Level II trauma center seeks others' triage orientation suggestions

JOURNALOF EMERGENCY NURSING

ical u n d e r s t a n d i n g t h a n w h a t a n u r s e w o u l d b r i n g to t h e situation. E m e r g e n c y n u r s i n g is t h e a s s e s s m e n t , diagnosis, a n d t r e a t m e n t of h u m a n r e s p o n s e s to h e a l t h p r o b l e m s t h a t are p r i m a r i l y e p i s o d i c or a c u t e in nature. 3 In a n y g i v e n p a t i e n t e n c o u n t e r , t h e n u r s i n g d i a g n o s i s repres e n t s t h e n u r s e ' s c o n s i d e r e d j u d g m e n t a b o u t w h i c h of t h o s e r e s p o n s e s are of g r e a t e s t s a l i e n c e to t h e clinical situation, t h e p a t i e n t , a n d t h e family. M e d i c a l d i a g n o s e s p r i m a r i l y n a m e p a t h o l o g i c p r o c e s s e s . To t h e e x t e n t t h e y c o n v e y a n y t h i n g at all a b o u t h u m a n r e s p o n s e s to h e a l t h or illness, t h e y do so i n c o m p l e t e l y at b e s t . A s n u r s e s w e c o l l a b o r a t e w i t h p h y s i c i a n s to c o m p l e t e i n t e r v e n t i o n s a i m e d at relieving t h e p a t i e n t ' s p a t h o l o g i c condition. T h e s e i n t e r v e n t i o n s are t r a d i t i o n a l l y c h a r t e d in t h e p a t i e n t c a r e record. Simult a n e o u s l y w e are also t r e a t i n g t h e p a t i e n t ' s r e s p o n s e to t h e p a t h o l o g i c p r o c e s s . T h e s e i n t e r v e n t i o n s , perf o r m e d in t h e i n d e p e n d e n t s c o p e of our p r a c t i c e , are n o t f r e q u e n t l y d o c u m e n t e d . This lack of d o c u m e n t a tion p r e v e n t s n u r s i n g from linking a n i d e n t i f i e d hum a n r e s p o n s e (nursing d i a g n o s i s ) w i t h i n t e r v e n t i o n s a n d u l t i m a t e o u t c o m e s . 4 T h e u s e of n u r s i n g d i a g n o s e s allows a c o n s i s t e n t f o r m a t for d o c u m e n t a t i o n , a n d t h e ability to i d e n t i f y p a t t e r n s of d i a g n o s e s , i n t e r v e n t i o n s , a n d o u t c o m e s for w h i c h w e h a v e p r i m a r y a c c o u n t ability. By i d e n t i f y i n g t h e s e p a t t e r n s w e c a n contribu t e to t h e d e v e l o p m e n t of n e w i n t e r d i s c i p l i n a r y m o d els of p a t i e n t c a r e b a s e d on c o m p l e m e n t a r y s e t s of p h i l o s o p h i c a l beliefs a n d a s s u m p t i o n s . 5 N u r s i n g is a b l e n d of biologic a n d social s c i e n c e . It is a social scie n c e b e c a u s e it a d d r e s s e s f e a t u r e s of h u m a n i t y , g e n der, class, a n d society. 6 A s such, I do b e l i e v e w e m u s t n o w d e m o n s t r a t e our v a l u e to s o c i e t y b y s t a t i n g , a n d b e i n g a c c o u n t a b l e for, our c o n t r i b u t i o n to p a t i e n t

outcomes.--Pam Kidd, RN, PhD, CEN, Associate Professor, College of Nursing, University of Kentucky, Lexington, Kentucky References 1. Webster's II new Riverside dictionary. Boston: Riverside Publishing, 1984. 2. American Heart Association. Advanced Cardiac Life Support manual. Dallas: American Heart Association, 1994; 1-11. 3. Emergency Nurses Association. Standards of emergency nursing practice. 3rd ed. St Louis: Mosby-Year Book, 1996. 4. Kirsch, E. Treating nursing's response to nursing diagnosis. J EMERGNURS 1991;17:125-6. 5. Henry B. Rethinking nursing and medicine. Image 1994; 26:254. 6. Gortner S. Nursing's syntax revisited: a critique of philosophies said to influence nursing theories. Int J Nurs Stud 1993;30:477-88.

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Dispensing medications dangerous: Physicians' support appreciated Dear Editor: In r e c e n t m o n t h s our e m e r g e n c y d e p a r t m e n t h a s b e e n g o i n g t h r o u g h t h e c o n f u s i n g a n d v a g u e i s s u e of d i s p e n s i n g . I w a s v e r y h a p p y to s e e t h a t this d a n g e r ous i s s u e h a s b e e n a d d r e s s e d b y your publication. In our s t a t e w e c a n n o t d i s p e n s e m e d i c a t i o n s in t h e e m e r g e n c y d e p a r t m e n t . Period. W e c a n n o t s e l e c t (even from a n e l e c t r o n i c p h a r m a c y ) , count, p a c k a g e , or fix a label to a m e d i c a t i o n to b e g i v e n to a p a t i e n t for a d m i n i s t r a t i o n a t a later t i m e (this is our s t a t e ' s d e f i n i t i o n of d i s p e n s i n g ) . We, as n u r s e s in t h e e m e r g e n c y d e p a r t m e n t , c a n only a d m i n i s t e r m e d i c a t i o n s . A h o s p i t a l c a n n o t d e v e l o p a policy t h a t b r o a d e n s this s c o p e of p r a c t i c e o u t l i n e d b y t h e S t a t e Board of Nursi n g a n d t h e S t a t e Drug Control Division. T h e d a n g e r s e e m s to lie in t h e fact t h a t m a n y doctors, n u r s e s , a n d n u r s e m a n a g e r s in s o m e facilities a p p e a r to b e una w a r e t h a t t h e u l t i m a t e r e s p o n s i b i l i t y for a d h e r e n c e to t h e s e l a w s a n d r e g u l a t i o n s lies w i t h t h e nurse. Pract i c i n g o u t s i d e this s c o p e c a n result in loss of a n u r s e ' s license. A h o s p i t a l ' s p o l i c y a n d p r o c e d u r e will not p r o t e c t t h e nurse; in a d d i t i o n , a l a w s u i t d o e s n o t h a v e to b e g e n e r a t e d , a s i m p l e c o m p l a i n t to t h e b o a r d of n u r s i n g will r e q u i r e i n v e s t i g a t i o n and, if it is f o u n d e d , r e s u l t in discipline. O n e solution t h a t s o m e of t h e d o c t o r s h a v e c o m e u p w i t h is for them to d i s p e n s e m e d i c a t i o n s to p a t i e n t s t h e m s e l v e s . T h e s e d o c t o r s are p a t i e n t a d v o c a t e s a n d are c o n c e r n e d t h a t n u r s e s s t a y safely w i t h i n t h e i r s c o p e of p r a c t i c e . W e a p p r e c i a t e their a d h e r e n c e to s t a t e r e g u l a t i o n s a n d t h e i r c o n c e r n for our p a t i e n t s a n d ourselves. I e x p e c t t h a t t h e i s s u e of d i s p e n s i n g will c o n t i n u e to c h a n g e as m o r e p h a r m a c y c o m p u t e r i z a t i o n occurs. Our s t a t e r e g u l a t o r y a g e n c i e s are involved in s o m e of t h e s e c h a n g e s , b u t until then, w e m u s t c o n t i n u e to inform o u r s e l v e s a n d follow c u r r e n t l a w s e v e n t h o u g h it m a y m a k e our j o b s a little m o r e difficult. T h a n k you for your t i m e a n d c o n s i d e r a t i o n of this evolving i s s u e . - - M . Lindy Hall, RN, staff nurse, Emer-

gency Department, Small Town, Connecticut

Level lI trauma center seeks others' triage orientation suggestions Dear Editor. Our e m e r g e n c y d e p a r t m e n t is p r e s e n t l y c h a n g i n g our t r i a g e p r o c e s s . W e are a level II t r a u m a c e n t e r a n d w e w a n t to i n c l u d e a m o r e c o m p r e h e n s i v e t r i a g e process.

JOURNAL OF EMERGENCY NURSING

We would like to take this opportunity to retrain staff m e m b e r s and set up a s y s t e m for orientation of n e w staff. We have d i s c u s s e d several w a y s to do this, but I am i n t e r e s t e d in hearing from other e m e r g e n c y d e p a r t m e n t s . Please s e n d me any information and s u g g e s t i o n s t h a t have worked in your d e p a r t m e n t s . -

Shelly Wilt, RN, BEN, CEN, Emergency Department, 701 6th Street South, St. Petersburg, FL 33701

Conducting tests after "the ME's patient" dies: Insights and guidelines sought

Dear Editor." After a p a t i e n t who is a "medical examiner's (ME) c a s e " dies in the e m e r g e n c y department, w h a t are the legal ramifications of the e m e r g e n c y physician c o n d u c t i n g tests to try to d e t e r m i n e the cause of death before notification of the ME? For example, after a patient has b e e n p r o n o u n c e d dead, can the ED doctor legally order blood tests and x-rays without consent of the ME? My u n d e r s t a n d i n g is t h a t once this p a t i e n t has died, he or she is under the jurisdiction of the ME, and therefore, any tests done should be ordered by the ME. Also, any tests done should be paid for by the "state." Is this correct? If the family did not w a n t an autopsy, and the ME w a s not notified until later, should the family have to p a y for the tests done after the d e a t h of their loved one? I i m a g i n e most families would not be informed that t h e s e tests were done after the d e a t h of their loved one; so they would not know to question it when t h e y received their bill. The hospital would probably bill the family for these tests without a s e c o n d thought. I would a p p r e c i a t e your insights about this matter and would like to come up with some guidelines for our department.--Name and address withheld by

request. (Letters will be forwarded to the author by the JOURNAL.)

ED nurse practitioner protocols and training sought by British nurse

Dear Editor. I have recently read with interest your article, "Timing Is Everything: The Growing Need for Emerg e n c y Nurse Practitioners" (J EMERGNURS1993; 19:26970). Here at the Royal Preston Hospital, we are currently in the process of setting up the role of nurse practitioners in the a c c i d e n t and e m e r g e n c y depart-

m e n t and I am looking for any information that m a y help us do this. I would be most grateful if I could call on your experience and ask if it would be possible for you to supply me with any information you m a y have on training programs for the nurse practitioner, both in the a c c i d e n t and e m e r g e n c y and orthopedic setting. I would also be interested in any care pathways/protocols you have, again for a c c i d e n t and e m e r g e n c y and also for trauma and cold orthopedics. Thanking you, in anticipation.--E. E. Yates, SRN, DPSN, Clini-

cal Nurse Manager, Trauma and Orthopaedics, Royal Preston Hospital, Sharoe Green Lane North, Fulwood, Preston, Lancashire, PR2 9HT England

e~/y There are currently no programs specifically designed for e m e r g e n c y nurse practitioners. From the period of 1981 to 1983, a few of these programs were available; however, they were federally funded. After 1983, the federal funds were cut and the programs discontinued. Although there are no e m e r g e n c y nurse practitioner programs, there are several universities that provide an opportunity for nurses to study to b e c o m e adult or family practice nurse practitioners with additional clinical time spent in the e m e r g e n c y setting. These universities are as follows: University of Texas, Houston; Columbia University, New York; University of Kentucky, Lexington; University of Miami, Miami, Florida; and University of California-San Francisco. You can r e q u e s t the list of schools and their a d d r e s s e s by c o n t a c t i n g the ENA D e p a r t m e n t of Professional Services at (800) 243-8362. In addition, the National League for Nursing has two publications, " M a s t e r ' s Education in Nursing: Route to Opportunities in Contemporary Nursing" (Publication No. 15-1312) and "Doctoral Programs in Nursing" (Publication No. 15-1448). You can call or write for these publications from the National League for Nursing, 350 Hudson St., 4th Floor, New York, NY 10014; phone, (212) 989-9393. ENA has not developed any clinical p a t h w a y s at this time. The ENA Board of Directors has charged the Case M a n a g e m e n t Task Force with developing a manual that would assist nurses in developing critical p a t h w a y s by presenting basic concepts involved in p a t h w a y construction and review. The manual is s c h e d u l e d to be available in April 1996.--Nancy Sto-

nis, Director of Professional Services, ENA, Park Ridge, Illinois

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