Emergency and Disaster Nursing:

1. Emergency and Disaster Nursing: A Systematic Approach to Providing Care

2. The Challenges of ED Care

3. 1/3 of hospital care begins in the emergency department • The majority of ED patients require immediate care • In 2003, 114 million visits to Emergency Rooms occurred • Since 1993, there has been a 14-percent decrease in the number of Emergency Departments nationwide. • In the 1990’s, hospitals lost 103,000 staffed inpatient medical/surgical beds and 7,800 ICU beds. • In 2004, nearly 70 percent of urban hospitals went on diversion to ambulances citing lack of critical care beds. • American Hospital Association (2006). Prepared to care: The 24/7 standby role of America’s full service hospitals. Retrieved September 28, 2009 from http://www.aha.org/aha/research-and-trends/AHA-policy-research/PreparedToCareIndex.html • American College of Emergency Physicians (2004). Report from a roundtable discussion: Meeting the challenge of emergency department overcrowding/boarding. Retrieved September 28, 2009, from http://www.acep.org/workarea/downloadasset.aspx?id=34350

5. 5 ESI Level Triage • Level One: Resuscitation – patients require immediate evaluation and management • Level Two: Emergent – patients require evaluation within 15 minutes for potential threats to life or limb • Level Three: Urgent – patients have conditions that cause significant discomfort and should be evaluated within 30-60 minutes • Level Four: Less Urgent – patients do not require rapid intervention, but should be evaluated within 60 minutes • Level Five: Non-urgent – patients may be seen in a delayed fashion and could be referred to other areas of the health care system Prah Ruger, J., Lewis, L.M., & Richter, C.J. (2007). Identifying high-risk patients for triage and resource allocation in the ED. AmericanJournal of Emergency Medicine. 25, 794-798.

6. Primary Survey

7. Airway • Assessed while maintaining Cervical Spine • Signs and symptoms of compromised airway • Jaw Thrust Maneuver

8. Breathing • Causes • Assessment • Treatment

9. Circulation • Central Pulse is Checked • Color, Temperature, Moisture • AMS and delayed capillary refill are the most significant signs of shock • 2 large bore IV’s with NS or LR

10. Disabilities • Level of Consciousness • Glasgow Coma Scale • Pupil Size

11. Secondary Survey

12. Secondary Expose – remove all clothing (special consideration for forensics) Full Set of Vital Signs Family Presence Five Interventions Give Comfort History and Head to Toe Assessment

13. Forensics • Trauma victims are often victims or perpetrators of crime • Work collaboratively with law enforcement • Maintain the chain of evidence

14. Diagnostic Tests • Blood type and cross • Blood alcohol level • Urine drug screen • Pregnancy test • What others can you think of?

15. Diagnostic Tests cont. • X-Ray, CT, MRI • Diagnostic Peritoneal Lavage (DPL) • Abdominal Ultrasound - Focused Assessment with Sonography for Trauma (FAST)

16. Medications Blood, crystalloids –NS or LR, volume expanders - Hespan Inotropic drugs after IV fluids Dopamine, dobutamine, isoproterenol Vasopressors dopamine, epinephrine Opioids - pain control Tetanus prophylaxis Antibiotics Mannitol

17. Death in the ER

18. Gerontologic Populations • Atypical presentations • Cognitive Impairment • Co-morbidities • Polypharmacy – Coumadin, • Beta-blockers, Anti-hypertensives Hwang, U., Richardson, L.D., Sonuyi, T.O., & Morrison, R.S. (2006). The Effect of emergency department crowding on the management of pain in older adult with hip fracture. Journal of the American Geriatric Society. 54, 270-275.

19. Poisonings • 1-800-POISON1 • Activated charcoal, gastric lavage, eye/skin irrigation, hemodialysis, hemoperfusion, urine alkalinization, chelating agents and antidotes - acetylcysteine • Contraindicated in AMS, ileus, diminished bowel sounds, ingestion of substance poorly absorbed by charcoal

20. Violence • Crosses all socioeconomic and sociocultural barriers • 1.5 million women and 834,000 men treated at ED’s have been battered by persons known to them • Make referrals, provide emotional support, inform victims about their options, ensure patient safety • Suspected abuse of elders, persons with disabilities and children MUST be reported by law. It is not an option to assume the social worker or doctor will report.

21. Bioterrorism

22. Chemical Emergencies • Release of a hazardous chemical that has the potential for harm • Biotoxins • Blood agents • Pulmonary agents • Nerve agents • Treatment depends on the chemical - some have no treatment

23. Radiation Emergencies • Can be incurred from handling of or exposure to radioactive materials • Radiological technicians/First Responders, ED personnel • Weapons of Mass Destruction –everyone is exposed

24. Mass Casualty Incident • Assessments conducted in less than 15 seconds… • System of colored tags to determine seriousness of injury and likelihood of survival • Total number of casualties a hospital can expect is estimated by doubling the number of casualties that arrive in the first hour.

25. NDMS, DMAT & CERT

26. Reverse Triage • Injury identification-rapid assessment at scene • Penetrating injuries to abdomen, pelvis, chest, neck or head • Spinal cord with deficit • Crushing injury to head, chest or abdomen • Major burns • Critical interventions • providing life support, immobilizing the cervical spine, managing the airway, and treating hemorrhage and shock • Rapid transport-ASAP to regional trauma center

27. MIEMSS A V P U A V P U A V P U Tourniquet @ _______ Extremity Splint Gauge PASG Inflated at _______________ Gross Decon. Final Decon. TRIAGE TAG Maryland Emergency Medical Services Maryland Department of Transportation HOSP NOTIFIED Triage Tag • Patient Information • Triage Status • Chief Complaint • Transportation • Peel - off Bar Codes • Transport Record • Vital Signs • History • Treatment

28. Chief Complaint Section Major obvious injuries or illness can be circled Indicate injuries on the human figure Additional information is added on the comments line

29. Pre-Hospital Care • Paramedics communicate with ED • Brief report about client with ETA • Severity of condition determines ED response • Champion Revised Trauma Scoring System

30. Nursing Diagnosis • Ineffective airway clearance • Altered tissue perfusion • Impaired gas exchange • Risk for infection • Impaired physical mobility • Spiritual distress • Risk for post-trauma syndrome

31. PTSD / Compassion Fatigue • Risk for patients and caregivers • Emotions range from fear, anger denial and shock. • May experience flashbacks and nightmares

32. Implications for Nursing • Recognition of our own values and perceptions • Need for evidenced based practice • Continuing education through inservices and online training • Department specific policies – no more than 8 hours in triage • Use of a different triage ranking system such as ESI where specific complaints are automatic level assignments

33. Worker’s Comp

34. Where did I put my keys?

35. It’s like there’s something stuck in my throat…