New Courses

Pediatric Seconds-to-Minutes Emergencies Part 1

Seconds-to-minutes emergencies in the Emergency Department frequently manifest as complicated cases requiring immediate evaluation and treatment. Seconds-to-minutes emergencies in the adult population are well delineated, but that is not the case in the pediatric population. In the pediatric population, seconds-to-minutes emergencies are a common source of great angst for the ED team. Generally, a practitioner will hope for organized chaos in these situations at best. Thus, it is critical to have a clearly defined list of diagnoses of common pediatric medical problems and illnesses that need to be considered in the time frame of seconds-to-minutes. Goals for the ED team should include early recognition of seconds-to-minutes emergencies, expedited evaluation and treatment, and the assignment of tasks to team members. In addition, early communication with consultants is critical. This activity is the first of two that review 10 diagnoses (5 per activity) in the pediatric population; the activities provide an in-depth understanding of seconds-to-minutes emergencies as a foundation for treating children with medical problems who need immediate attention and evaluation. A case study of each diagnosis is provided as an example of how to identify and treat these potentially critically ill children. The cases give examples of how these patients may present as well as some common scenarios in the ED. They also demonstrate some of the pitfalls you may encounter when dealing with this patient population. The scenarios not only teach about specific disease processes, but also offer valuable talking points for the medical team. After completing this activity, practitioners should be able to: identify key signs and symptoms of seconds-to-minutes emergencies in pediatric patients; select appropriate diagnostic tests for rapid evaluation and diagnosis of pediatric patients experiencing seconds-to-minutes emergencies; and identify key information for the medical team to communicate during the evaluation of pediatric patients experiencing seconds-to-minutes emergencies.

Ultrasound of the Abdominal Aorta

The timely diagnosis of an abdominal aortic aneurysm (AAA) is one the most important and time-critical applications of bedside ultrasound. Rupture of an AAA is the 13th leading cause of death in the United States, yet early detection and repair could prevent the majority of these deaths. To put it into specific terms, mortality from untreated AAA is 100% compared to mortality of 1%-6% following elective repair, with subsequent lifespans similar to matched controls. When these statistics are considered, it is clear why detecting AAA quickly and accurately cannot be overemphasized as a malpractice risk reduction initiative.

In this activity, we provide an overview of the epidemiology, clinical presentation, and physical exam findings related to AAA. We discuss the diagnostic evaluation for AAA and propose a clinical approach for patients presenting with AAA; we focus on the sonographic approach (i.e., techniques for imaging the abdominal aorta and the sonographic pathology of the abdominal aorta). After completing this activity, practitioners should be able to: create a standard approach to the evaluation of elderly patients that includes an analysis of risk factors for AAA in order to help prioritize AAA on the list of differential diagnoses; identify high-risk patients who should have a bedside ultrasound exam of their abdominal aorta as part of their Emergency Department evaluation; and consider surrounding structures when performing a bedside ultrasound that may confound the evaluation of the abdominal aorta.

Faculty Speaking Engagements

Arnie Mackles is on the road this month! Please contact Arnie if you are interested in learning more about his presentations or to check availability.

• Nov. 13th  Hackensack University Medical Center, Hackensack, NJ
• Nov. 16th - Lakeland, FL
• Dec. 5th  - Boca Raton, FL
• Dec. 9th  - Melbourne, FL
• Dec. 10th  - Spring Hill, FL 

Shelley Cohen, RN, MSN, CEN will be presenting at the following conferences:

2014 Emergency Care Conference
March 19-21, 2014

Emergency Nurses Association
Phoenix, Arizona
Leadership Conference
March 5-9, 2014

Top 5 Tips on Physician Engagement

Here are some of my tips on engaging physicians using CME:

1. Identify the goals of your organization/physician leaders and align education with those goals.
2. Understand the physician population you are trying to engage and select formats that appeal to them. Buy-in is achieved best when the knowledge is coming from a reputable colleague. You can also create incentive programs (i.e. gift cards, premium discounts or credits, department participation awards/contests, poster display of power users/top performers in break rooms, etc.) to increase participation.
3. Provide leadership training to create understanding of the value of CME while reinforcing the importance of leadership modeling.
4. Align education with state-based CME requirements to allow physicians to collect CME hours specific to the requirements for relicensure in their state.  
5. Lastly, measure the change. The real power of education is through observed change. 

• PatientSET™ #1: Introduction for All Healthcare Providers
• PatientSET™ #2: Hospital Best Practice High-Risk Videos
• PatientSET™ #3: Office Best Practice High-Risk Videos
• PatientSET™ #4: Introduction for Nurses - in development
• PatientSET™ #5: HCAHPS Videos for Nurses - in development
• PatientSET™ #6: Healthcare Customer Service Videos for Nurses - in development
• PatientSET™ #7: Healthcare Customer Service Videos for Other Employees - in development
• PatientSET™ #8: Healthcare Customer Service Videos for Triage Nurses - in development

Workplace Violence

Workplace violence has taken center stage as research continues to validate the frequency of incidence, particularly in the ED setting. The Emergency Nurses Association (ENA) 2010 position statement on Violence in the Emergency Care Setting defines workplace violence as any of the following:

• An act of aggression
• Physical assault
• Emotional or verbal abuse
• Coercive or threatening behavior

The trend of under-reporting these occurrences by ED staff (a very vulnerable setting) has resulted in a perception that violence is merely "part of the job." With a focus now on zero-tolerance policies for workplace violence, perceptions are shifting to acknowledge that no one deserves to be a victim of these often preventable acts.

To follow are findings from the 2011 Emergency Department Violence Surveillance Study (EDVS) (keep in mind the prevalence of under-reporting and its impact on the actual unknown numbers of victims/incidents):

• 1/4 of emergency nurses experienced frequent physical violence (more than 20 times!) during the past three (3) years.
• Verbal abuse was received by 1/5 of emergency nurses more than 300 times in the past three (3) years.
• 54.5% reported experiencing physical violence and / or verbal abuse from a patient / visitor during the past seven (7) days.

In response to these very concerning statistics revealed by the EDVS, the ENA developed workplace violence resources (available at www.ena.org).

ENA offers tools that impact ED workplace violence and are beneficial to the department as a whole as well as individual staff members. Whether it is a poster reminder of red flag alerts for violence potentials or a tool to assess your current process for minimizing violence, this all-inclusive toolkit has it all! Staff knowledge of these red flags is pivotal in minimizing risk and decreasing harmful incidents related to workplace violence. 

Sources:

Emergency Nurses Association (2010). Violence in the Emergency Care Setting. Retrieved from, http://www.ena.org/

Emergency Nurses Association (2011). Emergency Department Violence Surveillance Study. Retrieved from, http://www.ena.org

Editor's Note: As an active ED nurse, our triage author, Shelley Cohen, witnesses these acts of aggression and has been a victim, as many other ED nurses have. She drew from her personal experience to create the sixth course in the Triage Fundamentals series:  Violence Potentials and Victims.

 The Critical Importance of Effective Handoff Communication

The BAD news:

• 29% of ED providers revealed an adverse event or near miss in patients handed off to an in-patient service.
• 41% of discharged patients had test results reported after discharge, yet 61.6% of their primary care providers were not aware of results!
• Only 12%-34% of discharge summaries are present at first post-discharge visit, and 51%-77% at a 4-week follow-up visit.

The GOOD news:

Solutions to these problems are available and were presented during the Interactive Learning Sessions at The Sullivan Group Exhibit Booth. The mini interactive sessions highlighted online educational offerings that present strategies and techniques to improve communication and patient safety during handoffs, transitions and discharges.

In response to the growing need for targeted solutions, The Sullivan Group is offering the following CME/ CE activities:

• Handoffs, Transitions & Discharges: Key Moments in Patient Care 
• 7 Simple Strategies to Reduce Readmissions - coming soon
• Communication Strategies to Improve Patient Safety in High-Risk Situations
• 11 Simple Strategies to Prevent Medication Errors
• Technology Revolution: Improving Patient Safety, Reducing Liability
• Essentials of Patient Safety
• Prevention of Medical Errors

• Disclosure & Apology:  Fundamentals
• Disclosure & Apology:  Just-In-Time Trainer

One of the most common questions asked by risk managers is how they can get physicians to participate in new patient safety initiatives. Whether it involves attendance at simulation programs or completing online courses, it often seems that busy physicians in private practice are immune to attempts to engage them in patient safety activities.

While such frustration is understandable, there are means to overcoming physician intransigence. Physicians, like all individuals, respond to incentives and seek to avoid disincentives. The trick is to find the right combination of these that will motivate the physicians in your institution without creating a backlash of resentment.

Here are several tools that can be used to motivate physicians to participate in the patient safety programs that you have worked so hard to provide for them:

1. Exhortation. Include in your announcement to physicians about new patient safety initiatives a reminder about how such programs will improve the quality of care that they as physicians are able to give their patients. Remind them that their patients trust them to be safe, knowledgeable, and up-to-date care providers. Explain that by participating in your safety programs, they as physicians can fulfill their moral obligation to provide the safest possible care to those patients who have entrusted them with their care. 
2. Fear. Remind your physicians that when bad outcomes do occur, the care they provide will be reviewed to assess if it complies with the general national standards of care in their specialty. Care that is outdated, inappropriate, or does not follow current best practices will often be prima facie judged evidence of causation. Likewise, physicians are often questioned during malpractice trials regarding their preparation and training for  emergencies or complications. Lack of participation in such preparatory programs may be perceived by the jury as a physician's indifference toward providing the best care for their patients.
3. Money. Even small amounts of insurance premium credits for participation in patient safety programs go a long way to ensure participation. Even if the physician is not stirred to act by the prospect of saving premium dollars, the practice or office manager certainly will provide needed motivation. A premium surcharge for non-participation is also a possible tactic, but it is one more likely to breed resentment along with disingenuous compliance.
4. Credentialing. Institutions have every right to make certain that those who practice within their walls are in fact delivering the highest quality medical care and following best practices. Many institutions therefore require participation in ongoing education and patient safety programs for continued departmental and/or hospital privileges.

Risk managers, education leaders and hospital administrators often report being fearful that if they impose too stringent requirements on their physicians, they will move their patients to other institutions. This sort of fear is almost always exaggerated. In the first place, physicians choose to work at a certain hospital for many reasons: convenience, quality of the institution, access to services, and patient demand. It is not easy for physicians to uproot their pattern of practice and move to another institution. Certainly having to take a few courses or participate in learning programs does not rise to the level of inconvenience that would force a physician to change long-standing practice patterns. Moreover, it is often patients that drive the decision as to where they wish to be treated. Such decisions are not always solely in the hands of physicians. Furthermore, careful selection of courses mapped to the core competencies may help physicians meet CME requirements for licensure - this will likely be viewed as a valued service, not an imposition.

Bottom line: sugar always attracts more flies than vinegar. The vital importance of obtaining physician participation in patient safety activities is irrefutable. Tools to motivate physicians are available and compelling. Moreover, physicians by and large understand their obligation to practice the best quality medicine they can, and given programs that are interesting, useful, and time efficient, they will embrace them, especially when sweetened with the sorts of incentives outlined above.

• Neonatal Emergencies 
• Postpartum Hemorrhage
• Neonatal Asphyxia
• Ectopic Pregnancy in Obstetrics & Gynecology
• Pitfalls & Liability Risks in Labor - in development
• Pitfalls & Liability Risks in Prenatal Care - in development
• Shoulder Dystocia
• Anatomy of a Medical Negligence Lawsuit in Obstetrics & Gynecology