Are you overlooking crucial ED nursing competencies?
Are you overlooking crucial ED nursing competencies?
Focus on high-risk, low-volume procedures
Is maintaining competencies a growing problem for your ED, due to the nursing shortage, fewer resources, and increasing patient volumes? Surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are looking very closely at this area, reports Kim Colonnelli, RN, BSN, MA, district director for emergency and trauma services for Palomar Pomerado Health. The EDs at Palomar and Poway, CA-based Pomerado Hospital were surveyed in March 2005.
"We give nurses periodic refreshers on the high-risk, low-volume procedures, and JCAHO was happy with what we had done," she explains. Examples include splinting that is usually done by ED technicians, setting up a rapid infuser, and preparing a patient for a chest tube drainage system, she says.
To maintain ED nursing competencies, do the following:
• Have staff demonstrate skills on actual patients.
At Champlain Valley Physicians Hospital Medical Center in Plattsburgh, NY, yearly competencies for ED nurses include defibrillation, external pacing, airway management, transvenous pacing, glucometers, and jet ventilators with cricothyrotomy.
Although nurses sometimes demonstrate these skills in a classroom setting, this also can be done while caring for actual patients in the ED, says Ann Heywood, RN, BSN, SANE, clinical practice coordinator for the emergency care center
"Staff often do not feel competent until they have performed skills such as defibrillation and external pacing on an actual patient," she explains.
When the clinical educator is notified that a patient in cardiopulmonary arrest is coming to the ED, she coaches nurses on defibrillation, observes nurses performing the procedure, and signs off on their yearly skills.
"If I know a nurse is on that has not performed defibrillation on a real patient and only in the classroom, I will have that nurse come to the room and will coach him or her through the procedure," says Heywood. "This helps take the fear out of it and creates a great learning environment."
• Incorporate pediatrics.
You always should include pediatric cases in general competencies, such as fever management, recommends Colonnelli. Palomar Pomerado’s ED focused heavily on competencies for pediatric procedures, including mock codes using the Broselow/Hinkle Pediatric Emergency System (Armstrong Medical Industries, Lincolnshire, IL.)
"This was new for some nurses, so we did competencies on drug calculations and use of the Broselow Pediatric Emergency tape. The Joint Commission surveyors really liked that," says Colonnelli. "Pediatrics is low volume if you don’t see a lot of sick kids, and it is always high risk."
• Address competencies for standing orders.
Triage nurses at Palomar Pomerado’s EDs use emergency treatment protocols for patients with chest pain, abdominal pain, shortness of breath, and possible gastrointestinal bleeding. The protocols allow nurses to start intravenous lines, administer oxygen, administer pain medication, perform an electrocardiogram, and administer fluid therapy, says Colonnelli. "We implemented that this year, so this is another competency to ensure," she says.
• Review low-volume, high-risk tasks more often.
Low-volume, high-risk tasks include jet ventilation, because staff may never have the opportunity to assist with this procedure on an actual patient, Heywood says. "We have found that repetition of skill demonstration for low-volume procedures increases comfort level significantly," she says. "However, this is time intensive if you have a large staff."
• Have an annual "Skills Day."
At Edward Hospital in Naperville, IL, the ED has an annual eight-hour mandatory Marathon Skills Day, which covers all Joint Commission requirements for patient safety, point-of-care testing, age-appropriate care, cardiopulmonary resuscitation, and ED-specific skills.
Nurses are required to read and review mandatory competencies and submit a test prior to admission to the Skills Day, says Sharron Chivari, RN, MSN, CEN, clinical leader of the ED. "It is offered on three different days over a one-month period, to accommodate everyone’s schedule," she reports.
The skills day is held in the hospital’s education center, with stations set up for nurses to practice procedures and then do return demonstrations. "Our skills day incorporates more than just procedures," says Chivari. "It includes a review of policies and forms that aren’t utilized often and point-of-care testing."
To make the event more enjoyable, lunch is served and themes are chosen, such as "Cruising," with instructors dressed in formal wear and prizes given to the best-dressed staff.
All other competencies that are not covered on Marathon Skills Day are covered during the year at a monthly staff meeting, she says. "The mandatory certifications are just that — mandatory," says Chivari. "If a staff member lapses, they’re put on suspension without pay."
• Link competencies to performance reviews.
Competencies are tracked electronically and kept updated by nurses themselves, says Chivari. "Staff must bring their computer printout of their attendance [at the Skills Day and continuing education courses] to their annual performance review," she says. "Since eligibility for raises are based on compliance with all regulatory requirements as well as proof of maintaining competencies and continuing education, staff are enthusiastic about submitting their attendance."
Sources
For more information on ED nursing competencies, contact:
- Sharron Chivari, RN, APN-CNS, Clinical Leader, Emergency Department, Edward Hospital, 801 S. Washington St., Naperville, IL 60540. Telephone: (630) 527-5259. Fax: (630) 527-5018. E-mail: [email protected].
- Kim Colonnelli, RN, BSN, MA, District Director, Emergency and Trauma Services, Palomar Pomerado Health, 555 E. Valley Parkway, Escondido, CA 92025. Telephone: (760) 739-3320. Fax: (760) 739-3121. E-mail: [email protected].
- Ann Heywood, RN, BSN, SANE, Clinical Practice Coordinator, Emergency Care Center, Champlain Valley Physicians Hospital Medical Center, 75 Beekman St., Plattsburgh, NY 12901. Telephone: (518) 562-7483. E-mail: [email protected].
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