acute including bronchospasm, includingincluding •U advanced advanced airwayadvanced management airway management airway (intubation management (intubation and mechanical (intubation and mechanical and ventilation). mechanical ventilation). 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REMS. •T Increased Increased Mortality Increased Mortality in Elderly Mortality inPatients ElderlyinPatients With Elderly Dementia-Related Patients With Dementia-Related With Dementia-Related Psychosis Psychosis Psychosis a Elderly patients Elderly patients with Elderly dementia-related with patients dementia-related with dementia-related psychosis psychosis treatedpsychosis with treated antipsychotic with treated antipsychotic with drugs antipsychotic are drugs at anare drugs at anare at an increased p increased increased risk of death. risk of ADASUVE death. risk of ADASUVE is death. not approved ADASUVE is not approved foristhe nottreatment approved for the treatment of forpatients the treatment of patients with dementia-related of with patients dementia-related with dementia-related psychosis. psychosis. psychosis. •U •T p •P • ADASUVE • ADASUVE is contraindicated • ADASUVE is contraindicated isincontraindicated patients in patients with the in following: with patients the following: with the following: a — Current — diagnosis Current —diagnosis Current or history diagnosis orofhistory asthma, orofhistory asthma, chronic ofobstructive chronic asthma,obstructive chronic pulmonary obstructive pulmonary disease pulmonary (COPD), disease (COPD), or disease other lung or (COPD), other lung or other lung p disease associated disease associated disease with bronchospasm associated with bronchospasm with bronchospasm — Acute— respiratory Acute — respiratory Acute signs/symptoms respiratory signs/symptoms (eg, signs/symptoms wheezing) (eg, wheezing) (eg, wheezing) •N — Current — use Current of — medications use Current of medications use toof treat medications airways to treat disease, airways to treatdisease, such airways as asthma disease, such as or asthma such COPD asor asthma COPDor COPD •T — History —of History bronchospasm —ofHistory bronchospasm offollowing bronchospasm following ADASUVE following ADASUVE treatment ADASUVE treatmenttreatment Re — Known —hypersensitivity Known—hypersensitivity Knowntohypersensitivity loxapine to loxapine or amoxapine. to loxapine or amoxapine. 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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PEC=Positive and PEC=Positive Negative PEC=Positive Syndrome and Negative and Negative Scale-Excited Syndrome Syndrome Component. Scale-Excited Scale-Excited Intent-to-treat Component. Component. population Intent-to-treat Intent-to-treat with population last observation population with with last carried observation last forward. observation carried Agitation carried forward. symptoms forward. Agitation Agitation measured: symptoms symptoms tension, measured: excitement, measured: tension, tension, poor excitement, excitement, poorpoor impulse control,impulse uncooperativeness, impulse control, control, uncooperativeness, uncooperativeness, hostility. Each item hostility. ishostility. scored Eachon Each item a scale item is scored is from scored on 1 toa on 7scale (1=absent, a scale fromfrom 1 4=moderate, to 71 (1=absent, to 7 (1=absent, 7=extreme). 4=moderate, 4=moderate, Patient 7=extreme). total 7=extreme). PECPatient scores Patient total ranged total PECfrom PEC scores 14 scores ranged to 31ranged out from of afrom 14 possible to14 31toout 35. 31of out a possible of a possible 35. 35. The efficacy of The ADASUVE The efficacy efficacy 10ofmg ADASUVE ofinADASUVE the acute 10 mg treatment 10 in mg theinacute the of agitation acute treatment treatment associated of agitation of agitation withassociated schizophrenia associated with or with schizophrenia bipolar schizophrenia I disorder or bipolar or was bipolar established I disorder I disorder was in awas established short-term established in (24-hour), a short-term in a short-term randomized, (24-hour), (24-hour), randomized, randomized, double-blind, placebo-controlled, double-blind, double-blind, placebo-controlled, placebo-controlled, fixed-dose trial fixed-dose including fixed-dose 344 trialpatients including trial including who 344met 344 patients DSM-IV patients who criteria who met met DSM-IV for schizophrenia DSM-IV criteria criteria for and schizophrenia for in schizophrenia another study, and and in 314 another in patients another study, study, who 314met patients 314DSM-IV patients who criteria who met met DSM-IV for DSM-IV criteria criteria for for bipolar I disorder, bipolar manic bipolar I disorder, or Imixed disorder, manic episodes manic or mixed with or mixed or episodes without episodes with psychotic with or without orfeatures. without psychotic psychotic features. features.

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

WHAT HAPPENS IN VEGAS HELPS EVERYONE By Josh Gaby, ENA Connection

concentrating on state leaders and our leadership conference.’’ NA will redefine the idea of a State and chapter leaders will learn winning hand next February when about ENA governance guidelines and it holds the State and Chapter Leaders the strategic plan of the ENA Board of Orientation, a focused two-day event Directors to make sure their units and for all 2015 officers and core national ENA are running in leaders at the Paris Hotel in Las sync. There will be specific Vegas — a frequently requested sessions on finances, city for ENA events. association law, meeting The orientation previously management, conference was known as the State and planning, member engagement Chapter Leaders Conference and social media, along with and had in recent years been a dynamic general session Matthew lead-in to the ENA Leadership speakers. Advocacy and F. Powers Conference, the last of which government relations will be was this year in Phoenix. ENA switches key parts of the program — ‘‘how to to one larger conference, Emergency get more involved in changing law, Nursing 2015, beginning next fall. statute and regulation at your local, All state council and chapter officers state and national level,’’ Powers said. and core leaders — that includes In short, the orientation is about government affairs chairs, membership resources and, just as important, face chairs and any other core leaders — time with the people providing them. are strongly encouraged to attend the Powers, who attended his first ENA orientation Feb. 19-20. Registration conference in 2002 and became begins in November, with information president of the East Bay (Calif.) to be sent to all 2015 leaders who are Chapter the next year before rising reported in the State Council and through the California ENA State Chapter Online Management System. Council, knows how important these Matthew F. Powers, MS, BSN, RN, resources are to both seasoned and MICP, CEN, the 2015 ENA president, new leaders. The emergence of new said there’s no better way to ENA leaders each year is ‘‘amazing,’’ understand the roles, responsibilities he said. and processes of ENA and how your ‘‘It’s seeing the passion in new state council or chapter connects, faces, seeing new people that want to especially if you’re new to the job. get involved and make a difference, ‘‘The No. 1 reason to attend your and to be able to really get the best state and chapter leaders orientation out of the best from our members’ would be to learn more about your talent and experience,’’ Powers said. professional organization and what ‘‘You are able to see their eyes light and who ENA is, and what it stands up. They get revitalized, they get very for,’’ Powers said. ‘‘This orientation is involved, and I think our challenge is really focused for our member leaders, to keep that motivation going and we’ll be able to focus our time throughout the year.’’ and energy solely toward the Mari Hoover-McGarry, RN, CEN, orientation process vs. previously CCRN, is a veteran of ENA orientations

State and Chapter Leaders Orientation When: Feb. 19-20, 2015 – Paris Hotel, Las Vegas Signing up: Registration starts in November at www.ena.org; 2015 leaders in the Online Management System will receive a formal invitation. Registration, CE, breakfast and lunch are complimentary. Hotel, airfare and dinner expenses are not covered. Pre-orientation resources: tinyurl.com/ ENAofficers

B:12”

T:10”

S:9.5”

tinyurl.com/ ENAstateschapters

Official Magazine of the Emergency Nurses Association

Full program coming soon at www.ena.org. and calls them ‘‘an energizing environment.’’ As treasurer for the Palm Beach County (Fla.) Chapter and a past president and treasurer of the Florida ENA State Council, she stressed the importance of networking and becoming clear on fiduciary rules, particularly nonprofit tax status and how it governs advocacy efforts with politicians. It’s also great team-building, she said, both nationally with your board liaison and within your state. ‘‘It helps put you on the front lines with the ENA staff and the national board members,’’ she said. ‘‘And it’s nice to incorporate some social time with your state leaders because we all come from various parts of the state — we don’t all live in one small geographic location.’’

ENA FOUNDATION

SENT WITH LOVE

Helped by $500 Annual Conference Scholarship, This Emergency Nurse Will Keep Going Places By Kendra Y. Mims, ENA Connection

stay calm and relaxed in emergency situations was something I found really tacey Cernadas, ADN, RN, EMT, had soothing. It fit me perfectly. traveled the world as an ‘‘I really feel like it’s what I was put international flight attendant for almost here to do. It’s natural to me. I feel at nine years when she decided to ease and like emergency quit her job to pursue a career nursing is where I’m supposed in nursing. Even though it was to be. I look forward to the her third career change, the many years of making a former pre-med student knew difference in this profession.’’ the nursing profession was Cernadas has now been an where she belonged. emergency nurse for 16 She had always wanted to months and works at Baptist work in the medical field — she Stacey Cernadas Medical Center South in just had to find her way back to Montgomery, Ala., where she was it. She first was drawn to nursing at age encouraged to join ENA by Leigh 12 when her stepfather suffered a Parker, BSN, RN, CEN, the Alabama massive heart attack. ENA State Council president. ‘‘He had a quadruple bypass when ‘‘Leigh was one of my charge he was my current age [36],’’ Cernadas nurses, and she took me under her said. ‘‘I remember going through that wing and gave me goals to fulfill,’’ experience and seeing the care the Cernadas said. ‘‘She’s been a really nurses provided to our family and the good mentor and introduced me to patient advocacy. I remember very ENA very early in my career.’’ vividly how great it was and how Cernadas attended her first ENA life-changing that event was for my Annual Conference last year in family and for me at a young age. It’s Nashville after being selected to one of those things that has been a participate in the TNCC pilot course. very large part of my life.’’ ‘‘It was amazing,’’ she said. ‘‘I was The experience was one of so enthralled by everything that was Cernadas’ main motivators when she going on. There were so many sessions enrolled in nursing school in 2010. She available, and it was really awesome initially wanted to be a labor and being able to choose educational delivery nurse until her mentor sessions to attend. Everyone was very encouraged her to try emergency receptive. It was a nice brotherhood nursing. As soon as she decided to and sisterhood of nurses, and I felt like precept in the emergency department, it was like my family.’’ Parker also encouraged Cernadas to she fell in love and never looked back. apply for an ENA Foundation ‘‘I knew it immediately,’’ she said. professional development scholarship ‘‘I’m very calm and collected, and to attend the 2014 ENA Annual there’s not much that can get me Conference in Indianapolis. There are flustered or stressed, so being able to

Stacey Cernadas was in Nashville last year for the 2013 ENA Annual Conference and gets to return this year with scholarship assistance. 19 of these $500 scholarships this year, intended to reduce the conference cost and travel expenses for ENA members who would otherwise be unable to attend. When Cernadas received the call that she would be awarded one, she screamed in excitement. ‘‘I’m really thrilled, and I take this opportunity seriously,’’ she said. ‘‘I get to hear amazing speakers all day long, and at the end of the day, I have great CE credits. I’m looking forward to the educational sessions. I also get to see all of the vendors at the exhibit hall and the new things that are coming out on the market that I can take back to work. I’m just so excited.’’ Cernadas encourages emergency nurses to give back to the ENA Foundation to contribute to colleagues’ professional development and growth. ‘‘I think it’s very important to donate and give back because it lets us create and evolve our ENA nurses as the times pass,’’ she said. ‘‘If we don’t give back, then we are not showing our appreciation to the incoming nurses,

October 2014

and we are not willing to help mold them and make them the best they can be. You’re only as strong as your weakest link, so I think it’s very important for us to carry and put those values into the newer nurses and the nurses who want to continue their education. I really want to make sure that everyone is pushed to do everything that they can and be the best that they can be.’’ As a donor, you can make a difference in the future of emergency nursing. Your donation will help to provide funding for research that can improve the quality of patient care, build future leaders, support education that can change the practice of medicine in the future and much more. If you would like to join others in making a difference in emergency nursing, the ENA Foundation has opportunities for you to become involved. Visit www.enafoundation.org to find out how you can contribute to advancing emergency nursing.

Learning opportunities at ENA conferences are only the beginning for emergency nurses looking to advance their educations, and the ENA Foundation is here to help.

Academic Scholarship Recipients Non-RN Scholarships

2014 Scholarship and Research Grant Recipients The ENA Foundation would like to extend a special thank-you to the individuals, state councils, local chapters, industry, ENA staff and friends of emergency nursing who have supported the profession through their generous donations. Because of your contributions and passion to promote the advancement of the profession, our applicants are afforded the opportunity to receive educational scholarships and research grants in the discipline of emergency nursing. The ENA Foundation is excited to announce the following 2014 scholarship and research grant recipients and share how our donors are making a difference:

• New York State ENA September 11 Scholarships – $2,500 each Sean Davenport, CCEMT-P, Kentucky Margaret T. Swenson, EMT, Utah • ENA Foundation Emergency Department Employee Scholarships – $2,500 each Emily Carle, EMT, Maine Amanda Smith, Florida • Hill-Rom Scholarship – $2,500 William S. Guban, EMT-B, Vermont

Undergraduate Scholarships

• Physio-Control Inc. Scholarship – $3,000 each Jacquelyn Glendinning, RN, New York Linda Murray, RN, Kentucky

Graduate Scholarships • Stryker Masters in Healthcare Scholarship – $5,000 Jody L. Bauer, BSN, RN, Texas • Teleflex Scholarship – $5,000 Danita Mullins, BSN, RN, CEN, Arkansas • Judith C. Kelleher Memorial Scholarship – $5,000 Lori Bannon, BSN, RN, Virginia • Martha C. Wood Scholarship – $6,500 Erin S. Aston, BSN, RN, CPEN, North Carolina

• Charles Kunz Memorial Undergraduate Scholarship – $3,000

• California State Council – Antoinette Robinson Scholarship – $5,000

Pamela D. Bartley, BS, RN, CCRN, CEN, CPEN, South Carolina

Official Magazine of the Emergency Nurses Association

Petra Coronado, BSN, RN, CEN, California Continued on next page

ENA Foundation Scholarships and Research Grants Continued from previous page • Colorado State Council – Aurora Shooting Victims and Care Providers Scholarship – $5,000 Elizabeth Wolotira, BSN, RN, CEN, CPEN, CFRN, Oregon • Georgia ENA State Council – Georgia State Council Scholarship – $5,000

Thank you to the following organizations for their generous support.

Carrie L. Malone, BSN, RN, CEN, Indiana • Illinois State Council – Illinois State Council Scholarship – $5,000 Susan Remaly, BSN, RN, CEN, Illinois • Kentucky State Council – Kentucky ENA Founders Scholarship – $5,000

STRATEGIC SPONSORS

Kathy Tussey, BSN, RN, CEN, Kentucky • Maryland State Council – Maryland ENA State Council Scholarship – $5,000 Jennifer A. Bishop, BSN, RN, CEN, Pennsylvania • Michigan ENA State Council – Michigan State Council Scholarship – $5,000 Jo M. Tabler, BSN, RN, CEN, CFRN, Indiana • Minnesota State Council – “Pathways VI” Scholarship – $5,000 Pamela Sue Jenkins, BSN, RN, CPEN, Pennsylvania • New Jersey State Council – New Jersey State Challenge Scholarship – $5,000

STRATEGIC SUPPORTER

Valerie Jackson, BSN, RN, FNE, Indiana • Northern Chapter (NJ) – Mary Kamienski Scholarship – $5,000 Katie M. Bush, MA, RN, CEN, SANE-A, Ohio • West Central Chapter (NJ) – Jeanette Ash Memorial Scholarship – $5,000 Andrea Helman, BSN, RN, CEN, Illinois

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

• South Carolina State Council – The Survivor Scholarship – $5,000 Peter Giordano, BSN, RN, CEN, Illinois • Tennessee State Council – Brent Lemonds Memorial Scholarship – $5,000 Lynette Fair, BSN, Pennsylvania Continued on next page

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October 2014

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Scholarships and Research Grants Continued from previous page • Texas State Council – Vicki Patrick Texas Legacy Scholarship – $5,000 Josie Boyle, BSN, RN, CEN, Oregon • ENA Foundation State Challenge Scholarships – $5,000 each

Melissa Beans, BSN, Pennsylvania Emma Dragon, BSN, RN, CEN, EMT-B, Massachusetts Debra Kitchens, BSN, RN, CEN, NRP, South Carolina Melissa Kolarik, BSN, CEN, CFRN, Illinois Anne M. LeGare, BSN, RN, Wisconsin

• Gisness Advance Practice Scholarship – $3,000 Kathy Tussey, BSN, RN, CEN, Kentucky

• Karen O’Neil Memorial Scholarship – $3,000 Danita Mullins, BSN, RN, CEN, Arkansas

Doctoral Scholarships • Pamela Stinson Kidd Memorial Doctoral Scholarship – $10,000

Lisa M. Eckenrode, MSN, MBA, RN, NREMT-P, Pennsylvania

• ENA Foundation State Challenge Doctoral Scholarships – $5,000 each Meredith J. Addison, MSN, RN, CEN, Indiana Tobin Miller, MSN, RN, CEN, CCRN, California Elizabeth R. Tedesco, MSN, RN, CEN, Pennsylvania • ENA Foundation Doctoral Scholarship – $4,000 Cory Church, MSN, RN, Texas

• Hill-Rom Doctoral Scholarship – $2,500 Meredith J. Addison, RN, MSN, CEN, Indiana

Continuing Education Scholarships • Leadership Tapestry Conference Scholarships – $1,000 each

Erin Aston, BSN, RN, CPEN, North Carolina Danielle Bonca, BSN, RN, Nevada Molly Delaney, PhD, MBA, MNS, RN, CEN, CPEN, Minnesota Angela J. Hodge, MSN, RN, ACNS, CEN, EMT-P, Ohio Kelly Mills, BSN, RN, CEN, Indiana Rebekah Schelhaas, RN, CEN, South Dakota Ann B. Townsend, DNS, RN, ANP-BC, New Jersey Jessica A. Trivett, MSN, RN, CEN, New Jersey

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October 2014

• ENA Foundation Annual Conference Scholarships – $500 each

Tiffany Alves, MS, CNS, CEN, California Debra Bach, MSN, RN, CEN, Vermont Stacey M. Cernadas, ADN, RN, EM-T, Alabama Kelly Collins, BSN, Maine Lisa Cooley, BSN, RN, CEN, Virginia Tammy Lalmansingh, BSN, Florida Lisa Lietzke, BSN, RN, CPEN, Delaware Stacy L. Maitha, RN, Indiana Emilie Moore, RN, CEN, Ohio Tina Moseley, BSN, RN, Georgia Kara Moyer, BSN, RN, CEN, Indiana Melissa Myers, RN, CEN, Florida Miranda Newberry, BSN, RN, CEN, Indiana

Curtis Olson, BSN, BS, RN, EMT-P, CEN, Nebraska Mary Pargin, BSN, RN, CEN, Illinois Shannon Mays Smith, BSN, RN, CEN, CPEN, Florida Kathryn Taylor, RN, Texas Deborah Villars, RN, Indiana Katie Wade, BSN, RN, CPEN, Delaware

• ENA Staff Sponsored Foundation Annual Conference Scholarships – $500 each

RESEARCH GRANT OPPORTUNITIES

John Becklehimer, RN, Louisiana Katherine Mason, BSN, North Carolina

• ENA Foundation/ANIA Research

Research Grant Recipients

Applications due Oct. 1 for Grant – $6,000 • Industry Supported Research Grant – Supported by Stryker – $5,000 Applications due Nov. 1 for

• ENA Foundation/Sigma Theta Tau International Research Grant – $6,000 Allison Jones, RN, Kentucky

• ENA Foundation Seed Grants – $500 each

Applications are available at www.enafoundation.org.

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Official Magazine of the Emergency Nurses Association

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BOARD WRITES | Ellen (Ellie) H. Encapera, RN, CEN

Future of Nursing Calls for Both Education and Experience T

he state of nursing education in the mid-20th century was quite different from what it is today. Diploma nursing programs thrived and were readily available to the emerging high school graduate seeking a career path in a world of limited opportunities for young women.1 Students most commonly chose hospital-based diploma programs offering guaranteed clinical spaces for those accepted into the program, unlike the ADN and BSN models.3,5 During a demanding three-year program focused on the art and science of nursing, students participated in rigorous coursework in conjunction with ongoing clinical assignments in a variety of clinical settings with diverse patient populations and practice areas. Hospital-based diploma programs, although limited in liberal arts content, provided a well-rounded education for emerging professionals seeking a nursing degree and supplied hospitals with needed staff.1,3 Under the strict guidance of nursing faculty and instructors, students were assigned a variety of clinical roles and advanced toward assuming independent responsibility for patientcentered care upon graduation. During the next few decades, these dedicated bedside nurses gained further knowledge and experience and honed their skills while on the job. Those who showed leadership capabilities were identified by their superiors and offered job advancement opportunities at their current educational level. Seeking an advanced degree may not have been thought necessary unless one desired to move into formal management or a teaching position. Returning to school was certainly challenging while balancing both work and family obligations. Today, advancements in medical technology, complex clinical presentations and disease management require nurses to achieve higher degrees of theoretical knowledge, and thus diploma nursing programs have been phased out while newer models emerged.1,3,4 From 1980 to 2008, the number of new diploma graduates dropped significantly.3 While all might not agree, despite the decline of diploma programs, some studies suggest that diploma graduates are as competent in leadership and critical-thinking skills gained from on-the-job experience as graduates from other undergraduate nursing programs, and remain a valuable asset to the nursing profession.2 Students are now strongly advised to enter the nursing

profession at higher levels to appropriately educate the workforce of the future.4 Advancement through bridging programs, incentives and online opportunities ease the process, yet returning to school is still challenging, requiring both financial investment and time commitment. How does education differ from experience? The separation between the two is the source of knowledge. Education is attaining knowledge and theory through textbooks. Experience is based on attaining knowledge and theory and developing proficient skills over time.7 It seems that education and experience are not mutually exclusive but go hand-in-hand in charting one’s personal course and career path. Novice to Expert — the model developed by Patricia Benner, PhD, RN, FAAN — theorizes that expert nurses develop skills and understanding of patient care over time through a sound educational base as well as a multitude of experiences.8 The current nursing workforce is comprised of a high proportion of nurses who are nearing the end of their careers, as well as those who are just entering the profession.3 The mean age of nursing’s current workforce is estimated to be well over 45, and as the baby boomers make their exit, nursing will be faced with a void of thousands of practicing professionals in the years ahead.3 There exists a tremendous interest in nursing as a career, yet nursing schools are unable to handle the volume of applicants.4 How will we fill these vacancies and promote funding for faculty and programs needed to educate our workforce of the future?

October 2014

In response to the Patient Protection and Affordable Care Act of 2010, the Robert Wood Johnson Foundation released a comprehensive report, ‘‘The Initiative on the Future of Nursing,’’ and a vision for how nursing will play a critical role in health care. Recommendations include the removal of scope-of-practice barriers, expanding opportunities for nurses to lead and collaborate in improvement efforts, higher degrees of nursing education at entry levels and beyond, enabling nurses to lead change to advance health, implementing transition-to-practice programs, promoting lifelong learning and the collection of workforce data and research.9 Encompassing all these initiatives, nursing is perfectly poised to assume a commanding role in the future of preventive health care, coordination of care and providing comfort when cures are not possible.6 We all face personal challenges

along life’s journey, and sometimes we must make tough choices. At our core, we are all registered nurses, possessing unique talents, skills, education and experiences. As a diverse mixture of both educated and experienced nurses, we all can contribute to an exciting future of opportunities for nursing. Respecting our differences and embracing our commonalities is a recipe for success in meeting the challenges ahead. References 1. Scheckel, M. (2009). Nursing education: Past, present, future. In G. Roux & J. Halstead (Eds.), Issues and trends in nursing: Essential knowledge for today and tomorrow (pp. 27-61). Sudbury, MA: Jones and Bartlett Publishers, LLC. 2. Clinton, M., Murrells, T., & Robinson, S. (2005). Assessing competency in nursing: A comparison of nurses prepared through degree and diploma programs. Journal of Clinical Nursing, 14(1), 82-94. 3. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, Institute of Medicine. (2011). The future of nursing: Leading change, advancing health.

Washington, DC: National Academies Press. 4. Aiken, L. H. (2011). Nursing education policy priorities. In Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, Institute of Medicine (Eds.), The future of nursing: Leading change, advancing health (pp. 6-15). Washington, DC: National Academies Press. 5. Undergraduate nursing education. In Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, Institute of Medicine (Eds.), The future of nursing: Leading change, advancing health (pp. 369-374). Washington, DC: National Academies Press. 6. Key messages of the report. (2011). In Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, Institute of Medicine (Eds.), The future of nursing: Leading change, advancing health (pp. 21-46). Washington, DC: National Academies Press. 7. Difference between education and experience. (2011). Retrieved from http://www. differencebetween.net/miscellaneous/differencebetween-education-and-experience/ 8. Benner, Patricia E. (2013). From novice to expert. Retrieved from http://currentnursing.com/ nursing_theory/Patricia_Benner_From_Novice_to_ Expert.html 9. Robert Wood Johnson Foundation. (n.d.). IOM recommendations. Retrieved from http://www. thefutureofnursing.org/recommendations

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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

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PRACTICE

The Wisdom in Stories By Kathy Szumanski, MSN, RN, NE-BC, Deputy Executive Director, Nursing

ave you heard a good story lately? A good story is one that you don’t quickly forget. Stories are powerful because they show us rather than tell us about the human condition. Since the beginning of time, the best of our values have been passed from one generation to another, often through stories. Stories provide us with roots to our past. They are narratives of life that teach us valuable lessons. At one point in time, tribes gathered around central campfires to teach these lessons that helped provide the group with strength and wisdom. Because they are narratives of life, they encompass virtually every facet of human behavior. Stories weave threads of human interaction into our everyday life and can infuse into our workplace respect for our work and our peers. Storytelling has gained great value in the field of nursing. The stories told by nurses in the form of case studies translate in our mind the essential role of healing of body and spirit that nurses play each day. The work of nursing theorist Patricia Benner1 used storytelling as the basis for a professional development model. She applies this process to demonstrate distinctions in the levels of practice for nurses. These distinctions allow us to understand the relationship between practice levels and skills in the individual nurse so that professional development can be focused and move forward. Emergency nursing is practiced in a real world with real constraints, possibilities and concerns. It is within this type of setting that excellence can thrive and individual professional practice can grow stronger over time. When any individual nurse fails to understand the possibilities and potentials that are present in practice, the profession as a whole suffers. This brief excerpt of a developing professional in an emergency department illustrates the approach to clinical judgment used for her patient, who presented with a non-urgent complaint one evening: My patient certainly was not the most complex care I have ever given, but it illustrated for me the mental work that needs to go into my practice each and every day. The habit of nursing observation is one of the most essential things I do

with my patients, and since I am with that patient more than any other member of the team, my observation may be key to safe and appropriate treatment. What I observed and the conclusion that I drew from those observations was essential in defining a very different course of treatment than what was anticipated. I always tell new nurses coming to the emergency department to be vigilant, look for all clues and decide what those clues may mean for this patient. The nurse who wrote this narrative asked to not include her name. She stated that her reason to remain nameless was to convey the message that everyone has stories to tell that can benefit others. Narrative accounts such as these reveal an aspect of the nursing role that is never captured in the formal procedures, skill lists and job descriptions. Expert nurses often use phrases such as ‘‘gut feeling’’ or ‘‘something just didn’t feel right.’’ Watching for subtle changes or recognizing those early-warning signs are a part of the everyday practice for emergency nurses. It has been said that storytelling can teach many lessons as well as have a profound effect on recuperative and restorative powers. Stories of emergency nurses will be presented from time to time so that the essential threads provided by nurses can be woven into the fabric of emergency care. The new edition of CATN (Course in Advanced Trauma Nursing) is based on case-study stories in advanced trauma. Reference 1. Benner, P. (2001). From novice to expert: Excellence and power in clinical nursing practice, commemorative edition. New York, N.Y: Prentice-Hall.

October 2014

HOW GOOD IS YOUR

DEPTH PERCEPTION?

33%

OF CHEST COMPRESSIONS ARE TOO SHALLOW.

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Visit www.physio-control.com/CPRQuality to get the report.

Morrison L, Neumar R, Zimmerman J, et al. Strategies for improving survival after in-hospital cardiac arrest in the United States: 2013 consensus recommendations: A consensus statement from the American Heart Association. Circulation. 2013;127:1538–1563. Meaney P, Bobrow B, Mancini M, et al. CPR quality: improving cardiac resuscitation outcomes both inside and outside the hospital. Circulation. 2013;128:1–19.

ELECTIONS

INSIDE THE MARGINS

Numbers Say Game-Changing Votes Are Out There For ENA Races By Josh Gaby, ENA Connection

we get them more engaged? One barrier is obvious. our vote would never swing an ‘‘There’s often a similar group of ENA election, right? people voting, and I think one of the If that thought has kept you from big things is people say, ‘We don’t participating during election season, know who we’re voting for,’ ’’ said when only 5 to 7 percent of ENA committee member Lucinda Rossoll, members have voted in recent years, MSN, RN, CEN, CPEN, CCRN. then here’s a number you might want Wiping out that concern has to consider: Seven. That’s how many become a top priority. Rossoll sees times in the last 11 elections continued value in the that an ENA position has been candidate forums held and decided by fewer than 30 votes. recorded at ENA conferences One contest for president-elect (attending one years ago is in that span was decided by 18 what first convinced her to votes, another by 11. A race for vote) and in the traditional a director position was decided candidate biographies by a single vote in 2004. published each spring in ENA Terry Foster We’re not just talking close, Connection and on the ENA said Nominations Committee website. She and Foster agree member Terry Foster, MSN, RN, that giving candidates more CCRN, CEN, CPEN, FAEN. questions to flesh out their “Very, very, very close,” positions on issues would be a Foster said. step forward. Driven by this spring’s 6.17 ‘‘Tell me how you feel about percent voter participation rate Lucinda Rossoll mandatory overtime,’’ Foster (just under last year’s 6.36 and said. ‘‘Tell me how you feel not atypical for professional association about unions for nurses. Tell me how elections) and the idea that races you feel about unlicensed personnel in affecting ENA’s direction could easily the emergency department doing some go a different way with more voters nursing duties. Tell me some of those involved, Foster looked online for things — like five questions. I think inspiration. What he found was ‘‘The that would be great. Then you can say, Power of One,’’ a variation of an article ‘Oh, no, I don’t like what they’ve said celebrating the importance of on that,’ or you can say, ‘I really like democratic voting and citing historical what this person said.’ You have a examples of a single vote affecting an much better idea, and that’s the power outcome. That document of one vote.’’ (tinyurl.com/ Rossoll envisions ENA state councils powerofonevote, QR and chapters — themselves no code at left) has since strangers to close elections — become a rallying point for the becoming major difference-makers. Nominations Committee against two This goes further than simply reminding constant questions: How do we get members to vote. New Jersey ENA has more ENA members voting? How do posted the national candidates’ pictures

and position statements on the walls for reference at election time, Rossoll said. New Hampshire, her home state, once had a computer set up at its monthly meeting and encouraged members to sign in and vote right there. Challenging states and chapters to have spirited conversations about national candidates could get many more members invested. ‘‘They could have their own little forum there,’’ Rossoll said. ENA members already can ask candidates questions on a dedicated Facebook page during election season. Rossoll said another idea would be to separately record candidates answering a list of identical questions and then share those videos for viewing at state and chapter meetings. ‘‘I think that would be interesting to compare the answers,’’ Rossoll said, ‘‘and [one candidate] wouldn’t know what the other [candidate] had said. I’d like to have it done in front of a group, too, just to see how composed they can be.’’ As the Nominations Committee explores these and other ways of enhancing the process, there’s one certainty: Voting has never been more important. These efforts are crucial. ‘‘I’ve been a nurse for 37 years,’’ Foster said. ‘‘I have never seen it be so crazy in healthcare as it has been in the past two or three years — I mean, just crazy. Every day you work, there’s something different, there’s a new directive, there’s something that’s changed. Now, more than ever, I think nurses need their professional association to represent them. Because of that, you need to vote to make sure our association is going in the direction that the majority wants it to.’’

October 2014

FUTURE OF YOUR NURSING | Bridget Walsh, PHR, Chief Talent Officer

Let’s Do Lunch: Networking Matters I

f you were to poll a small group of your colleagues, there is a high probability that at some point in their career, most have gotten a new job through the power of networking. An April 2013 LinkedIn article indicates networking as the top source of hire, according to data obtained from a source-of-hire survey conducted by best-selling author Lou Adler. The process of building and maintaining a solid professional network has multiple benefits. Professional contacts can be a valuable source of information such as benchmarking, the sharing of best practices, information on new career opportunities and an established social network. Building a professional network does require time and effort, but it doesn’t have to be a burden. Capitalize on all the different ways to make and maintain your connections. In today’s technology-driven world, there are many ways to build your network without leaving the house. Participate on a listserv or discussion forum or touch base with contacts via

e-mail. Be sure to supplement the technology-driven networking with good, old-fashioned personal connections: Call an old colleague to catch up, attend a professional networking meeting or have lunch with some current colleagues. As your professional organization, ENA is committed to helping you accomplish your professional goals and build your professional network. For more resources and information, visit the career wellness page at tinyurl.com/ENAwellness (QR code at left) or e-mail careerwellness@ena.org.

Click. Shop. Done. • Leadership books, study guides and reference books • ENA merchandise – apparel, pins and more • Member discounts

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Official Magazine of the Emergency Nurses Association

3/26/14 10:10 AM

QUALITY AND SAFETY

MISSION: TRANSITION Alarmed By Information Gaps During Transfers of Older Adults, Michigan ED Team Starts a Coalition to Change the Local System omissions can increase the possibility of adverse events associated with long ED wait times, thereby compromising quality and safe delivery of care.

By Joan Michelle Moccia, MSN, ANP-BC, CCRN

or older adults living in long-term-care, assisted and independent living facilities, the transition of care to the emergency department is fragmented. Healthcare facilities and EDs traditionally operate independently. Thus, the sharing of information is inconsistent or missed. The significant variability in the amount of information sent with patients from these types of senior residences became apparent in July 2010 when St. Mary Mercy Livonia Hospital opened Michigan’s first senior emergency center for patients age 65 and older. As exciting as it was to have this specialized facility for this population, what wasn’t anticipated was the disconnect between each patient’s current chart information and the key transfer elements, such as reason for transfer, code status, medical/surgical history, medication profile and baseline cognitive and functional status necessary for emergency decision, diagnosis and disposition. Unavailable data when transferring patients resulted in unnecessary rework, inefficiencies and emergency healthcare providers working blindly. Moreover, incomplete information predisposes the patient to receive unwanted or less care, unnecessary tests and even wrongful resuscitation in some cases. According to Terrell et al., incomplete patient data contributes to a

Identifying the Problem

flawed care plan, safety issues (such as medication errors) and rehospitalization. Moreover, flawed executed care transitions can further lead to overuse of emergency services and subsequent unnecessary hospital admissions, thus increasing healthcare costs. A smooth patient flow is critical for ED patients. Any lack of communication interrupts care as ED staff time and energy is diverted from primary responsibilities to calling facilities to obtain clinical information to treat transferred patients in a competent manner. Healthcare professionals are then removed from the ED patient’s side, which adds minutes to turnaround time, affecting throughput and contributing to ED overcrowding and eventually patient and staff dissatisfaction. Overall, instances of

The ED team (nurses, physicians, techs, clerks, senior social worker and case manager) at St. Mary Mercy Livonia recognized that efforts to address these failures would require systems-based changes to improve patient safety during transitions of care in both directions. ENA’s ‘‘Practical Guide to Safer Handoff of Older Adult Patients Between Long-Term Care Facilities and the ED’’ was used as a guide to help facilitate the first meeting. The guide has been replaced by the new Geriatric Emergency Nursing Education product, which can be accessed at tinyurl.com/ENA-GENE or by scanning the QR code at left. The team then extended an invitation to long-term care facilities, emergency medical services and other providers of care in the area to partner in improving the transition process. The response was outstanding. On Nov. 14, 2011, they held their first meeting. The energy in the room was palpable as each member shared his or her facility’s capabilities, transfer documents and protocol. It became clear how little everyone knew of each

October 2014

other’s scope-of-care capabilities and transport procedures. Without hesitation, the group agreed to continue to meet monthly and focus on improving transitions of care. A bond was created, and a name was selected to reflect the mission. ‘‘STARForUM: Safe Transition of All Residents For yoU & Me’’ was born.

Making Improvements The group has been meeting monthly. Two-and-a-half years later, this grassroots organization has been responsible for many innovations and interventions, including the following: • Process-flow mapping of each facility (skilled, assisted living, independent, home health care) and EMS response to a resident’s symptoms requiring transport to the ED and return • Color-coded phone directory to help identify the facility level of care (red =

skilled; yellow = assisted; green = independent)

• Transition letters from independent facilities detailing services and/or care plan detailing purchased support services, i.e., medication reminders, assist with ADLs

• The facility care nursing capability, i.e., wound care or IV therapy, hyperlinked to the directory • Audit tool (members self-monitor the information sent to the ED by reviewing the information sent from the previous month) • Transition checklist (list of key elements needed for ED care) - Medication assessment record noting time of last dose given - Recent antibiotic use - Reason for stay in facility - Medical/surgical history - Family notification - Code status - Baseline mental and functional status - Last known time normal - Fall patients: Mechanical or physiological

• Universal transfer form • ED transition envelope/checklist for safe return of ED patient back to facility as a resident, followed by an ED phone call detailing care received in the ED and response of resident • Encouragement of facility to send in picture ID of their resident • Discharge instructions including size and manufacturer of peg tube replacement • Discharge instructions including PICC lumen size and manufacturer • Sepsis cue card to alert caregivers on SIRS criteria

Continued on page 44

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Visit www.ena.org and take advantage of all the resources your ENA membership has to offer. Membership Ad_Connection_half_10 2014.2.indd 1

Official Magazine of the Emergency Nurses Association

9/1/14 9:56 PM

Lantern Team Always Has a Light On By Amy Carpenter Aquino, ENA Connection

ith the 2014 ENA Lantern Award recipients announced in August, it would seem the members responsible for the months-long application review process could kick back and relax. However, the work of the Lantern Award Review Committee is ongoing as members continually seek to improve the process, chairperson Tami Morin, MS, RN, NEA-BC, said. The Lantern Award is a recognition award given to emergency departments that exemplify exceptional practice and innovative performance in the core areas of leadership, practice, education, advocacy and research. Morin, director of emergency services at the University of Wisconsin Hospital, leads a group of seven members who review and score applications submitted annually. The members’ work begins in January with a conference call to discuss the committee’s charges and the award scoring tool and process. The next step is that members receive sample Lantern Award applications falling into each of the scoring bands — low, medium and high — to try their hand at scoring. These results are reviewed and compared to see how much inter-rater reliability there is — whether members are scoring consistently or if there are gaps that need to be addressed. The committee receives actual applications in early spring. ‘‘That is where the true work begins,’’ Morin said. For the 2014 cycle, each committee member was assigned multiple applications. Each application is scored by more than one person. ‘‘It takes me about three to four hours to score one application,’’ Morin said. ‘‘When you multiply three to four hours by 14, it’s a significant time commitment. ‘‘But when you think about how important it is to the facilities that have applied, you don’t want to rush it. You want to do a really good job because they’ve invested a significant amount of time in preparing their application.’’ The committee meets at ENA headquarters in July to discuss the selected award recipients, review any issues with the scoring tool and make recommendations for revisions. This is also when members draft letters to facilities that did not receive an award. ‘‘I think this year was the year that we spent the most time

THE ENA LANTERN AWARD COMMITTEE: Clockwise, from lower left: Catherine Olson, MSN, RN, staff liaison; Sheryl Bloomer, MA, BSN, RN, CPN; Ellen Siciliano, BA, staff liaison; Tobin Miller, MSN, RN, CEN, CCRN, MICN; Jennifer Davis, MSN, MPH, RN, EMT-P, CEN, NE-BC; Tami Morin, MS, RN, NEA-BC, chairperson; India Owens, MSN, RN, CEN, NE-BC, FAEN. Not pictured: JoAnn Lazarus, MSN, RN, CEN, Board of Directors liaison; Kenneth Grubbs, MBA, RN; Jason Moretz, MHA, BSN, RN, CEN, CTRN. in drafting those letters, trying to give very specific feedback that is useful to the facilities so if they reapplied, they would really focus their energies in certain areas,’’ Morin said. After all applicants are notified, the committee has more homework. Members conduct literature searches on specific sections within the application to ensure that the latest literature is cited. A few members also participate in a Q&A session at the ENA Annual Conference. For potential applicants who can’t attend the committee’s session in Indianapolis, Morin shared the following advice: ‘‘Make sure to read the guide provided by ENA on applying for the Lantern Award. It really has the tips and tricks to make sure that you are submitting a strong application.’’ Her second piece of advice is to ‘‘really look at your department and your data and determine when the right time to apply is. There are facilities who are doing great things, but when you look at the requests for data showing tracking and trending and sustained improvements, there has to be a time frame on the back end of implementation where they can really demonstrate those improvements.”

October 2014

Details Matter.

Past Presidents: Their Work Continues By Amy Carpenter Aquino, ENA Connection

t’s an exclusive group that accepts only one new member each year. It takes years to qualify, including one final whirlwind year of travel, meetings, speaking engagements and high-level decision-making, but once you’ve gained access to this group, you are guaranteed a spot for life. The group is the ENA past presidents, who reached 42 members this year. When their latest addition, JoAnn Lazarus, MSN, RN, CEN, the 2013 president, was conferring with past presidents during the course of her term last year, she realized the association was not taking full advantage of their wealth of leadership experience. ‘‘I recognized as we were moving into the changes that were happening within ENA last year, and even before that, that we really weren’t tapping into the wisdom and knowledge of our past presidents,’’ Lazarus said. ‘‘I wanted to figure out a way to bring a group together to find out how they were feeling about their role as past presidents, and were they being acknowledged in their role?’’ Lazarus proposed the formation of the Past Presidents Task Force, which the Board of Directors approved in 2013. Lazarus appointed Vicki C. Patrick, MS, APRN, ACNP, CEN, FAEN, 1981-1982 ENA president and chairperson; Joanne M. Fadale, BSN, RN, FAEN, 1990 ENA president; Benjamin E. Marett, EdD, MSN, RN, CEN, CCRN, FAEN, 2000 ENA president; Sherri-Lynne Almeida, DrPH, MSN, MEd, RN, CEN, FAEN, 2002 ENA president; and Nancy Bonalumi, MS, RN, CEN, 2006 ENA president. The same members are on the 2014 Past

THE ENA PAST PRESIDENTS WORK TEAM: From left: Nancy Bonalumi, MS, RN, CEN; Joanne M. Fadale, BSN, RN, FAEN; current ENA president Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN; Benjamin E. Marett, EdD, MSN, RN, CEN, CCRN, FAEN; chairperson Vicki C. Patrick, MS, APRN, ACNP, CEN, FAEN; and Sherri-Lynne Almeida, DrPH, MSN, MEd, RN, CEN, FAEN. Not pictured: ENA Board of Directors liaison JoAnn Lazarus, MSN, RN, CEN, immediate past president. Presidents Work Team. Lazarus said she intentionally chose past presidents from different decades to represent varying years of experience and service to ENA ‘‘because ENA has changed, and with that, perceptions have changed,’’ she said. ‘‘As we prepare for the future, we can’t forget about how we got where we are, and that’s through a lot of our traditions and just the knowledge that a lot of these past presidents have.’’ In a testament to their legacy as high achievers, the task force immediately created a survey for past presidents to gauge their perceptions of their role since leaving the board. The survey helped fulfill the task force’s charge, which Marett said was ‘‘to make recommendations to the board of what the expectations, roles and recognition of past presidents should be.’’ The survey assessed the past

presidents’ opinions on experiences such as their first year off the board and resuming the member role, as well as whether they thought there should be an orientation to the past president role and what roles could be identified for past presidents, Almeida said. ‘‘This is a rich source of information, not only about what’s currently going on in the association but the history of the association,’’ she said, adding that it would be a shame to ‘‘lose that knowledge bank.’’ The group received responses from 33 of the 37 living past presidents, an impressive 85 percent response rate, and the overall results were positive. ‘‘I think that most of the group felt that there was a place for them within ENA, that there were contributions that they were able to make and willing to make and that they wanted to be involved in the association,’’ Bonalumi

October 2014

said. ‘‘They felt that while their role was different, there was still value that they could bring to the association.’’ Marett said past presidents expressed interest in varying levels of ENA involvement, from publishing in the Journal of Emergency Nursing to serving as mentors for the Academy of Emergency Nursing and volunteering for the ENA Foundation. Lazarus said the second phase for the work team is to help prepare ENA presidents to move into the role of a past president and to ease a transition that she compared to ‘‘falling off a cliff.’’ ‘‘One minute you’re in the know, you’ve got all the information, people are talking to you, and that’s through Dec. 31,’’ she said. ‘‘And then Jan. 1 — well, now you’re not.’’ Immediate past presidents experience a ‘‘sudden information deficit’’ at the end of their term, Lazarus said, and ‘‘there needs to be some assistance with that transition.’’

Requesting input from presidents of different eras ensures that a depth of experience and collective wisdom will contribute to creating better transitions for ENA presidents, Patrick said. Since ENA has many past presidents involved at many different levels, there are ample opportunities to stay active. The ‘‘transition team,’’ as Patrick referred to the work team, aims to help past presidents arrive at how they can productively make contributions once they return to the role of the volunteer rather than the elected official. ‘‘You have to decide what your level of activity is going to be and how you can offer to make those contributions in a constructive manner for the association,’’ Patrick said. Fadale said it was surprising to find in the research that some associations ‘‘put their past presidents out to pasture; they have no say-so, no activity, no involvement in their association ever again, which I feel is very sad. It’s not a

good use of nursing knowledge or management knowledge.’’ ‘‘Or association knowledge,’’ Marett added. A literature search revealed that very little information exists about transitioning out of an association leadership role or how to support people going through that transition, Bonalumi said. ‘‘I think we’re actually carving out some new knowledge,’’ she said. ‘‘We’re at least identifying a plan for our organization that may serve as a template to others down the road.’’ Lazarus sees the work team continuing for the foreseeable future because each Dec. 31 will see a mentoring opportunity for the newest past president. Having people who have been through that experience will be invaluable. As Almeida said, ‘‘You have to walk in these shoes to appreciate how difficult it can be to walk in these shoes.’’

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TNCC Ad_Connection_Half_08 2014.indd 1

Official Magazine of the Emergency Nurses Association

6/25/14 4:02 PM

Technology For Post-Disaster Tracking By Amy Carpenter Aquino, ENA Connection

lthough it’s being sunsetted at the end of this year, the Emergency Nursing Technology and Informatics Work Team has created several resources that ENA members will be able to use for years to come, including some that offer guidance on how technology can improve emergency preparedness planning in the emergency department. Work team member Jeannette Jefferies, MS, RN, CCRN, posted a preliminary article titled ‘‘Preparing for Disaster – Use of a Patient Tracking System’’ to the ENA committee shared documents site, and the complete paper should soon be available to all ENA members. In the paper, Jefferies describes how using a disaster tracker board can help ED staff who need to track both disaster patients who came into the ED and regular ED patients. The regular ED patients stay on regular tracker, while disaster patients could be quickly assigned to the disaster tracker. Jefferies shows how to create a quick registration for disaster patients and includes screen shots of the quick registration and the disaster tracker board. A technology Jefferies has been exploring is radio frequency identification, or RFID, which she said is superior to the more common barcode scanning technology. While barcode scanning is simpler and less expensive, problems can arise with vital processes such as patient identification; if the admitting department, for example, merges records and changes a patient’s account number that is already printed on his wristband, someone has

THE EMERGENCY NURSING TECHNOLOGY AND INFORMATICS WORK TEAM: Front row, from left: Dagny S. Scofield, RN, CEN, CPEN; Monica Escalante, MSN, RN, senior associate, IQSIP. Middle row: Jeannette Jefferies, MS, RN, CCRN; Debra Esse, MHA, BS, RN, CEN. Back row: Mitch Jewett, RN, CEN, ENA Board of Directors liaison; David G. Holman, MNSc, RN; Michael Seaver, BA, RN, chairperson; and Leslie Talbert, senior administrative assistant, IQSIP. to make sure to switch out the patient’s wristband. Sometimes a patient can end up with two wristbands, and the wrong code can be scanned. Patients also can become disturbed and remove their wristbands. ‘‘There are lots of potential risks when it comes to scanning patients,’’ Jefferies said. To decrease these and other risks, some EDs have started using RFID to track patients and be used for patient identification. The technology has been commonly accepted for tracking

equipment, such as monitors and IV pumps, and even has been used to track staff, she said. For example, RFID can tell when a physician enters a patient’s room to pinpoint exactly when the medical screening exam started, Jefferies said. Her current facility, Mercy Medical Center in Baltimore, where she works in nurse informatics, uses a form of RFID on the inpatient side. ‘‘We have it hooked up to our call-light system, so when the nurse walks into the room, it actually turns

October 2014

the call light off,’’ she said. Another advantage RFID has over barcode scanning for patient identification is the inability to avoid the system, said chairperson Michael Seaver, BA, RN. ‘‘There was actually an article published on the top 20 ways to work around barcoded patient identification,’’ he said. Not that workarounds are always negative. ‘‘Nurses, and emergency nurses in particular, are notoriously adept at making things work, whether it’s 101 uses for tape, or how do we avoid delays due to technology, for which the processes of the new technology have not been thought out yet,’’ Seaver said. Sometimes the workaround provides a better outcome than the original process, in which case Seaver suggested people should keep an open mind and consider making the

workaround the standard process. ‘‘To come up with a decent workaround typically means that someone has put in some good, creative thinking,’’ he said. Electronic medical record technology is also being used more in disaster preparedness planning. The ability to create virtual care areas, for example, can help an ED prepare for what happens when 27 unexpected patients are brought in after a train accident. ‘‘It’s one thing to be able to recognize that this is where we’re going to put all these people, for instance,’’ Seaver said. ‘‘You may have the greatest plan in the world — walking wounded all going to this area of the hospital — but then how do you keep them organized? How do you keep a head count? If you have them built into the patient tracking, the more information you have, the more easily you can recognize that information and deal with that

information.’’ Another way in which technology can help in disaster planning is syndromic surveillance, which is also addressed in many electronic medical record systems. Seaver explained syndromic surveillance as an ED’s ability to report on a large influx of a vague gastrointestinal complaint, for example. ‘‘Is it just coincidence, or is it maybe something in the water supply?’’ he said. Monitoring and reporting such outbreaks to the Centers for Disease Control and Prevention or the county health department can help prevent a biological hazard from becoming more widespread. The work team’s EMR handbook, which also should be available to ENA members soon, includes information on patient identification, building virtual locations and syndromic surveillance, among other technology issues.

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Official Magazine of the Emergency Nurses Association

9/1/14 10:02 PM

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Transitions of Care Continued from page 37 • “Plan in a Can” (tennis ball can innovation) and “Just in Case” emergency brochure to secure vital health information, www.mymercy.us/justincase • ‘‘Transitions of Care: The Perfect Storm,’’ a live show consisting of one-act vignettes showcasing excellent and poor transitions of care; the show was recently presented to the Wayne State University Institute of Gerontology • A website (in creation) to share STARForUM’s tools

Reinforced by Data A retrospective quality assurance review held between Nov. 19, 2013, and Feb. 14, 2014 (n = 123) demonstrated that those onboard with the mission of STARForUM were much more likely to send in key elements on a 15-point transfer of information scale than those who were not invested. STARForUM members soon will be testing the response of information received by using a checklist delivered

7 N-Pak

39 Stryker www.stryker.com 15 Teleflex Incorporated www.teleflex.com

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by EMS personnel to facility staff when they arrive to transport their resident to the ED. Checklists can provide guidance to paramedics and facility staff and act as verification following documentation of the identified key clinical elements for a safe transition. Checklists serve to aid in memory recall, standardization and regulation of processes, providing an outline for evaluations or as a diagnostic tool.

Conclusions The success of the STARForUM group is due to the unwavering devotion of each individual to ensure the safe transition of the vulnerable older adult. An opportunity exists for every ED in the nation to engage and strengthen relationships with providers involved in transition of care from nursing facilities (skilled, assisted and independent), EMS (interim providers of care), licensed and nonlicensed home care personnel, social workers, case managers and ED personnel. We hold our patients’ hearts in our hands. Use your passion, wisdom and advocacy to help remove barriers and

improve care quality and safety to this vulnerable subset of older adult patients through a coordinated care transition approach that also will impact 30-day readmissions. Let’s cross this healthcare quality chasm together. References Coleman, E. A., Smith, J. D., Frank, J. C., Min, S., Parry, C., & Kramer, A. M. (2004). Preparing patients and caregivers to participate in care delivered across settings: The care transitions intervention. Journal of the American Geriatrics Society, 52, 1817-1825. Hales, B. M., & Pronovost, P. J. (2006). The checklist—A tool for error management and performance improvement. Journal of Critical Care, 21, 231-235. Terrell, K. M., & Miller, D. K. (2006). Challenges in transitional care between nursing homes and emergency departments. Journal of the American Medical Directors Association, 7, 499-505.

Resources Improving on Transitions of Care: How to Implement and Evaluate a Plan, www.ntocc.org Better Outcomes by Optimizing Safe Transitions (BOOST), www.hospitalmedicine.org/BOOST Project RED (Re-Engineered Discharge), www.bu. edu/fammed/projectred INTERACT (Interventions to Reduce Acute Care Transfers), interact2.net/ Remington Report (Interventional strategies and programs to improve care transitions with supporting evidence), www.remingtonreport.com

October 2014

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Average improvement in throughput for admitted and discharged patients

Average improvement in time from arrival to seeing a physician.

Typical improvement in patient satisfaction scores and likelihood to recommend

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

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

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

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Senior Consultant Blue Jay Consulting, LLC