Transcription
The National Patient Safety Goals for hospitals look at and include the following associated patient harm resulting from pole core competencies: assessment, priority setting, clinical decision making, multitasking, communication, and training.
The core competencies of the IDI nurse include skills on patient assessment, priority setting, clinical decision-making, multitasking, and communications. Competent assessments include a rapid and accurate account of the client's normal and abnormal data and the ability to interpret those findings based on age and their acuity level. Pre-existing conditions include comorbidities, which need to be considered when completing a competent assessment and factoring in other disease processes during the assessment, which will provide the nurse with additional information regarding the patient's presenting condition. Comorbid conditions also often include diseases such as COPD, diabetes, heart disease, hypertension, and such.
Priority setting is an essential component of the ebee nursing care delivery. A triage system identifies and categorizes patients so that the most critical clients are treated first. Triage, the word itself, is a French word meaning to sort.
Clinical decision-making skills are often enhanced as the nurse gains experience in the IDI. The use of simulators, protocols, and case studies can also improve the IDI nurse's ability to implement clinical decision-making skills without the potential to harm clients. The use of protocols allows the nurse to initiate certain interventions, including cardiac monitoring, oxygen therapy, IV therapy, and even the initiation of certain medication during cases like anaphylactic shock and cardiac arrest.
In this high-stress, high-pressure environment, the ED nurse must have a unique ability to multitask. The nurse must have proficient knowledge of standing orders, protocols, emergency equipment use, and interpretation of lab values. An example of a procedure completed in the ED would might include wound suturing, foreign body removal, central line insertion, EP intubation, transvenous pacemaker insertion, lumbar puncture, pelvic examination, chest tube insertion, lavage, paracentesis, and fracture reductions. Of course, the nurse might not perform the individual procedure but would definitely have to know how to assist in the procedure.
Communication with all members of the healthcare team is also essential. Communication with the client can often be difficult or even impossible. The nurse needs to utilize his or her unique assessment abilities to gain pertinent information if that client is unable to communicate effectively. They may come in with a motor vehicle accident and be unconscious, or communication with hostile clients can also prove to be a difficult situation for the IDI nurse.
To be an ED nurse takes special skill and training. Typically, ED nurses obtain certification to work in the ED. This certification indicates that the nurse has completed specific training and education to work there. Standard certifications include BLS and ACLS. BLS, of course, is your basic life support, which educates healthcare practitioners on the principles of cardiopulmonary resuscitation, and your ACLS is advanced cardiac life support, and it includes things such as invasive airway management, pharmacology, EKG interpretation, and intravascular access technique, special resuscitation techniques, and even post-resuscitation management.
Triage is the process of determining the priority of patients' treatments based on their severity of their condition. Once again, the French word triage means to sort, so you're basically sorting out the patients according to their severity and priority. Triage may result in determining the order and priority of emergency treatment, the order and priority of emergency transport, or the transport destination for the patient. To ensure that patients are treated in the order of their clinical urgency, you want to ensure that treatment is appropriately and timely. To end, you want to allocate the patient to the most appropriate assessment and treatment area, and you want to gather information that facilitates the description of the departmental case mix. That means the type of injuries you may be seen.
Triage is an essential function in the emergency department. That's where many patients may present simultaneously, and you may have to triage a large group at one time. Urgency refers to the need for time or the timing of the critical intervention, and urgency is not synonymous with the severity for the acuity. Patients are triaged to lower acuity categories; maybe they can be safe to wait longer for an assessment or treatment, but may still require hospital admission. The levels that we'll look here include emergent, urgent, and non-urgent.
The emergent is a level one, and that's life or limb-threatening illness or injury. Urgent is a level two, and it requires prompt care but will not cause loss of life or limb if left untreated for several hours. Non-urgent, which is level three, means that time is not a critical factor; it's a minor illness or injury that you're looking at there.
So, let's start with the emergent or the level one. This could include a code for an arrest, respiratory or cardiac, patients with cardiac or pulmonary arrest, or imminent arrest, like you know that it's going to happen in the next few seconds or minutes if you don't do something. It could also include severe respiratory distress. Level one conditions include near-fatal asthma, airway obstruction by foreign body, infant bronchiolitis, intracranial events, pneumothorax, congestive heart failure, anaphylaxis, and severe metabolic disturbances. Signs could include inability to speak, cyanosis, lethargy or confusion, tachycardia or bradycardia, and hypoxemia with O2 saturation less than 90 percent. These patients require rapid assessment of the ABCs, immediate physician intervention, medications, and equipment for management of respiratory and ventilatory failure. That includes intubation equipment, rapid sequence intubation drugs, bronchodilators, inotropes, and vasodilators must be immediately available for these patients.
Also falling under this emergent or level one is major trauma. Level one injuries include severe injury to any single body system or multiple system injury, head injury with Glasgow Coma Scale less than 10, severe burns greater than 25% of the total body surface area, or those burns, people with burns who have airway problems, chest or abdominal injury with altered mentation, tachycardia, bradycardia, hypotension, severe pain, or respiratory signs or symptoms. Also included are unconscious or unresponsive patients who have had maybe a CNS event, central nervous system events, metabolic disturbances, and intoxications or overdoses can all present with an alteration of mental function ranging from disorientation or confusion to complete unresponsiveness or seizures. Airway protection, supportive care, and prompt assessment to determine the cause and the necessary treatment are of critical importance in these patients. Hypoglycemia is a rapidly reversible problem that should be identified using the rapid bedside screening test. Shock states fall into this category: conditions where there is an imbalance between the oxygen supply, such as cardiogenic shock, pulmonary dysfunction, blood loss, disorders of oxygen and oxygen demand, hyperdynamic states for oxygen utilization problems like sepsis. And in children, tachycardia is an early response, while bradycardia and hypotension are late symptoms, and those late symptoms could signal imminent cardiac arrest. Typical level 1 patients have one or more of the following: non-responsiveness, vital signs are absent or unstable, severe dehydration, severe respiratory distress, major burns, septic shock, or anaphylaxis. Those are findings in typical level 1 patients.
Let's move on to urgent or level 2, and this refers to conditions that are a potential threat to life, limb, or function requiring rapid medical intervention or delegated acts. Level 2 conditions include conditions that are often associated with significant discomfort and the inability to work or carry out activities of daily living. Level 3 patients may deteriorate and require emergency intervention. This is the most critical triage category for assessment, reassessment, and reassignment.
Respiratory, the lower airway concerns may present with audible wheezing, tachypnea, or cough as evidence of lower respiratory distress. Dyspnea is subjective and may correlate poorly with lung function or deficits in oxygen and pulmonary function. This could include moderate asthma, moderate respiratory distress, altered mental state, head injury, and with the head injury, level 2 head injury patients may have had a high-risk mechanism but should be alert. They would have a Glasgow Coma Scale of 14 or 15 with only moderate pain, like less than an 8 out of 10. You might also see nausea or vomiting in these patients, and these level 2 head injury patients should be upgraded to a level 1 if they are deteriorating or appear unwell. So, the head injury patient has to be reassessed frequently and possibly reassigned to a level 1 if you see them deteriorating. Also with the level 3 is the moderate trauma patients with fractures, volume depletion with near or normal vital signs, abdominal pain, acute psychosis, and suicidal ideation. Moderate pain, not to say that these patients aren't to be watched, but when you're triaging a large group of people, that's the levels that they typically put these patient types of patients in.
The non-urgent conditions may be acute but non-urgent, just as its name, or they may be part of a chronic problem and may show or not show evidence of deterioration. Investigation or interventions for some of these illnesses or injuries can be delayed or referred to other areas of the hospital or healthcare system. Upper respiratory infections, sore throat, minor skin problems, minor trauma problems such as contusions, abrasions, lacerations not requiring any kind of closure, suture removal, and sunburns, those fall in there. With abdominal pain, mild pain that is chronic or recurring with normal vital signs, just vomiting alone or just diarrhea alone, these types of patients have no signs of dehydration and they have normal mental status and vital signs.
Under the non-urgent psychiatric or psych patients may seem to have minor or insignificant problems. They may have presented to the emergency room because they're frustrated by a lack of availability of other healthcare options, and it could be community-specific, or they may even simply be unaware of what other options are available to them, like urgent care clinics and free clinics, that type of thing.
There's also other multi-tiered models that the emergency rooms may use, and there's several, at least five-tiered systems that are used widely in the United States. A few of those include the Emergency Severity Index and the Canadian Triage Acuity Scale. You could also have triage algorithms or scoring systems such as START, S.T.A.R.T., which means Simple Triage and Rapid Treatment, and that can be used by quickly trained laypersons or emergency personnel in emergencies, and it has been taught to California emergency workers for their use in earthquakes. Another example is the ISS, or the Injury Severity Score, and that uses like an ABC type of system where A is a face and neck and head, B is a thorax and abdomen, and C are extremities and external skin. Then they go with a scale of like 0 to 75, but based on the injury and depending on the triage situation, it can indicate whether the patient is a first priority for care or maybe not even be likely to survive.
So, regardless of the system being used, it is important to use solid clinical assessment, judgment, and decision-making to appropriately care for those ED clients. The majority of clients entering the emergency room do not need resuscitative care. However, they come in from a variety of reasons. They may be experiencing stroke-like symptoms, heart attack, or other acute illnesses. Following the initial triage process, the ED nurse next focuses on completing a thorough assessment. Based on assessment findings, the nurse may be permitted to institute care and interventions based on predetermined protocols, including initiating oxygen, cardiac monitoring, lab testing, and IV access. The nurse then documents the information and informs the ED physician about the client's pertinent health information. Following the physician assessment, the nurse must focus on re-evaluation, implementation of the physician's orders, administering medications, and providing the necessary care. Reprioritization of care needs to be completed frequently as the current condition either improves or worsens.
Care of mentally ill clients: The behaviors of mentally ill clients can be unpredictable and produce problems in the environment. Providing a safe environment is of primary importance. To promote a safe environment, the nurse can rid the room of any unnecessary equipment, including extra linens, supplies, and furniture. Other sharp objects or long objects such as oxygen tubing, call light cords, telephone cords, all of those things should be removed or out of patient access. These clients may be transferred to an appropriate psych facility if necessary. They can also have a psych team come in or behavioral services team come in and assess the patient as well.
This position includes the decision on the client's final aspect of care delivery. They can be stable enough to be sent home or may require additional healthcare services and may be admitted to the facility. If the client's condition is too severe, they may be transferred to another higher acuity facility.
Case management: Case managers can be employed in the ED to assist in the arrangement of appropriate homecare services and additional care as requested. The case manager can arrange additional services, including rehab programs or cardiac rehab, pulmonary rehab. And the goal of case management is to prevent unnecessary admissions to the hospital and ED by educating clients on how to better manage their disease process in their home environment. Additional duties of the case manager include assisting the homeless, the victims of domestic violence and abuse, and finding stable, safe environments for the clients.
Patient and family education is also important in the ED. Discharge teaching is essential for any client who is not admitted to the facility. Proper education should include disease presentation, management, medication administration, activity levels, diet, wound care, and follow-up visits to the primary care practitioner.
Death in the ED can many times be sudden and unexpected. These unexpected events create a crisis environment for the staff as well as their family, as the family of the client. Preparation of the dead client prior to presentation to the family is necessary. If the death is unexpected or unexplained, a forensic examination or autopsy may take place. If this situation occurs, the nurse may not be allowed to remove any of the intubation equipment or IV lines. Remember to demonstrate compassion and empathy to the family members and provide support to all of the healthcare providers who participated in the client's care.
The American College of Surgeons appoints certain levels to their trauma centers. We're going to talk about levels one, two, three, and four as we go on here, and a level five. They don't recognize that. We'll mention level one provides comprehensive trauma care, serves as a regional resource, and provides leadership in education, research, and system planning. A level one trauma center is required to have immediate availability of trauma surgeons, anesthesiologists, physician specialists, nurses, and resuscitation equipment. The American College of Surgeons volume performance criteria further stipulates that level one trauma centers treat 1,200 admissions a year or 240 major trauma patients per year, or an average of 35 major trauma patients per surgeon.
Level two provides comprehensive trauma care, either as a supplement to the level 1 trauma center or in a large urban area as a lead hospital, or in a less population-dense area. An example of a level 1 hospital is like OSU. Level 2 centers must meet essentially the same criteria as level 1, but the volume performance standards are not required, and they may depend on geographically served areas. Those level 2 trauma centers are not expected to provide leadership in teaching and research either. Examples in our area include Lima Memorial and St. Rita's Hospital; they are both trauma level 2 hospitals.
Level 3 provides prompt assessment, resuscitation, emergency surgery, and stabilization with transfer to a level 1 or 2 as indicated. Level 3 facilities typically serve communities that do not have access to a level one or two trauma center. Those could possibly include Joint Townships, Mary Ratan, Blanchard Valley, and Miami Valley, those types of hospitals where they would be able to do surgery there if needed, but they don't have quite the strict requirements as the levels two and one.
Level four and five provides advanced trauma life support prior to patient transfer in remote areas which do not have any higher level of care available to them. The key role of the level four center is to resuscitate and stabilize patients and arrange for their transfer to the closest, most appropriate trauma center level facility. Level five trauma centers are not formally recognized by the American College of Surgeons, but they are used by some states to further categorize hospitals that provide life support prior to transfer.
Trauma systems provide the community with the necessary care providers while having adequate knowledge of disaster readiness. These systems provide an integrated and organized approach to trauma care, including timely care, rapid transport to the qualified trauma center, early rehab, and injury prevention research and education. A trauma system is an organized, coordinated effort in a defined geographic area that delivers the full range of care to all injured patients and is integrated with the local public health system. The true value of a trauma system is derived from the seamless transition between each phase of care, integrating existing resources to achieve improved patient outcomes. Success of a trauma system is largely determined by the degree to which it is supported by public policy. Trauma systems are regionalized, making efficient use of healthcare resources. From a system, they are based on the unique requirements of the populations served, such as rural, inner-city, urban, or Native American communities. Trauma systems must emphasize the prevention of injuries in the context of community health. Ultimately, nationwide development of trauma systems would allow for seamless and effective care across the United States with the ability to expand to meet the medical needs of the community from a man-made or natural disaster.