Domestic violence training at an inner-city hospital found helpful

JOURNAL OF EMERGENCY NURSING

r e a c t i o n s to l a t e x while working. I w o u l d h o p e it will n o t t a k e d e a t h s in our c o m m u n i t y to w a k e u s u p to t h e reality of t h i s harmful p r o d u c t w h e n s u c h s i m p l e c h a n g e s c a n occur.--Carol Brown, 2201 Elba Circle,

Lincoln, NE 68521; E-mail: carolbr@juno, corn More on latex allergy

Dear Editor." I w o u l d like to r e c o g n i z e your major effort in e d u c a t i n g your r e a d e r s r e g a r d i n g latex sensitivity. Yes, w e all k n o w t h a t m a n y a r t i c l e s h a v e b e e n w r i t t e n on t h i s subject, b u t all are n e a t l y t u c k e d a w a y in t h e p a g e s of m a n y p r o f e s s i o n a l journals. S o m e s o u r c e s s t a t e t h a t one in five h e a l t h c a r e w o r k e r s a r e s e n sitive. M a n y n u r s e s are afraid to r e p o r t t h e i r s y m p t o m s out of fear of l o s i n g their jobs. E a c h a n d e v e r y h e a l t h c a r e p r o v i d e r n e e d s to b e e d u c a t e d - - t h a t i n c l u d e s EMTs, R e d Cross staff, volunteers, a n d p r o f e s s i o n a l s w h o p r o v i d e c a r e a n d or h a v e u s e d l a t e x gloves. W e all n e e d to e n c o u r a g e staff to d o c u m e n t their p e r s o n a l f i n d i n g s of s y m p t o m s , s u c h a s s k i n rash, hives, swollen r e d skin, tears, i t c h i n g or b u r n i n g of eyes, s h o r t n e s s of b r e a t h , dizziness, difficulty b r e a t h i n g , w h e e z i n g , n a u s e a , diarrhea, a b d o m i n a l pain, fainting, a n d anaphylaxis.--Susanne Heinzerling, FNP,,

CEN, Bristol, Vermont," E-marl: [email protected] Advice on productivity factors sought

Dear Editor. I a m p r e s e n t l y m a n a g i n g a level II t r a u m a c e n t e r in a 2 5 0 - b e d h o s p i t a l in t h e M i d w e s t . A y e a r ago, our h o s p i t a l h i r e d a c o n s u l t i n g firm to c o m e in, study, a n d d e v e l o p a n o p e r a t i o n a l i m p r o v e m e n t p l a n for t h e e m e r g e n c y d e p a r t m e n t . After this study, w h i c h w a s b a s e d on activities, frequency, a n d volume, m y prod u c t i v i t y factor w a s d r o p p e d from a 3.6 to a 2.9 a n d finally e n d i n g a t 2.322. M a n a g e m e n t h a s b e e n g i v e n t h e d i r e c t i v e to m e e t a n d m a i n t a i n our factor b e t w e e n 95% a n d 100% for job security. A d m i n i s t r a t i o n is u n w i l l i n g to r e v i s i t a n d d e a l w i t h t h e i n c r e a s e d volu m e a n d a c u i t y t h a t w e are n o w e v a l u a t i n g in t h e emergency department. I would appreciate any help m y E N A c o l l e a g u e s w h o h a v e h a d a similar e x p e r i e n c e c a n s h a r e w i t h me. I a m looking for a n y a d v i c e , a s s i s t a n c e , or m e t h o d s u s e d to t r e n d a c u i t y v e r s u s volume. I w o u l d also gladly s h a r e m y e x p e r i e n c e w i t h m y h o s p i t a l ' s c o n s u l t i n g g r o u p w i t h a n y of m y E N A col-

leagues.--Christine M. Hoag-Apel, RN, CEN, 2811 Delaware, Joplin, MO 64804; home (417) 623-5824; work (417) 625-6637; beeper (417) 659-7031; fax (417) 626-3000

Domestic violence training at an inner-city hospital found helpful

Dear Editor. Emergency departments across the country have b e c o m e t h e g a t e w a y for a n i n c r e a s i n g n u m b e r of d o m e s t i c a b u s e v i c t i m s to r e c e i v e initial m e d i c a l t r e a t m e n t . Consequently, e m e r g e n c y h e a l t h c a r e prov i d e r s m u s t r e c e i v e s o m e formal t r a i n i n g on this topic to correctly i d e n t i f y a n d a s s e s s at-risk p a t i e n t s a n d victims. This is a n i m p o r t a n t first a n d i n t e r v e n t i o n a l s t e p t o w a r d h e l p i n g p a t i e n t s b r e a k t h e cycle of viol e n c e w i t h i n b a t t e r i n g r e l a t i o n s h i p s . Unfortunately, m o s t crisis p a t i e n t s r e t u r n m u l t i p l e t i m e s for t r e a t m e n t b e f o r e t h e c a u s e of t h e i r injuries is correctly i d e n t i f i e d b y p r o f e s s i o n a l staff. It is e n c o u r a g i n g to r e a d h o w one h o s p i t a l ' s e x p e r i e n c e in e d u c a t i n g t h e h o u s e staff r e s u l t e d in p o s i t i v e c h a n g e a n d i n c r e a s e d a w a r e n e s s a m o n g p h y s i c i a n s - i n - t r a i n i n g (Varvaro FF, G e s m o n d S. ED p h y s i c i a n h o u s e staff r e s p o n s e to t r a i n i n g on d o m e s t i c v i o l e n c e . J E m e r g N u r s 1997;23:17-22). In 1994 P r o v i d e n c e Hospital, a n i n n e r - c i t y h o s p i tal in W a s h i n g t o n DC, e s t a b l i s h e d a n A d H o c C o m m i t t e e on D o m e s t i c Violence c e n t e r e d a r o u n d similar objectives. It c o m p r i s e d t h e a s s i s t a n t c h a i r of the Emergency Department, along with a multidisciplinary g r o u p of i n d i v i d u a l s w h o h a d t h e m o s t experie n c e in w o r k i n g w i t h b a t t e r e d p a t i e n t s . A major focus of t h e c o m m i t t e e w a s to s h o w m e d i c a l professionals, p r i m a r i l y n u r s e s , h o w to b o t h i d e n t i f y b a t t e r i n g vict i m s a n d i n t e r v e n e effectively on their behalf. T h e group organized training workshops, including a pretest and posttest assessment, which was comp l e t e d b y m o r e t h a n 65% of t h e p a r t i c i p a n t s . T h e t e s t r e s u l t s h e l p e d to b o t h i d e n t i f y future t e a c h i n g m a t e rial a n d affirm t h e validity of i n f o r m a t i o n offered b y the workshop instructors. Particular interest was d i r e c t e d a t e d u c a t i n g t h e ED staff (EMTs, n u r s e s , a n d physicians), because they treated the largest number of d o m e s t i c v i o l e n c e victims. In r e s p o n s e to t h e t r a i n i n g s e s s i o n s , a n e w t r i a g e q u e s t i o n on a b u s e w a s d e v i s e d in t h e e m e r g e n c y d e p a r t m e n t a n d will b e i n c l u d e d a s p a r t of t h e nursi n g a s s e s s m e n t for e v e r y p a t i e n t visit. A n i m p o r t a n t h o s p i t a l - w i d e r e s p o n s e to t h e e d u c a t i o n a l p r o g r a m s w a s t h e p r o d u c t i o n of a b r o c h u r e to b e d i s t r i b u t e d to all p a t i e n t s . It i n c l u d e s g e n e r a l i n f o r m a t i o n on a b u s e , a d a n g e r s e l f - a s s e s s m e n t q u e s t i o n n a i r e , a n d directions for f o r m i n g a s a f e t y p l a n w h e n t h e p a t i e n t is r e a d y to l e a v e t h e a b u s i v e relationship. In addition, t h e n u r s i n g a s s e s s m e n t form for all i n p a t i e n t s h a s b e e n r e v i s e d to i n c l u d e a n i n d i r e c t , o p e n - e n d e d s c r e e n i n g q u e s t i o n on e x p o s u r e to i n t i m a t e violence.

August 1997 299

JOURNAL OF EMERGENCY NURSING

This is a n i m p o r t a n t a d d i t i o n to t h e i n f o r m a t i o n - g a t h e r i n g p r o c e s s , b e c a u s e it p r o v i d e s a n o p p o r t u n i t y for v i c t i m s to d i s c u s s t h e i r fears a n d s e e k help w i t h a nurse. During t h e t r a i n i n g , e m p h a s i s w a s p l a c e d on corr e c t d o c u m e n t a t i o n b y ED staff i n c l u d i n g t h e u s e of family v i o l e n c e ICD-9 a n d E - c o d e s (External C a u s e s of Injury a n d Poisoning) a s well as t h e a d d i t i o n of forensic p h o t o g r a p h y w h e n a p p r o p r i a t e . During t h e l a s t 9 m o n t h s , t h e r e h a s b e e n a d r a m a t i c i n c r e a s e in t h e n u m b e r of a b u s e p h o t o g r a p h s t h a t h a v e b e e n t a k e n b y t h e e m e r g e n c y p h y s i c i a n s . In a few c a s e s t h i s e v i d e n c e h a s b e e n helpful in s u c c e s s f u l l y p r o s e c u t i n g b a t t e r e r s . In a d d i t i o n , t h e t r a i n i n g w o r k s h o p s h a v e h a d a p o s i t i v e i m p a c t on t h e m e d i c a l r e c o r d s d e p a r t m e n t . T h e H e a l t h Information M a n a g e m e n t Director h a s s u g g e s t e d a c h a r t r e v i e w p r o j e c t for i d e n t i f y i n g all a s s a u l t c a s e s d i a g n o s e d in t h e e m e r gency department. This information would be pres e n t e d a s p a r t of a q u a l i t y a s s u r a n c e r e v i e w for b o t h departments. I a m p r o u d to s t a t e t h a t t h e w o r k of P r o v i d e n c e H o s p i t a l ' s A d H o c C o m m i t t e e h a s s e t t h e s t a n d a r d for o t h e r D C - a r e a h o s p i t a l s to follow. It is only t h r o u g h similar s y s t e m a t i c holistic a n d collaborative efforts at o t h e r i n s t i t u t i o n s t h a t t h e r e c a n b e h o p e for i m p r o v i n g t h e a s s e s s m e n t a n d s u p p o r t of b a t t e r e d p a t i e n t s . Thankfully, P r o v i d e n c e H o s p i t a l is a l r e a d y b e g i n n i n g to m a k e a n i m p a c t locally t o w a r d i m p r o v i n g c a r e to t h i s long o v e r l o o k e d a n d i s o l a t e d p a t i e n t p o p u l a t i o n . - - K / m Bullock, MD, FAAFP, Assistant Chair-

person, Providence Hospital, Emergency Department, Washington, District of Columbia Blood transfusion error (barely) avoided Dear Editor: A p a l e 70-year-old m a n w a s a d m i t t e d to t h e e m e r g e n c y d e p a r t m e n t . I s t a r t e d a n IV line a n d obt a i n e d b l o o d s a m p l e s . I m a d e labels off o f h i s p a t i e n t w r i s t b a n d . I t h e n t o o k t h e b l o o d a n d t h e ' l a b e l s to t h e counter, w h e r e I i n i t i a l e d t h e labels a n d p u t t h e m on t h e t u b e s . I s e n t t h e b l o o d to t h e lab. It i n c l u d e d a t y p e a n d c r o s s - m a t c h for four u n i t s of p a c k e d r e d b l o o d cells. I s i g n e d t h e p r e p a r e d b l o o d out of t h e blood b a n k . W h e n t h e b l o o d w a s ready, I s i g n e d it o u t of t h e l a b a n d took it to t h e p a t i e n t ' s room. I s p i k e d t h e b a g , p r i m e d t h e t u b i n g , a n d h u n g t h e b l o o d on a n IV pole. I h a d a n o t h e r n u r s e w i t h m e for t h e final c h e c k s . Standing at the patient's bedside and speaking out loud, w e followed t h e p r o t o c o l for h a n g i n g blood. T h e a r m b a n d s , n a m e s , d a t e s , a n d n u m b e r s w e r e all c h e c k e d a n d verified. T h e final s t e p w a s to confirm

:300 Volume 23, Number 4

t h a t t h e blood t y p e on t h e u n i t of b l o o d m a t c h e d t h e b l o o d t y p e on t h e slip. It did. T h e p a t i e n t a s k e d m e to r e p e a t t h e blood t y p e . "A positive," I said. "That's strange. I have had blood transfusions before and I am s u r e I h a v e a l w a y s b e e n O n e g a t i v e , " h e said. I i m m e d i a t e l y r e t u r n e d t h e blood to t h e l a b a n d told t h e m w h a t t h e p a t i e n t h a d said. T h e lab d i s c o v e r e d t h a t t h e y h a d t y p e d a n d c r o s s e d a t u b e of blood t h a t w a s l a b e l e d w i t h t h e p a t i e n t ' s n a m e , b u t d i d not h a v e m y initials on it. W h e n t h e lab t h e n r a n t h e blood I h a d initialed, it c a m e out O n e g a t i v e . T h e p a t i e n t ' s b l o o d w a s d r a w n a g a i n for Verification. It w a s O n e g ative. T h e p a t i e n t w a s r e a s s u r e d a n d r e c e i v e d a t r a n s f u s i o n w i t h t h e c o r r e c t b l o o d type. W h e r e t h e e x t r a t u b e c a m e from, w h o it actually b e l o n g e d to, or h o w t h e w r o n g label Came to b e on it w a s n e v e r d i s c o v e r e d . Extra a r m b a n d labels for t h e p a t i e n t w e r e found, b o t h on t h e c o u n t e r in t h e e m e r gency department where I had labeled the blood and in t h e l a b w h e r e t h e u n i t s of blood w e r e labeled. Not surprisingly, no o n e a d m i t t e d to l a b e l i n g a s t r a y t u b e of blood. T h e lab t e c h n i c i a n a c k n o w l e d g e d t h a t in her h a s t e to p r e p a r e t h e blood, s h e r a n a t u b e w i t h o u t m y initials on it. She t h o u g h t t h a t b e c a u s e I h a d i n i t i a l e d t h e t y p e a n d t h e c r o s s form, b u t failed to initial t h e forms for t h e i n d i v i d u a l u n i t s of blood, t h a t I h a d forg o t t e n to p u t m y initials on t h e t u b e . This b r e a k d o w n in t h e p a p e r c h a i n c o u l d h a v e r e s u l t e d in a fatality. We w e r e f o r t u n a t e t h a t t h e p a t i e n t w a s a w a k e , alert, k n e w his b l o o d t y p e , a n d s p o k e up. A s I d i s c u s s e d t h i s i n c i d e n t w i t h o t h e r n u r s e s in t h e host~ital, m o r e ' t h a n one said, "Well, it's a g o o d t h i n g y o u l i s t e n e d to him. If all t h e b l o o d a n d p a p e r w o r k h a d c h e c k e d out, I p r o b a b l y w o u l d h a v e told h i m h e w a s w r o n g a n d g i v e n h i m t h e b l o o d anyway." Several v a l u a b l e l e s s o n s s h o u l d b e r e m e m b e r e d b y all n u r s e s : • Do n o t m a k e e x t r a labels. • N e v e r t h i n k t h e lab is perfect. • Be grateful t h e lab is p r a c t i c i n g g o o d quality i m p r o v e m e n t w h e n t h e y r e t u r n l a b slips t h a t are n o t filled out properly. And, m o s t i m p o r t a n t • A l w a y s l i s t e n to your patient--Carol Cramer, RN,

BSN, CEN, Centerville, Utah Scope of practice issues for LVNs in the emergency department Dear Editor: In a n a t t e m p t to "dilute" a n a l l - r e g i s t e r e d n u r s e staff in our e m e r g e n c y d e p a r t m e n t , w e a r e u s i n g s o m e l i c e n s e d v o c a t i o n a l n u r s e (LVN) staff. Our probl e m is definition of t h e s c o p e of p r a c t i c e for t h e LVN