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the Official Magazine of the Emergency Nurses Association

connection November 2012 Volume 36, Issue 10

Help Is On the Way

What We’re Doing to Make It Better for Behavioral Health Patients in the ED Pages 6-7, 11-13

PLUS: Emergency Nurses Spring Into Action After Aurora Theater Shooting Pages 8-10



NEW THIS MONTH: Members in Motion


Leadership Conference 2013 What’s to Come PAGE 14 The Emotional Rewards of the ENA Foundation


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Dates to Remember Nov. 12, 2012 Deadline for applications for the Blue Jay Consulting/ENA Award for Outstanding Nurse Leader of the Year, to be presented Feb. 28, 2013, in Fort Lauderdale, Fla., at Leadership Conference 2013. Nov. 30, 2012 Deadline for applications for the Academy of Emergency Nursing’s 2013 class of fellows. Jan. 15, 2013 Deadline for poster submissions for 2013 Annual Conference in Nashville, Tenn. March 15, 2013 Deadline for proposed bylaws and resolutions for 2013 General Assembly at Annual Conference in Nashville, Tenn.

ENA Exclusive Content PAGE 8 A Special Midnight Showing: Colorado Theater Tragedy Brings Out the Best in ED Staff Reponse PAGE 11 Board Writes: Caring for Behavioral Health Patients in the ED PAGE 12 The National Council Mental Health and Addictions Conference PAGE 14 What’s to Come at Leadership Conference 2013 PAGE 23 ENA Report from NEMSAC

Monthly Features PAGE 3 Letter from the President PAGE 4 NEW! Free CE of the Month PAGE 4 NEW! Members in Motion PAGE 5 ENA Connected PAGE 16 ENA Foundation PAGE 17 Course Bytes


The (Not So) Happy Holidays The holiday season is just around the corner, and people soon will be decorating, gathering at parties, carving turkeys and shopping for that perfect gift. While some will be enjoying the excitement of the holidays with loved ones, others may not be as fortunate. Television, film and advertisements may depict expectations for the holidays that seem unrealistic to many of us. Some of us – staff and patients – face challenges and may not be able to afford those holiday celebrations. Some of us may be remembering the loss of loved ones. For others, there may be no family, or only an estranged one, and holidays can bring to mind what is forgotten the rest of the year. During the holidays, some won’t be able to shake the depression that descends and engulfs them, either because of sad reminders or because of SAD, seasonal affective disorder, a form of depression that may be related to a season, in this case, one with shorter days, less sunlight and/or inclement weather interfering with

normal activities. A problem for people around the globe, 5 percent, or 15 million, Americans suffer severely from SAD, with symptoms of hopelessness, increased appetite and weight gain, increased sleep, less energy, an inability to focus, loss of interest in work and activities, social withdrawal, irritability and feelings of depression. Another 33 million feel some moodiness or loss of creativity or productivity during the winter, according to the National Institute of Mental Health. If you or your patients are severely affected, there is a wide variety of effective therapies, such as medication, hormone supplements, light therapy, cognitive behavioral therapy, vitamin regimens and physical exercise of which to be aware. If you are mildly affected, begin to make plans with friends or co-workers ahead of time to keep yourself busy during the holiday season. Volunteer to help people less fortunate than you – on a medical mission, in a homeless shelter or with a parish nurse.

Your ED staff may have cared for patients this past year with devastating injuries, or victims of mass casualties and their families who may appreciate being remembered in some meaningful way. Lastly, summon the energy to share feelings of isolation and seek support during this difficult time. This particular holiday season, more people may be vulnerable to sadness and situational depression, given the loss of jobs and financial hardship as a result of the current economy, so be alert for subtle changes in the mood of those around you, and offer a lifeline when it is needed. In the end, the very best gift of the season may be the support we give to others, something at which emergency nurses excel! Reference Nursing Care Plan Seasonal A  ffective Disorder. (2010). Retrieved from nursing-care-plan-ncpseasonal.html.

PAGE 18 Washington Watch PAGE 20 Ready or Not? PAGE 22 State Connection PAGE 23 ENA Call For . . .

Coming in December • 2012 Annual Conference Coverage from San Diego • Spotlight on the Historical Perspectives Work Team • More Coverage of ED Response to the Colorado Theater Shooting

Official Magazine of the Emergency Nurses Association


With a new month comes a new opportunity for free continuing education through ENA. Our November offering, worth 1.0 contact hours, is “Prevention of Health Care-Associated Infections,” a webinar presented by Rhonda Morgan, DNP, RN, CEN, CNRN, CCNS, APN. The course focuses on the major types of health care-associated infections, identifies the causes and risks and explores prevention strategies the emergency nurse can use to keep them from developing. To take the course and earn your credit: • Go to, where you’ll log in as an ENA member (or create a new account). • Add the course to your cart and “check out” (no charge for members). • Proceed to your personal learning page to start or complete a course for which you have registered or to print a certificate when you’re done. It’s as simple as that. ENA has a growing back catalog of free CE courses on a range of topics, so if you haven’t yet taken them, complete the checkout process for each course you want. Free education at your leisure, at the comfort of your computer, is just one of the perks available to you as an ENA member, and response has been enormous. Take full advantage!

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© 2012 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.

‘Leader in Patient Safety’ Makes Villanova Proud On her mission to improve medication safety, Susan Paparella observes and advises health care professionals around the country. This year, her work couldn’t have brought her closer to home. Paparella, MSN, RN, who earned both her nursing degree and master’s at Villanova University, was honored April 14 with a Villanova College of Nursing Medallion — the college’s highest recognition — for ‘‘Distinguished Contributions to Clinical Practice.’’ The presentation occurred during the 23rd Annual Mass and Alumni Awards program held at St. Thomas of Villanova church, where Paparella was married and where her first son was baptized. She’d only days earlier learned her second son had been accepted as a Villanova student. The experience, she said, was ‘‘wonderful.’’ ‘‘It was a little intimidating to be standing in front of Villanova faculty members, all experts in the field of nursing,’’ Paparella said. ‘‘It was because of their encouragement and mentorship that I have been able to accept challenges throughout my career. The faculty at Villanova was instrumental in helping me recognize how essential clinical inquiry is to advancing nursing practice and patient safety science. They shaped my values and gave me a voice as a professional nurse.’’ Today she’s educating practitioners far and wide. As vice president of the Horsham, Pa.-based Institute for Safe Medication Practices, Paparella develops consulting and educational services and travels in that role, helping hospitals to adopt safe medication practices to avoid harmful errors. ISMP is a non-profit 501(c)(3) charity and operates the only practitioner-based medication error reporting program in the U.S. While it doesn’t set standards for medication use, it collaborates with the bodies that do (including the FDA and the Joint Commission). ‘‘I feel lucky because I get to connect with my ED colleagues regularly and understand what their challenges are,’’ Paparella said. ‘‘ED nurses face a number of issues that have the potential to impact safe clinical practice. We need to understand: How do you combine the complex task of medication use within a challenging ED environment and do it in a way that will avoid inadvertent patient harm?’’

POSTMASTER: ­Send address changes to ENA Connection 915 Lee Street Des Plaines, IL 60016-6569 ISSN: 1534-2565 Fax: 847-460-4002 Web Site: E-mail:

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


Susan Paparella, MSN, RN, at her award presentation.

Paparella’s ties to her alma mater have become stronger over the years. She has lectured to undergraduate students and is working with faculty on a safety-related research project. ‘‘I see their graduates on a regular basis, and they’re always such high caliber, which makes me very proud to be one of them,’’ she said. An ENA member since 1994, Paparella is a former chairperson of ENA’s Patient Safety Work Group. Currently she is a member of the Advisory Committee for ENA’s Institute for Quality, Safety & Injury Prevention. She is an adjunct assistant professor at the Temple University School of Pharmacy and the author of ‘‘Danger Zone,’’ a column on medication safety in the Journal of Emergency Nursing. ‘‘Susan Paparella is a leader in patient safety on a national and global stage,’’ said M. Louise Fitzpatrick, EdD, RN, FAAN, a dean and professor of the College of Nursing. ‘‘She uses her comprehensive knowledge and background to influence changes in practice and improve patient care outcomes. We are proud to say she is a Villanova nurse.’’ Josh Gaby

SPOTLIGHT ON YOU! Do you have a professional or educational achievement you want your fellow ENA members to know about? Do you want to sing the praises of a member colleague who has received a new degree, promotion or award? We encourage you to submit these items to for inclusion in monthly roundups in the new “Members in Motion” section. Include names, credentials, a short explanation of the accomplishment and a high-resolution photo (if available), along with contact information for follow-up by the ENA Connection staff for select features.

Editor in Chief: Amy Carpenter Aquino Assistant Editor, Online Publications: Josh Gaby Writer: Kendra Y. Mims Editorial Assistant: Dana O’Donnell BOARD OF DIRECTORS Officers: President: Gail Lenehan, EdD, MSN, RN, FAEN, FAAN President-elect: JoAnn Lazarus, MSN, RN, CEN

Secretary/Treasurer: Deena Brecher, MSN, RN, APRN, ACNS-BC, CEN, CPEN Immediate Past President: AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN Directors: Kathleen E. Carlson, MSN, RN, CEN, FAEN Ellen (Ellie) H. Encapera, RN, CEN Mitch Jewett, RN, CEN, CPEN Marylou Killian, DNP, RN, FNP-BC, CEN Michael D. Moon, MSN, RN, CNS-CC, CEN, FAEN Matthew F. Powers, MS, BSN, RN, MICP, CEN Karen K. Wiley, MSN, RN, CEN Executive Director: Susan M. Hohenhaus, LP.D., RN, CEN, FAEN

November 2012

ENA Connected

Taking the Next Steps With Social Media By Thomas Barbee, ENA Digital Marketing Manager It was great having the opportunity to meet so many of you at the ENA Wired lounge at the Annual Conference in San Diego. For the first time, we were able to provide an immersive social media experience for not only those who attended but also for many who were unable to make the conference. Using Facebook, Twitter and Foursquare, you were able to follow what was happening at conference, participate by posting or tweeting your experience and even check in at various conference events. Fast-forward to what we have in store for Leadership Conference, where social media will be even further integrated with your overall conference experience — right down to being able to share the website ( with your colleagues through Twitter or Facebook. Providing this level of experience allows you to use your mobile devices and network on the fly without taking away from your ability to attend all the sessions you want. Meet up with colleagues, discuss experiences, share photos or stories with your peers back home — all of these possibilities are simply a click away through any of our social media avenues. As ENA continues to advance and grow technologically, we look for ways to enhance your experience as members. This is just one of the many ways we hope to shape the future and provide you with the ultimate networking experience, whether during conference or throughout the rest of the year.

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Elizabeth Stone Griffin, BS, RN, CPEN

Non-Suicidal Self-Injury in Adolescents

Coping Mechanism, or a Cry For Help? A few weeks ago, ENA member Claudia AyalaRivera, RN, CPEN,* was preparing to start an IV on a 15-year-old female when she noticed an unusual number of cuts on the girl’s forearm. They appeared to be fairly superficial and in various stages of healing. Ayala-Rivera pulled the patient’s mother aside and asked her about the wounds. The mother explained very matterof-factly, ‘‘She and her sister think it’s fun to cut on their arms like that.’’ It was a form of play for them, the mother explained. However, Ayala-Rivera recognized this behavior as a method of stress relief and a symptom of a larger problem. She discussed this with the emergency physician, who then helped Ayala-Rivera educate the family about cutting, a common form of non-suicidal self-injury. The patient received a behavioral health assessment in the ED and was later discharged with a referral for outpatient psychiatric treatment.

What is Non-Suicidal Self Injury? Self-harm behaviors such as cutting and burning are impulsive behaviors which involve conscious decisions to mutilate or hurt oneself without suicidal intent.1,2,3 Injuring oneself can stimulate endorphins (naturally occurring opiates) which are produced by the brain in response to pain.4 These acts provide instant, temporary release and relief from stress, anger and other negative feelings.2,4 Common sites for cutting and other forms of NSSI are the arms, wrist, ankles and lower legs.2 NSSI is usually performed at least once a week in a private setting, such as a bedroom.2 Occasionally, such as in the case of Ayala-Rivera’s patient, the family is aware of the self-injury and accepts the behavior as a form of play or a harmless coping mechanism. Self-injury can be extremely addictive, and without psychiatric treatment it often continues for several years, even into adulthood.2 Due largely to a lack of understanding about selfinjury and to the stigmas that surround it, this behavior is often perceived by others (including health care professionals) as being manipulative or attention-seeking.5


Looking Beyond the Scars The rate of NSSI is higher in adolescents and young adults than in the general population — 14-21 percent vs. about 4 percent, respectively.1 Females are more likely to engage in NSSI than males.2 The rate is also up to six-fold higher in people who have been

exposed to physical violence or threat to life.1 NSSI, while not currently recognized by major medical classification systems as a separate mental health disorder, is recognized as a symptom of borderline personality disorder.3,4 (While searching online for website resources to list in this column, I noticed that NSSI was

November 2012

usually found only under the heading of BPD.) However, according to the research, NSSI in adolescence, especially, does not seem to be limited to those to suffer from BPD. It is a behavior found not only in adolescents who suffer from other psychopathologies but also in those who practice various forms of ‘‘indirect self-injury,’’ such as substance abuse, eating disorders and abusive relationships.1 NSSI can even be found in adolescents with no history of any of the above behaviors or conditions.1

NSSI and Suicide Risk A 2011 study by St. Germain and Hooley found that compared to individuals who engage only in indirect self-injury (risky behaviors/lifestyles), those who engage in NSSI are ‘‘much more harshly self-critical … the individuals who engage in NSSI may regard suffering and pain as something that they deserve’’ (page 81). Not surprisingly, they are also more prone to suicidal tendencies and have higher rates of suicide attempts.1,6 The time immediately after an episode of NSSI holds the greatest risk of both repeated NSSI and completed suicide.6

Attitudes, Assessments and Referrals Sometimes, as in Ayala-Rivera’s case, the patient’s family is unconcerned about the behavior. Often the NSSI is not the primary reason for the ED visit but a secondary finding during the nurse or physician assessment. Health care providers who identify a selfcutting injury need to determine whether the injury was part of a suicide attempt or a self-cutting episode. Asking nonjudgmental questions about the length of time the behavior has been used, and how, when and why it is performed is appropriate and will help ED providers guide the patient toward the appropriate referral and subsequent care.2 Much inconsistency exists in the frequency of both ED mental health assessments and outpatient mental health treatment for patients who engage in NSSI.6 Emergency departments are in a position to help close these gaps in care by providing mental health assessments while the patient is in the ED, when possible, and by providing potentially life-saving referrals for follow-up mental health services. Finally, staff knowledge and attitudes are also vital to the effective management of patients who self-injure; those who lack knowledge on the subject of NSSI are most likely to exhibit negative attitudes toward these patients.5 Health care professionals, as well as school staff (both are often the first to identify self-injurous behavior) can help de-stigmatize self-harm behavior by educating themselves and thereby becoming more effective providers

of support and care.5 We should all focus not on the scars themselves, but on the people behind the scars.

pscychresns.2011.12.012 4. National Alliance on Mental Illness Website. Accessed 10/1/2012:

Resources and References 1. St Germain, S. A., & Hooley, J. M. (2012). Direct and indirect forms of non-suicidal self-injury: Evidence for a distinction. Psychiatry Research, 197(1-2), 78-84. doi: 10.1016/j.psychres.2011.12.050 2.Puskar, K. B., Bernardo, L., Hatam, M., Geise, S., Bendik, J., & Grabiak, B. R. (2006). Selfcutting behaviors in adolescents. Journal of Emergency Nursing, 32(5), 444-446. doi: 10.1016/j.jen.2006.05.025 3. Plener, P. et al, Prone to excitement: Adolescent females with non-suicidal selfinjury (NSI) show altered cortical pattern to emotional and NSS-related material, Psychiatry Research: Neuroimaging(2012), doi:10.1016/j.

5. Timson, D., Priest, H., & Clark-Carter, D. (2012). Adolescents who self-harm: Professional staff knowledge, attitudes and training needs. Journal of Adolescence, 35, 1307-1314 6. Olfson, M., Marcus, S. C., & Bridge, J. A. (2012). Emergency treatment of deliberate self-harm. Archives of General Psychiatry, 69(1), 80-88. doi: 10.1001/ archgenpsychiatry.2011.108 7. (a great website for patients who self-harm as well as the health care providers who care for them). Accessed 10/1/2012. * Claudia Ayala-Rivera’s name and story used with her permission.

Establish Yourself as a Leader Join the faculty for ENA Leadership Conference 2014, Phoenix, March 5-9

Grow your career when you become part of ENA Leadership Conference Faculty. Share your leadership knowledge, experience and skills to help grow the profession of emergency nursing. Do you have specific knowledge in a particular area of emergency nursing, management or policy? Has a particular experience given you new insights into a current issue or trend and led to new best practices? Do you have experience dealing with leadership challenges and issues?

Share your insights related to current issues, trends, and best practices as a faculty member at ENA Leadership Conference 2014, March 5-9 in Phoenix, Arizona

Topic areas: • Management • Operations • Government affairs • Technology • Team building • Research • Education

Submission Deadline is

March 25, 2013

• Advance practice • Orientation • Retention • Community relationship building • Customer satisfaction • Personal and professional development

Find full information and course proposal guidelines at and click on Leadership Conference 2014 Call for Course Proposals in the Calls and Opportunities Section. We look forward to hearing your cutting-edge course ideas.

Official Magazine of the Emergency Nurses Association


A Special Midnight Showing Colorado Theater Tragedy Brings Out the Best in ED Staff Response By Kendra Y. Mims, ENA Connection

July 20, 2012, Aurora, Colo. 12:30 a.m. When Jennifer Hahn-Farris, RN, charge nurse at the Medical Center of Aurora, received word from the onsite emergency department police officer that a shooting had occurred at the Town Center at Aurora shopping mall, she figured it was gang-related and organized her trauma nurses to prepare the trauma rooms for gunshot wounds. Because the hospital is located about two miles from the mall, Hahn-Farris expected to receive two or three patients, so she also notified the lab, along with the ICU charge nurse. It wasn’t until she returned to triage five minutes later for an update that Hahn-Farris realized the magnitude of the shooting: More than 20 victims had been shot at close range in a crowded movie theater. Hahn-Farris took a deep breath and received the first victim in triage at the same time she received the update. The patient was eight months pregnant with significant injury to her face. With limited time to assess the patient, the patient was categorized as their highest level of trauma team activation and taken back to the trauma room. Hahn-Farris immediately huddled with her triage nurses and told them there were unknown severities and that they needed to be ready for the worst-case scenario. Her nurses began Jennifer Hahn-Farris, RN moving all of the stable patients out of the rooms as quickly as possible to make room for the ones soon to come. The triage nurse moved all of the patients who were already in the waiting room before the shooting incident to an urgent-care area so that they could be spared from seeing any traumatic visual images caused by the mass shooting. Hahn-Farris called ICU, requesting every ICU nurse who was available, and contacted her emergency department director to inform him of the situation. Patients started arriving two to three at a time via police cars. HahnFarris said her team was able to quickly identify which patients could be in the hallway vs. which patients that needed to be in the trauma room. ‘‘My team was phenomenal, and they did a great job at assessing the patients and their GCS levels immediately,’’ she said. ‘‘At no time did my staff become unorganized or chaotic. We took every single patient and moved them on a constant basis for acuity and straight to the OR. Everyone just did what they needed to do for the best of the patient.’’ Many patients arriving needed immediate life-saving interventions. Thoracostomies were started instantly. Hahn-Farris assigned ED nurses and ICU nurses to work one-on-one with every victim. She quickly realized that doctors were not able to go from the patients to the computer to enter orders as usual, so she switched to an efficient system for communicating orders. Order sheets and labels went on the patients so that physicians could write orders and give them directly to her secretary. Hahn-Farris and her nurses didn’t have time to prepare for the obstacles they would encounter during the next several hours. ‘‘We were already full, but we had life-threatening emergencies,’’ she said. ‘‘Gunshot wounds can’t wait.’’


12:55 a.m. Emergency department director Mark Mayes was asleep when he received the phone call. Hahn-Farris informed him that a mass shooting had occurred and victims were coming in by police cars. There was also a possibility of gas exposure. Mayes, MHA, RN, CEN, immediately threw on scrubs and headed to the hospital and notified the hospital’s house supervisor to use the external disaster page. By the time Mayes arrived at 1:05 a.m., the hospital had already received 11 patients from the shooting, and two were in the OR. He huddled with Hahn-Farris to reassess patients and determine which ones needed to go to surgery immediately with which surgeon. Mayes had an administrative worker send out an all-response page to every ED employee via text message, and staff immediately responded. ‘‘We got eight staff members that showed up to the ED to help, and that was a perfect number for us to make sure we had plenty of people to take care of the extra patients, as well as the patients who were not involved in the tragedy but still needed ED care,’’ Mayes said. Mayes also called in Justin Mast, RN, BSN, CEN, FAWM, the hospital emergency response team coordinator, for assistance with running incident command within the ED. When Mast arrived, the ED was very full and busy. The injuries were caused by range of weapons, from large-caliber to small shotgun pellets. There were limb and extremity injuries. Torso, head and dental injuries. Shrapnel injuries. Inhalation injuries. Twisted knees from running and falling. Lodged bullets. Blowout shotgun wounds to the leg. Mark Mayes, Patients who needed immediate surgery were MHA, RN, CEN already in the OR. Mast quickly assisted a patient who needed a CT scan and evaluated several others who complained of burning and itching before he headed to the command center to facilitate what was going on throughout the hospital. Although the Medical Center of Aurora had received an influx of patients from a plane crash in 2009, the emergency response team and ED staff had never dealt with a disaster of this magnitude. Justin Mast, ‘‘In the plane crash, we had advance notice and BSN, RN, CEN, FAWM 16 patients who came scattered over an hour,’’ Mast said. ‘‘They were definitely less severely injured, and the time frame of their arrival was spread out. This event had really high-acuity patients arriving in a short period of time and a number of them at the same time. There were multiple patients in police cars. The immediate response of the staff with little notice was phenomenal.’’ Staff came to the ED from all over the hospital to help manage the surge throughout the night. ‘‘I had folks come down to tell me, ‘I don’t know what to do, but I’ll do whatever you need me to,’ ” Mast said. ‘‘The ED was hit hard and fast. Everyone that was there did a superb job of trying to get people shifted around to make extra room. We knew the patients were getting the care they needed, and we were supporting them in the operating room.’’ The hospital typically runs a maximum of two ORs a night. ‘‘We received 18 patients from the incident. We opened up five ORs that night,’’ Mayes said. ‘‘That was a big challenge that we had a lot of help with. Our sister hospital, Swedish Medical Center, sent us OR nurses

November 2012

Photo by Karl Gehring, Denver Post, for the Associated Press The mass shooting by a lone gunman at the Century 16 theater in Aurora, Colo., shortly after midnight July 20 resulted in 12 deaths and scores wounded. No victims taken to the Medical Center of Aurora died of their injuries.

and scrub techs to help us because they knew we would get the brunt of the patients. It’s amazing how everyone came together to send resources. We had staff from the labor and delivery department, ICU and our trauma floor come down to the ED to help. There were no walls up. All of the walls were knocked down instantly when people heard of this tragedy. People came from all directions willing and wanting to help.’’ Another challenge for staff was the limited amount of space in the ED. Not only was the Medical Center of Aurora’s emergency department full before the shooting victims arrived, but it also was under construction for remodeling. The four main trauma rooms were shut down, leaving only two temporary trauma rooms in service. A total of 12 beds were out of service, and a third of the ED was walled off for construction. As patients arrived, they were treated in every area of the ED, including the hallways. Mayes recalled one of the patients losing his pulse in the hallway. The ED physician didn’t have a trauma surgeon with him at the time, so he inserted a chest tube himself, decompressed the patient’s chest and revived him. ‘‘Every patient was able to get the care they needed,’’ Mayes said. ‘‘All of that is because of how our emergency nurses and physicians worked together. One thing that was very impressive is that everybody clicked into mass casualty triage mode and they still took good care of the patients.’’ Despite the severity of the injuries and how they arrived at the hospital, all of the victims treated at the Medical Center of Aurora survived. Still, the night took a physical and emotional toll. Some patients already knew their loved ones were dead or missing. Along with treating patients medically, the staff had to help them emotionally and comfort concerned loved ones who arrived looking for answers.

Separated and Searching Hahn-Farris remembers seeing patients screaming in pain while bleeding all over — many calling out for loved ones they could not find. Because of the number of critically injured people at the scene, police officers transported victims to different hospitals in the area, and many patients were separated from their loved ones. Others had died at the scene. ‘‘When we were trying to help people find loved ones, we didn’t even comprehend that there were that many people dead on scene,’’ HahnFarris said. ‘‘We were trying to be optimistic and help them, and it started to hit us that we weren’t going to find everybody because not everybody was going to make it to an ER. It was difficult. ‘‘At some point we received a lot of advocates, which I directed to the patients who I felt needed the advocates the most.’’ The waiting room was quickly filled with concerned parents and loved ones. The shooting victims at the Medical Center of Aurora ranged from 13 to 31 years old. Hahn-Farris did not know many by name — she only knew them by injury. But she also knew that all of the patients in her ED were alive, and she went into the waiting room to reassure the families. ‘‘Being a mom myself, I knew they were terrified,’’ she said. ‘‘But I promised them that we were taking care of them, and if they were contacted via phone and they knew for a fact that their loved one was in my ED, then everyone I had was alive. I let them know that it’s a scary situation, but to please stay calm so that we could take care of them efficiently and quickly. They responded well to that. ‘‘We connected the families as quickly as we

Official Magazine of the Emergency Nurses Association

TeamSTEPPS Helps ED Staff Keep Order Mark Mayes, MHA, RN, CEN, emergency department director of the Medical Center of Aurora, said the TeamSTEPPS implementation that began in his ED two years ago gave the staff tools to help increase communication and accomplish everything in a systematic manner after the theater shooting July 20. ‘‘Because we already had this framework in practice, one of the simple things from TeamSTEPPS that came out and really helped us was having ‘huddles,’ situational awareness, leaders in place and using repeat back communication,’’ Mayes said. ‘‘Those things just happened naturally. ‘‘I think the best part of the night, as far as the ED was concerned, was that all of the people who needed to know what was going on were aware. Our medical director, Frank Lansville, was there, working hard and informed. Our charge nurse, Jennifer, was aware of everything. Justin [Mast, emergency response coordinator] knew. The doctors knew. The surgery team knew. And that’s because we had those communication pieces like ‘huddles’ in place. That was our real saving grace. There wasn’t uncontrolled chaos or mass confusion. Our communication was excellent in the ED in such a chaotic situation.’’ Mayes commended his charge nurse, Jennifer Hahn-Farris, RN, for maintaining situational awareness and for keeping her team going. ‘‘She took primary role of patient flow and really did a very good job with that,’’ he said. ‘‘Through the TeamSTEPPS process, we developed a team leader structure. That gave us the right kind of communication structure and the oversight we needed to run the place as efficiently as possible, to not lose track of people and to not forget about patients. We didn’t miss something. I think it had a lot to do with TeamSTEPPS.’’ Kendra Y. Mims

Continued on page 10


Critical Incident Review

Medical Center of Aurora – Mass Shooting, July 20 (Times shown are estimates) Time 00:15 00:30 00:51 00:55 00:57 01:02 01:05 01:16 01:34 01:48 02:00 02:00 02:30 03:00 03:45 03:58 04:06 04:20 04:26 04:28 04:38 04:46 05:20 05:25 05:45 06:20 06:45 06:50 07:00 07:15 08:57 09:20 09:27 10:00 10:36


Event Description Suspect enters theater 9 and begins shooting Ocean 1 in ED relays radio traffic to ED Charge Nurse 1st patient arrival Patient Arrival Timeline ED Charge RN Calls ED Director ED Director calls House Supervisor, requests disaster page Page sent out “Internal disaster in ED” ED Director arrived in ED Text sent out to all ED staff to respond if available Call to open incident command made 1st conference call made Level 2 lockdown initiated 1st patient decontaminated All directors to respond, page sent out Disaster radios dispersed ED phone calls overwhelming, hotline requested AFD I.C. confirms no more patient transports at this time 9 News on site at TMCA Decon of last contaminated patient Decon team ceases operations Hotline number set up Live BBC phone interview- Frank Lansville Increasing radio traffic, switch made to Channel 2 Staff voicemail/emotional support set up Possible volatile family situation, increased security and APD presence Media staging in 020 Spanish interpreter requested, EMT sent from ED Meeting Room 1 & 2 open for patient families Media Update at I.C. Ryan Simpson, COO designated as Interfacility Liaison Hospital census update given at I.C. Family update given to families waiting in physician conference room Hotline number found to be routing to voicemail at patient billing Update sent to media on hotline number ED/OR/L&D staff and physician debrief in ED Oasis room I.C. Command to ED Director I.C. Command to Administrator On-Call, Roberta Barton-Joe Jennifer Barry assigned as Logistics Chief Some position transfers of command begin 211 and state-wide hotline set up TV requested at family support center Incident Command roles assigned and communication structure reviewed

From left: Cassandra Hixson, RN; Justin Mast, BSN, RN, CEN, FAWM; Jocelyn Hubbach, RN; Marian Bezio; Karen Nerger, RN, SANE; Corey Casarez, EMT; Hal Anderson, EMT; Mark Wissman, RN; Jennifer Hahn-Farris, RN; Mark Mayes, MHA, RN, CEN.

Aurora Shooting Continued from page 9 could. That was really important to us. I found my youngest patients and walked parents back personally. It meant a lot to me to really reassure these parents as a mother, as their nurse and as the charge nurse of the department that their children had been cared for, and though their injuries looked significant, they were doing OK.’’ Administration quickly developed a separate room for families to help support them. Refreshments and counselors were brought in. The Medical Center of Aurora was the first hospital to set up a public hotline to increase communication. ‘‘I think we can say that was a big challenge for us,’’ Mayes said. ‘‘Multiple patients went to different hospitals, so in the beginning, we didn’t have a good way to communicate where that family member was or how they could find their loved ones. It was tough because it happened so quickly.’’

The Aftermath Hahn-Farris is proud of how her team and colleagues responded and took care of all of the patients despite the many obstacles they faced throughout the night. ‘‘I don’t think we realized as caregivers how big this was going to be,’’ she said. ‘‘It’s amazing to me how well everything flowed. My nurses stayed focused. They stayed on point and were able to give me all of the information that I needed one-on-one every time we huddled. We have a great disaster team, and Justin is phenomenal at what he does. It has changed us as a team, it changed us as nurses, and it changed me as a leader. This makes me realize what our ED is capable of.’’

She says the shooting has created some anxiety in some of her nurses who treated patients that night. ‘‘For my nurses who smelled it and heard it and who washed the blood off of these patients and listened to their stories, it increased their own anxiety of why this happened and how many lives were forever changed,’’ said Hahn-Farris, who made sure she focused on her nurses’ emotional status after the incident. ‘‘We will forever have a connection with these patients and hold a special bond with each other. ‘‘It’s been a roller coaster of emotions for a lot of our nurses, but I think that in the end, everyone is doing well knowing that every patient we received survived. They all stepped up and listened to me and had faith in me, but they also had faith within themselves and faith in their team. We got through all of it.’’ Hahn-Farris feels the nurses who weren’t working that night also hold a lot of pride in knowing they work for a facility that provides support to staff and high-quality care to patients. ‘‘I know they would have stepped up and done the same thing,’’ she said. ‘‘As a leader, I know that we are capable of a lot. I’m very proud of what I do. I’m very proud of my nurses. I’m very proud of where I work, and I’m very proud of the director [Mayes] that I have. We had absolutely nothing to do with what happened and had no control over what happened, but I feel like we certainly proved ourselves to the community that above all else, when we are in that position, we take it very seriously and very close to our hearts. We are there for a reason, and we are very available for our city, and we will take care of anybody to the best of our ability that needs us.’’

November 2012

BOARD WRITES | Kathleen E. Carlson, MSN, RN, CEN, FAEN

Caring for Behavioral Health Patients in the ED

Searching for Solutions to Unfortunate Holding Pattern

Across our country, as inpatient behavioral legislators, and the state is now well on its way Level  II trauma center in Wilmington, N.C., health beds have closed, emergency reports that they have a designated eight-bed toward building a 25-bed facility to care for the departments have become the default location pod where boarded behavioral health patients state’s forensic psychiatric patients. for patients requiring psychiatric care. are cared for as they await placement. ‘‘There is now light at the end of the tunnel L E A D E R S H I P C O N F E R E N C E 0 model 1 3 where an ED However, caring for these patients in the ED is ‘‘We’ve created a2care with the state agreeing to build a new facility expensive and places an additional burden on RN provides care to the patients, and a BH RN due to open late 2013 or early 2014,’’ crowded facilities. Most hospitals are holding provides a psychiatric screening, while other Kouwenhoven said. F Eassists B R with U Apatient R Y placements,’’ 2 7 – M R C H involuntary emergency psychiatric patients for F O R T L A U D E R D A L E , F L staff sheAsaid. Christy Spivey, RN, administrator of several days as they await placement. This Emergency Department and Trauma Services at Continued on page 24 article will share some strategies being used by LEADERSHIP CONFERENCE 2013 New Hanover Regional L E A D EMedical R S H I Center, P C O Na F E R E N C E 2 0 1 3 our nursing colleagues to care for patients and caregivers in this difficult situation. The New Hampshire ENA State Council FORT LAUDERDALE, FL FEBR UARY 27 – MARCH 3 recently hosted a breakfast for emergency E N A L E A D E R S H I P C O N F E R E N C E 2 0 1 3 R E N C E 2nursing 0 1 3 leaders with a panel of psychiatric F O R T L A U D E R DA L E , F L F E B R U A R Y 2 7 – M A R C H 3 experts. New Hampshire has only one state hospital that admits psychiatric patients, and FORT LAUDERDALE, FL FEBR UARY 27 – MARCH 3 most of the attendees were unclear about how many beds the state has and the process FEBRUARY 27 – MARCH 3 to admit patients. The attendees had a ENA LEADERSHIP CONFERENCE 2013 passionate discussion about the problem and T L A U D E R DA L E , F L F E B R U A R Y 2 7 – M A R C H 3 shared practical toolsF O Rto help the staff caring directly for these patients. Stacey Savage, BSN, RN, CPEN, New Hampshire ENA state president, felt this discussion was ‘‘a major step toward collaboration and, hopefully, some support.’’ Vermont’s state forensic hospital was destroyed by Hurricane Irene last year, to be immediately moved O N F E R Ecausing N C E 2 patients 013 ENA LEADERSHIP CONFERENCE 2013 into outpatient settings, lower-acuity Offering Educational and Networking units and even into the E B R U A R Y 2psychiatric 7 – M A R C H inpatient 3 Opportunities for Current and Future correctional system. Without the state F O R T L A U D E R DA L E , F L F E B R U A R Y 2 7 – M A R C H 3 Emergency Nurse Leaders. hospital to house the highly acute forensic behavioral health patients, Vermont’s emergency departments have been severely impacted. Many EDs are finding themselves holding multiple psychiatric patients awaiting ‘‘appropriate’’ placement for days at a time. Derek Kouwenhoven, RN, CEN, Vermont ENA State Council president, reports that ‘‘a few months ago, it appeared that the long-term plan was to use community health centers and stretch the outpatient settings for these forensic patients, which would, in turn, For more information, scan QR code, or visit continue the impact on emergency departments throughout Vermont’’ with overcrowding and violence. Vermont ENA members, ED staff and R TU LDAEUR DD E RADA C HA3R C H 3 members from the remaining inpatient F O R T FLO A L EL E, , FFLL FFEE B RRUUAAR YR Y2 7 2–7M A–R M behavioral health units lobbied their


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Official Magazine of the Emergency Nurses Association


The National Council Mental Health and Addictions Conference By Kendra Y. Mims, ENA Connection Mental health and addictions experts, clinicians, community-based advocates, researchers, social workers, direct care staff and many more health care professionals and organizations convened in Chicago in April for the 42nd National Council Mental Health and Addictions Conference. ENA Connection covered the following sessions:

Addressing Secondary Traumatic Stress: A Guide to Caring for Staff In this trauma-informed care session, Dr. Richard Mollica, MD, MAR, director, Harvard Program in Refugee Trauma, Harvard Medical School, discussed how caring for consumers who suffer from the impact of trauma can affect health care professionals. He also talked about the importance of health care professionals developing a self-care program, which plays a role in providing effective care. ‘‘This is an exciting topic because we all know that the pain of others becomes our pain,’’

Mollica said. ‘‘You can’t do this work, working with highly traumatized people, unless you have a model of self-care.’’ Although a majority of the attendees raised a hand when asked if they had experienced burnout, very few raised a hand when asked if their organization had a written, efficient self-care protocol. ‘‘One of the things I want you to understand here is that the symptoms and the problems of self-care are essential to the treatment,’’ Mollica said. ‘‘They are part of the treatment. They are part of the diagnosis. You’re going to see from the neuroscience that your experience of the patient that often leads to burnout and compassion fatigue is a diagnostic experience.’’ As Mollica talked about the differences between burnout (more organizational) and compassion fatigue (more personal), he also shared stories of how he and his team have previously been affected when caring for highly traumatized patients, including experiencing the same nightmares as their patients.. ‘‘Our hopelessness about the patients came from the patients. We felt hopeless because the

patients felt hopeless,’’ he said. Attendees also learned about empathy and its impact on self-care and healing. ‘‘You can’t understand self-care unless you understand empathy,’’ Mollica said, challenging the audience to embrace the new concept of empathy, which no longer involves putting yourself in other people’s shoes. ‘‘Empathy is the key to our treatment and to our healing. If one believes empathy heals, then self-care is essential. ‘‘This idea of putting yourself in the shoes of other people is aggressive in some cultures. It goes against the neuroscience, because what the neuroscience research has shown is to imagine the self as the other.’’ He said this concept of maintaining independence causes less distress and higher empathy. The session ended with a discussion on the effectiveness of using Balint groups in all health care settings (peer supervision on relationships and not techniques). Mollica also engaged the audience in a conversation about lifestyle practices to prevent compassion fatigue and burnout (such as diet, exercise, sleep, spiritual health, etc.) and the importance of making these practices a reality.

Preventing the Use of Seclusion and Restraint Conference attendees learned about promoting alternatives to seclusion and restraints through


Exemplary Practice and Innovation? T he ENA Lantern Award recognizes exemplary emergency departments that demonstrate exceptional performance and innovative practice in the core areas of: • Leadership • Practice • Education • Advocacy • Research

B ecome a Lantern Award recipient Apply today. Applications are due February 20, 2013.

A Coaching Guide is now available to help you identify how best to demonstrate your emergency department’s achievements. To learn more and apply, visit : Development of the Lantern Award program criteria funded in part by Stryker, an ENA Strategic Sponsor.

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November 2012

Building New Leaders and a Commitment to Mental Health Keynote speaker David Satcher, MD, PhD, director of the Satcher Health Leadership Institute and former U.S. surgeon general, presented his vision to nurture leaders in public health and medicine who can contribute to eliminating disparities in health. He also discussed the importance of integrating mental health and primary care. Satcher promoted leadership partnership to meet the challenge of ensuring a health system that provides access to quality health care for all. ‘‘We have to find other people who share our mission but perhaps who bring different talents and resources to the table, and we have to work together, especially true when dealing

trauma-informed care practices. Joan Gillece, PhD, project manager, National Association of State Mental Program Directors/National Center for Trauma-Informed Care, discussed SAMHSAsponsored technical assistance and support to publicly funded systems to prevent the use of seclusions and restraints and to create a culture change. ‘‘We know that there is nothing therapeutic about seclusion. We know it is treatment failure,’’ Gillece said. ‘‘… Seclusion and restraint is awful for the staff, it’s awful for the other people observing it, and it’s clearly awful for the person being restrained.’’ Gillece said almost every seclusion and restraint boils down to a staff member trying to enforce a rule. When she asked attendees to identify the most volatile times for seclusion and restraint, one audience member suggested shift change. Audience members who worked in facilities that use seclusion and restraint ranged from residential treatment programs to hospitals and crisis centers. Raul Almazar, MA, RN, a senior consultant to SAMHSA’s Promoting Alternatives to Seclusion and Restraints through Trauma Informed Practices, shared his input on the importance of helping organizations seek alternatives. He said the only way to effectively change the culture is to understand the amount of trauma in that culture. ‘‘The majority of clients in our mental health system have experienced trauma,’’ Alazae said. ‘‘When we begin to look at what people do to manage the world, we understand that what we are trying to treat are actually adaptations. … The common bond amongst all of us — providers and the people we provide services to — is that we’re all just trying to manage in this world. We should never

with social determinants of health,’’ he said. ‘‘Regardless of how good we are, we need to be part of an effective team.’’ Satcher encouraged attendees to talk more about the importance of mental health. ‘‘We think a lot about mental illness, but I don’t think we talk enough about mental health,’’ he said. ‘‘We want people to think about mental health and to appreciate what it really means to have mental health and how to promote mental health and prevent mental illness.’’ He shared statistics showing 1 in 5 Americans is diagnosed with a mental disorder and the World Health Organization’s prediction that mental disorders will be the leading cause

compare people’s trauma.’’

of disability by 2020. He said many patients diagnosed with a mental disorder don’t receive treatment until they are in a crisis. ‘‘A mental health emergency in the ED can be a disaster,’’ Satcher said. However, “we found that it is possible to dramatically improve the experience of people in the ER when they go in for mental health emergencies, or we found that, in fact, we can improve the waiting times.’’ ‘‘Maybe we can’t cure mental disorders,’’ he concluded, ‘‘but we can help people recover in the sense that they return to productivity, fulfilling relationships with others and they’re able to deal with challenges in their lives.’’

outside to manage the world, we bring them into

Almazar challenged the audience to

our systems and say, ‘Behave like an angel, and

understand patient behavior.

if you don’t, we take privileges away.’ For a

‘‘We wonder why people are agitated,’’ he said. ‘‘We take away everything people use

lot of people, that’s their connection to the outside world.’’

Established in 1991, the mission of the ENA Foundation is to provide educational scholarships and research grants in the discipline of emergency nursing.

Invest in the future of your profession. Support the ENA Foundation.

Official Magazine of the Emergency Nurses Association

Your Dollars = Your Future Investing in a nurse today is an immeasurable contribution to the future of emergency nursing and patient care.

Donate Now.


ENA LE A D E R S H I P C O N F E REN C E 2 013











Strengthen your leadership skills and empower your career today, tomorrow and for the future at ENA Leadership Conference, February 27- March 3, 2013 in Fort Lauderdale, FL Shape the Future is about you shaping your future by gaining the knowledge and leadership skills you need to succeed. You can begin to shape your conference experience by participating in illuminating presessions that cover diverse and crucial information. Learn the skills you need to succeed as a leader from developing budgets and appropriate staffing to developing a mission/vision statement with your team. For those aspiring future

speakers you will learn how to write and deliver an award-worthy presentation. These presessions are designed to strengthen your existing knowledge base and provide you with new information that will help you as a leader. Continue shaping your future with evidence-based sessions providing vital knowledge in several focus areas including: safety, professional development, health, quality and management.



WHAT’S NEW @ CONFERENCE IgNITE ® SESSIONS Watch your colleagues present their own take on “What Makes an Emergency Nurse Unique?” in these fast-paced 5-minute sessions packed with creativity, humor and insight.


To view the new conference offerings and complete details on conference sessions and keynote speakers, please scan the QR code or visit

JAm SESSIONS These instructor-led, open forum sessions encourage expanded interactivity between attendees and instructors well beyond the classroom atmosphere of a traditional session. Expert faculty will guide the discussion by providing a base presentation of ideas and soliciting the experience, stories and ideas from you the attendee.

HANd-OFF SESSIONS These unique sessions encompass two related topics in a concise 35-minute format to form one information packed session with must-knows that are important to you.

dEEp dIvE SESSIONS Experience in-depth exploration of topics that simply can’t be covered in a traditional course length.

ENA WIREd A self-serve computerized system area, Social Media and Wi-Fi hotspot available to all attendees. Access your e-mail, record the educational sessions you attend and print a completed certificate onsite.

New this year are three unique learning experiences, including: Jam sessions, Hand-off sessions and Deep Dive sessions. Become inspired with the general session speakers; Carmine Gallo, Jon Gordon and Marcus Engel have been specifically selected to compliment the educational experience presented throughout each day. Each speaker offers their unique perspective on leadership skills ranging from how to inspire leaders, methods to overcome life obstacles and changing the things that you can. This leadership conference is a must attend event as these impactful sessions are truly geared toward you shaping your future.


Important dates to Remember Registration .....................................Now Open Early Discount Rate Closes ....... Jan. 16, 2013 State and Chapter Leaders Conference ........... Feb. 27 – 28, 2013 Presessions................................ Feb. 28, 2013 Educational Sessions ............ Mar. 1 – 3, 2013 Exhibit Hall ...................Feb. 28 – Mar. 2, 2013

VE – SAh E – TATE D 2013 ENA ANNuAl CONFERENCE Nashville, TN • Sept. 17 – 21, 2013 ENA lEAdERSHIp CONFERENCE 2014 Phoenix, AZ • Mar. 5 – 9, 2014


Laura Giles, BS, RN, 2012 ENA Foundation Chairperson

Your Generosity Has Moving Results This year I have been promoting the idea of the ENA Foundation as your charity of choice. In 2012, the board of trustees and I have endeavored to establish a culture of philanthropy in our appeals to our membership. We want you to think of the ENA Foundation as a valued and trusted charity. We seem to be on the right path. In the past year, individual giving by ENA members has increased. Despite the challenges we faced in 2012, we still had the most successful State Challenge ever. And we can do even

better in the coming years. If you read ENA Connection from cover to cover, as I do, then you certainly have read how your contributions have helped support research in the field of emergency nursing and provided emergency nursing education. The August 2012 article about the effects of sexual assault on sex workers was a significant milestone. Researcher Dr. Lola Prince has made a contribution to the literature and opened the eyes of ENA members with her study; her research affects the lives of patients as a result.

New ENA monthly offering for FREE Continuing Education with contact hours for our members. • Available November 1 Prevention of Healthcare-associated Infections 1.0 contact hour Rhonda Morgan, RN, DNP, CEN, CNRN, CCNS, APN

Don’t miss out on enhancing your education. Go to for additional free continuing education opportunites.

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

The ENA Foundation provided support to Dr. Prince to conduct her research. An article in the March 2012 issue paid tribute to paramedic Bryan Stow, whose poignant story of recovery after being brutally attacked after a baseball game touched people nationwide. The California ENA State Council stepped up and used funds it raised during the 2011 ENA Foundation State Challenge to name a 2012 academic scholarship in Stow’s honor. In the April 2012 issue, Charlotte Schnakenberg, the first recipient of the ENA Foundation’s new International Exchange Program, supported by Stryker, shared her 10-day experience in Ipswich, Suffolk County, England. The ENA Foundation provided Schnakenberg with a scholarship that helped her enhance her professional development and knowledge of emergency care and build international relationships with other emergency nurses. Let me assure you that the ENA Foundation is an excellent steward of your contributions. The results of the 2012 State Challenge campaign mean that 2013 will see 100 percent of the $116,000 raised go to our members for scholarships and research grants. We have an experienced scholarship review team and a set of specific criteria. This year, 47 scholarships in the total amount of $194,000 were disbursed to our fellow ENA members, as well as multiple research grants and continuing educational scholarships. (To view the list of scholarship and grant recipients, visit Default.aspx). Typically, the development staff informs the scholarship recipients. This year, I asked to ‘‘puh-lease let me make two of the calls to recipients myself.’’ When I called one recipient, he took a long and very deep breath and stated, ‘‘I can’t tell you how much this means to me. I was reviewing my finances for the coming school year and was wondering how I was going to make it. What an impact! Thank you! Thank you! Thank you!’’ Wow! I felt tears come to my eyes as I heard his response to the good news. I was walking Continued on page 23


November 2012

Course Administrative Procedures Updated The Course Administrative Procedures have been updated and posted on the ENPC and TNCC pages of The procedures and the 4th edition of ENPC were effective Sept. 1.

ENPC 4th Edition Instructions have been sent to all current ENPC 3rd edition instructors regarding how to access the Instructor Update modules and test through ENA’s online Center for e-Learning. The letter is also posted on the ENPC page of www.ena. org. Access to the update modules and test opened Aug. 27, and several instructors have already passed. Upon successful completion, the instructor may print a certificate of completion; a new ENPC 4th edition provider and instructor status will be issued within the ENA database. Instructors may call ENA Course Operations at 800-942-0011 to order an ENPC 4th edition provider manual to study for the update test.

address. Both of the above are distributed to the recipient by an e-mail that includes a link to access either the downloadable PDF instructor supplement or the online pre-course modules. More directions will be added to the eCourseOps landing page. These functions are separate but work in a similar format.

ENPC 4th Edition Course DVD The demonstrations of the ill and injured child skill stations that are used for the provider and instructor courses are located in the Center for e-Learning, along with the instructor update modules. Course directors who are teaching ENPC 4th edition instructor and/or provider courses in areas that have limited classroom Internet access may download the Management of the Ill or Injured Pediatric Patient Skill Station Demonstration videos. The link to the ENPC 4th edition material is within the Course Directors Only section of The videos are available as large MP4 files; ENA recommends that you download them from a location with high-speed Internet access. Click on the link to download the files to your computer.

Your Input Is Welcome Coursebytes is the official communication to all TNCC and ENPC course directors and instructors. Topics for future issues and feedback are welcome at


your Career Looking to expand your experience, your reach or your knowledge base?

Develop a Plan

Achieving your goal requires time and commitment. It also requires a plan. Determine what opportunities exist that you could participate in to reach that goal.

Use the Right Equipment New Functionality for Course Directors Along with the rollout of the ENPC 4th edition course is new functionality available through eCourseOps: • Purchase downloadable ENPC 4th edition instructor supplements by clicking on the “Manage E-books” menu item on the left side of the screen. • Assign course participants to your specific ENPC 4th edition provider course to enable them to view the pre-course modules by clicking on the “Pre-course” icon on the far right-hand side of the related course. You will find it listed under “Upcoming Courses.” In order to assign the downloadable books or the participants of the provider course, the course director will receive an online form in which to enter the recipient’s name and e-mail

Leverage the tools and resources of your ENA membership to help you achieve your goals. Build a professional profile and resume and look for new opportunities through ENA’s Career Center. Access Career Wellness resources online at

Participate in ENA Educational Opportunties

ENA is pleased to partner with the National Healthcare Career Network to offer a series of webinars that can help you TAKE CHARGE OF YOUR NURSING CAREER! The November class titled “How You Can Enable Excellence” is on November 29, 2012 and is available for 24 hours. Additional sessions will be held in January and February 2013. Don’t miss out!

Powered by the ENA Career Center 2012 Advancing Your Career AD Nov.indd 1

Official Magazine of the Emergency Nurses Association

Career Center

Wellness 10/24/2012 11:31:52 AM



Kathleen Ream, MBA, BA, Director, ENA Government Affairs

Sequester Could Lead to More than 760,000 Lost Health Care Jobs In September, the American Hospital Association, the American Medical Association and the American Nurses Association released a new report that found up to 766,000 health care and related jobs could be lost by 2021 as a result of the 2 percent sequester of Medicare spending mandated by the Budget Control Act of 2011, scheduled to begin Jan. 2. The report measures the anticipated effect of the cuts in Medicare payments on health care providers and reflects how reductions in Medicare payment for health care services will lead to direct job losses in the health care sector and reduced purchases by health care entities of goods and services from other businesses. As the impact of these cuts ripples through the economy, jobs will be lost across many sectors beyond health care. In the press release announcing the report, ANA First Vice President Cindy R. Balkstra noted that ‘‘nurses have always strived to put patients at the center of a health care system that emphasizes prevention, wellness and coordination of care, the kinds of services that experts agree are essential to not only improving the health status of patients but also lowering overall health care costs. Cutting Medicare spending in a way that eliminates health care jobs is an extremely short-sighted way to contain the high cost of health care.’’ The report estimates that during the first year of the sequester, more than 496,000 jobs will be lost. It also found that the job losses will affect many economic sectors beyond health care and will be spread across every state, with more than 78,000 jobs lost in California alone by 2021. The health care sector has long been an economic mainstay, providing stability and growth even during times of recession. The Bureau of Labor Statistics’ data show that health care created 169,800 jobs in the first half of 2012 and accounted for one out of every five new jobs created this year. Last year’s budget deal requires $1.2 trillion over a decade in automatic


across-the-board cuts for some federal programs to take effect unless Congress finds an alternative. Most policy analysts expect lawmakers to get more serious about funding and tax decisions after the November elections.

Nation’s EMS Policy Advances With the nation’s emergency medical services systems facing challenging problems, two multidisciplinary committees have been working collaboratively to define the direction of federal research and initiatives for the EMS community. Both the Federal Interagency Committee for Emergency Medical Services and the National EMS Advisory Council held summer 2012 meetings, providing updates on the significant accomplishments they have achieved.

FICEMS FICEMS specifically is charged with coordinating federal EMS efforts for the purposes of identifying state and local EMS needs, recommending new or expanded programs for improving EMS at all levels and streamlining the process through which federal agencies support EMS ( At its last meeting in June, FICEMS noted that much progress had been made through its use of Technical Working Groups comprising interagency staff-level employees who meet monthly conducting the work of FICEMS’s eight standing committees. While each committee has developed two-year work plans to help guide FICEMS’s ongoing EMS projects ( Committee_Updates_Dec2011_Final.pdf), one of the many projects discussed at the June meeting was a model uniform core criteria for mass casualty triage.

Model Uniform Core Criteria FICEMS’s TWG on preparedness has been assessing the feasibility and efficacy in promoting the implementation of a consensus-based national guideline for model uniform core criteria for mass casualty triage. Jurisdictions at a mass casualty incident use various triage methods, such as Simple Triage and Rapid Treatment and JumpSTART, the pediatric equivalent to START. At issue are MCIs crossing jurisdictional lines and involving responders from multiple agencies that may be using different triage methods. Were all the responders at a given MCI to use the same triage method, operational simplicity, communications interoperability and clinical efficiency may be more readily attained. However, accepting MUCC as the national triage system has a number of hurdles to overcome, such as the lack of

November 2012

evidence regarding the impact of using a MUCC-compliant MCI triage method vs. a non-MUCC-compliant MCI triage method. The MUCC project had its beginnings in 2006 when the Centers of Disease Control and Prevention convened a workgroup of subject matter experts to examine the science supporting existing mass-casualty triage systems and make a recommendation for the adoption of a single system as a national standard for MCI triage. In September 2008, an article, ‘‘Mass casualty triage: an evaluation of the data and development of a proposed national guideline,” (Disaster Medicine and Public Health Preparedness) was published, proposing national guidelines that became known as SALT triage: Sort – Assess – Lifesaving Interventions – Treatment/Triage. SALT, a non-proprietary free system, was developed from available research, widely accepted best practices of existing mass-triage systems and consensus opinion from the workgroup. The SALT workgroup considered the development of SALT to be a first step in creating a national guideline for MCI triage systems. Expanding upon the SALT workgroup, MUCC was created by a 30-member CDC-funded group. The MUCC comprises 24 specific criteria, which the MUCC workgroup recommended as model minimum elements that all MCI triage systems should include. According to FICEMS, although ‘‘the MUCC is supported by the best available science, the evidence base for evaluating MCI triage systems in prehospital settings is limited. The majority of MUCC’s criteria — pdf/2011/December/10-MUCC_Options_ Paper_Final.pdf — are supported by indirect evidence (i.e., evidence that comes from different situations or different patient populations) and consensus decisions, meaning the SALT and MUCC workgroups found gaps in the science.’’ While a number of EMS stakeholder organizations (e.g., American Academy of Pediatrics, American College of Emergency Physicians, American College of Surgeons– Committee on Trauma, National Association of EMS Physicians, National Association of State EMS Officials) endorsed MUCC, a national model would necessitate everyone at every level changing current practices.

NEMSAC held an orientation meeting at the end of August 2012 with its newly appointed experts from various EMS disciplines, including Michael A. Hastings, MS, RN, CEN, who was nominated by ENA. (See Hastings’ NEMSAC meeting report on page 23.) To assist the new members, the meeting covered NEMSAC accomplishments including various council advisories, such as: • EMS System Performance-based Funding and Reimbursement Model to sponsor a comprehensive: o EMS System Design project that will identify the essential components and functions of EMS systems, standardize terminology, and establish performance standards for minimum levels of service; o EMS System finance study that accounts for all costs and revenues.

• The Next Steps for Prehospital Care EvidenceBased Guidelines to include urging NHTSA to lead the effort in forming relationships with stakeholder organizations and academic journals in order to hasten the process of publishing EBGs, as well as to assist in decreasing the time to implementing EBGs in the field through measures such as developing implementation toolkits or training curricula to ensure that the EBG is incorporated into providers’ clinical practice. More details about the NEMSAC meeting can be accessed at

Article prepared by Terri L. Nally, ENA senior public policy specialist.


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NEMSAC The National EMS Advisory Council provides expert advice and recommendations to the National Highway Traffic Safety Administration and its federal partners on key issues, including recruitment and retention of EMS personnel, quality assurance, data collection and EMS.

Official Magazine of the Emergency Nurses Association



Knox Andress, BA, RN, AD, FAEN

Photo by Ed Mund, BA, FF/EMT

Mass Casualty Incident: ‘Where’s My Child?’

Rescue workers practice at a 2008 school bus mass casualty incident workshop in Clark County, Wash.

A mass casualty incident in the emergency department has many requirements for processes, procedures and resources including personnel, medical materials, supplies and equipment. An important process includes patient tracking.

MCI Incidents – Tracking Them Down On Aug. 28 in Louisville, Ky., 48 children were sent to multiple hospital emergency departments after an automobile ‘‘T-boned’’ their school bus, causing it to roll. Local news media reported the frustrations of frantic parents searching area hospitals trying to locate their children after learning of the accident.1 School and commercial bus wrecks are not uncommon and are a source of mass casualty incidents. In 2010, there were 249 fatalities and 12,000 persons reported injured in U.S. bus crashes. On July 20 in Aurora, Colo., 59 movie-goers suddenly became casualties during the earlymorning mass shooting at a movie theater (see article on page 8). Justin Mast, RN, of The


Medical Center of Aurora emergency department, reported several casualties arrived via police vehicles. Consequently, they were not entered into the community patient tracking system before their arrival. Communications between responding hospitals helped account for patients. Emergency department director Mark Mayes, MHA, RN, CEN, reports what seemed like thousands of calls to a hospital hotline as worried friends and family tracked down loved ones. The hospital command center at Swedish Medical Center in Englewood, Colo., reportedly handled hundreds of phone calls from panicked people looking for family members and friends.

Benefits to MCI Patient Tracking There are multiple reasons for patient tracking in an MCI. Tracking will facilitate family and loved-one reunification. Patient tracking can improve resource management. Many Web-based, patient-tracking applications can

provide ED and hospital leadership with visibility of incoming casualties and casualty characteristics, including injury types, acuities, gender, age and others. Having incoming casualty visibility allows prepositioning of medical resources and can ‘‘buy’’ prep time. Sharing patient tracking data with the hospital command center and hospital leadership will provide situational awareness of the MCI’s impact based on the facility and community.

Considerations for Tracking Planning for MCI patient tracking in the emergency department and hospital includes making decisions regarding the following: 1. The person and team responsible for the plan. 2. Technology (paper, electronic or both). 3. The trigger for activating the tracking process. 4. The forms used and how will they be deployed. 5. What patient identifiers will be assigned.

November 2012

6. How forms will be collected. 7. How often forms will be collected. 8. Where tracked patient data will be collated. 9. Who is responsible for data collation during an incident. 10. How patient tracking data will be shared. 11. Who will share the data. 12. Who will be the point-of-contact for community providers and inquiries. Important considerations include coordination with regional patient tracking systems that may already be in place within your region or state.

Tracking Technologies

Summary Benefits to patient tracking include family and loved-one reunification, improved resource allocation and management, among others. Patient tracking will provide leadership, improved surveillance and situational awareness of an MCI’s impact. Are you ready to track? Resources 1. E  xhibit 4, FARS/GES 2010 Data Summary 2. NEWS0105/309280109/Frantic-parents-frustrated-trying-findchildren-JCPS-bus-wreck. 2. h  ttp:// 3. 4. 5. main_training_summit/10-esf8_patient_tracking_force_multiplier. pdf.

Tracking technologies for emergency departments include variations of electronic and paper-based tools. Many electronic versions include an Internet, Web-based application that collects data facilitated by a patient’s assigned, scannable bar code, radio frequency identification chip or infrared transmission. These tags, chips and barcodes are associated with a patient-specific number or identifier. Many times the Web-based applications offer impressive reporting and data-sharing capabilities. Paper systems are perhaps the most prevalent MCI tracking system. Readers may contact the author at Paper tracking systems may be considered rudimentary but are Follow Knox Andress @ENAdman. inexpensive, function without electricity and do not have password requirements. Many times the paper system incorporates a ready-to-assign armband that is part of a disaster registration package Lawrence ‘‘Jeff’’ Jeffries, RN, the ED clinical and preparedness coordinator at Jefferson Memorial Hospital, Ranson, W.Va., recalled the school bus fire impacting his emergency department. ‘‘Fortunately there were no serious injuries, but we were getting calls from parents before the 50 children arrived. Our paper-based tracking system helped manage and track the Research and Evidence-based Practice Projects children once they arrived in our ED,” he said. The Hospital Emergency Incident Command System offers a substantial paper patient-tracking procedure which Don’t Miss this Opportunity to Showcase includes the Mass Casualty Tracking Chart, MCI Chart, Flow Your Work on Emergency Department Tags and Flow Tag Boxes.2 Other patient tracking resources and procedures are Management, Leadership and Research found in the Hospital Incident Command System. Roles and responsibility for patient tracking in an ICS-type response are established. Patient tracking procedures are outlined in the accompanying Patient Tracking Job-Action-Sheet and reference tracking logs and forms necessary.3 Submission Deadline: January 15, 2013

Call For Paper and Poster


National Efforts In 2005, the U.S. DHHS’s Agency for Health and Research Quality convened an expert panel and began studying and developing the needs for a national patient tracking system. In 2009, AHRQ released ‘‘Recommendations for a National Mass Patient and Evacuee Tracking, Transportation and Regulating System.”4 The U.S. DHHS’s Joint Patient Assessment and Tracking System tracks patients through the federal patient movement system and is being made available to states. To assist in consistent communications from a prehospital to the hospital or final point of care setting, the DHS, with the guidance of an expert provider group developed the Tracking Emergency Patients, EDXL messaging standard. TEP is in the final stages of international standards evaluation and acceptance.5

Official Magazine of the Emergency Nurses Association

Online: E-mail: Telephone: 800-900-9659, ext. 4119


ENA STATE CONNECTION Nebraska ENA State Council Submitted by Sue Deyke, MSN, RN, CEN, The Nebraska ENA State Council attended a political reception held at the Thompson Center on the University of Nebraska Campus in Omaha. This session was sponsored by the Nebraska Nurses Association, and the Nebraska ENA State Council was one of the silver champion sponsors. The members had an opportunity to hear bipartisan speakers on the local, state and national levels. The members felt it was important to hear the candidates’ stances on health care reform and used this day for advocacy.

On Sept. 29, the Nebraska ENA State Council collaborated with the Nebraska Nurses Association to address the issue of nursing fatigue. The issue of safety and professional practice has become a topic very near and dear to emergency department staff. This workshop featured two national speakers on nursing fatigue: Ann Rodgers, PhD, RN, FAAN, and Karlene Kerfoot, PhD, RN. There was also an opportunity for panel discussion to discuss best practices to achieve safe staffing.

State Council and Chapter Meetings and Events Kansas ENA State Council State Meeting: KENA (Kansas Emergency Nurses Association) meets every other month. Meetings start at 10:30 am. Dec. 14 - University of Kansas, Kansas City For more information: and visit us on Facebook.

Kansas Chapter Meeting: Central Kansas ENA Meetings are planned for the fourth Monday of the odd months of the year at 7 pm. Nov. 14 - Kansas City From left: Karen Wiley, MSN, RN, CEN; Adam Bruhn, RN; Sue Deyke, MSN, RN, CEN; and Cindy Slone, RN, CEN, of the Nebraska ENA State Council.

Limited Annual Conference Pins Still Available It’s not too late to wear the 2012 ENA Annual Conference close to your heart. The Greater Los Angeles Chapter of California ENA has about 200 souvenir conference pins remaining from September’s extravaganza in San Diego and is offering them to ENA members via mail order at a cost of $10 each. The

Statement of Ownership, Management and Circulation (Required by 39 U.S.C. 3685). Title of publication: ENA Connection. Publication no.: 1534-2565. Date of filing: October 1, 2012. Frequency of issue: Monthly. Number of issues published annually: 11. Annual subscription price: members, free; non-members, $50 U.S., $60 foreign. Complete mailing address of known office of publication: 915 Lee Street, Des Plaines, Cook County, Illinois 60016-6569. Complete mailing address of the headquarters or the general business office of the publisher: 915 Lee Street, Des Plaines, Cook County, Illinois, 60016-6569. Publisher: Emergency Nurses Association, 915 Lee Street, Des Plaines, Cook County, Illinois, 60016-6569. Amy Carpenter Aquino, Editor in Chief: 915 Lee Street, Des Plaines, Cook County, Illinois, 60016-6569. Owner: Emergency Nurses Association, 915 Lee Street, Des Plaines, Cook County, Illinois, 60016-


pins are the size and style of a postage stamp and feature the Annual Conference logo below a trio of Pacific palms (see photo at left). Fasten the pin to your clothing, coat or bag using the tie-tack clasp on the back. To purchase a pin, contact Barbara VanEck, the Greater L.A. Chapter secretary, at

6569. Known bondholders, mortgagees, and other security holders: None. Issue Date for Circulation Data: September 2011. Extent and nature of circulation: A. Total Number of Copies: Average number of copies each issue during preceding 12 months (hereinafter “Average”), 41,720. Actual number of copies of single issue published nearest to filing date (hereinafter “Most recent”), 41,820. B. Paid circulation: B1. Outside-county paid subscriptions stated on Form 3541: Average, 40,832. Most recent, 40,399. B2. In-county paid subscriptions stated on Form 3541: Average 0. Most recent, 0. B3. Paid distribution outside the mail including sales through dealers and carriers, street vendors, counter sales, and other paid distribution outside USPS: Average 400. Most recent, 443. B4. Paid distribution by other classes of mail through the USPS: Average, 0. Most recent, 0. C. Total paid distribution (sum of B1, B2, B3, and B4): Average 41,232. Most recent, 40,842. D. Free or nominal fee rate

distribution. D1. Outside-county copies included on Form 3541: Average, 18. Most recent, 25. D2. In-county copies included on Form 3541: Average, 0. Most recent, 0. D3. Copies distributed through the USPS by other classes of mail: Average, 0. Most recent, 0. D4. Copies distributed outside the mail: Average, 273. Most recent, 850. E. Total. Free or nominal rate distribution (sum of D1, D2, D3, D4): Average 291. Most recent 875. F. Total distribution (sum of C and E): Average: 41,523. Most recent, 41,717. G. Copies not distributed: Average, 197. Most recent, 103. H. Total (sum of F and G): Average 41,720. Most recent, 41,820. I. Percent paid (C divided by F times 100): Average, 99%. Most recent, 98%. This Statement of Ownership will be printed in the November 2012 issue of this publication. I certify that the statements made by me above are true and complete. Amy Carpenter Aquino, Editor in Chief. Date: October 1, 2012.

November 2012

ENA Report from NEMSAC By Mike Hastings, MSN, RN, CEN I had the privilege of attending my first National Emergency Medical Services Advisory Council meeting in Washington, D.C., on Aug. 28-29. This was the first meeting since the 26 members were appointed or reappointed to two-year terms by Ray LaHood, Secretary of the Department of Transportation. Each person on the committee represents a different area of interest, though not a particular agency. As a committee member, I represent emergency nurses, not the Emergency Nurses Association. For the next two years, I will be the only nurse on the committee. The NEMSAC charter states that the scope of its activities is to ‘‘provide advice and recommendations regarding EMS to DOT’s National Highway Traffic Safety Administration (NHTSA).’’ Some areas this committee covers include patient and provider safety, research and EMS system improvement and sustainability.

This meeting was an introductory meeting for the 12 new members on the committee. In addition, we were given an update on NEMSAC projects and on the transition of the committee from a discretionary to a statutory committee. This transition makes this committee a standing committee, which means the charter does not have to be renewed every two years. Making this transition also provides a direct reporting structure to the DOT and to the Federal Interagency Committee on EMS. Our next meeting will be held in the coming months. As this committee continues its previous projects and begins work on new projects, I will provide updates through ENA Connection. If you have any questions or feedback, e-mail me at You can also find details about the NEMSAC meeting at

ENA Call for…

Applications for the 2013 Class of Fellows The Academy of Emergency Nursing will accept online applications for the 2013 class of fellows through 5 p.m. CST, Nov. 30, 2012. Information and a link to the applications are available under “Calls and Opportunities” at: default.aspx. If you have questions, please contact Ellen Siciliano, board relations manager, at academy@

Your Generosity Has Moving Results Continued from page 16 on air after that. Trust me, we make a difference. Support emergency nursing by choosing the ENA Foundation as your charity of choice. Let’s all foster the culture of philanthropy by making a year-end contribution to the ENA Foundation. As we approach the holiday season with Thanksgiving looming around the corner, it is the perfect time to reflect on all of the things for which to be grateful. I am thankful for each and every one of you who has made this year a success by providing means for many others in our profession; and, in turn, those people will be thankful for these educational opportunities and your support. The holiday season gives everyone an opportunity to pay it forward — those who donate and those who receive. Together we all can do more!

Official Magazine of the Emergency Nurses Association


Caring for Behavioral Health Patients in the ED Continued from page 11 They also have a consulting psychiatrist available. ‘‘We have worked with staff and leadership from our organization’s behavioral health hospital to develop a comprehensive care policy and ED BH orders to safely manage these patients,’’ she said. ‘‘We’ve even been able to stabilize patients who were awaiting placement over several days and actually discharge them.’’ As they have a large population of BH patients, they are also implementing the ENA workplace violence toolkit to make sure they have a safe environment. Kerry O’Neill, RN, clinical educator, City Hospital, Martinsburg, W.Va., reports that her institution employs ‘‘crisis workers’’ who come to the ED for psychiatric interventions. ‘‘We have a 16-bed in-house adult psychiatric unit in which they work with the inpatient population but respond to pages from the ED,’’ she said. There is a crisis worker on call 24 hours a day to provide acute interventions and facilitate the admission and transfer for these patients. Steven Fraime, assistant manager, Emergency & Trauma Services at WellStar Health System Greater Atlanta Area, reports that at his facility, every potential mental health patient is triaged as an ESI level 2, placed in a safe room with a specially trained MH sitter, seen by the MD within 10 minutes of arrival (goal), and screened by a certified mental health evaluator within two hours. All home medications are reconciled and provided through the main pharmacy so that any psychiatric medication regimen is not interrupted during an extended stay. A new trend is the use of telepsychiatry. With this medium, psychiatric evaluations take place with the use of televideo equipment. Consultations are conducted and treatment plans are initiated in a timely manner and access to proper care is initiated. This method is said to be cost effective, especially in rural areas where care is not readily available.1 However, ‘‘although telepsychiatry is one of the most common uses of telemedicine, the use of ED telepsychiatry is rare.”2 The research that is needed to prove efficiency and efficacy to establish evidence-based practice is waiting to be done. Some hospitals have a separate psychiatric area staffed with psychiatric nurses and a psychiatrist. Denver’s HealthOne hospital chain is opening a new psychiatric ward with 40 beds. According to Dr. George Bussey, chief medical officer, ‘‘psychiatric patients with no place to go can really slow things down.’’ He admits that HealthOne might lose money on its new psychiatric unit, but he believes it will be able to ‘‘recoup the losses if it can provide speedier


service’’ in the ED.3 Alegent Health’s Omaha, Neb., campus includes inpatient care for patients ages 4 to 100. It also has several offsite clinics and psychiatric offices that provide partial care and day programs for various ages. There is an initiative to reach the goal of two hours to admit patients to an inpatient bed. The ED has a locked six-bed assessment area staffed by experienced psychiatric nurses, and the psychiatrist is on call to determine the patient’s disposition. Bed placement can be obtained as far as 250 miles if the campus is full. Lasting Hope, an inpatient adult assessment facility, also coordinates patient disposition into inpatient beds in the community. The Sentara Virginia Beach General Hospital, where I work, is investigating such an option. We are seeing 180 to 200 psychiatric patients a month in our ED, averaging a length of stay of approximately 10 hours. As we have electronic charting, we are gathering data from newly created behavioral health flow sheets as a key to implementing change. While it is obvious that the care of these patients is labor intensive, the data show that more than 90 percent of our safety events, including elopements, patient or staff injury and the need for a ‘‘take down’’ can be attributed to patients with behavioral health needs. We are part of a system that includes nine hospitals and three free-standing facilities, so a system-wide team was formed to seek solutions. The team met with ED directors and in-house behavioral

health representatives in our system and magistrates from our jurisdictions to focus on standardizing behavioral health care. An outside consultant recommended an inpatient behavioral health unit, and there is currently an application in process for a certificate of need to add such a unit. Under the proposal, 24 currently licensed inpatient beds will be converted into licensed beds for geriatric and general adult psychiatric patients. These beds also will include the capability to serve medical psychiatric patients. The data we are collecting is an important part of the application. Caring for this special population of patients is indeed challenging. We can help each other and our patients by sharing with our colleagues our success stories as well as our failed trials. Above are just a few strategies. What are you doing in your state, hospital system or department to meet the needs of behavioral health patients while limiting their hospital stays and maximizing their health care delivery?

References 1. w LIBRARY%20Files/PDF/T/PDF%20 TelepsychiatryProgramsED.pdf accessed July 23, 2012. 2. ibid 3. w 154004864/as-psychiatric-wards-closepatients-languish-in-emergency-rooms accessed August 7, 2012.

November 2012

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ENA Connection November 2012  
ENA Connection November 2012  

ENA Connection November 2012