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the Official Magazine of the Emergency Nurses Association


November 2013 Volume 37, Issue 10

Tests of


Is Social Jet Lag Winding You Down? CODE YOU, PAGE 14

Adjusting Our Thinking on Waiting PERSPECTIVES, PAGE 20


FEATURES   6        ENA, NIOSH Joining Forces   to Create   Workplace Violence Prevention Video 8       Compassion: Are You Satisfied or Fatigued? 18    The Registered Nurse Safe Staffing Act of 2013



March 5-9, 2014 Phoenix, AZ

Phoenix Convention Center


For the latest news on Leadership Conference 2014, visit Follow the action


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

Dates to Remember Nov. 1, 2013 Deadline to apply for 2013 ENA Foundation Seed Research Grants. Dec. 2, 2013 Deadline to apply for the Academy of Emergency Nursing’s 2014 Class of Fellows. Dec. 6, 2013 Deadline to apply for Leadership Tapestry Scholarship to attend Leadership Conference 2014 in Phoenix, March 5 - 9. Feb. 26, 2014 Deadline to submit applications for 2014 Lantern Award.

ENA Exclusive Content PAGE 6 The Video Hookup: ENA, NIOSH Joining Forces on Workplace Violence Prevention PAGE 8 Board Writes: Compassion: Are You Satisfied or Fatigued? PAGE 12 Big Little Lessons: Sharp Memorial ED Making Vital Lessons Fun With ‘ER Kids Day’ PAGE 14 Code You: Social Jet Lag Requires You to Make Adjustments PAGE 20 Honing Our Understanding of What It Means to Wait

Regular Features PAGE 4 Free CE Ask ENA PAGE 10 ENA Foundation PAGE 15 ENA Connected PAGE 16 Pediatric Update PAGE 18 Washington Watch


Truths About Teams


  he football season makes me think about the importance of teamwork in nursing. Each member of the football team plays a certain position, and together they have a common goal: win the game. As emergency nurses, we each have positions to play and a common goal: provide safe, quality patient care. Teams accomplish more when they pull together than when each member is focused on an individual agenda. Teamwork has to be part of our daily activity as nurses. On any given day, the patient care team may include per diem staff, staff who float from other units or shifts and staff from outside agencies. These individuals may or may not be familiar with the work setting, and they may or may not be known to other members of the team. In the ED, we form teams at different times of the day — sometimes at the start of a traditional shift, sometimes in response to a critical event. Each team member may have different expectations of what a team should look like. The following are important components that make up effective teams: Communication and Team Interaction: To succeed at teamwork, members must understand when, how and what to communicate. You may think communication is easy. Talking is easy; communication requires greater skills. Communication requires skill in listening more than in speaking. Good teamwork also requires standardized, effective conflictresolution skills. Team members who are able to remain calm and professional when discussing differences and choose the appropriate way to manage and resolve conflicting ideas or viewpoints are the most successful members of a team. Common Goals: Having an eye on a common goal gives the team a sense of purpose along with checkpoints that help to measure success. If the team has a shared mental model, such as the use of TeamSTEPPS™, this ideally

motivates all team members to work together. Understanding the goals of the team helps the team members to hold each other accountable for getting the work done. Defined Roles and Responsibilities: What we do every day is specified by our job description and assigned roles and responsibilities. Not everyone on the football team gets to run with the ball, but each player’s role is critical to the overall win. Mutual Support/Trust: Most important, effective teams are built on trust, a key component in a healthy work environment. Trust often develops naturally over time, through experience and successes gained in accomplishing goals and overcoming setbacks together. However, there are times when we do not know the people that are a part of our team. What we need to remember in those cases is that we trust that the other person is also performing his or her role to the best of his or her ability and with the same common goal in mind. Mutual support, helping other members of our team and creating an atmosphere where everyone bends over backward for other teammates is key to safe and effective emergency care. Teamwork is also critical to the success of ENA, and all of you are a part of this team. You have unique talents that you share at the local, state or national level. Some of you serve as team captains and some as coaches. ENA team members also act as scouts who recruit talent to join them as team members. As these new members join our team, I ask that you help to prepare them for their role. Together we will have many winning seasons.

Official Magazine of the Emergency Nurses Association


Learn how to combat lateral violence in your department with ENA’s latest free continuing education offering!

Available to you starting Nov. 1 . . . ‘‘Lateral Violence: It Goes Much Further Than Those Who ‘Eat Their Young,’ ’’ presented by Melinda J. Stibal, MSN, MBA, RN. (Credit: 1.0 contact hour.) In this e-learning course recorded at Leadership Conference 2013, Stibal explains lateral and vertical violence in nursing and then examines the consequences of lateral violence, including decreased patient safety, poor nursing retention and loss to the nursing profession. The discussion then turns to effective ways to eliminate lateral violence among a nursing staff. To take these and other CE courses free as an ENA member: • Go to, where you’ll log in as a member (or create an account). • Add desired courses to your cart and ‘‘check out.’’ • Proceed to your Personal Learning Page to start or complete any course for which you have registered or to print a final certificate. • To return to your Personal Learning Page later, go to and find ‘‘Personal Learning Page’’ under the Education tab. Please be sure you are using the e-mail address associated with your membership when logging in. If you have questions about any free e-learning course or the checkout process, e-mail

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

Q: What if a patient leaves the emergency department before he or she undergoes an assessment? Does the medical screening need to be completed by a physician in compliance with EMTALA? A: Thank you for the questions. These are frequently asked by nurses working in the ED. Actually, these questions could be significant concerns. The obligation to do the medical screening examination is to determine whether the patient exhibits an emergency medical condition, and it is couched in absolute terms. Sometimes there is confusion regarding the difference between the medical examination and triage. Triage is the process by which Use ‘‘Ask ENA’’ to ask about the quick determination is made as to organization and emergency nursing how quickly and how extensively in general. Questions will be referred the ED’s resources should be used to the appropriate ENA staff or to provide treatment to a patient. It department. Submission does not is important to remember this guarantee publication. E-mail crucial point: Triage is not the same questions to as a medical screening examination. Triage is a process that determines when a patient is seen by a physician, not whether he is seen. The medical screening examination is generally done by a physician. In the past, it was mandatory that the physician perform the medical examination. Now, designating appropriate ‘‘physician substitutes’’ — such as an advanced practice nurse or a physician assistant — is reasonable, as long as there is institutional policy supporting competence as well as when a physician must see a patient. It is important to familiarize oneself with the EMTALA rules and regulations because deviating from the rules may result in complications for the patient and significant fines for the institution. For more information, please see

— Paula M. Karnick, PhD, ANP-BC, CPNP Director of the Institute for Emergency Nursing Education

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

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

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

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

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

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ENA, NIOSH Joining Forces to Illustrate Strategies to Nurses Online By Kendra Y. Mims, ENA Connection In an ongoing effort to proactively promote best practices for emergency nurses and provide members with valuable resources, ENA has partnered with the National Institute for Occupational Safety and Health to develop a case-study video on workplace violence prevention in the emergency department. For ENA, the video will be an important component of its workplace violence prevention online training program, scheduled to launch in the spring of 2014. For NIOSH, the video will be a critical part of a new module for its new online workplace violence prevention course for nurses and health care workers. Together, ENA and NIOSH will use the video in their courses to illustrate how emergency nurses can implement workplace violence prevention strategies in their emergency departments to create a safer environment. The video will be a representation of a real-life workplace violence incident. It will show an agitated patient presenting to the emergency department, the hand-off process from the paramedic to the emergency nurse and best practices to de-escalate the situation to keep the patient from becoming violent. Interactive learning activities for the video also will be incorporated into the courses, along with nurse testimonials, lesson quizzes and skill-based exercises. Dan Hartley, EdD, of the NIOSH Division of Safety Research, said the feedback from nurses who have taken the ‘‘Workplace Violence Prevention for Nurses’’ course has been positive. NIOSH premiered the free online course in August to train nurses on recognizing and preventing workplace violence. Dan Hartley, EdD Hartley has addressed the topic at numerous conferences, including the ENA Workplace Violence Prevention Summit and the ENA 2012 Annual Conference. ‘‘Over the past 10 or 15 years, we have had a lot of informal discussions at conferences and meetings with other health care professionals and Lisa Wolf, PhD, researchers, and one of the things that RN, CEN, FAEN kept coming up was that many health


care professionals go their entire career without receiving any training on workplace violence prevention,’’ Hartley said. ‘‘We wanted to come up with a way to get that valuable training to them so that it would not be a burden on them, so we came up with the idea of an online course that they could do at home or at their workplace at their own convenience. Then we decided to make it free and offer free CEs as an incentive to take this course. That’s what our final product is.’’ Although the NIOSH course focuses on helping nurses and health care workers understand the scope of violence in the workplace, it did not have ED-specific information. ENA reached out to NIOSH to incorporate some of NIOSH’s videos and materials into the ENA workplace violence prevention training course, and in return, offered to assist NIOSH with the development of an ED-specific module. ‘‘It’s been a nice cross-pollination effort between NIOSH and ENA in terms of sharing information and giving health care professionals who take NIOSH’s course a sense of what is different about the ED setting as opposed to a psychiatric or primary care setting,’’ said Lisa Wolf, PhD, RN, CEN, FAEN, director of ENA’s Institute of Emergency Nursing Research. ‘‘It always amazes me when we talk to people in other disciplines that they have no idea what working in an emergency room is like. We were able to provide really good details for them about ED-specific situations that we pulled together from narratives that emergency nurses sent to us as part of our research study.’’

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Hartley anticipates the new module will be completed and added to NIOSH’s current online course in 2015. He believes the course will help emergency nurses take a proactive stance on preventing workplace violence and help raise their awareness of what constitutes workplace violence. ‘‘A lot of times nurses say, ‘This is just part of my job and something that happens,’ ’’ Hartley said, ‘‘but we provide examples that this is truly workplace violence and not part of your job. You shouldn’t be assaulted in the workplace while you’re trying to help out a person who is sick. The course walks them through what workplace violence is, how to prevent it and, if it does happen, here’s what to expect as far as dealing with it and procedures you may come up against afterwards. ‘‘I presented at a couple of conferences at ENA and received very good input as far as some of the things that needed to be included in the course. ENA is nationally working on trying to get emergency nurses to be more proactive and getting policies and procedures passed in workplaces to prevent violence, and this course would help with that effort. We really appreciate the work that ENA does, and we hope that this course helps to keep emergency nurses safe.’’ For more information on the NIOSH Workplace Violence Prevention for Nurses course, please visit NIOSHviolencetraining.

Don’t Miss This Fall’s Hottest TV Show Ready to get your career on a path to success? Then plan to watch Nursing Success TV brought to you by ENA’s Career Center! Nursing Success TV brings you… § Monthly 5 minute segments designed to educate, inform, inspire and entertain you § “Ask Dr. Phyllis” segments that feature Dr. Phyllis Quinlan answering questions relevant to nursing career advancement § A viewable format on any computer or mobile device Nursing Success TV is supported by the Emergency Nurses Association and the National Healthcare Career Network (NHCN)

Visit the ENA Career Center today to view previously aired and upcoming episodes at:

9/24/13 3:02 PM Official Magazine of the Emergency Nurses Association

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Kathleen E. Carlson, MSN, RN, CEN, FAEN, Director

Compassion: Are You Satisfied or Fatigued? A

s emergency nurses, we are faced with a unique set of stressors. We care for higher-acuity patients, deal with the results of crowding and fight delays in getting inpatient beds and are exposed to traumatic events, violence and more. We are also pressured to improve patient satisfaction and the sometimes unrealistic expectations of patients and their families with the initiation of the Hospital Consumer Assessment of Healthcare Providers and Systems, with public reporting of the results and consequential effects on hospital reimbursement. We are subject to staffing shortages, missing or malfunctioning equipment and doing more with less. To top it off, patients are becoming responsible for more of their hospital bills and ‘‘want their money’s worth.’’ Why did you become a nurse? Chances are you wanted to help others, relieve suffering and make a difference. Many of us had an idealistic picture of the Lady with the Lamp, making our rounds to reach out and touch our patients. While that might have drawn you into nursing, I’ll bet it isn’t the reason you have stayed. The satisfaction that comes from using your critical thinking skills when caring for a critically ill patient, the gratitude that you receive from your patients and their families when their pain is relieved or diminished and the ability to share your expertise and knowledge with your colleagues and new nurses are just some of the reasons we are kept engaged. Meanwhile, we often put other’s needs before our own and learn to bury our stressors. In essence, we, as


nurses, deliver the essential product of ourselves.1 Coetzee 2 defines compassion satisfaction as the ‘‘invigoration and inspiration that a nurse receives from connecting with and sharing in a patient’s suffering.’’ A nurse who is satisfied is able to balance out the negative, relieve suffering without getting emotionally overwhelmed and receive gratification from delivering care.3 We are rewarded by helping the patient suffer less and are able to connect to the patient, no matter what the outcome.3 Compassion fatigue is the opposite. This term was first introduced in 1992 by Carla Joinson,1 who stated that ‘‘overpowering, invasive stress can begin to dominate us and interfere with our ability to function. We become angry, ineffective, apathetic, and depressed.’’ It is a cumulative process that stems from intense and continued contact

with patients and can lead to the expenditure of energy that is greater than your ability to restore. Are you going through the motions without empathy or involvement with the patient? The process is subtle in progression, and compassion fatigue is difficult to recognize without a heightened awareness. Compassion fatigue affects the performance of the whole work group. The quality and safety of patient care suffers. There is a decrease in productivity, a decrease in morale and an increase in turnover. Therefore, we need to take an active role in recognizing when our co-workers (or ourselves) are flailing. Together we can intervene to support and help each other by adopting positive strategies to combat fatigue and bring back that satisfaction we had when we first became a nurse. The biggest problem with

November 2013

compassion fatigue is recognizing it in the first place. Look for the danger signs. You begin to distance yourself from others, have a decreased ability to work at your usual level, have a decreased attention span and have difficulty concentrating. Perhaps you become bored with work, use more sick days, make careless mistakes, feel anxious or depressed or have a desire to quit. Even if you think this description doesn’t fit you, self-assessment tools are available to help you see where you fit on the compassion scale and determine if you are sliding down a slippery slope. ProQOL (www.proqol. org) is a tool that measures the positive and negative aspects of compassion. It is a valid measure that is easy to score. Two other useful tools are the compassion fatigue self-test: an assessment ( and the life stress test (www.

Early in my career, a wise teacher said, ‘‘If you let yourself get sick, you’ll be no good to yourself or your patients.’’ Wellness starts at home, and a good first step is to determine where you fit on the compassion scale. References 1. Joinson, C. (1992). Coping with compassion fatigue. Nursing, 92, 116–121. 2. Coetzee, S., & Klopper, H. (2010). Compassion fatigue within nursing practice: A concept analysis. Nursing and Health Sciences, 12 (2), 235–243. 3. Newsome, R. (2010). Compassion fatigue: Nothing left to give. Nursing Management, 41 (4), 42–45. 4. Young, J. L., Derr, D. M., Cicchillo, V. J., & Bressler, S. (2011). Compassion satisfaction, burnout, and secondary traumatic stress in heart and vascular nurses. Critical Care Nursing Quarterly, 34 (3), 227–234.

Call for Applications: 2014 Class of Fellows The Academy of Emergency Nursing was instituted on Sept. 28, 2004, to honor nurses who have made substantial and enduring contributions to the field of emergency nursing; who advance the profession of emergency nursing, including the health care system in which emergency nursing is delivered; and who provide visionary leadership to ENA. The Academy will accept online applications for the 2014 class of fellows through noon Central time on Dec. 2. Information and a link to the applications are available under “Get Involved” at E-mail with any questions.

A BCEN® certification… the perfect gift to give yourself. You’ve worked hard all year developing your knowledge and skills. Reward yourself with the validation you deserve – earn a BCEN certification!

Visit the Board of Certification for Emergency Nursing (BCEN) website for details and resources to become a Certified Emergency Nurse (CEN®), Certified Flight Registered Nurse (CFRN®), Certified Pediatric Emergency Nurse (CPEN®), or Certified Transport Registered Nurse (CTRN®).

BCEN ENA Connect Ad_FNL.Nov 13.indd 1

Official Magazine of the Emergency Nurses Association

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Put Your Appreciation Toward the Advancement of Our Specialty

By Kendra Y. Mims, ENA Connection


  hanksgiving is the opportune time to reflect on what is most important in life and to give thanks for everything for which you are grateful. It’s also a perfect time to reach out and help make a difference in the lives of others. If you are looking for a simple yet special way to express your gratitude during the holiday season, consider giving back by donating to the ENA Foundation.

Taking On Lateral Violence With Scholarship Assistance

Your contribution to the ENA Foundation will help advance the future of the emergency nursing profession through its mission to provide educational scholarships and research grants in the discipline of emergency nursing. As a donor, your support can help the ENA Foundation’s scholarship recipients enhance their education to improve the quality of patient care. It also can help the ENA Foundation’s research grant recipients discover new technologies and advance the specialized practice of emergency nursing.

them feel insecure or intimidated.’’ She aims to infiltrate the educational process and become an advocate for As the 2013 recipient of the Jeanette students entering emergency care. Ash Memorial Scholarship, Wendi ‘‘As a nurse educator, I will be able Brown, BSN, RN, is grateful for the to get to the root of the problem where opportunity to further her education lateral violence begins,’’ she said. ‘‘I and enhance the education of believe that treating preceptees future emergency nurses in with respect and allowing them return. She decided to pursue to take pride in their profession further education after teaching as a nurse is a start to getting her first semester at a local rid of the lateral violence we community college as a clinical are experiencing today. I instructor. She realized she believe this, in return, will loved teaching and could play attract more nurses to the Wendi Brown, a positive role in molding BSN, RN emergency medicine field and future nurses. result in improved quality care As a nurse educator, Brown is to the patients we serve. passionate about ending lateral violence ‘‘This ENA Foundation scholarship at the educational level before nurses will forever be a part of the process of enter the workforce. During her first changing the way nursing instructors year in emergency care, she realized treat nursing students. I promise to lateral violence was a part of the devote my time, energy and education emergency nursing culture as she to putting an end to lateral violence.’’ witnessed preceptors belittling, insulting and being rude to their preceptees. Thankful For You ‘‘Once I started precepting, I knew Since 1991, the ENA Foundation that I was part of the determining factor has given more than of whether that nurse would love or $2  million in hate emergency medicine,’’ Brown said. ‘‘I realized that I could instill confidence in nursing students, new grads and seasoned nurses without ED experience instead of making


educational scholarships and research grants to emergency nurses because of the donations received from individuals, ENA state councils and chapters, corporations and friends of emergency nursing. The ENA Foundation would like to extend a special thank you to donors who have generously supported the ENA Foundation. Your support has helped thousands of emergency nurses like Brown pursue further education to create a positive change in emergency nursing. Thank you for making 2013 a successful year. If you would like to express gratitude for your colleagues and the emergency nursing profession, please visit to make your holiday donation on behalf of yourself or in honor of someone special.

Call for Resolutions and Proposed Bylaws Amendments for 2014 General Assembly The ENA General Assembly meets before the start of the ENA Annual Conference to determine official association policy and positions by reviewing, debating and voting on proposed bylaws amendments and resolutions. This is your opportunity to bring important professional emergency nursing issues to the 2014 General Assembly. Resolutions may be submitted by any active ENA member. Others who may submit resolutions include the ENA Board of Directors, state councils, chapters, the Journal of Emergency Nursing editorial board and ENA committees. Bylaws amendments may be proposed by the ENA Board of Directors, state councils and chapters or five active members of the association. All resolutions and proposed bylaws amendments must be submitted in the proper template form and must follow the format as outlined in the Resolutions and Bylaw Guidelines. The guidelines may be found at in the General Assembly area (members only). The Resolutions Committee is available to help ENA members develop their proposals. This assistance provides members with additional resources to effectively write proposed bylaws amendments and resolutions

before the deadline. If you are interested in bringing a resolution or proposed bylaws amendment to the 2014 General Assembly, it is recommended that you begin drafting your proposal and working with the Resolutions Committee no later than December. Please contact ENA Component Relations at to obtain assistance from the Resolutions Committee. Final resolution submissions must be sent to by Saturday, March 1, 2014. Per ENA Bylaws, proposed bylaws amendments must be submitted at least 90 days prior to the General Assembly, no later than Thursday, July 10, 2014. However, it is highly recommended for proposed bylaws amendments to be submitted by March 1 to allow the Resolutions Committee adequate time to thoroughly review amendment proposals and to work with the authors to finalize amendments for inclusion in the General Assembly Handbook. Formal consideration of proposed bylaws amendments and resolutions will occur at the 2014 General Assembly, Oct. 8 - 9, in Indianapolis.

Coming in Early 2014 SEVENTH EDITION Highlights Include: § Initial assessment § New chapters include Teamwork and Trauma Care, Pain, The Bariatric Trauma Patient, Dealing with Interpersonal Violence, and Post Resuscitation in the Emergency Department § Balanced fluid resuscitation and blood component transfusion

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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Joshua McCabe, MSN, RN, CEN, and “ER Kids Day’” event co-coordinator Annette Austin, BSN, RN, CEN, give kids and their parents information to chew on in front of the Mercy Air helicopter at last year’s event at the Sharp Memorial Hospital ED.


ED Staff Making Vital Information Fun Through Annual ‘ER Kids Day’ By Annette Austin, BSN, RN, CEN, Lovely Bolano, BSN, RN, CEN, and Christopher Walker, MS, RN, NP, CNS, CCRN, CEN


mergency department staff encounter unfortunate situations with injured and sick children every day. As health care providers, emergency nurses have an opportunity to use their knowledge, skills and experience to educate children about health and safety. Staff at the Sharp Memorial Hospital ED in San Diego hold ‘‘ER Kids Day’’ each fall on the Saturday after Emergency Nurses Week — including the fourth annual one held Oct. 12 — with the collaboration of several community emergencyresponse personnel and the leadership, vision and commitment of emergency nurses. What started as a ‘‘bring your kid to work’’ day grew into an emergency health care community project to educate a large group of children about health, wellness, fire safety, infection prevention, disaster preparedness and emergency response teams. Fundraising,


educational planning, community-relationship building, volunteer coordination and hospital support are instrumental to a successful event. ER Kids Day coordinators developed an education plan for children, who best learn through demonstration. The goal was for the event to be interactive and fun for both the kids and the volunteers. Stations include multiple hands-on activities. ED staff enlists participation from San Diego Medical Services, San Diego City Fire-Rescue Department, California Highway Patrol, San Diego County Sheriff’s Search and Rescue, East County Sheriff’s Department and Mercy Air. Twenty-two ED staff members volunteered last year to teach an education station, lead groups of children to stations or coordinate station areas. Six groups of about 15 children and their parents were led to five stations outside of the Sharp Memorial ED, with each station highlighting different health and safety topics: • Firefighters spoke about fire safety and proper use of 911. They demonstrated putting on the full gear needed to

November 2013

fight a fire and let the children walk through the inside of the fire engine. Paramedics described how they transport patients and allowed children to climb through the rig.

community collaboration will continue at Sharp Memorial Hospital for years to come. Since last year’s ER Kids Day, one of the coordinators took the education out to her community • Children got to sit on a CHP and presented the same topics to a officer’s motorcycle and pose for group of 30 preschoolers and 100 pictures while the officer spoke kindergartners. It is gratifying to about the importance of wearing think this education could save a seatbelts. The Search and Rescue child from injury or severe illness. team, including the search dogs, This is an amazing event made educated the children about possible through ED staff safety when hiking and outdoors. volunteerism and engagement The sheriff’s department provided coupled with excellent community information about stranger collaboration. All participants leave danger, traffic safety and nighttime with a new knowledge of the safety tips. community efforts in place to keep • Mercy Air coordinated a them safe or provide them with flyover, landing and takeoff, and assistance or care in the event of the flight nurse talked about her illness or injury. Sharp HealthCare’s Tunisia McDowell, BSN, RN, teaches a youngster responsibility to safely transport mission is ‘‘to improve the health of injured patients to various hospitals. about pulse-taking at the lifesaver station. those we serve with a commitment to excellence in all we do.’’ What better way to improve • The children had opportunities to learn in the three health and demonstrate excellence than to educate our stations inside the ED. The germ-busting station highlighted community’s children? the importance of hand washing and illness prevention. Kids got gooed with luminescent ‘‘germs’’ and then were asked to wash their hands. They looked at their hands under a blacklight to see if they were able to wash off their germs effectively. There was also education on what to do when you have the stomach flu and how to ‘‘catch your cough and snatch your sneeze’’ to prevent the spread of germs. • The first-aid station taught the kids about helmet safety with a demonstration that illustrated what happens to an egg with and without a helmet. In addition, the educator spoke about seatbelt safety, bones of the body and wound management.

Call for Paper and Poster Abstracts

Research and Evidence-based Practice Projects Don’t Miss this Opportunity to Showcase Your Work on Emergency Department Management, Leadership and Research

Submission Deadline: January 15, 2014

• The lifesaver station presented the children with information on various topics as well as career building. The children were able to ask questions about the emergency nursing role and take a guided tour through the department. Topics included heart health, exercise and healthy food choices. Demonstrations included taking vital signs and how that allows health care providers to ‘‘see’’ how healthy the child is at that moment. This is the first collaboration among county emergency service providers and a Sharp Healthcare ED team for the benefit of injury prevention education to children. The education development and planning by staff members has been innovative and captivating for the young audience. The accessibility of education to the kids through our staff members is excellent. The vision is that this demonstration of

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

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10/3/13 2:56 PM

TIMELY TIPS Select ideas from Scrubs magazine for shift nurses to get more sleep: 1. Think of sleep as a priority for your health. 2. Nothing affects your body’s circadian clock like light. After you’ve woken up, tell your body it’s supposed to be awake by going out into the sun. 3. Create a ritual at bedtime. This can include music, reading a book or taking a bath. After your shift, get to bed as soon as possible — within two hours if you can.


Social Jet Lag Requires You to Make Some Adjustments By Kendra Y. Mims, ENA Connection


f you find yourself struggling to wake up to the sound of your alarm in the morning, you may be experiencing social jet lag. It’s defined as a syndrome caused by the mismatch between the body’s biological clock and one’s actual sleep schedule. For example, your sleep pattern may be different on your days off, and you may go to bed later than usual or sleep in for a couple of hours because you don’t have to wake up to an alarm. Researchers suggest a person’s sleep pattern on non-work days is more aligned with his or her body’s natural rhythms. Sleep researcher Dr. Till Roenneberg, a professor at the Institute of Medical Psychology at the University of Munich who coined the term ‘‘social jet lag,’’ reported that for every hour of social jet lag, the risk of being overweight or obese rises about 33 percent due to chronic sleep loss. Roenneberg estimates that two-thirds of


the population experiences social jet lag.1 In his study published in Current Biology, his results demonstrate that improving the correspondence between biological and social clocks contributes to the management of obesity.2 Shift workers are prone to social jet lag because of the inconsistency in their sleep schedules on work days and days off. Brian Ericson, BSN, RN, CEN, clinical lead nurse at the Mercy Hospital Emergency Department in Portland, Maine, believes social jet lag impacts a majority of emergency nurses because of their 12-hour work schedule. ‘‘There have been a myriad of studies on poor performance related to suboptimal sleep patterns,’’ Ericson said. ‘‘We all have seen the colleague working extra shifts, and it shows. Furthermore, after we have survived our long hours, we are thrown into society’s bad habits of tablets and televisions, prompting us beyond hours we should be awake.’’ Ericson said going to bed earlier is

4. Whether it’s a work day or a weekend, strive to keep your sleep schedule regular and consistent. For more suggestions, visit

not always an easy solution. ‘‘If you are extending your natural rhythms, the best thing you can do is fortify yourself,’’ he said. ‘‘Exercise is great after a shift, as it releases stress and allows you to achieve better-quality sleep. It doesn’t have to be a strenuous session, just enough to get the heart rate up and sweat a little bit. Also, hydrate throughout the day so your body is able to fully rejuvenate while sleeping. Sleep is essential and shouldn’t be ‘shortened’ when possible, but if it is, do yourself a favor and treat your body well.’’ References 1. Goodman, B. (2012). Do you have social jetlag? Retrieved from http:// news/20120510/do-you-have-socialjet-lag 2. Roennberg, T., Allebrandt, K. V., Merrow, M., & Vetter, C. (2012). Social jetlag and obesity. Current Biology, 22 (10), 939–943.

November 2013

ENA CONNECTED | Thomas Barbee, ENA Digital Marketing Manager

Grassroots Campaigning in the Digital Age O

ne of the greatest impacts of social media is its ability to take the most straightforward message and allow it to grow and reach far beyond what has been possible before. It is a concept we have seen in many ways between friends or even with those who follow particular celebrities or news outlets. Despite all this, resources do not necessarily allow for the planning and scheduling needed to execute a full social media plan. To help alleviate concerns about lack of time or resources, I propose the following to help establish a simple and easy way to get your message out: 1. Recognize Your Champions At its simplest form, social media is not all that dissimilar to e-mail or other forms of communication. The one

difference is that to be engaged in a social media group, you have to actively click to join and participate. While it may make it more difficult to add initial members to your groups, you should think of those who are already in it as your champions. These are the people you can turn to for help with creating content or taking your messages and sharing them with other colleagues. By making content they can easily share and engage with, you are well on your way to crafting a viral message. 2. Engage in Two-Way Conversation The best posts are always ones that allow for reaction from followers. In addition to posting news-related items, sharing photos and videos is also a fantastic way to help generate interest. Last, but not least, you can always create polls or simply ask questions to your

followers to help generate feedback. 3. Keep Your Message Simple The most effective way to reach out is to keep your message as straightforward as possible. Want to promote an event? Use a hashtag that everyone can use. Hashtags work on all platforms (not just Twitter) and are an easy way to organize what everyone is saying about your event. 4. Be Creative! Don’t be afraid to post something different. Sometimes the most popular topics are unexpected. Social media, like a successful grassroots campaign, starts with your members. The more you are able to engage them, the more impact you will have. Have some success stories you want to share? E-mail me at

A New, Updated Online Learning Geriatric Emergency Nursing Educational Course

Coming Soon! For additional details please visit:

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

GENE Coming Soon_Connection_half_10 2013.indd 1

Official Magazine of the Emergency Nurses Association

8/30/13 1:12 PM


PEDIATRIC UPDATE |  Elizabeth Stone Griffin, BS, RN, CPEN

Weigh, Document and Speak in Kilograms Only! A Continued Discussion on Metric Conversion


n the article ‘‘First, Do No Harm,’’ Hughes and Edgerton 1 state, ‘‘Of all the ways that pediatric patients can be harmed during treatment, medication errors are the most common and most preventable.’’ Pediatric medications are dosed according to weight, specifically the child’s weight in kilograms. Although adult medications are often unit-dosed, many critical intravenous drips are also based on the adult’s weight in kilograms. Medications have been metric-dosed for years, yet many patients are still being weighed in pounds or on scales that toggle between pounds and kilograms. These are examples of system failures that put patients at unnecessary risk for harm. Weighing and documenting in kilogramsonly is a medication safety issue, as noted in the literature.1–6 A 2009 analysis of 479 medication errors involving incorrect weights in patients of all ages reported that more than 25 percent were due to ‘‘confusion between pounds and kilograms.’’ 2 The option to weigh a patient in pounds alone increases the chance of incorrect weight documentation. This can lead to medication errors that follow the patient throughout the hospital stay by providing a false basis for medication calculations. 7,8 In 2012, ENA issued two position statements on the importance of weighing both children and adults in kilograms only.7,8 Both position

statements have since been endorsed by other major medical associations and serve as powerful resources on the importance of this issue. The conversation continued in the September 2012 issue of ENA Connection with a story on three hospitals that had begun their metric conversion, often as a result of persistent local nursing champions. A year later, we asked ENA members on Facebook and through the ENA Pediatrics listserv whether their institution was now weighing patients in kilograms only. Although some institutions recognized this safety issue early on and converted to a metric system, it clearly hasn’t happened everywhere. Roadblocks exist at every point from the scales to the electronic medical record to the bedside. The following are some comments, concerns and ideas from ENA members: • Lorie Smiley Jones: ‘‘We are a pediatric hospital and only weigh in kilograms. We do not convert it for the parents, [as it is] against our policy.’’ • Kathy Wertz: ‘‘Our-peds only ER has scales only in kilograms. We took down our conversion charts and have made an unofficial effort to not tell/

‘We have switched to scales that only use kilograms. ... I believe it has decreased mistakes in documentation of weights.’ AMBER FERGUSON, ENA MEMBER ON FACEBOOK


convert the weight into pounds until after it’s electronically charted. Our charting also attempts to alert us when [an] out-of-average range for age is entered. We have had a decrease in errors.’’

me letting me know that he has now converted all of the adult scales on the unit to kilograms-only also.’’ • A Minnesota ENA member: ‘‘We made this change February of this year. [We had a] pediatric overdose of an antibiotic — the old scale weighed in pounds, and the nurse entered pounds in kilogram spot. . . . We just completed a renovation/expansion this year, and with that we purchased new scales and were then able to set them to only show kilograms.’’

• Amber Ferguson: ‘‘We have switched to scales that only use kilograms. I believe the manager or educator implemented this. I believe it has decreased mistakes in documentation of weights.’’ • Wendy Saliger: ‘‘Heartland Health in St. Joseph, Mo., has been documenting weight in kilograms for years in our ER and all other floors.’’ Additional challenges and solutions to metric conversion were shared by e-mail: • A Colorado ENA member: ‘‘I initially talked to our manager about converting our four pediatric scales. She encouraged this, telling me I would probably need to contact the

company and make it happen that way. . . . So I called the scale company, and the technician there was wonderful and walked me through it, on all four scales. Then he sent an instruction book to us. . . . [Our hospital’s] Biomed representative has since approached

The Pediatric Special Interest Group at this year’s Annual Conference in Nashville, Tenn., also held a discussion on this issue. SIG members shared ideas, concerns and creative solutions regarding the process of metric conversion. One member explained that his hospital’s electronic medical record had a hard stop built in for estimated weights; if an estimated weight was

Continued on page 22



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ENA Foundation_Connection_half_09 2013.indd 1

Official Magazine of the Emergency Nurses Association

8/5/13 10:01 AM



The Registered Nurse Safe Staffing Act of 2013 By Ken Steinhardt, ENA Director of Government Relations


s every emergency nurse knows,   appropriate staffing is critical to the delivery of quality patient care. Proper staffing levels allow nurses the time they need to make patient assessments, complete nursing tasks, respond to health care emergencies, and provide the level of care that their patients deserve. Proper staffing levels also increase nurse satisfaction and reduce staff turnover, an important priority given today’s nursing shortage. In response to this, on April 30, Rep. Lois Capps (D-Calif.) re-introduced H.R. 1821, the Registered Nurse Safe Staffing Act of 2013. Capps is a former nurse and

co-chair of the Congressional Nursing

importance of safe staffing levels while

Caucus and has been a consistent

explaining the difference between

champion for ENA priorities in

prescribed nurse-to-patient ratios and


the more flexible approach set forth in

This legislation is different from many

Registered Nurse Safe Staffing Act. We

other nurse staffing bills because it does

must make it known that research

not require specific nurse-to-patient ratios.

shows that higher staffing levels by

Instead, it empowers nurses to drive

experienced RNs are linked to lower

staffing decisions in hospitals by requiring

rates of patient falls, infections,

hospitals to establish unit-specific staffing

medication errors and even death.

plans through a committee comprised of

While the fate of this legislation is

at least 55 percent direct-care nurses.

unknown, it is important that your

These committees would base their

federal representatives hear directly of

decisions on multiple factors, such as the

your support for H.R. 1821. You are

number of patients on the unit, severity of

the experts in this field, and your

the patients’ conditions, experience and

legislators will listen to your first-hand

skill level of the RNs, availability of

accounts on the importance of

support staff and technological resources.

appropriate staffing levels in emergency

Nurses must raise awareness on the


NIH’s Office of Emergency Care Research Appoints Director By Richard Mereu, ENA Chief Government Relations Officer


n an important development for improving research into care provided in emergency departments, the National Institutes of Health selected Jeremy Brown, MD, to be the first permanent director of the recently established Office of Emergency Care Research. Brown, who started at NIH in July, was formerly an associate professor of emergency medicine and chief of the clinical research section in the Department of Emergency Medicine at George Washington University. OECR was established in 2012 and is housed at NIH’s National Institute of General Medical Sciences. It organizes and coordinates basic, clinical and translational emergency care research across NIH. OECR is also responsible for publicizing NIH funding opportunities and enhances the training of emergency care researchers.


OECR will spur improvements in emergency care by: • Coordinating funding opportunities that involve multiple NIH institutes • Working closely with the NIH Emergency Care Research Working Group, which includes representatives from most NIH institutes and centers • Organizing scientific meetings to identify new research and training opportunities in the emergency setting • Informing investigators about funding opportunities in their areas of interest • Fostering career development for trainees in emergency care research • Representing NIH in government-wide efforts to improve the nation’s emergency care system The creation of OECR is the culmination of more than five years of discussions between NIH and the emergency medicine community. ENA was a strong backer of the creation of OECR and recently issued a statement praising the selection of Brown to head OECR.

November 2013


...towards staff at work is dramatically on the increase, especially in our Hospitals. Verbal abuse, threats with weapons, cuts, punches, even serious injuries are becoming everyday occurences.

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Which is why, over 20 years, INSTANTalarm® 5000 has been probably the most widely-installed, staff duress alarm system in the world.




Kathy Szumanski, MSN, RN, NE-BC, Director, Institute for Quality, Safety and Injury Prevention

Honing Our Understanding of What It Means to Wait T

 he concept and importance of time has changed through the course of human history. Our ancient ancestors looked at daylight as a time to hunt for food and night as a time to seek shelter and rest. As more structured civilizations developed, time was used to arrange the events of the day into units that could be tracked and managed by the population. The methods used to track the passage of time have also evolved from the ancient sundial to the atomic clock, the official time standard for the United States. Our current view of time has definitely changed with the arrival of the global commun­ ication network provided by the Internet. As we have become accustomed to instant communication, we also seem to have shifted our focus about time from how long an activity will take to how long we wait. The timely access to emergency care has been the subject of much discussion as emergency department visits have increased and wait times have climbed. As studies show, the impact of factors such as patient flow, complexity and race/ethnicity on wait time has demonstrated variable results. 1,2 It is evident, however, that the standard definition of wait time differs from one location to another. This variability raises a concern about the reliability of reported data on timely emergency department care. 3 In July 2013, the ENA Board of Directors endorsed the American


practice and safe care. If you are curious to know how the wait times in your setting compare to other settings, you can explore the timely and effective ED care data that is now reported on the Hospital Compare website at www. hospitalcompare/ search.html. You can find data specific to your setting as well as the state and national comparative data on each individual measure. College of Emergency Physicians’ Policy Statement on Standards for Measuring and Reporting Emergency Department Wait Time. 4 In its policy statement, ACEP recommended that the ‘‘reporting of emergency department patient waiting times for initial evaluation be standardized.’’ There are seven components identified in this policy statement that contribute to the accurate measurement of wait time. The use of electronic medical records in emergency departments can be a valuable adjunct in capturing this accurate time data since time stamps are retrievable at various data points in the care delivery process. The investigations between the length of wait time and patient outcomes provide us with opportunities to study the impact of wait times on safe

References 1. Jones, C., Bourgeois, F., & Shannon, M. (2005). Association of race/ethnicity with ED Wait Times. Pediatrics, 115, 310-315. 2. Schull, M., Kiss, A., Szalai, J. (2007). The effect of low-complexity patients on emergency department wait time. Annals of Emergency Medicine, 49, 257-264. 3. Sanmartin, C. (2003). Toward standard definitions for waiting time. Healthcare Management Forum, 16, 49-53. 4. American College of Emergency Physicians. (2012). Standards for measuring and reporting emergency department wait times. Retrieved from — Practice-Management/Standards-for Measuring-and-Reporting-EmergencyDepartment-Wait-Times/

November 2013

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

Partnering in the fight against stroke Explore online educational modules and increase your knowledge of stroke ENA and Genentech have partnered together to provide online training, with educational resources to help you better identify, diagnose, and treat stroke, featuring: • Quick, easily accessible interactive lessons that teach proper recognition and management of stroke • Knowledge assessments and progress checks • Certificate of completion*

Module 1:

Stroke basics

Module 2:

In-hospital diagnosis of stroke

Module 3:

Treatment and management of stroke

To learn more about this online learning management system, visit: • or • *This program certificate does not satisfy requirements for Continuing Education credits.

© 2013 Genentech USA, Inc. All rights reserved. ACI0001983500 Printed in USA.

Pediatric Update Continued from page 17 recorded, it was flagged so that a double check would be necessary before any medication administration. A couple of members stated that their EMR alerted the documenter if a weight out of normal range for the patient’s age was entered. Members shared examples of how they explain the importance of using metric weights to parents, who always ask about their child’s weight in pounds. One nurse explained that she keeps the explanation simple, telling parents that ‘‘it is a safety issue; we weigh in kilograms because medications are dosed based on kilogram weights.’’ Another nurse said that if a parent asks her to convert the weight for them and tell them the weight in pounds, she will only do this after the kilogram weight has been entered into the patient’s chart. Every patient, if stable, should be weighed on initial presentation to the emergency department. When estimated weights have to be used initially, checks by different providers and hard stops in the EMR may help decrease the chance of wrong weight documentation. Emergency

departments should ensure that they have the capacity to weigh every patient, no matter how sick or injured, and document in kilograms. Kilogram weights also should be included in verbal reports and patient handoffs. 7,8 Metric conversion has proved to be challenging in many ways, but by sharing stories and ideas, we can keep the conversation going and support one another in the process of this critical patient safety initiative. References 1. Hughes, R. G., & Edgerton, E. A. (2005). First, do no harm: Reducing pediatric medication errors: Children are especially at risk for medication errors. American Journal of Nursing, 105(5), 79–84. 2. Pennsylvania Patient Safety Authority. (2009). Medication errors: Significance of accurate patient weights. Pennsylvania Patient Safety Advisory, 6(1), 10–15. 3. Paparella, S. (2009). Weighing in on medication safety. Journal of Emergency Nursing, 35(6), 553–555. 4. American Academy of Pediatrics; American College of Emergency

Physicians; Emergency Nurses Association. (2009). Joint policy statement—guidelines for care of children in the emergency department. Pediatrics, 124(4), 1233–1243 5. Thomas, D. O. (2010). Implementing the IOM recommendations for improving pediatric emergency care in your emergency department: Start from where you are! Journal of Emergency Nursing, 36(4), 375–378. 6. The Joint Commission. (2008, April 11). Preventing pediatric medication errors. Sentinel Event Alert, (39). Retrieved from http://www.joint 7. Emergency Nurses Association. (2012, March). Weighing pediatric patients in kilograms [position statement]. Retrieved from www.ena. org/sitecollectiondocuments/ position%20statements/ weighingpedsptsinkg.pdf 8. Emergency Nurses Association. (2012, September). Weighing patients in kilograms. Retrieved from http:// Position%20Statements/ WeighingPTsinKG.pdf

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, 2013. 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-inChief: 915 Lee Street, Des Plaines, Cook County, Illinois, 60016-6569. Owner: Emergency Nurses Association, 915 Lee Street, Des Plaines, Cook County, Illinois, 60016-6569. Known bondholders, mortgagees and other security holders: None. Issue Date for Circulation Data: October 2013. Extent and nature of circulation: A. Total Number of Copies: Average number of copies each issue during preceding 12 months (hereinafter “Average”), 42,414. Actual number of copies of single issue published nearest to filing date (hereinafter “Most recent”), 45,682. B. Paid circulation: B1. Outside-county paid subscriptions stated on Form 3541: Average, 41,627. Most recent, 45,090. 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, 412. Most recent, 422. 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, 42,039. Most recent, 45,512. D. Free or nominal fee rate distribution. D1. Outside-county copies included on Form 3541: Average, 0. Most recent, 0. 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, 190. Most recent, 10. E. Total. Free or nominal rate distribution (sum of D1, D2, D3 and D4): Average, 190. Most recent, 10. F. Total distribution (sum of C and E): Average, 42,229. Most recent, 45,522. G. Copies not distributed: Average, 185. Most recent, 160. H. Total (sum of F and G): Average, 42,414. Most recent, 45,682. I. Percent paid (C divided by F times 100): Average, 99.5%. Most recent, 99.9%. This Statement of Ownership will be printed in the November 2013 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, 2013.


November 2013

connection Recruitment & Professional Opportunities

ellness W Career Center

For ad rates and information, contact ENA Sales Representative Maureen Nolimal at 847-460-4076 or

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November 2013

Rush-Copley in Aurora, IL is looking for an experienced ER Clinical Educator to be responsible for planning and implementing staff orientation, in-service education and staff development for Emergency Services, including the free-standing Emergency Center, located in Yorkville, IL.

Memorial Hermann is a world-class health system with locations throughout Houston and the surrounding areas. With benefits eligibility that begins the first day of employment, this is a great time to become part of our award-winning organization. Our team of more than 20,000 consistently votes us among Houston’s Best Places to Work. Find out why—and take your career to a higher level.

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Official Magazine of the Emergency Nurses Association


28 41 55 68 %

Average improvement in throughput for admitted and discharged patients


Average improvement in time from arrival to seeing a physician.


Typical improvement in patient satisfaction scores and likelihood to recommend

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


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Senior Consultant Blue Jay Consulting, LLC

ENA Connection November 2013