- Email: [email protected]
Managers Forum
HA2 MAT DECONTAMINATION n What are other emergency departments’ procedures for handling hazardous material decontamination? Answer No. 1 Our military hospital’s procedue is first to use an outside water spigot and a 200-ft hose to wash down the affected individuals about 50 to 75 m away from the ED entrance. We only have access to cold water with this plan, but our weather is mild enough that the use of cold water is acceptable. ED staff can only handle 5 litter/stretcher (nonambulatory) or 10 to 15 ambulatory, announced patients. Should there be a larger number of victims, the hospital would have to rally its resources and set up an alternative site on the compound. A side issue is what to do with the contaminated runoff water. Some facilities use a “kiddy pool” type of container; we take the approach that “dilution is the solution.” We use a lot of water, then a weak hydrochlorite solution. We attempt to make our procedures as comprehensive as possible, including having access to diagrams of the operation’s physical layout. A few other key points for dealing with hazardous material contamination include the following: 1. When the contamination is widespread, the hospital must immediately be locked down so that only one entrance can be used. Every hospital has multiple entrances where people could come in to seek treatment and inadvertently contaminate the entire hospital. 2. If the contaminating incident occurs near the hospital, the hospital ventilation system should be shut down, particularly in light of the current wind direction. 3. Contaminated clothing must be left outside the hospital. I learned that with the Japanese sarin The opinions expressed are those of the respondents and should not be construed as the official position of the institution, ENA, or the Journal. J Emerg Nurs 2000;26:158-65. Copyright 0 2000 by the Emergency Nurses Association. 0099-1767/2000$12.00+0 18/g/104563 doi:10.1067/men.2000.104563
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LTC Nanette A. Hill and EMS staff at William Beaumont Army Medical Center, Ft Bliss, El Paso, Tex
incident, the hospital staff became contaminated because the exposed patients’ clothes were kept in bags beside their ED hospital bed. The military has a long history of preparing to deal with hazardous material decontamination and a realistic understanding of the importance of such preparation-LTC Nanette A. Hill, RN, MS, CEN, Chief Emergency Medical Services, William Beaumont Army Medical Center, Ft Bliss, El Paso, Tex Answer No. 2 Our Interhospital Coordinating Council worked together to have a standardized readiness for any decontamination needs. Our hospital has a hazardous material team that includes personnel from several departments, including public safety, housekeeping, and our ED EMTs. These individuals received specialized training and are tested to wear the self-contained breathing apparatus (SCBA) respirator masks. We have taken the position that, while a registered nurse may go to the decontamination site for consultation, the nurses’ higher level skills are needed inside the department for patient care. Our plan uses an external faucet, which provides warm water, from our former mobile lithotriptor. A special hazmat tent inflates in 3 minutes. It has separate
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sections for undressing, showering, and exiting after showering to maintain the patients’ privacy. Each patient receives a pre-made kit that includes a bag and label for their contaminated clothes, a bag for valuables, and a postshower garment that is like a garbage bag with its head and arms cut out. S.Kay Sedlak. Our community re. RN, MS, CEN ceived a Local Emergency Planning Committee on Hazardous Materials grant to assist in developing standardized protocols and to provide training to personnel at all facilities. Whenever the fire department hazmat team responds to a level 2 or greater hazmat event, all hospitals are notified by centralized dispatch to be alert for potential walk-ins. The government considers our area a potential site for future terrorist biological warfare activity. When our consortium met with the Federal Bureau of Investigation, the differences in perspectives were very evident. As health care providers, we focus on patient confidentiality. With potential terrorist activity, however, the possibility of large-scale implications exists, and the Federal Bureau of Investigation focuses on immediate knowledge of all information.-.% Kay Sedlak, RN, MS, CEN, Clinical Nurse Specialist, Emergency Department, St Mary3 Regional Medical Center, Reno, Nev
Each patient receives a pre-made kit that includes a bag and label for their contaminated clothes, a bag for valuables, and a postshower garment that is like a garbage bag with its head and arms cut out.
Answer No. 3 Historically we have been prepared to deal with significant large decontamination needs because of the oil refineries located near Houston. Our plan usually is activated upon Houston Fire Department notification and transportation of the victim(s).
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The Material Safety and Data Sheets (MSDS) information is kept in triage. We have a large permanent chamber outside the emergency department with a run-off collection basin underneath it. A separate decontamination company drains this basin after it is used. Patients disrobe after entering the chamber, and we discard their clothes. A security officer stationed on the ambulance dock handles their valuables. Ail ED staff are trained in decontamination procedures. However, we have technicians do the “people scrubbing” unless there is a critical medical need. We believe that overall ED patient care would be strained if a registered nurse were to be gone for the usual decontamination time of 20 to 25 minutes per person. Technicians are also “runners”; for example, they provide patients with a clean stretcher and gown and then transport them into the department after decontamination has been completed. Training is provided through an annual hospital program that includes fitting ED staff for a self-contained breathing apparatus respiratory mask. We developed a film that includes a case scenario, first with mistakes and then with the correct action. Participants must also pass a written test and demonstrate the correct technique for donning and doffing protective clothing. A Houston Contamination Committee is currently developing a citywide, 8-hour course. In the meantime, given staff turnover, our course may need to be offered more than once a year to ensure that every shift includes an adequate number of trained staff. We have merged with another hospital system. As a result, the possibility of putting a similar chamber at a facility located closer to the refineries than our inner-city location is being considered at a senior administrative level. Contamination of the transporting helicopter has been an issue. I recommend creating a door/tunnel from the chamber to allow patients direct access into the emergency department. Our current setup requires the patient to go outside through the ambulance ramp, which can be a problem in cold weather. -Michael Wicklander, RN, Clinical Educator, Emergency Department, Hermann Hospital, Houston, Tex Answer No. 4 We have two enclosed alleys on either side of the hospital main entrance that are set up for ambulatory patients who need to be decontaminated. These alleys contain 12 shower heads, drained floors, and private areas on either end. The two alleys allow separation of males and females to ensure privacy. After decontamination, ambulatory patients are given gowns and blankets and walked up a flight of stairs to the back entrance of the emergency department. This
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system wo:ked well recently with a patient who had doused herself with gasoline in a suicide attempt. Critical patients are decontaminated on stretchers in a special tent designed for this purpose. The tent is set up as necessary adjacent to the ED entrance. After decontamination, the patient is transferred to a “clean” stretcher and then rolled into the emergency, department. The heated water provided to the alleys or the water hose to the tent is controlled from inside the hospital, Vents adjacent to the alleys blow warm air, Schmidt, RN, which also keeps patients warm.-Julie
Coordinator and Cardiac Rehabilitation Nurse (former ED Manager), Central Peninsula General Hospital, Soldotna, Alaska; E-mail: jiohnson@cpgh. org
ENHANCING EFFICIENCY n What tricks do other emergency departments use to manage patient flow effectively?
BSN, Clinical Resource Supervisor, and Barbara Mitchell, RN, BS, Clinical Operations Director for the Emergency Department, Department of Emergency Medicine, George Washington University Hospital, Washington, DC Answer No. 5 In reality, for a biohazardous disaster with a large number of victims, decontamination often is completed at the scene. We do have a shower in our department with outside access and a water drain that is channeled to a special tank. The shower is large enough to accommodate two stretchers at one time. Besides being available for obvious decontamination needs, the shower is also frequently used to meet the general cleanliness needs of our large numbers of homeless patients. We have an abundant clothing bank for patients whose clothing has been ruined or for homeless patients with clothing needs.-Denise
Huff. RN, BSN, Director of Emergency and Trauma Services, Santa Barbara Cottage Health Systems, Santa Barbara Hospital, Santa Barbara, Calit E-mail: DhuffQsbch. org Answer No. 6 Patients with potential decontamination needs would most likely come from local oil refineries, which already have elaborate decontamination processes in place. We are working on agreements with EMS regarding how best to continue that piece during transport. If a contaminated paJan Johnson, RN, tient walked up to our facilBSHA, CEN, SANE ity, we would use our heated ambulance bay. A wading pool collects the run-off because the floor drain is conJohnson, nected with the city sewer system.-Jan
RN, BSHA, CEN, SANE, Clinical Forensic Services
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(1. tar.): Doreen Anderson, RN, Kathleen Raife, RN, MS, Emergency CNS, Ingrid Bachtel. RN, MA (seated), Nichols Treece, RN, MSN, and Debra Howard, RN.
Answer No. 1 We are working toward acquiring a computer-tracking system and an automated discharge instruction program. However, for more than 20 years, we have successfully used a system of colored clothespins to track our ED patients. The clothespins are kept in a basket, and our unit aide creates replacements as needed. All staff take responsibility to clip the clothespin of the correct color on the chart. The color code is as follows: PURPLE ED pediatric physician to see YELLOW ED adult physician to see GREEN Nursing intervention needed RED Laboratory work pending BLUE Respiratory technician PLAIN X-ray BLACK Technician procedure needed (suture setup, etc) WHITE Ready to be discharged We also have colored laminated cards that can be placed on the front of the chart. These cards include “Priority” (eg, the physician to see next of all waiting patients), “Admitted, Waiting for a Bed,” or “Staff MD” (private physician is coming). The visual cues allow everyone in the department to see, at a glance, the current stage of any patient’s ED care, without breaking confidentiality. In addition,
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we can answer the question “What am I waiting for?” without reading the chart.-Nichols Treece, RN, MSN, Assistant Director; Deb Howard, RN Assistant Director; Doreen Anderson, RN, Assistant Director; Lngrid Bachtel, RN, MA, Director; and Kathleen Raife, RN, MS, Emergency CNS, Emergency Department, Desert Samaritan Medical Center, Mesa, Ariz Answer No. 2 Our 20/30 rule is one solution for the congestion resulting from ED patients who are admitted. We give residents 20 minutes to get to the emergency department after notification and 30 minutes to complete a workup after arriving. The exceptions are surgical admissions because those cases are evalColeen Vesely,RN, uated one at a time by an BSN. CEN intern, resident, and then attending physicians. For these cases we allow 2 hours until a final decision or disposition is expected. We do not always follow the rule, but having some established time limits is helpful.-Coleen Vesely RN, BSN, CEN, Shift Manager Bassett Health Care, Cooperstown, NY E-marl: ColvesQTELENETNET Answer No. 3 “Cell phones” and chart racks have been helpful in our new emergency department. The phone antennas are located in the department so they only work in that vicinity. Because the phones are not true cellular phones, conversations cannot be monitored from outside, and thus patient confidentiality is not an issue. At first the cell phones were an inconvenience; now the staff cannot live without them. The unit secretary can transfer a call to a physician or registered nurse without having to use an overhead page while keeping the person on hold. If the physician or registered nurse is busy or does not choose to answer the phone, the call bounces back to the secretary so he or she can take a message. Unfortunately, we have found staff members using the cell phones to make personal phone calls in closets, lounges, and empty rooms. I am dealing with this issue by highlighting any calls on the monthly phone bill that are made to staff home phone numbers and/or are longer than 15 minutes. Our system of chart racks satisfactorily tracks the progress of patients during their ED visit. After triage and initial registration, the chart goes into a “Charge
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Nurse to See” rack so he or she can assign a room. The chart is then placed in a “Physician to See” rack where it stays until the physician has completed his or her assessment. When testing or medications are ordered, the physician hands the chart to the unit secretary, who enters the orders. The secretary then places the chart in an “Orders” rack. The nurse carries out the orders, and finally, thechart is placed in the main rack to wait for results, disposition, etc. The charge nurse monitors result reporting and reminds the physicians if the patient is ready for further decisions. The physician places the chart in the “Discharge Rack” after writing the discharge instructions. Charts for admitted patients are handed to the charge nurse, who then makes the arrangements with admitting. The admission is noted on the status board and the chart, and then placed back in the main rack until the patient is transported to the inpatient room. It sounds like we use a lot of racks, but the system works well for us.-Laura Roepe, RN, MA, CEN, Administrative Manager, Emergency Nursing Services, Norwalk Hospital, Norwalk, Conn; E-mail: laura. [email protected]
PSYCHIATRIC OBSERVATION/HOLDINGAREAS n How are other emergency departments handling the prolonged observation and/or seclusion requirements of patients with psychiatric care needs? Answer No. 1 We have a special room that can be used for either infectious isolation or security seclusion. The routine room setup is limited to a stretcher, equipment cart, general waste container, and laundry hamper. The suction/ oxygen outlet is kept locked unless it is needed. A patient with a disease requiring negative air flow Robert C. Knies, Jr, RN, MSN, CEN will be placed in the room only if he or she is medically stable; someone requiring extensive equipment or interventions will be placed in an alternative room. Similarly, the room is used for psychiatric observation only if the patient is medically stable and requires minimal interventions. The following procedures are done before placing a psychiatric patient there: (1) a weapons search by security, (2) removal
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and documentation of all belongings, (3) removal of room equipment except for the stretcher mattress, (4) removal of the nurse call light cord, (5) trirning on the video monitor that is transmitted to the unit secretary’s control desk, and (6) having security staff present during the initial placement and as needed. Security personnel help ED staff move the patient into the room. The electronic locking door switch, located at the control desk, is then activated. Personnel perform ongoing audio/video and/or direct personal monitoring with security backup as needed. We require at least two staff members to be present whenever an employee accesses the room. One person always remains outside the room. On occasion, a stable patient requiring physical restraints (eg, 4-point limb restraints) and demonstrating no significant medical needs may be placed in the room. Such patients are provided with direct 1:l monitoring.-Robert C. Knies, Jr, RN, MSN, CEN, Clinical Nurse Specialist, Emergency Services, HealthSystem Minnesota, St Louis Park, Minn
The area is located behind the nursing station with hallway access to the ambulance entrance. The idea was to make it accessible to ambulance and police personnel without bringing the disruptive patient through the main department. Answer No. 2 Our emergency department has a behavioral control unit (also known as a psychiatric holding room) that has 6 beds separated by curtains. Behind each bed is a locked wall panel containing oxygen and suction equipment. Handcuff rails are located along the headwalls, allowing us to secure the stretcher to the wall if necessary. Carpeting has been placed on the wails to help control noise. The area is located behind the nursing station with hallway access to the ambulance entrance. The idea was to make it accessible to ambulance and police personnel without bringing the disruptive patient through the main department. Our policy precludes placing male and female patients together in the area unless a sitter is present. We also do not “mix” types of patients in the depart-
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ment without a sitter, for example, an intoxicated patient and a psychiatric patient. Same-sex intoxicated patients can be in the area together with 15-minute checks by the staff. If a patient is in restraints, a sitter is required. We do not allow children younger than 18 years in the area unless there are no other occupants. A video camera transmits images to the security desk; security personnel will watch the screen closely when asked to do so. However, at this time, we have only one monitor that also scans several other cameras. As a result, we use many sitters, resulting in significant cost to the department. If a sitter is not available, the ED technician or unit secretary is used, which has a negative impact on the remainder of the department. I would recommend this type of observation setup for other departments only if adequate budget and staffing are allowed for sitters.-Laura Roepe, RN, MA, CEN, Administrative Manager Emergency Nursing Services, Norwalk Hospital, Norwalk, Conn; E-mail: [email protected] Answer No. 3 A difficulty with our psychiatric and dependency patients is the long wait after medical clearance for insurance approval for admission. These patients tend to be difficult and disruptive; they may scream, require restraints, or be intoxicated. They may be heavy smokers or exhibit manipulative behaviors. As a result, they are time-consuming for the staff to deal with and upsetting to the other ED patients (especially children). Preventing flight or hidden weapons is hindered by the California laws that allow patients to wear street clothes after their medical clearance. In our remodeled emergency department, we are attempting to set up an outpatient cardiology section as an evening/night holding area for psychiatric patients who do not have acute medical needs. This way we will be able to isolate them and observe them more carefully. In addition, we are seeking additional dedicated ED security. The presence of a man in a uniform often seems to deter inappropriate behavior. California has high managed care penetration. As a result of working with these providers, we came to the agreement that they must call back within 15 minutes, or the visit is automatically approved. However, this rule does not currently apply to psychiatric admissions. We are now reapproaching the payers on this issue, including setting time limits, so the problems of the psychiatric patients’ increased length of stay are not all on our end.-Denise L. Huff RN, BSN, CEN, Director of ED and Trauma Services, Santa Barbara Cottage Health Systems, Santa Barbara Hospital, Santa Barbara, Calif E-mail: [email protected]
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SECURING SUPPLIES ACCORDING TO JCAHO REQUIREMENTS W I know the Joint Commission for Accreditation of Healthcare Organizations (JCAIIO) requires many supplies to be locked up, but that does not seem feasible for operations in our busy emergency department. How are other departments solving this problem? Answer No. 1 We originally had unlocked storage bins that hung on the walls for many supplies, such as syringes. It was a great use of space but did not meet JCAHO requirements, even though someone is in our nursing supply area 24 hours a day.
We need supplies to be freely available for our traumaexclusive room. Therefore, we took the approach of leaving the supplies out on a large exchange cart but securing that entire room with a combination lock on its door. We are now changing to C-lockers that have shelves and a sliding door that can be pulled down to secure all the contained supplies. We have some open racks with zip-on covers but do not use them to store any needles, medications, or trays containing sharps. We also have various “tool boxes” for chest pain, etc, with breakable plastic security tabs. However, we need supplies to be freely available for our trauma-exclusive room. Therefore, we took the approach of leaving the supplies out on a large exchange cart but securing that entire room with a combination lock on its door. The two adjacent critical beds are sometimes used for nontrauma patients, and thus those trauma supplies are provided by exchange carts kept behind the trauma room’s secured doors. The carts are covered with a zippered cover for transport and storage. The sealed cart is only opened for a particular patient and then sent afterward to central supply for restocking and billing. These systems have successfully allowed us to have the needed supplies secured and easily accessible, as well as capturing the charges.-Stephanie Jones, RN, Clinical Nurse Manager, Emergency Department, Western Medical Center, Santa Ana, Calif
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Answer No. 2 Each ED patient treatment area has a locked drawer with syringes, sharps, and local anesthetic. Color-coded key covers have been placed on one each of the locked drawer keys, medication room keys, and the stock room keys. Each shift’s staff members sign out a set of keys (ie, green keys, pink keys, etc) at the beginning of the shift and return them at the end of the shift. If a staff member takes a set of keys home, he. or she must return them immediately. Our ED physicians also have their own keys to the locked drawers so they can obtain their own supplies for wound infiltration. The system works well for us, and the physicians like it because they do not always have to wait for staff to retrieve the supplies they need.-Rhonda Miller, RN, MS, CEN, CCRN, ECRN, Educa tion/QI CooroTinatar, Emergency Departmen t, CGH Medical Center, Sterling, LU Answer No. 3 Our emergency department is set up with multipurpose rooms and the staff bring a specialty cart to the bedside as needed, for example, for suturing, pelvic examination, etc. Each ED room has a generic bedside supply cart with a top, locked drawer containing restricted supplies, such as sharps. That is the only place in the department, outside of the supply room, where these types of supplies are kept. All ED employees who provide direct patient care are provided with a drawer key that they keep during their employment. This system works well for us and has twice passed our JCAHO regulatory visit. -Nichols Treece, RN, MSN, Assistant Director; Deb Howard, RN, Assistant Director; Doreen Anderson, RN, Assistant Director; ikgrid Bachtel, RN, MA, Director; and KatNeen RaiTe, RN, MS, Emergency CNS, Emergency Department, Desert Samaritan Medical Center, Mesa, Ariz Answer No. 4 Where I formerly worked, the sharps are in drawers, with a built-in combination lock, in the central medication preparation area in the nurses’ station’s inner core. The code can be posted on the inside door of the cabinets above. Some supplies are also locked up in our automatic teller dispensing machines that are located at strategic areas within the department. Both areas are not accessible to patients but are readily available to appropriate staff .-Colleen Andreoni, RN, MS, CEN# Education Coordinator. Trauma Services, Loyola Medical Center, Maywood, Lll; former Clinical Nurse Specialist, Emergency Services, Ingalls Memorial Hospital, Harvey, Lll
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n What are the responsibilities and compensation for the charge nurse role at other emergency departments? Answer No. 1 Our charge position was recently changed from a rotation among all the nurses to a permanently assigned “care coordinator.” Charge nurses were given a promotion to a higher grade with a corresponding pay increase. Their responsibilities include triaging ambulance patients, chart review (100% each shift), maintaining staffing levels, solving problems, dealing with complaints by patients, families, or physicians, tracking loaned equipment, and being a resource person. Most do not take patients for care unless the department is overwhelmed. This new position appears to be helping us maintain better continuity of care in following up with patients, making appointments, and handling discrepancies.-Patrick Smith, RN, BSN, CEN, EMT-e Trauma Coordinator Christus St MYichael Health System, Texarkana, Tex; E-mail: smithpQcableone.net Answer No. 2 Our assistant nurse managers do not take patients but function as a director of traffic and problem solver. This way, someone has an ongoing overview of the department and where needs exist, such as a new trauma patient with only one nurse available. The system works for us because it provides a free pair of hands to “put out fires” as they start. The people in this position are compensated by a higher rate of pay and by being sent, on a regular rotation, to a national nursing conference.-Cynthia Wtight, RN, BS, MS, Education Coordinator Tallahassee Memorial Hospital, Tallahassee, Fla; E-mail: WRIGHT-CQMAU.TMH.ORG Answer No. 3 In our military hospital, the charge nurse functions as a head nurse in his or her absence. This job includes making staff assignments, administrative management duties, and notifying the head nurse or upper administration of pertinent information, such as an entire unit coming down with nausea/vomiting. Military hospitals vary in whether the units’ head nurses take clinical patient assignments.-LTC Nanette A. Hill, RN, MS, CEN, Chief, Emergency Medical Services, William Beaumont Army Medical Center, Ft Bliss, El Paso, Tex Answer No. 4 I work at two different hospitals. The charge nurse takes some patients at one hospital and does not takes patients at the other hospital. In my opinion, the charge nurse role is more functional when
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it is not included in the staffing assignments. The charge person then has a better overview of the unit’s flow and is able to provide assistance as needed. One of the hospitals compensates the charge nurse with an extra dollar per hour; the other facility gives this nurse an extra hour of pay. I believe it is important that we remember that the charge person is the captain of the ship and whichever direction the captain goes, so goes the ship.--Jim Thomas, RN, BSN, CEN, per diem ED staffnurse, Lakeland Medical Center, St Joseph, Mich, and Assistant Nurse Manager l7linois Masonic Medical Center, Chicago, rU Answer No. 5 The charge nurse assignment is posted with the schedule. The charge nurse usually also triages and keeps the patient flow board up to date. Our census has been increasing, up from 17,00O/year, and it is becoming more difficult for one nurse to perform both roles. However, we have a highly experienced group of nurses (average 16 years in nursing), which enables them to independently handle many situations for which a less seasoned staff might need more assistance. The role is equally rotated among the more experienced staff, and no compensation is offered for this role. I do not put a seniority qualifier on who can do the role. An experienced ED nurse who is new to our facility may be ready for the role in a few months, while a nurse who is new to emergency nursing would need more time to become comfortable.-Kay Gay, RN, Clinical Coordinator, Emergency Services, Peachtree Regional Hospital, Newnan, Ga (thanks also to Eileen Boehn, RN, MN, CEN) Answer No. 6 We have clinical coordinators who permanently function in the charge role and are compensated an extra $2/hr. However, on their days off, nurses who are designated as “charge-capable” fill in for the role at only a $l/hr extra compensation. This discrepancy has caused some concerns and is under reconsideration, as is Robin J. Gilbert, RN, BSN, CEN the role of the clinical coordinator. We are also looking at the criteria for a nurse to be considered capable of the charge role. In the past, the role tended to be assigned according to seniority among the regular staff who had been oriented to the charge role. Now, however, on
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some off shifts, the most senior full-time nurse may only have 2 years experience or less, while a department “per diem nurse” may be a former full-time staff nurse with ample experience.-Robin J. Gilbert, m,
BSN, CEN, ED Nurse Manager, Central Main Medical CenteJ Lewiston, Me; E-mail: [email protected] Answer No. 7 We have developed nurse job descriptions based on the ENA Practice Standards, using the accomplishments at each of the levels described by Benner.’ For instance, while a novice nurse is expected to be able to greet and elicit a chief complaint from a patient in a triage, a competent nurse is expected to obtain a rapid analysis of each patient’s acuity while facilitating the movement of many patients through the department. A staff nurse would need to be evaluated at the competent level before being assigned to relief charge nurse duties. We have a designated charge nurse who is responsible for coordinating all activities of the department. She is scheduled for staff days and office days. During the staff days, she works in the department and assumes charge of the department activities. For one to two shifts a month she is scheduled for office days, which are used to complete duties such as evaluations and quality improvement activities and to attend and participate in leadership meetings. When the charge nurse is scheduled off, or during the off shifts, a senior competent staff nurse is assigned as relief charge nurse. The charge nurse/relief charge nurse is a functioning member of the team and may assume responsibility for a patient assignment depending on patient flow in the department. The primary role is to triage patients, assign staff to the ongoing treatment/care of the patient, and keep the department activities flowing through such functions as reviewing patient records, following up on laboratory/radiograph results, or finding coverage for a staff sick call.
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The charge nurse is compensated by a higher rate of pay. The relief charge nurse is compensated at an hourly bonus rate.-Irene
Louda, RN, BSN, MHA, CEN, CNA, Administrative Director, Ohio Valley Medical Center. wheeling, WV and East Ohio Regional Hospital, Martins Ferry, Ohio Reference
Irene Louda, RN, BSN, MHA, CEN, CNA
1. Benner P. From Novice to expert: excellence and power in clinical nursing practice. Menlo Park (CA): Addison-Wesley Publishing Company; 1984. Answer No. 8 We have identified the need to specifically train nurses on how to handle the charge role throughout our hospital because the nurses do not feel prepared to assume the role. We are hoping to help them feel more confident through a formal educational program; ENA’s Role of the Charge Nurse is Stewone resource we are considering.-Jacqueline
art, MSN, RN, CEN, CCRN, Clinical Nurse Specialist, Education Department, Community Medical Center Health Care System, Scranton, Pa Management questions from nurses are welcome, as are names and addresses of nurses in management who are interested in answering questions. RN, MS, Submit to PoUy Gerber Zimmermann, MRA, CEN, 4200 NFrancisco, Chicago, IL 60618; phone (773) 539-1048; E-mail: pzimmermann@ ccc.edal.
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LTC Nanette A. Hill and EMS staff at William Beaumont Army Medical Center, Ft Bliss, El Paso, Tex
incident, the hospital staff became contaminated because the exposed patients’ clothes were kept in bags beside their ED hospital bed. The military has a long history of preparing to deal with hazardous material decontamination and a realistic understanding of the importance of such preparation-LTC Nanette A. Hill, RN, MS, CEN, Chief Emergency Medical Services, William Beaumont Army Medical Center, Ft Bliss, El Paso, Tex Answer No. 2 Our Interhospital Coordinating Council worked together to have a standardized readiness for any decontamination needs. Our hospital has a hazardous material team that includes personnel from several departments, including public safety, housekeeping, and our ED EMTs. These individuals received specialized training and are tested to wear the self-contained breathing apparatus (SCBA) respirator masks. We have taken the position that, while a registered nurse may go to the decontamination site for consultation, the nurses’ higher level skills are needed inside the department for patient care. Our plan uses an external faucet, which provides warm water, from our former mobile lithotriptor. A special hazmat tent inflates in 3 minutes. It has separate
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sections for undressing, showering, and exiting after showering to maintain the patients’ privacy. Each patient receives a pre-made kit that includes a bag and label for their contaminated clothes, a bag for valuables, and a postshower garment that is like a garbage bag with its head and arms cut out. S.Kay Sedlak. Our community re. RN, MS, CEN ceived a Local Emergency Planning Committee on Hazardous Materials grant to assist in developing standardized protocols and to provide training to personnel at all facilities. Whenever the fire department hazmat team responds to a level 2 or greater hazmat event, all hospitals are notified by centralized dispatch to be alert for potential walk-ins. The government considers our area a potential site for future terrorist biological warfare activity. When our consortium met with the Federal Bureau of Investigation, the differences in perspectives were very evident. As health care providers, we focus on patient confidentiality. With potential terrorist activity, however, the possibility of large-scale implications exists, and the Federal Bureau of Investigation focuses on immediate knowledge of all information.-.% Kay Sedlak, RN, MS, CEN, Clinical Nurse Specialist, Emergency Department, St Mary3 Regional Medical Center, Reno, Nev
Each patient receives a pre-made kit that includes a bag and label for their contaminated clothes, a bag for valuables, and a postshower garment that is like a garbage bag with its head and arms cut out.
Answer No. 3 Historically we have been prepared to deal with significant large decontamination needs because of the oil refineries located near Houston. Our plan usually is activated upon Houston Fire Department notification and transportation of the victim(s).
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The Material Safety and Data Sheets (MSDS) information is kept in triage. We have a large permanent chamber outside the emergency department with a run-off collection basin underneath it. A separate decontamination company drains this basin after it is used. Patients disrobe after entering the chamber, and we discard their clothes. A security officer stationed on the ambulance dock handles their valuables. Ail ED staff are trained in decontamination procedures. However, we have technicians do the “people scrubbing” unless there is a critical medical need. We believe that overall ED patient care would be strained if a registered nurse were to be gone for the usual decontamination time of 20 to 25 minutes per person. Technicians are also “runners”; for example, they provide patients with a clean stretcher and gown and then transport them into the department after decontamination has been completed. Training is provided through an annual hospital program that includes fitting ED staff for a self-contained breathing apparatus respiratory mask. We developed a film that includes a case scenario, first with mistakes and then with the correct action. Participants must also pass a written test and demonstrate the correct technique for donning and doffing protective clothing. A Houston Contamination Committee is currently developing a citywide, 8-hour course. In the meantime, given staff turnover, our course may need to be offered more than once a year to ensure that every shift includes an adequate number of trained staff. We have merged with another hospital system. As a result, the possibility of putting a similar chamber at a facility located closer to the refineries than our inner-city location is being considered at a senior administrative level. Contamination of the transporting helicopter has been an issue. I recommend creating a door/tunnel from the chamber to allow patients direct access into the emergency department. Our current setup requires the patient to go outside through the ambulance ramp, which can be a problem in cold weather. -Michael Wicklander, RN, Clinical Educator, Emergency Department, Hermann Hospital, Houston, Tex Answer No. 4 We have two enclosed alleys on either side of the hospital main entrance that are set up for ambulatory patients who need to be decontaminated. These alleys contain 12 shower heads, drained floors, and private areas on either end. The two alleys allow separation of males and females to ensure privacy. After decontamination, ambulatory patients are given gowns and blankets and walked up a flight of stairs to the back entrance of the emergency department. This
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system wo:ked well recently with a patient who had doused herself with gasoline in a suicide attempt. Critical patients are decontaminated on stretchers in a special tent designed for this purpose. The tent is set up as necessary adjacent to the ED entrance. After decontamination, the patient is transferred to a “clean” stretcher and then rolled into the emergency, department. The heated water provided to the alleys or the water hose to the tent is controlled from inside the hospital, Vents adjacent to the alleys blow warm air, Schmidt, RN, which also keeps patients warm.-Julie
Coordinator and Cardiac Rehabilitation Nurse (former ED Manager), Central Peninsula General Hospital, Soldotna, Alaska; E-mail: jiohnson@cpgh. org
ENHANCING EFFICIENCY n What tricks do other emergency departments use to manage patient flow effectively?
BSN, Clinical Resource Supervisor, and Barbara Mitchell, RN, BS, Clinical Operations Director for the Emergency Department, Department of Emergency Medicine, George Washington University Hospital, Washington, DC Answer No. 5 In reality, for a biohazardous disaster with a large number of victims, decontamination often is completed at the scene. We do have a shower in our department with outside access and a water drain that is channeled to a special tank. The shower is large enough to accommodate two stretchers at one time. Besides being available for obvious decontamination needs, the shower is also frequently used to meet the general cleanliness needs of our large numbers of homeless patients. We have an abundant clothing bank for patients whose clothing has been ruined or for homeless patients with clothing needs.-Denise
Huff. RN, BSN, Director of Emergency and Trauma Services, Santa Barbara Cottage Health Systems, Santa Barbara Hospital, Santa Barbara, Calit E-mail: DhuffQsbch. org Answer No. 6 Patients with potential decontamination needs would most likely come from local oil refineries, which already have elaborate decontamination processes in place. We are working on agreements with EMS regarding how best to continue that piece during transport. If a contaminated paJan Johnson, RN, tient walked up to our facilBSHA, CEN, SANE ity, we would use our heated ambulance bay. A wading pool collects the run-off because the floor drain is conJohnson, nected with the city sewer system.-Jan
RN, BSHA, CEN, SANE, Clinical Forensic Services
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(1. tar.): Doreen Anderson, RN, Kathleen Raife, RN, MS, Emergency CNS, Ingrid Bachtel. RN, MA (seated), Nichols Treece, RN, MSN, and Debra Howard, RN.
Answer No. 1 We are working toward acquiring a computer-tracking system and an automated discharge instruction program. However, for more than 20 years, we have successfully used a system of colored clothespins to track our ED patients. The clothespins are kept in a basket, and our unit aide creates replacements as needed. All staff take responsibility to clip the clothespin of the correct color on the chart. The color code is as follows: PURPLE ED pediatric physician to see YELLOW ED adult physician to see GREEN Nursing intervention needed RED Laboratory work pending BLUE Respiratory technician PLAIN X-ray BLACK Technician procedure needed (suture setup, etc) WHITE Ready to be discharged We also have colored laminated cards that can be placed on the front of the chart. These cards include “Priority” (eg, the physician to see next of all waiting patients), “Admitted, Waiting for a Bed,” or “Staff MD” (private physician is coming). The visual cues allow everyone in the department to see, at a glance, the current stage of any patient’s ED care, without breaking confidentiality. In addition,
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we can answer the question “What am I waiting for?” without reading the chart.-Nichols Treece, RN, MSN, Assistant Director; Deb Howard, RN Assistant Director; Doreen Anderson, RN, Assistant Director; Lngrid Bachtel, RN, MA, Director; and Kathleen Raife, RN, MS, Emergency CNS, Emergency Department, Desert Samaritan Medical Center, Mesa, Ariz Answer No. 2 Our 20/30 rule is one solution for the congestion resulting from ED patients who are admitted. We give residents 20 minutes to get to the emergency department after notification and 30 minutes to complete a workup after arriving. The exceptions are surgical admissions because those cases are evalColeen Vesely,RN, uated one at a time by an BSN. CEN intern, resident, and then attending physicians. For these cases we allow 2 hours until a final decision or disposition is expected. We do not always follow the rule, but having some established time limits is helpful.-Coleen Vesely RN, BSN, CEN, Shift Manager Bassett Health Care, Cooperstown, NY E-marl: ColvesQTELENETNET Answer No. 3 “Cell phones” and chart racks have been helpful in our new emergency department. The phone antennas are located in the department so they only work in that vicinity. Because the phones are not true cellular phones, conversations cannot be monitored from outside, and thus patient confidentiality is not an issue. At first the cell phones were an inconvenience; now the staff cannot live without them. The unit secretary can transfer a call to a physician or registered nurse without having to use an overhead page while keeping the person on hold. If the physician or registered nurse is busy or does not choose to answer the phone, the call bounces back to the secretary so he or she can take a message. Unfortunately, we have found staff members using the cell phones to make personal phone calls in closets, lounges, and empty rooms. I am dealing with this issue by highlighting any calls on the monthly phone bill that are made to staff home phone numbers and/or are longer than 15 minutes. Our system of chart racks satisfactorily tracks the progress of patients during their ED visit. After triage and initial registration, the chart goes into a “Charge
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Nurse to See” rack so he or she can assign a room. The chart is then placed in a “Physician to See” rack where it stays until the physician has completed his or her assessment. When testing or medications are ordered, the physician hands the chart to the unit secretary, who enters the orders. The secretary then places the chart in an “Orders” rack. The nurse carries out the orders, and finally, thechart is placed in the main rack to wait for results, disposition, etc. The charge nurse monitors result reporting and reminds the physicians if the patient is ready for further decisions. The physician places the chart in the “Discharge Rack” after writing the discharge instructions. Charts for admitted patients are handed to the charge nurse, who then makes the arrangements with admitting. The admission is noted on the status board and the chart, and then placed back in the main rack until the patient is transported to the inpatient room. It sounds like we use a lot of racks, but the system works well for us.-Laura Roepe, RN, MA, CEN, Administrative Manager, Emergency Nursing Services, Norwalk Hospital, Norwalk, Conn; E-mail: laura. [email protected]
PSYCHIATRIC OBSERVATION/HOLDINGAREAS n How are other emergency departments handling the prolonged observation and/or seclusion requirements of patients with psychiatric care needs? Answer No. 1 We have a special room that can be used for either infectious isolation or security seclusion. The routine room setup is limited to a stretcher, equipment cart, general waste container, and laundry hamper. The suction/ oxygen outlet is kept locked unless it is needed. A patient with a disease requiring negative air flow Robert C. Knies, Jr, RN, MSN, CEN will be placed in the room only if he or she is medically stable; someone requiring extensive equipment or interventions will be placed in an alternative room. Similarly, the room is used for psychiatric observation only if the patient is medically stable and requires minimal interventions. The following procedures are done before placing a psychiatric patient there: (1) a weapons search by security, (2) removal
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and documentation of all belongings, (3) removal of room equipment except for the stretcher mattress, (4) removal of the nurse call light cord, (5) trirning on the video monitor that is transmitted to the unit secretary’s control desk, and (6) having security staff present during the initial placement and as needed. Security personnel help ED staff move the patient into the room. The electronic locking door switch, located at the control desk, is then activated. Personnel perform ongoing audio/video and/or direct personal monitoring with security backup as needed. We require at least two staff members to be present whenever an employee accesses the room. One person always remains outside the room. On occasion, a stable patient requiring physical restraints (eg, 4-point limb restraints) and demonstrating no significant medical needs may be placed in the room. Such patients are provided with direct 1:l monitoring.-Robert C. Knies, Jr, RN, MSN, CEN, Clinical Nurse Specialist, Emergency Services, HealthSystem Minnesota, St Louis Park, Minn
The area is located behind the nursing station with hallway access to the ambulance entrance. The idea was to make it accessible to ambulance and police personnel without bringing the disruptive patient through the main department. Answer No. 2 Our emergency department has a behavioral control unit (also known as a psychiatric holding room) that has 6 beds separated by curtains. Behind each bed is a locked wall panel containing oxygen and suction equipment. Handcuff rails are located along the headwalls, allowing us to secure the stretcher to the wall if necessary. Carpeting has been placed on the wails to help control noise. The area is located behind the nursing station with hallway access to the ambulance entrance. The idea was to make it accessible to ambulance and police personnel without bringing the disruptive patient through the main department. Our policy precludes placing male and female patients together in the area unless a sitter is present. We also do not “mix” types of patients in the depart-
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ment without a sitter, for example, an intoxicated patient and a psychiatric patient. Same-sex intoxicated patients can be in the area together with 15-minute checks by the staff. If a patient is in restraints, a sitter is required. We do not allow children younger than 18 years in the area unless there are no other occupants. A video camera transmits images to the security desk; security personnel will watch the screen closely when asked to do so. However, at this time, we have only one monitor that also scans several other cameras. As a result, we use many sitters, resulting in significant cost to the department. If a sitter is not available, the ED technician or unit secretary is used, which has a negative impact on the remainder of the department. I would recommend this type of observation setup for other departments only if adequate budget and staffing are allowed for sitters.-Laura Roepe, RN, MA, CEN, Administrative Manager Emergency Nursing Services, Norwalk Hospital, Norwalk, Conn; E-mail: [email protected] Answer No. 3 A difficulty with our psychiatric and dependency patients is the long wait after medical clearance for insurance approval for admission. These patients tend to be difficult and disruptive; they may scream, require restraints, or be intoxicated. They may be heavy smokers or exhibit manipulative behaviors. As a result, they are time-consuming for the staff to deal with and upsetting to the other ED patients (especially children). Preventing flight or hidden weapons is hindered by the California laws that allow patients to wear street clothes after their medical clearance. In our remodeled emergency department, we are attempting to set up an outpatient cardiology section as an evening/night holding area for psychiatric patients who do not have acute medical needs. This way we will be able to isolate them and observe them more carefully. In addition, we are seeking additional dedicated ED security. The presence of a man in a uniform often seems to deter inappropriate behavior. California has high managed care penetration. As a result of working with these providers, we came to the agreement that they must call back within 15 minutes, or the visit is automatically approved. However, this rule does not currently apply to psychiatric admissions. We are now reapproaching the payers on this issue, including setting time limits, so the problems of the psychiatric patients’ increased length of stay are not all on our end.-Denise L. Huff RN, BSN, CEN, Director of ED and Trauma Services, Santa Barbara Cottage Health Systems, Santa Barbara Hospital, Santa Barbara, Calif E-mail: [email protected]
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SECURING SUPPLIES ACCORDING TO JCAHO REQUIREMENTS W I know the Joint Commission for Accreditation of Healthcare Organizations (JCAIIO) requires many supplies to be locked up, but that does not seem feasible for operations in our busy emergency department. How are other departments solving this problem? Answer No. 1 We originally had unlocked storage bins that hung on the walls for many supplies, such as syringes. It was a great use of space but did not meet JCAHO requirements, even though someone is in our nursing supply area 24 hours a day.
We need supplies to be freely available for our traumaexclusive room. Therefore, we took the approach of leaving the supplies out on a large exchange cart but securing that entire room with a combination lock on its door. We are now changing to C-lockers that have shelves and a sliding door that can be pulled down to secure all the contained supplies. We have some open racks with zip-on covers but do not use them to store any needles, medications, or trays containing sharps. We also have various “tool boxes” for chest pain, etc, with breakable plastic security tabs. However, we need supplies to be freely available for our trauma-exclusive room. Therefore, we took the approach of leaving the supplies out on a large exchange cart but securing that entire room with a combination lock on its door. The two adjacent critical beds are sometimes used for nontrauma patients, and thus those trauma supplies are provided by exchange carts kept behind the trauma room’s secured doors. The carts are covered with a zippered cover for transport and storage. The sealed cart is only opened for a particular patient and then sent afterward to central supply for restocking and billing. These systems have successfully allowed us to have the needed supplies secured and easily accessible, as well as capturing the charges.-Stephanie Jones, RN, Clinical Nurse Manager, Emergency Department, Western Medical Center, Santa Ana, Calif
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Answer No. 2 Each ED patient treatment area has a locked drawer with syringes, sharps, and local anesthetic. Color-coded key covers have been placed on one each of the locked drawer keys, medication room keys, and the stock room keys. Each shift’s staff members sign out a set of keys (ie, green keys, pink keys, etc) at the beginning of the shift and return them at the end of the shift. If a staff member takes a set of keys home, he. or she must return them immediately. Our ED physicians also have their own keys to the locked drawers so they can obtain their own supplies for wound infiltration. The system works well for us, and the physicians like it because they do not always have to wait for staff to retrieve the supplies they need.-Rhonda Miller, RN, MS, CEN, CCRN, ECRN, Educa tion/QI CooroTinatar, Emergency Departmen t, CGH Medical Center, Sterling, LU Answer No. 3 Our emergency department is set up with multipurpose rooms and the staff bring a specialty cart to the bedside as needed, for example, for suturing, pelvic examination, etc. Each ED room has a generic bedside supply cart with a top, locked drawer containing restricted supplies, such as sharps. That is the only place in the department, outside of the supply room, where these types of supplies are kept. All ED employees who provide direct patient care are provided with a drawer key that they keep during their employment. This system works well for us and has twice passed our JCAHO regulatory visit. -Nichols Treece, RN, MSN, Assistant Director; Deb Howard, RN, Assistant Director; Doreen Anderson, RN, Assistant Director; ikgrid Bachtel, RN, MA, Director; and KatNeen RaiTe, RN, MS, Emergency CNS, Emergency Department, Desert Samaritan Medical Center, Mesa, Ariz Answer No. 4 Where I formerly worked, the sharps are in drawers, with a built-in combination lock, in the central medication preparation area in the nurses’ station’s inner core. The code can be posted on the inside door of the cabinets above. Some supplies are also locked up in our automatic teller dispensing machines that are located at strategic areas within the department. Both areas are not accessible to patients but are readily available to appropriate staff .-Colleen Andreoni, RN, MS, CEN# Education Coordinator. Trauma Services, Loyola Medical Center, Maywood, Lll; former Clinical Nurse Specialist, Emergency Services, Ingalls Memorial Hospital, Harvey, Lll
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n What are the responsibilities and compensation for the charge nurse role at other emergency departments? Answer No. 1 Our charge position was recently changed from a rotation among all the nurses to a permanently assigned “care coordinator.” Charge nurses were given a promotion to a higher grade with a corresponding pay increase. Their responsibilities include triaging ambulance patients, chart review (100% each shift), maintaining staffing levels, solving problems, dealing with complaints by patients, families, or physicians, tracking loaned equipment, and being a resource person. Most do not take patients for care unless the department is overwhelmed. This new position appears to be helping us maintain better continuity of care in following up with patients, making appointments, and handling discrepancies.-Patrick Smith, RN, BSN, CEN, EMT-e Trauma Coordinator Christus St MYichael Health System, Texarkana, Tex; E-mail: smithpQcableone.net Answer No. 2 Our assistant nurse managers do not take patients but function as a director of traffic and problem solver. This way, someone has an ongoing overview of the department and where needs exist, such as a new trauma patient with only one nurse available. The system works for us because it provides a free pair of hands to “put out fires” as they start. The people in this position are compensated by a higher rate of pay and by being sent, on a regular rotation, to a national nursing conference.-Cynthia Wtight, RN, BS, MS, Education Coordinator Tallahassee Memorial Hospital, Tallahassee, Fla; E-mail: WRIGHT-CQMAU.TMH.ORG Answer No. 3 In our military hospital, the charge nurse functions as a head nurse in his or her absence. This job includes making staff assignments, administrative management duties, and notifying the head nurse or upper administration of pertinent information, such as an entire unit coming down with nausea/vomiting. Military hospitals vary in whether the units’ head nurses take clinical patient assignments.-LTC Nanette A. Hill, RN, MS, CEN, Chief, Emergency Medical Services, William Beaumont Army Medical Center, Ft Bliss, El Paso, Tex Answer No. 4 I work at two different hospitals. The charge nurse takes some patients at one hospital and does not takes patients at the other hospital. In my opinion, the charge nurse role is more functional when
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it is not included in the staffing assignments. The charge person then has a better overview of the unit’s flow and is able to provide assistance as needed. One of the hospitals compensates the charge nurse with an extra dollar per hour; the other facility gives this nurse an extra hour of pay. I believe it is important that we remember that the charge person is the captain of the ship and whichever direction the captain goes, so goes the ship.--Jim Thomas, RN, BSN, CEN, per diem ED staffnurse, Lakeland Medical Center, St Joseph, Mich, and Assistant Nurse Manager l7linois Masonic Medical Center, Chicago, rU Answer No. 5 The charge nurse assignment is posted with the schedule. The charge nurse usually also triages and keeps the patient flow board up to date. Our census has been increasing, up from 17,00O/year, and it is becoming more difficult for one nurse to perform both roles. However, we have a highly experienced group of nurses (average 16 years in nursing), which enables them to independently handle many situations for which a less seasoned staff might need more assistance. The role is equally rotated among the more experienced staff, and no compensation is offered for this role. I do not put a seniority qualifier on who can do the role. An experienced ED nurse who is new to our facility may be ready for the role in a few months, while a nurse who is new to emergency nursing would need more time to become comfortable.-Kay Gay, RN, Clinical Coordinator, Emergency Services, Peachtree Regional Hospital, Newnan, Ga (thanks also to Eileen Boehn, RN, MN, CEN) Answer No. 6 We have clinical coordinators who permanently function in the charge role and are compensated an extra $2/hr. However, on their days off, nurses who are designated as “charge-capable” fill in for the role at only a $l/hr extra compensation. This discrepancy has caused some concerns and is under reconsideration, as is Robin J. Gilbert, RN, BSN, CEN the role of the clinical coordinator. We are also looking at the criteria for a nurse to be considered capable of the charge role. In the past, the role tended to be assigned according to seniority among the regular staff who had been oriented to the charge role. Now, however, on
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some off shifts, the most senior full-time nurse may only have 2 years experience or less, while a department “per diem nurse” may be a former full-time staff nurse with ample experience.-Robin J. Gilbert, m,
BSN, CEN, ED Nurse Manager, Central Main Medical CenteJ Lewiston, Me; E-mail: [email protected] Answer No. 7 We have developed nurse job descriptions based on the ENA Practice Standards, using the accomplishments at each of the levels described by Benner.’ For instance, while a novice nurse is expected to be able to greet and elicit a chief complaint from a patient in a triage, a competent nurse is expected to obtain a rapid analysis of each patient’s acuity while facilitating the movement of many patients through the department. A staff nurse would need to be evaluated at the competent level before being assigned to relief charge nurse duties. We have a designated charge nurse who is responsible for coordinating all activities of the department. She is scheduled for staff days and office days. During the staff days, she works in the department and assumes charge of the department activities. For one to two shifts a month she is scheduled for office days, which are used to complete duties such as evaluations and quality improvement activities and to attend and participate in leadership meetings. When the charge nurse is scheduled off, or during the off shifts, a senior competent staff nurse is assigned as relief charge nurse. The charge nurse/relief charge nurse is a functioning member of the team and may assume responsibility for a patient assignment depending on patient flow in the department. The primary role is to triage patients, assign staff to the ongoing treatment/care of the patient, and keep the department activities flowing through such functions as reviewing patient records, following up on laboratory/radiograph results, or finding coverage for a staff sick call.
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The charge nurse is compensated by a higher rate of pay. The relief charge nurse is compensated at an hourly bonus rate.-Irene
Louda, RN, BSN, MHA, CEN, CNA, Administrative Director, Ohio Valley Medical Center. wheeling, WV and East Ohio Regional Hospital, Martins Ferry, Ohio Reference
Irene Louda, RN, BSN, MHA, CEN, CNA
1. Benner P. From Novice to expert: excellence and power in clinical nursing practice. Menlo Park (CA): Addison-Wesley Publishing Company; 1984. Answer No. 8 We have identified the need to specifically train nurses on how to handle the charge role throughout our hospital because the nurses do not feel prepared to assume the role. We are hoping to help them feel more confident through a formal educational program; ENA’s Role of the Charge Nurse is Stewone resource we are considering.-Jacqueline
art, MSN, RN, CEN, CCRN, Clinical Nurse Specialist, Education Department, Community Medical Center Health Care System, Scranton, Pa Management questions from nurses are welcome, as are names and addresses of nurses in management who are interested in answering questions. RN, MS, Submit to PoUy Gerber Zimmermann, MRA, CEN, 4200 NFrancisco, Chicago, IL 60618; phone (773) 539-1048; E-mail: pzimmermann@ ccc.edal.
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