ENA Connection October 2014

connectionOctober 2014 Volume 38, Issue 9

the Official Magazine of the Emergency Nurses Association

SafekeepingEXPANDING THE WAYS WE CAN PROTECT PATIENTS YOUNG AND OLD — AND OURSELVES

♦ Day of Dialogue on ED Violence 8

♦ Looking Out For Child Passengers 12

♦ Rethinking Elderly Transitions of Care 36

WORKPLACE VIOLENCE PREVENTIONKNOW YOUR WAY OUT: RECOGNIZE, AVOID, PREVENT AND MITIGATE EMERGENCY DEPARTMENT VIOLENCE

WORKPLACE VIOLENCE PREVENTIONKNOW YOUR WAY OUT: RECOGNIZE, AVOID, PREVENT AND MITIGATE EMERGENCY DEPARTMENT VIOLENCE

Interactive, online course designed to mitigate violence in the emergency department. Nurses, managers, and staff who work in emergency care settings will learn to:¡ Recognize risk factors¡ Apply prompt and appropriate responses¡ Implement organizational prevention strategies¡ Report and analyze patterns of violence

2 Hour Course ¡ Video Demonstrations ¡ 1.13 Contact HoursInteractive Quizzes ¡ Developed by ENA with a grant from OSHA

Violence is not part of the job—Protect Yourself!Go to www.ena.org/workplaceviolence

The Emergency Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credential Center’s Commission on Accreditation.

This material was produced under grant number SH-23534-12-60-F-17 from the Occupational Safety and Health Administration, U.S. Department of Labor. It does not necessarily re�ect the views or policies of the U.S. Department of Labor, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.

WORKPLACE VIOLENCE PREVENTIONKNOW YOUR WAY OUT: RECOGNIZE, AVOID, PREVENT, AND MITIGATE EMERGENCY DEPARTMENT VIOLENCE

Workplace Violent Prevention Ad_Connection_Full_08 2014_print.pdf 1 7/24/14 12:55 PM

‘Hey, Can I Grab You For a Second?’

FROM THE PRESIDENT | Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN

You are in the medication room,

making an insulin drip for a 12-year-

old patient in diabetic ketoacidosis.

The charge nurse comes into the

room to let you know the OR is ready

for your patient with appendicitis.

You are reviewing a medication

order for a patient. You need some

clarity about the order, as you are

not sure the dose is correct for the

patient. You walk toward the

physician, who is getting sign-out

from a resident, saying, ‘‘Hey, can I ask you

a question?’’

In the ED, we are constantly balancing a

need for information and communication

with tasks and responsibilities. Have you

ever considered that the where, when and

how of seeking out that information impacts

patient safety? Take the patient with

abdominal pain. You have made your

mental task list before walking out of the

room. Within 45 seconds, your thoughts are

interrupted when you are asked about

lunch. Now, trust me, making sure you get

to lunch is incredibly important, not only to

maintain adequate glucose levels to the

brain but to take a much-needed break.

However, how easy is it for you to recover

from that interruption? Is it possible you

forgot what questions you need to ask? Is it

possible one thing might have fallen off your

list of things to do? Is it possible you forgot

what your patient’s blood glucose result

was? By not doing what you forgot to do, is

it possible the patient can be harmed?

There is much evidence that identifies the

ED as a place where distractions and

interruptions are prevalent. There is also

evidence to show that interruptions during

the medication preparation and delivery

processes can lead to serious errors.

How is your emergency department

working to limit distractions and

interruptions? Do you have ‘‘distraction-free’’

zones in your department? Can you create

‘‘sterile cockpit’’ environments where

interruptions are unacceptable? Medication

rooms are one place that should be

interruption-free. What about where we are

discussing important patient information?

How many times have you interrupted a

conversation about patient care to ask a

noncritical question? Do we need to

Dates to Remember

PAGE 4Free CE of the MonthMembers in Motion

PAGE 9Letters to the Editor

PAGE 30Board Writes

PAGE 35Future of Your Nursing

Regular Features

Oct. 7-11, 2014 ENA 2014 Annual Conference, Indianapolis

PAGE 6Update From the Executive Director

PAGE 8ENA, AONE Hold a Day of Dialogue on Workplace Violence

PAGE 10A Trip Through the ENA Archives

PAGE 12Your Role in Child Passenger Safety

PAGE 14Medical Errors Are on Senate’s Radar

PAGE 16ED Getting a Helping Hand From a Suicide Crisis Center

PAGE 23Focused State and Chapter Leaders Orientation Coming to Las Vegas

PAGES 24 - 29ENA Foundation Scholarship and Research Grant Award Recipients

PAGE 32The Wisdom in Nursing Stories

PAGE 34Game-Changing Votes Are Out There For ENA Elections

PAGE 36Michigan ED Plugs the Gaps in Transitions of Care for the Elderly

PAGES 38 - 43Committee Reports: ENA Lantern Award, Past Presidents and Technology

ENA Exclusives

Y ou are at the bedside caring for a patient with abdominal pain.

This patient has a history of colon cancer, diabetes and

hypertension. The patient has questions about the plan of care, and

you need to speak to the physician to get the answers. The patient is

also hyperglycemic and needs insulin coverage.

You walk out of the room with a list of questions, tasks and interventions to accomplish.

As you are walking toward the team station, you are stopped by a peer asking what time you

would like to go to lunch.

Continued on page 9

Official Magazine of the Emergency Nurses Association 3

Congratulations and appreciation to all emergency nurses from the ENA Board

of Directors in celebration of

Emergency Nurses Week Oct. 5 - 11

Emergency Nurses Day Oct. 8

In celebration

of Emergency Nurses

Week and Emergency

Nurses Day this month,

ENA is giving you not one

but two new free continuing education courses as

part of our catalog of offerings.

Available to you starting Oct. 1 . . .‘‘Shift Work Disorder: Are You At Risk?’’, presented

by Mary Alice Vanhoy, MSN, RN, CEN, CPEN,

NREMT-P. This

session explores

shift work disorder,

its impact on

practice and

strategies for

mitigating it.

‘‘Difficult Airway

Response Teams

(DARTs) in the Hospital Setting,’’ presented by

Michael J. Chicarelli, MSN, RN, CEN. Learn about the

basics of DARTs and DART alerts, along with the

benefits, equipment costs and challenges that come with

implementing DARTs.

To take these and other eLearning courses free as an

ENA member:

• Go to www.ena.org/freeCE, where you’ll log in

as a member (or create an account).

• Add desired courses to your cart and select

‘‘check out.’’

• Proceed to your Personal Learning Page to start or

complete any course for which you have

registered or to print a final certificate.

• To return to your Personal Learning Page later, go

to www.ena.org and find ‘‘Go to Personal

Learning Page’’ under the Education tab.

Be sure you are using the e-mail address associated

with your membership when logging in. If you have

questions about any free eLearning course or the

checkout process, e-mail [email protected].

ENA Connection is published 11 times per year from January to December by: The Emergency Nurses Association

915 Lee Street Des Plaines, IL 60016-6569

and is distributed to members of the association as a direct benefit of membership. Copyright ©2014 by the Emergency Nurses Association. Printed in the U.S.A.Periodicals postage paid at the Des Plaines, IL, Post Office and additional mailing offices.

POSTMASTER: Send address changes to ENA Connection915 Lee StreetDes Plaines, IL 60016-6569ISSN: 1534-2565Fax: 847-460-4002 Website: www.ena.orgE-mail: [email protected]

Non-member subscriptions are available for $50 (USA) and $60 (foreign). For editorial inquiries, e-mail [email protected]

Publisher:Kathy Szumanski, MSN, RN, NE-BCEditor-in-Chief:Amy Carpenter AquinoAssociate Editor:Josh GabySenior Writer:Kendra Y. Mims

BOARD OF DIRECTORSOfficers:President:

Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN

President-elect: Matthew F. Powers, MS, BSN, RN, MICP, CEN

Secretary/Treasurer: Kathleen E. Carlson, MSN, RN, CEN, FAEN

Immediate Past President: JoAnn Lazarus, MSN, RN, CEN

Directors:

Ellen (Ellie) H. Encapera, RN, CENMitch Jewett, AA, RN, CEN, CPEN Michael D. Moon, PhD, MSN, RN,

CNS-CC, CEN, FAENSally K. Snow, BSN, RN, CPEN, FAENJeff Solheim, MSN, RN-BC, CEN,

CFRN, FAENJoan Somes, PhD, MSN, RN-BC, CEN,

CPEN, FAEN, NREMT-PKaren K. Wiley, MSN, RN, CEN

Executive Director: Susan M. Hohenhaus, LPD, RN, CEN, FAEN

Member Services: 800-900-9659

Kentucky ENA Names 2014 Emergency Nurse of the YearThe Kentucky ENA State Council honored Meg Candage, BSN, RN,

CFRN, as its emergency nurse of the year, presenting her with the

second annual Cheryl L. Westbay Award for

Emergency Nursing Excellence at its annual

educational conference in London, Ky., in May.

Candage, the current Kentucky ENA treasurer and

2012 president of the Bluegrass Chapter, works in

the education department at Georgetown

Community Hospital in Georgetown, Ky., and as a

flight nurse for Air

Care at the University

of Cincinnati.

The first Cheryl L.

Westbay Award was

presented in 2013 to

Linda J. Murray, RN,

CEN, CPEN, a staff

development

instructor in the

University of Kentucky

HealthCare emergency

department.

Meg Candage

More Members in Motion, page 7

Do you have a recent professional or educational success story you want to share about yourself or an ENA member colleague? Have you won an award or earned a promotion? Has another member you know been recognized for outstanding work?

Tell us! Send an e-mail to [email protected] with the subject line “Members in Motion.” Be sure to include names, credentials and, if applicable, photos of the nurse(s) being recognized. ENA staff may follow up with you for additional details.

Candage receives the Award for Emergency Nursing Excellence from Cheryl L. Westbay.

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ENA ad_Layout 1 8/5/14 11:27 AM Page 1

6 October 2014

UPDATE FROM THE EXECUTIVE DIRECTOR | Susan M. Hohenhaus, LPD, RN, CEN, FAEN

Strength in the 2nd QuarterDear ENA Members,

As always, ENA

staff remains focused on

the work that supports

its members. Here is an

overview of the health and well-being of ENA

at the end of the second quarter of 2014:

♦ ENA’s Government Relations staff focused

on the following federal issues in the second quarter of

2014: trauma care legislation, EMS for Children, the

Pedestrian Safety Act and support for nurses in the VA

system. At the state level, ENA GR staff assisted Louisiana in

becoming the 31st state to make assault against an

emergency nurse a felony, assisted the California ENA State

Council with finding a sponsor for a similar bill that is

expected to be introduced in 2015 and assisted the Illinois

ENA State Council in preventing poison centers from closing.

ENA’s EN411 program increased by 66 members in Q2; 145

members took action to 445 offices on Capitol Hill for EMSC

— the largest response to an action alert. Ninety-nine ENA

members attended Day on the Hill, up from 77 in 2013. GR

staff also worked with the National Association of EMTs and

the American Academy of Critical-Care Nurses on air medical

safety rules being recommended by the Federal Aviation

Administration.

♦ ENA’s marketing team has been extremely busy,

evidenced by the fact that our social media presence

continues to grow. Our largest presence is on Facebook,

where we achieved more than 29,000 ‘‘likes’’ on our main

ENA page in the first half of 2014.

Web Presence

• Web traffic increased by about 30,000 unique visitors.

• Time spent per visit increased slightly.

• New visitors increased by approximately 4 percent.

• Mobile usage increased by 6 percent.

• While e-mail open rates are down approximately

6 percent, the click-through rates are up by almost

1 percent, which we believe means content is relevant.

Social Media

• Our number of followers has increased by approximately

2,400 (Q1: 30,132; Q2: 32,520).

• Impressions for Q2 have more than doubled since Q1

(Q1: 267,000; Q2: 429,750). This shows our message is

resonating and expanding to a wider audience by

spreading virally.

♦ ENA’s Market Research staff has

completed several studies, including

surveys of Academy of Emergency

Nursing members, election

candidates and conference and Day

on the Hill attendees.

♦ ENA’s Institute for Emergency

Nursing Education (IENE) continues to monitor our

courses, manage the ANCC Continuing Nursing Education

units and maintain the free CE process for our members’

benefit. Three courses were deployed in Q2 2014.

♦ ENA’s Institute for Emergency Nursing Research

(IENR) has several studies on target, including studies on

discharge criteria for patients receiving narcotics; acuity

assignment; fatigue and cognitive ability; and moral distress

in emergency nurses.

♦ ENA’s Institute for Quality, Safety and Injury

Prevention (IQSIP) completed the fourth cycle of the

Lantern Award program. Staff has been assisting member

work teams and committees in the creation of several

products, including topic briefs and position statements.

♦ Course Operations: Trauma Nursing Core Course 7th

edition is on target with 2,410 provider courses and 138

instructor courses in Q2. There were 7,731 attendees at

provider courses and 248 attendees at instructor courses.

Emergency Nursing Pediatric Course had 911 provider

courses with 2,334 attendees and 67 instructor courses with

78 attendees.

♦ Membership: ENA’s membership at the end of Q2 2014

was 40,443, compared to 40,059 at the end of Q2 2013.

♦ Finances: The second quarter continued to yield healthy,

vibrant financial results. Revenue is up 10 percent from

2013, and while expenses are 7 percent higher than in 2013,

we are managing them well at 8 percent better than budget.

Total investment income as of June 30 was $754,000.

As always, we thank our members for their support,

encouragement and thoughtful feedback of ENA’s processes

and programs and look forward to a productive second half

of 2014.


Minneapolis ED Determined to Drop Pounds TogetherEmergency department staff at the University of Minnesota

Medical Center–East Bank in Minneapolis recently took

part in an ‘‘en masse’’ weight-loss challenge organized by

ENA member Erica Myking, RN, CEN, CPEN, to see who

could lose the highest BMI percentage over 12 weeks.

Each participant contributed $5 into a pot to be awarded

to the first-place winner. Weights were reported on the

honor system every other Monday and communicated via

e-mail. Along the way, Myking provided tips, recipes and

motivating quotes.

Among 15 other participants who finished the challenge

were ENA members Pete Benolken, MSN, CEN, CPEN;

Molly Delaney, PhD, RN, CEN, CPEN; Lisa Wright,

MA, RN, CEN; and Sandra Fonkert, MSN, CEN, CPEN, a

member of ENA’s Peer Review Education Committee, who

took second place. Participants lost 116.5 pounds combined.

A second challenge began Sept. 2 because the first was

so well-received.

‘‘This was a great activity for our department to do

together because everyone could participate,’’ Myking said.

‘‘When you work in a department that runs 24/7, it can be

difficult to get people together for any sort of extracurricular

activities because everybody’s schedules are so crazy. Having

the challenge be ‘on your honor’ so nobody had to ever

drive in to do a weigh-in made it easy for everyone to

participate.’’

Christina M. Weaver, MSN, RN, CEN, of the

Cardinal Chapter of North Carolina, was

elected to a four-year term on the North

Carolina Board of Nursing from January 2015

to December 2018.

‘‘I am looking forward to my service and am proud to

say I am also a member of ENA,” Weaver wrote.

Kathy Lebowitz, MSN, RN, CEN, is the 2014

recipient of the Alumni Nurse Leader Award

from Mount St. Joseph University near

Cincinnati. Lebowitz, the emergency

department manager at Bethesda Butler

Hospital Emergency Department in Hamilton, Ohio, also

recently became certified as an advanced nurse executive.

Debora La Torre, BSN, RN, received the Clinical Excellence

Award at New Jersey ENA’s annual Emergency Care

Conference. Other award winners from the conference were

listed in the August issue of ENA Connection.

Continued from page 4

Emergency nurses cannot solve the

problem of violence in the

emergency department by themselves.

On July 14-15, members of ENA and

the American Organization of Nurse

Executives held a day of dialogue in

Chicago to discuss workplace violence

and how the organizations can partner

to provide solutions.

The following ENA members and

staff represented the association: Deena

Brecher, MSN, RN, APN, ACNS-BC,

CEN, CPEN, 2014 president; JoAnn

Lazarus, MSN, RN, CEN, immediate past

president; Susan M. Hohenhaus, LPD,

RN, CEN, FAEN, executive director;

Kathy Szumanski, MSN, RN, NE-BC,

deputy executive director for nursing;

Lisa Wolf, PhD, RN, CEN, FAEN,

director of the Institute for Emergency

Nursing Research; Kristine Powell,

MSN, RN, CEN, NEA-BC, corporate

director of emergency services for

Baylor, Scott & White Emergency

Services-North Texas; and Sean Elwell,

MSN, RN, EMT-B, trauma program

manager and interim ED manager at

the Alfred I. DuPont Hospital for

Children in Wilmington, Del.

AONE was represented by Pamela

Thompson, MS, RN, CENP, FAAN, chief

executive officer of AONE and senior

vice president for nursing for the

American Hospital Association; Karen

Wray, MSN, RN-BC, NEA-BC, nursing

director, acute care, at the University of

Kansas Hospital; Reynaldo R. Rivera,

DNP, RN, NEA-BC, FAAN, director of

nursing, New York Presbyterian

Hospital; and Erik Martin, MSN, RN,

clinical director for the Pediatric

Intensive Care Unit at Cincinnati

Children’s Hospital Medical Center.

‘‘I thought it was an exciting idea to

bring together the nurse executives

with the emergency nurses,’’ said

Powell, who was invited to the day of

dialogue by Brecher. ‘‘I believe that

when the nurse executive is actively

involved and aware of the issue of

workplace violence, we can be more

proactive and more effective in dealing

with the issue itself.’’

Powell said the meeting began with

a session in which the two groups met

separately to discuss what they would

say to the other group.

‘‘If you could tell the nurse

executives whatever you want about

workplace violence, what would those

things be from the perspective of a

clinical staff nurse in the emergency

department?’’ Powell said. ‘‘And

alternately, the nurse executives were

responsible for doing the same thing.’’

Powell said that session was “very

insightful’’ because when the two

groups shared their results, the

importance of other expected issues

such as lateral violence came to the

forefront. While lateral violence, or

violence between colleagues, is usually

not physical, it is no less harmful.

‘‘Violence is violence, regardless of

who the perpetrator is,’’ Powell said.

Elwell said he appreciated the format

for the two-day meeting because it

offered a platform not only for

discussing the problems but for

formulating a plan to move forward and

establishing priorities for the two groups

in managing workplace violence.

‘‘I think there needs to be buy-in on

this from all different levels,’’ he said.

‘‘It’s definitely important for emergency

nurses, but it’s important from a

leadership standpoint, too, that there is

support for this moving forward. I

think that’s a big piece.’’

ENA continues to reach out to new

partners. On Aug. 21, members of the

International Association of Healthcare

Security and Safety visited ENA

headquarters in Des Plaines, Ill., to

share their perspective on the issue of

violence in the ED. Brecher wrote

about the meeting in the Aug. 26

edition of her ENA President’s Blog

(enapresident.wordpress.com).

Additional coverage will appear in

next month’s issue of ENA Connection.

‘‘Workplace violence is not just a

staff safety issue,’’ said Powell, who also

attended the Aug. 21 meeting. ‘‘It’s a

patient safety issue. The shared goal for

all of us is to make the environment

safer for our patients and ourselves.’’

8 October 2014

PUTTING OUR HEADS TOGETHERENA, Nursing Execs Meet For Day of Dialogue on Workplace Violence

PARTNERSHIPS

By Amy Carpenter Aquino, ENA Connection “I think there needs to be

buy-in on this from all different levels. It’s definitely important for emergency nurses, but it’s important from a leadership standpoint, too, that there is support for this moving forward.’’Sean Elwell, MSN, RN, EMT-B, ENA Representative at meeting with AONE

Kristine Powell Sean Elwell


interrupt patient handoff to ask a question?

If the patient’s life depends on it right now, the answer is

yes. If it’s a question that needs to be asked but not critical in

this moment in time, should you be interrupting a patient care

conversation to ask it? How do we partner with the

interdisciplinary team to limit unnecessary distractions and still

engage in critical communication?

First, we need to change our own behavior. The next time

you are heading out to ask a question of a colleague, pay

attention to the task that person is engaged in. If your

colleague is obviously engaged in a critical patient task, such

as handoff or medication preparation, hold your question until

the task is complete. Then ask if it’s a good time for a question.

If you are engaged in a task and someone approaches with

a question, say, ‘‘I need to focus on this critical task. I am happy

to answer your question when I am finished.’’ By recognizing

unsafe clinical behavior in ourselves, we can change that

behavior and move closer to an error-free ED.

Read more from Deena Brecher on the ENA

President’s Blog (enapresident.wordpress.com

or QR code at left).

From the President Continued from page 3

On Aug. 26, ENA announced the appointment of Anne

Manton, PhD, PMHNP-BC, FAEN, FAAN, as editor-in-

chief of the association’s Journal of Emergency Nursing.

She had been interim editor-in-chief since September 2013.

Manton, who specializes in psychiatric and mental

health care, brings extensive emergency nursing experience

to this role, as well as decades of involvement with ENA.

She was ENA president in 1998 and previously was a

contributing editor to JEN.

‘‘As the editorial board looked at the future of JEN and

how it fits into ENA’s strategic plan, it was evident that Dr.

Manton not only has the expertise to elevate the journal

but has already made substantial contributions since she

began serving as interim editor,’’ said ENA president Deena

Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN. ‘‘Her

clinical expertise, leadership skills and involvement with

ENA provide a solid foundation for producing a journal

with the highest level of editorial excellence.’’

JEN is the official peer-reviewed journal of ENA and

reaches more emergency nurses, emergency/trauma

departments and ED managers than any other journal.

Marie Grimaldi

Look for more information about Manton’s new role in an

upcoming issue of ENA Connection.

JEN Editor-in-Chief Named

In recognition of Emergency Nurses Week, I felt

compelled to submit a letter as a celebration of all

emergency nurses and the job we all do daily without a

second thought about the impact we make on the lives of

others. A short time ago, I was moved by the circumstances

that resulted in my elementary-school-age daughter bringing

home a 30-minute video for her ‘‘Hero Classic Assignment,’’

and I wanted to share my thoughts with gratitude.

The assignment was to watch the video and reflect on

the central idea of ‘‘experiencing risk is part of being

human.’’ By complete coincidence, my daughter chose the

Florence Nightingale video. When her teacher (a nurse)

questioned her choice, she stated that she liked Florence’s

name, having no idea that she was the nurse who shaped

her mother’s professional life.

That evening found the entire family viewing the video

about this hero, Florence Nightingale, and her life as the

founder of modern nursing. The amazement in my child’s

eyes as she saw the care that Florence provided to the

soldiers and how she herself became ill created feelings of

pride in my heart. As I reflected on my years in nursing

and the patients who had been in my care, I thought of

those close to me who were choosing nursing as their

profession and found myself with tears in my eyes in

appreciation for the legacy that we all continue to uphold.

As emergency nurses, we all see more in our career than

most people see in a lifetime. But despite the critical and

dying patients, sick children, verbally inappropriate patients

and others who touch us emotionally, we continue to

perform our job without hesitation. All too often, we do not

hear words of thanks. As we celebrate Emergency Nurses

Week, it is important to take a moment to reflect on our

work and to say thank you for the care you provide, and

for being a true risk-taker. You make our specialty

profession outstanding, and there is nothing trivial about

your impact on the lives of others. As Florence Nightingale

once said, ‘‘Live life when you have it. Life is a splendid gift

— there is nothing small about it.’’

Mary Cain, BSN, RN, CEN,

Emergency Department Staff Nurse,

St. Anthony Hospital, Lakewood, Colo.

ENA Connection welcomes letters from members. Letters should address content previously published in the magazine. Letters may be edited for space and clarity. Submission does not guarantee publication. Please include your name, credentials and contact information for verification. Send letters to [email protected].

October 201410

ENA ARCHIVES

T he ENA Collection is a

comprehensive history of the

association that consists of seven

boxes containing original

correspondence from ENA founders

Anita Dorr, RN, FAEN, and Judith C.

Kelleher, RN, MSN, CEN, FAEN, along

with other donated historical items. It’s

housed at the Eleanor Crowder Bjoring

Center for Nursing Historical Inquiry,

which was established at the University

of Virginia School of Nursing in 1991

to acquire nursing materials and

preserve nursing history.

ENA’s volunteer historian, Joanne

Fadale, BSN, RN, FAEN, and ENA staff

archivist Laura Peter took their first

visit to the Bjoring Center in August.

The primary purpose was to verify the

materials donated to the collection and

confirm how many of the documents

were original as opposed to copies.

After a full day of examining the

contents of the boxes — archived in

the Claude Moore Health Sciences

Library — Fadale found an estimated

80 percent of the documents were

originals. Archived items included

letters, minutes, reports, a cloth patch

displaying ENA’s first mascot and logo

(the Roadrunner), the first Emergency

Department Nurses Association

national conference program and

volumes of ENA Connection and ENA

Daily News.

Fadale said she didn’t realize how

many people were involved in forming

ENA until she went through the

collection. She discovered numerous

letters between Dorr and ENA past

president Marion Dover, RN, and

would like to see original

correspondence from other past

presidents included, as well as the

history of the first Trauma Nursing

Core Course and Emergency Nursing

Pediatric Course.

‘‘I don’t think we need to send

everything, but I think we need to

include how we got funding for the

first TNCC and ENPC,’’ Fadale said.

‘‘Those things are significant because

when you do a project like that, there

are people involved and funding.’’

The library where the collection is

housed has historical nursing books and

artifacts on display, including a nursing

student uniform similar to the one

Fadale wore more than 40 years ago.

‘‘They had just about every book on

nursing history and nursing from all

parts of the world — you could just sit

there for hours and read,’’ Fadale said.

‘‘They have a nice collection of their

own historical artifacts. They also have

a window display, currently of the year

1906. They have appropriate

newspaper articles on the diseases of

that time, like influenza. The display

shows a child going to the hospital

with their mother, and it shows a

nurse. It was all done in appropriate

clothing for that time.’’

Fadale said she was impressed with

the care the University of Virginia took

with the ENA Collection.

‘‘They organized the collection so

How the Archiving Project Came to BeAt its July 2004 meeting, the ENA Board of Directors approved a proposal to donate records related to the foundation and formation of ENA to the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry at the University of Virginia School of Nursing. The initial donation was made at a dedication ceremony on Sept. 28, 2005.

By Kendra Y. Mims, ENA Connection

ENA volunteer historian Joanne Fadale, BSN, RN, FAEN, and staff archivist Laura Peter stand with the seven-box ENA Collection they went through in August at the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry in Charlottesville, Va.

Seeing What’s in StoreTrip to Review Collection Confirms ENA Treasures

well that we didn’t have to dig

through,’’ she said. A meeting with the

center’s director, Arlene W. Keeling,

PhD, RN, FAAN, provided insight into

what ENA actually should be saving.

Fadale’s favorite part of the trip was

reviewing old documents that she had

seen at one point in her life.

‘‘Most of those documents came

from my chapter,’’ she said. ‘‘In 1985,

we found all of these documents after

one of our former state presidents

passed away. She had all Anita’s old

documentation, and we gave it to the

national president in a binder. Those

are the only copies that we have of

those. It tickled my heart knowing that

I had put my fingers on these pieces of

paper before.’’

For more on the ENA Collection

and to view a list of the contents, visit

tinyurl.com/

ENACollection or scan

the QR code at left.


Demonstrate your commitment to excellence and professional advancement; earn a Board of Certification for Emergency Nursing (BCEN®) specialty certification.

Visit www.BCENcertifications.org to learn more.g Certified Emergency Nurse (CEN®)g Certified Flight Registered Nurse (CFRN®)g Certified Pediatric Certified Nurse (CPEN®)g Certified Transport Registered Nurse (CTRN®)

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You already have the expertise. It’s time to get certified.You already have the expertise. It’s time to get certified.

Among other nursing items on display at the Bjoring Center’s Claude Moore Health Sciences Library: a quilt honoring the profession and an old uniform of the type once worn by student nurses.

October 201412

Alarming statistics show that

preventable injuries are the No. 1

killer of children in the United States

and that U.S. emergency departments

treat almost 9 million pediatric patients

for injuries every year.

The National Child Passenger Safety

Certification Training program attempts

to reduce that by raising awareness

and educating communities and

families about child safety on the road.

The State Farm-sponsored program

certifies child passenger safety

technicians and instructors. More than

131,000 people have completed the

certification course since 1997,

including 36,000 currently certified CPS

technicians. CPS technicians contribute

to improving children’s safety by

conducting child car seat checks,

providing families with hands-on

instructions on how to install seats and

safety belts properly and educating

parents on what they can do to

prevent injuries.

Meanwhile, Safe Kids Worldwide is

an organization committed to

protecting children from unintentional

injuries through advocacy, research,

education and awareness programs. As

the CPS certification specialist for Safe

Kids Worldwide, Kim Herrmann travels

nationally, developing continuing

education opportunities to help CPS

technicians maintain their certification.

‘‘It’s a two-year certification,’’

GET CERTIFIED, EARN CE CREDITUpon successful completion of the National Child Passenger Safety Certification Training course, ENA will provide 23.75 contact hours. In order for nurses attending a certification course to receive 23.75 nursing contact hours (6.91 Pediatric designation), the lead instructor must follow the requirements detailed in the checklist (tinyurl.com/LeadInstructorChecklist or QR code below). Course documentation

must be maintained for six years.

ENA is accredited as a provider of continuing

nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

For questions regarding any details for contact hours, please email the CNE unit with your questions at [email protected].

TECH SUPPORTEmergency Nurses Encouraged to Take the Wheel on Child Passenger Safety as Certified TechniciansBy Kendra Y. Mims, ENA Connection

INJURY PREVENTION


Herrmann said. ‘‘We’ve been able to

really increase the quality, as well as

the numbers of certified technicians.

They come from a background of not

only hospital-based programs, but also

firefighters, EMS personnel, law

enforcement and public health. Many

people who want to be advocates for

children come from a lot of different

walks of life. Many people, like first

responders, are frustrated when there

is a crash-related injury and it could

have been prevented had the child

been properly secured in an

appropriate car seat.’’

Herrmann said almost half of the

36,000 certified CPS technicians are

from the health field (hospital/medical

personnel make up 19 percent and

rescue/EMS personnel 28 percent). She

actively searches for ways to promote

the importance of CPS certification.

‘‘Children really do not have the

capability of protecting themselves,’’

she said. ‘‘We treat them, we try to

help them recuperate, but it takes the

family to do that. If we had a way of

connecting emergency nurses

to families to help them

understand that there is more

that can be done to protect

their children and keep them

safer, I think the emergency

nurse would have a big role

in that.’’

ENA member and National

Child Passenger Safety Board

member Thelma Kuska, BSN,

RN, CEN, FAEN, has

long been a proponent

of emergency nurses

becoming certified CPS

technicians.

‘‘Should all

emergency nurses be

certified technicians? It

would be nice, but the

reality is they do not all have to be

certified,’’ said Kuska, who has been

involved in child passenger safety for

more than 15 years. ‘‘But all of them

should have the correct information so

that they can provide the correct

discharge instructions to parents and

caregivers.’’

“Emergency nurses are in a very

unique position to influence the

parents because of the teachable

moments in the ED,’’ Kuska added.

‘‘We see the victims of car crashes and

know their injuries. Routine encounters

with young children and their parents

provide excellent opportunities for

assessing car seat and booster seat use.

Emergency nurses are also in a unique

position to educate

parents and caregivers

on how to keep

children safe while

traveling in motor

vehicles. Routine

encounters in the

emergency department

provide a perfect setting

for this educational opportunity.’’

The CPS Technician Certification

Course is three to four days of

classroom instruction with hands-on

skill assessments, written quizzes and a

community safety seat checkup event.

Highlights of the course include

learning about the different parts of the

car seat, how to read instructions, how

to install car seats in different vehicles

and the basics of injury prevention.

Nurses can earn contact hours for

completing the national course.

‘‘Nurses would also learn about

some of the technology involved in the

vehicles and car seats, so we can point

those out to families and provide

guidance to families,’’ Kuska said. ‘‘We

can also make sure their current

data is appropriate for the age

and weight of their child, and it

fits them properly.’’

Safe Kids Worldwide

continues to raise awareness

and promote CPS technician

certification through initiatives

such as the nationally

recognized Child Passenger

Safety Week in September and

partnering with advocacy

agencies to help families

protect their children.

‘‘It’s a big responsibility,

and there’s a real passion for

people who want to help

children,’’ Herrmann said. ‘‘We

would just like to be able to let

more people know about child

passenger safety as a potential

to fit in with their current job

responsibilities to protect and

advocate for children.’’

STATISTIC

Safe Kids Worldwide reports that child safety seats can reduce fatal injury by up to 71 percent for infants and 54 percent for toddlers. In 2011, restraint use saved 263 lives, according to the organization.

STATISTIC

Motor vehicle crashes are the No. 1 cause of death for people ages 1 to 19 years, according to Safe Kids Worldwide.

14

WASHINGTON WATCH | Ken Steinhardt, ENA Director of Government Relations

‘Medical harm is a major cause of

suffering, disability and death

— as well as a huge financial cost to

our nation,’’ Sen. Bernie Sanders

(I-Vt.) said at the outset of the July 17 hearing of the Senate

Subcommittee on Primary Health and Aging. At this

subcommittee hearing, hospital quality and patient safety

experts urged lawmakers to establish measures to minimize

the number of medical errors in hospitals. According to one

of the witnesses at the hearing, more than 220,000 deaths

occur each year because of preventable medical mistakes.

Another witness cited the figure of 440,000 preventable

deaths due to errors committed by the health care system.

In addition to deaths and injuries, medical errors also cost

the United States billions of dollars. The health policy journal

Health Affairs published a study that put the figure at

$17 billion a year. Counting indirect costs such as lost

productivity due to missed work days, medical errors cost

nearly $1 trillion each year, according to a 2012 report in the

Journal of Health Care Finance.

One of the witnesses at the congressional hearing was

Joanne Disch, PhD, RN, FAAN, clinical professor at the

University of Minnesota School of Nursing. Disch testified

there are many factors that lead to medical errors, including

the ‘‘complexity of health care, the rapid generation of new

knowledge and interventions, the patchwork nature of our

health care system, the incentives to do too many

interventions and not enough assessment and prevention,

and the use of new technology (both too much and little).’’

Disch also highlighted several recommendations based on

her 46 years of experience as a nurse that she believes will

lead to a measurable improvement in patient safety. These

include (1) ensuring a sufficient supply of highly educated

nurses, (2) actively engaging patients and families as

partners in their care and (3) convincing hospitals and other

healthcare settings to embrace a culture of safety.

Another witness, Dr. Peter Pronovost, director of the

Armstrong Institute for Patient Safety and Quality at Johns

Hopkins University, testified that though progress has been

made, thousands of patients are still dying unnecessarily

from infections, preventable blood clots, adverse drug

events, falls, overexposure to medical radiation and

diagnostic errors.

‘‘We need to declare right now that preventable harm is

unacceptable and work to prevent all types of harm,’’

Pronovost said.

Ashish Jha, MD, MPH, a Harvard School of Public Health

professor, testified that American hospital patients are no

safer today than they were in 1999, when the Institute of

Medicine released its report ‘‘To Err is Human.’’

‘‘We have not moved the needle in any demonstrable way

overall,’’ he said. ‘‘No one is getting it right consistently.’’

In addition to the recommendations set forth by Disch,

witnesses offered a wide array of initiatives for reducing

medical errors, such as expanding the role of the Centers for

Disease Control and Prevention to compile and report

patient safety data, establishing a national patient safety

board or increasing the oversight responsibilities of Centers

for Medicare and Medicaid Services and the Joint

Commission. Witnesses also called on providers to improve

information technology systems and create incentives to

enhance safety throughout the entire health care system.

The hearing by the Primary Health and Aging

Subcommittee wasn’t the only activity in Washington

focused on patient safety. In April, Sen. Barbara Boxer

(D-Calif.) released a new report detailing the most common

and harmful errors at our nation’s hospitals and what

hospitals in California are doing to prevent them.

Boxer wrote to 283 California acute-care hospitals asking

them to respond with the actions they are taking to improve

patient safety. As of July, 87 percent of the hospitals had

responded. Notably, the survey found that all the hospitals

are taking at least some steps to address the most common

medical errors, while others were pursuing unique

approaches to enhance patient safety.

For example, UCLA Medical Center reported that it

disinfects hospital rooms using ultraviolet technology,

prohibits the use of home-laundered scrubs and bans

healthcare professionals with open wounds, bandages or

casts from scrubbing into surgeries. Desert Valley Hospital in

Victorville reported that it reduced the number of surgical

site infections from 16 in 2009 to 2 in 2013 after starting an

innovative program that rewards medical staff who are

observed practicing good hand hygiene.

The hearing held by the Senate Subcommittee on

Primary Health and Aging and the important

report produced by Boxer’s office show an

increased focus by our federal

representatives on the issue of

medical errors and patient safety.

Given the opportunity to save

countless lives, it is our

hope that this work will

lead to meaningful

legislation.

Medical Errors on Senate’s Radar When vascular access presents a challenge

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References: 1. Rogers JJ, Fox M, Miller LJ, Philbeck TE. Safety of intraosseous vascular access in the 21st century [WoCoVA abstract O-079]. J Vasc Access. 2012;13(2): 1A-40A. 2. Paxton JH, Knuth TE, Klausner HA. Proximal humerus intraosseous infusion: a preferred emergency venous access. J Trauma. 2009;67(3):1-7. 3. Cooper BR, Mahoney PF, Hodgetts TJ, Mellor A. Intra-osseous access (Ez-IO®) for resuscitation: UK military combat experience. J R Army Med Corps. 2007; 153(4):314-316. 4. Dolister M, Miller S, Borron S, et al. Intraosseous vascular access is safe, effective and costs less than central venous catheters for patients in the hospital setting [published online ahead of print January 3, 2013]. J Vasc Access. doi:10.5301/jva.5000130.

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Potential complications may include local or systemic infection, hematoma, extravasations or other complications associated with percutaneous insertion of steri le devices.

References: 1. Rogers JJ, Fox M, Miller LJ, Philbeck TE. Safety of intraosseous vascular access in the 21st century [WoCoVA abstract O-079]. J Vasc Access. 2012;13(2): 1A-40A. 2. Paxton JH, Knuth TE, Klausner HA. Proximal humerus intraosseous infusion: a preferred emergency venous access. J Trauma. 2009;67(3):1-7. 3. Cooper BR, Mahoney PF, Hodgetts TJ, Mellor A. Intra-osseous access (Ez-IO®) for resuscitation: UK military combat experience. J R Army Med Corps. 2007; 153(4):314-316. 4. Dolister M, Miller S, Borron S, et al. Intraosseous vascular access is safe, effective and costs less than central venous catheters for patients in the hospital setting [published online ahead of print January 3, 2013]. J Vasc Access. doi:10.5301/jva.5000130.

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October 201416

BEHAVIORAL HEALTH

T he U.S. Substance Abuse and Mental Health Services

Administration (SAMHSA) and the Mental Health

Association of New York City (MHA of NYC) launched the

National Suicide Prevention Lifeline in 2005 to provide

confidential, free support to those in a suicidal crisis via a

network of 24/7 crisis intervention centers. Through the

National Suicide Prevention Lifeline Crisis Center Follow-Up

grant program, funded by SAMHSA, a subdivision of crisis-

center grantees also provides follow-up services and continuity

of care for patients discharged from emergency departments.

With the patient’s consent, these centers contact the patients to

help them receive the appropriate behavioral health services.

One of these centers, the Acute Care Services lifeline crisis

center in West Bend, Wis., is partnered with Froedtert & the

Medical College of Wisconsin St. Joseph’s Hospital and

handles 1,000 to 1,200 contacts per month, consisting of

walk-ins, mobile crisis interventions, calls coming into the

center and follow-ups. Lori Landy, the behavioral health care

coordinator at St. Joseph’s Hospital, says partnering with a

24/7 mobile crisis team that responds to the ED has been an

invaluable resource.

‘‘It’s been five years [that we’ve] worked cooperatively

trying to meet the needs of patients with behavioral health

issues or concerns in the ER while focusing on the least

restrictive interventions whenever possible,’’ Landy said. ‘‘In

return, they [ACS] connect the patient to the lifeline and

follow up with them.’’

Although St. Joseph’s does not have a behavioral health

unit onsite, Landy says her position allows her to complete

consultations in the ED and assess suicidal patients.

‘‘St. Joseph’s recognizes that just because we don’t have a

behavioral health unit, it doesn’t mean that we are not going

to have a behavioral health crisis in the ED. We might have

them more frequently,’’ she said.

When an ED nurse recently called her about a suicidal

patient who had relapsed, she was able to assess the patient

instead, allowing the nurse to get back to bedside patient care.

‘‘St. Joseph’s recognizes the need for a specialized role in

the ER,’’ Landy said. ‘‘One of the nurses’ frustrations, often, in

our ER is that they spend more time on the phone calling for

services for patients with behavioral health needs and the

amount of time it takes to get a person referred to

appropriate services. That’s where I come in. It can take

hours to find beds and find treatments, and that’s not always

the best use of the ER nurse’s skill. I think the biggest benefit

for the ED nurses is having a crisis partnership like this that

gets them back to bedside where they are needed and away

from the role of trying to be a nurse case manager on the

phone. It’s out of their scope and takes them away from

patients and critical health issues.’’

St. Joseph’s staff nurse Ginger Knapp, RN, CEN, considers

Acute Care Services another part of her ED team.

‘‘ACS comes to the patient’s bedside and spends time

talking to our suicidal patients and then determines the best

plan for these patients,’’ Knapp said. ‘‘For some patients, ACS

can ‘safety plan to home.’ ACS coordinates the safety plan

based on the patient’s needs and also coordinates the

follow-up for this. A safety plan to home is a great option for

people. It saves money by preventing a hospitalization. It also

prevents the patient from having to appear before a judge, as

they would if they were chaptered. Also, these patients do not

need the added stress of missing work for a hospitalization.’’

After ACS interviews the patient, a determination may be

made on inpatient care, which can be voluntary or involuntary.

‘‘ACS can facilitate these transfers a lot faster than I can,’’

Knapp said. ‘‘A transfer requires a lot of sitting on the phone,

calling different mental health facilities to find openings. ACS

takes care of all of this. They provide the nurse with the name

of the hospital and the phone number to intake. Sometimes

you go through the intake process, only to find out the patient

is declined at a certain facility. We just let ACS know, and they

do the legwork and provide us with another facility.’’

The partnership with ACS gives patients an opportunity to

talk openly.

‘‘Patients really appreciate the ability to talk,’’ Knapp said.

‘‘The ER staff frequently does not have time to do this. These

patients are often accompanied by the police. For the most

part, when ACS does their interview with the patient, the

police step out of the room. ACS can really get to the root of

the problem. This can really diffuse a situation.’’

Patients who consult with ACS typically move through the

department faster, Knapp said.

‘‘This helps overall throughput,’’ she said. ‘‘If the

department keeps moving, all of our patients are happy.’’


Lori Landy Ginger Knapp

A Friend to Call OnGrant Program for Suicide Crisis Lifelines Allows Wisconsin Center to Give Local ED a Helping Hand


Save the DateApril 28-29, 2015

Plan to join ENA in Washington D.C. to advocate for issues that are

important to emergency nurses.

Details about the event and registration information will be available in January 2015.

Day on the Hill 2015 Ad_Connection_half_10 2014.indd 1 8/29/14 1:14 PM

ENA Trauma Committee Develops Tourniquet-Use TIPCongratulations to ENA’s Trauma Committee on the

development of a Translation Into Practice document

regarding the use of tourniquets. This evidence-based

document includes recommendations for the use of

tourniquets, along with

supporting rationale as it

relates to extremity trauma to

reduce blood loss, thus

decreasing morbidity and

mortality.

Committee members

include Ellie Encapera, RN, CEN, board liaison; Patricia Kunz

Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN,

chairperson; Pete Benolken, MSN, RN, EMT-B, CEN, CPEN;

Stacey Hill, BSN, RN; Kimberly Murphy, MSN, RN, CEN,

ACNP-BC, MICN, PHN; Maria Tackett, EdD, MSN, RN, CEN,

CCRN; Leslie Gates, senior administrative assistant; and Dale

Wallerich, MBA, BSN, RN, CEN, staff liaison.

This and other TIPs may be found at

tinyurl.com/ENA-TIPS or by scanning the

QR code here.

Chamberlain College of Nursing | National Management Offi ces3005 Highland Parkway | Downers Grove, IL 60515 | 888.556.8CCN (8226) | chamberlain.edu

Comprehensive program-specifi c consumer information: chamberlain.edu/studentconsumerinfo. Program/program option availability varies by state/location. The Bachelor of Science in Nursing degree program and the Master of Science in Nursing degree program are accredited by the Commission on Collegiate Nursing Education (CCNE, One Dupont Circle, NW, Suite 530, Washington, DC 20036, 202.887.6791). Chamberlain College of Nursing, 2450 Crystal Drive, Arlington, VA 22202 is certifi ed to operate by the State Council of Higher Education for Virginia, 101 N. 14th Street, 10th Floor, James Monroe Building, Richmond, VA 23219, 804.225.2600. Chamberlain College of Nursing has provisional approval from the Virginia Board of Nursing, Perimeter Center, 9960 Mayland Drive, Suite 300, Henrico, VA 23233-1463, 804.367.4515. ©2013 Chamberlain College of Nursing, LLC. All rights reserved.

Take advantage of your ENA membership benefi ts at Chamberlain College of Nursing.

• 15% savings of current tuition rate• Online coursework• No mandatory login times

Find your extraordinary at chamberlain.edu/enaorg

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FAST ONSET

Statistically signifi cant reduction in agitation at 2 hours, with improvement rapidly achieved at 10 minutes post-dose1

References: 1. ADASUVE [package insert]. Horsham, PA: Teva Select Brands, a division of Teva Pharmaceuticals USA, Inc; December 2013. 2. Data on fi le. Clinical Study Report 004-301. Teva Pharmaceuticals. 3. Data on fi le. Clinical Study Report 004-302. Teva Pharmaceuticals.

Orally inhaled medicine indicated for the acute treatment of agitation associated with schizophrenia or bipolar I disorder in adults

The mean baseline PEC scores in all treatment groups were 17.3 to 17.7.

BIPOLAR I DISORDERSCHIZOPHRENIAENDPOINT

AT 2 HOURS(PRIMARY)

AT 10 MINUTES (SECONDARY)

Reduction from baseline in agitation symptoms2,3

PEC=Positive and Negative Syndrome Scale-Excited Component. Intent-to-treat population with last observation carried forward. Agitation symptoms measured: tension, excitement, poor impulse control, uncooperativeness, hostility. Each item is scored on a scale from 1 to 7 (1=absent, 4=moderate, 7=extreme). Patient total PEC scores ranged from 14 to 31 out of a possible 35.The efficacy of ADASUVE 10 mg in the acute treatment of agitation associated with schizophrenia or bipolar I disorder was established in a short-term (24-hour), randomized, double-blind, placebo-controlled, fixed-dose trial including 344 patients who met DSM-IV criteria for schizophrenia and in another study, 314 patients who met DSM-IV criteria for bipolar I disorder, manic or mixed episodes with or without psychotic features.

ADASUVE ADASUVEPLACEBO PLACEBO

33%49%

10%19%

27%53%

10%23%

10min

S:9.5”

T:14”

T:10”

B:17”

B:12”

S:13.5”






















single-use inhaler









visit ADASUVE.COM




ORAL INHALATION

FAST ONSET






AT 2 HOURS(PRIMARY)





33%49%

10%19%

27%53%

10%23%

10min

S:9.5”

T:14”

T:10”

B:17”

B:12”

S:13.5”






















single-use inhaler









visit ADASUVE.COM




ORAL INHALATION

FAST ONSET






AT 2 HOURS(PRIMARY)





33%49%

10%19%

27%53%

10%23%

10min

S:9.5”

T:14”

T:10”

B:17”

B:12”

S:13.5”






















single-use inhaler









visit ADASUVE.COM




ORAL INHALATION

FAST ONSET






AT 2 HOURS(PRIMARY)





33%49%

10%19%

27%53%

10%23%

10min

S:9.5”

T:14”

T:10”

B:17”

B:12”

S:13.5”






















single-use inhaler









visit ADASUVE.COM




ORAL INHALATION

FAST ONSET






AT 2 HOURS(PRIMARY)





33%49%

10%19%

27%53%

10%23%

10min

S:9.5”

T:14”

T:10”

B:17”

B:12”

S:13.5”






















single-use inhaler









visit ADASUVE.COM




ORAL INHALATION

FAST ONSET






AT 2 HOURS(PRIMARY)





33%49%

10%19%

27%53%

10%23%

10min

S:9.5”T:14”

T:10”B:17”

B:12”

S:13.5”

BRIEF SUMMARYADASUVE® (loxapine) inhalation powder, for oral inhalation use The following is a brief summary only; see full prescribing informa-tion, included Boxed Warnings for complete product information.

WARNING: BRONCHOSPASM and INCREASED MORTALITYIN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS

Bronchospasm ADASUVE can cause bronchospasm that has the potential to lead to respiratory distress and respiratory arrest. Administer ADASUVE only in an enrolled healthcare facility that has immediate access on-site to equipment and personnel trained to manage acute bron-chospasm, including advanced airway management (intubation and mechanical ventilation) [see Warnings and Precautions (5.1, 5.2)]. Prior to administering ADASUVE, screen patients regarding a current diagnosis, history, or symptoms of asthma, COPD and other lung diseases, and examine (including chest auscultation) patients for respiratory signs. Monitor for signs and symptoms of bronchospasm following treatment with ADASUVE [see Dosage and Administration (2.2, 2.4) and Contraindications (4)].Because of the risk of bronchospasm, ADASUVE is available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS) called the ADASUVE REMS [see Warnings and Pre-cautions (5.2)]. Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with anti-psychotic drugs are at an increased risk of death. ADASUVE is not approved for the treatment of patients with dementia-related psycho-sis [see Warnings and Precautions (5.3)].

1 INDICATIONS AND USAGEADASUVE is a typical antipsychotic indicated for the acute treatment of agitation associated with schizophrenia or bipolar I disorder in adults.“Psychomotor agitation” is defined in DSM-IV as “excessive motor activity associated with a feeling of inner tension.” Patients experiencing agitation often manifest behaviors that interfere with their care (e.g., threatening behaviors, escalating or urgently distressing behavior, self-exhausting behav-ior), leading clinicians to the use of rapidly absorbed antipsychotic medica-tions to achieve immediate control of the agitation [see Clinical Studies (14)].The efficacy of ADASUVE was established in one study of acute agitation in patients with schizophrenia and one study of acute agitation in patients with bipolar I disorder [see Clinical Studies (14)]. Limitations of Use:As part of the ADASUVE REMS Program to mitigate the risk of broncho-spasm, ADASUVE must be administered only in an enrolled healthcare facility [see Warnings and Precautions (5.2)].4 CONTRAINDICATIONSADASUVE is contraindicated in patients with the following:• Current diagnosis or history of asthma, COPD, or other lung disease

associated with bronchospasm [see Warnings and Precautions (5.1)]• Acute respiratory symptomsor signs (e.g., wheezing) [see Warnings

and Precautions (5.1)]• Currentuseofmedicationstotreatairwaysdisease,suchasasthmaorCOPD[see Warnings and Precautions (5.1)]

• HistoryofbronchospasmfollowingADASUVEtreatment[see Warnings and Precautions (5.1)]

• Knownhypersensitivityto loxapineoramoxapine.Seriousskinreac-tions have occurred with oral loxapine and amoxapine.

5 WARNINGS AND PRECAUTIONS5.1 BronchospasmADASUVE can cause bronchospasm that has the potential to lead to respi-ratory distress and respiratory arrest [see Adverse Reactions (6.1)]. Administer ADASUVE only in an enrolled healthcare facility that has immediate access on-site to equipment and personnel trained to manage acute bronchospasm, including advanced airway management (intuba-tion and mechanical ventilation) [see Boxed Warning and Warnings and Precautions (5.2)].Prior to administering ADASUVE, screen patients regarding a current diagnosisorhistoryofasthma,COPD,andotherlungdiseaseassociatedwith bronchospasm, acute respiratory symptoms or signs, current use of medicationstotreatairwaysdisease,suchasasthmaorCOPD;andexam-ine patients (including chest auscultation) for respiratory abnormalities (e.g., wheezing) [See Dosage and Administration (2.2) and Contraindi-cations (4)]. Monitor patients for symptoms and signs of bronchospasm (i.e., vital signs and chest auscultation) at least every 15 minutes for a minimum of one hour following treatment with ADASUVE [see Dosage and Administration (2.4)]. ADASUVE can cause sedation, which can mask the symptoms of bronchospasm.

BecauseclinicaltrialsinpatientswithasthmaorCOPDdemonstratedthatthe degree of bronchospasm, as indicated by changes in forced expira-tory volume in 1 second (FEV1), was greater following a second dose of ADASUVE, limit ADASUVE use to a single dose within a 24 hour period. Advise all patients of the risk of bronchospasm. Advise them to inform the healthcare professional if they develop any breathing problems such as wheezing, shortness of breath, chest tightness, or cough following treatment with ADASUVE.5.2 ADASUVE REMS to Mitigate Bronchospasm Because of the risk of bronchospasm, ADASUVE is available only through a restricted program under a REMS called the ADASUVE REMS. [see Boxed Warning and Warnings and Precautions (5.1)] Required compo-nents of the ADASUVE REMS are:• Healthcarefacilities thatdispenseandadministerADASUVEmustbeenrolled and comply with the REMS requirements. Certified health-care facilities must have on-site access to equipment and personnel trained to provide advance airway management, including intubation and mechanical ventilation.

• WholesalersanddistributorsthatdistributeADASUVEmustenroll inthe program and distribute only to enrolled healthcare facilities.

Further information is available at www.adasuverems.com or 1-855-755-0492.5.3 Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsy-chotic drugs are at increased risk of death. Analyses of 17 placebo- controlled trials (modal duration of 10 weeks), largely in patients tak-ing atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of 1.6 to 1.7 times the risk of death in placebo-treated patients. Overthecourseofatypical10-weekcontrolledtrial,therateofdeathindrug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the cases of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sud-dendeath)orinfectious(e.g.,pneumonia)innature.Observationalstud-ies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies can be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. ADASUVE is not approved for the treatment of elderly patients with dementia-related psychosis [see Boxed Warning].5.4 Neuroleptic Malignant Syndrome Antipsychotic drugs can cause a potentially fatal symptom complex termedNeurolepticMalignantSyndrome(NMS).Clinicalmanifestationsof NMS include hyperpyrexia, muscle rigidity, altered mental status, and autonomic instability (irregular pulse or blood pressure, tachycardia, dia-phoresis, and cardiac dysrhythmia). Associated features can include ele-vatedserumcreatinephosphokinase(CPK)concentration,rhabdomyoly-sis, elevated serum and urine myoglobin concentration, and renal failure. NMS did not occur in the ADASUVE clinical program.The diagnostic evaluation of patients with this syndrome is complicated. It is important to consider the presence of other serious medical con-ditions (e.g.,pneumonia,systemic infection,heatstroke,primaryCNSpathology, central anticholinergic toxicity, extrapyramidal symptoms, or drug fever). The management of NMS should include: 1) immediate discontinua-tion of antipsychotic drugs and other drugs that may contribute to the underlying disorder, 2) intensive symptomatic treatment and medical mon-itoring, and 3) treatment of any concomitant serious medical problems. There is no general agreement about specific pharmacological treatment regimens for NMS.If a patient requires antipsychotic drug treatment after recovery from NMS, the potential reintroduction of drug therapy should be carefully considered. The patient should be carefully monitored, since recurrences of NMS have been reported. 5.5 Hypotension and SyncopeADASUVE can cause hypotension, orthostatic hypotension, and syncope. Use ADASUVE with caution in patients with known cardiovascular dis-ease (history of myocardial infarction or ischemic heart disease, heart failure or conduction abnormalities), cerebrovascular disease, or condi-tions that would predispose patients to hypotension (dehydration, hypo-volemia, or treatment with antihypertensive medications or other drugs that affect blood pressure or reduce heart rate).In the presence of severe hypotension requiring vasopressor therapy, the preferred drugs may be norepinephrine or phenylephrine. Epinephrine should not be used, because beta stimulation may worsen hypotension in the setting of ADASUVE-induced partial alpha blockade.In short-term (24-hour) placebo-controlled trials of patients with agitation associated with schizophrenia or bipolar I disorder, hypotension occurred in 0.4% and 0.8% in the ADASUVE 10 mg and placebo groups, respec-tively. There were no cases of orthostatic hypotension, postural symptoms,

Table 1. Adverse Reactions in 3 Pooled Short-Term, Placebo-Controlled Trials (Studies 1, 2, and 3) in Patients with Schizophrenia or Bipolar Disorder

Adverse ReactionPlacebo(n = 263)

ADASUVE(n = 259)

Dysgeusia 5% 14%Sedation 10% 12%Throat Irritation 0% 3%

Airway Adverse Reactions in the 3 Trials in Acute Agitation Agitated patients with Schizophrenia or Bipolar Disorder: In the 3 short-term (24-hour), placebo-controlled trials in patients with agitation asso-ciated with schizophrenia or bipolar disorder (Studies 1, 2, and 3), bron-chospasm (which includes reports of wheezing, shortness of breath and cough) occurred more frequently in the ADASUVE group, compared to the placebo group: 0% (0/263) in the placebo group and 0.8% (2/259) intheADASUVE10mggroup.Onepatientwithschizophrenia,withouta history of pulmonary disease, had significant bronchospasm requiring rescue treatment with a bronchodilator and oxygen. Bronchospasm and Airway Adverse Reactions in Pulmonary Safety TrialsClinicalpulmonarysafetytrialsdemonstratedthatADASUVEcancausebronchospasm as measured by FEV1, and as indicated by respiratory signs and symptoms in the trials. In addition, the trials demonstrated thatpatientswithasthmaorotherpulmonarydiseases,suchasCOPDare at increased risk of bronchospasm. The effect of ADASUVE on pulmonary function was evaluated in 3 randomized, double-blind, placebo-controlled clinical pulmonary safety trials in healthy volunteers, patientswithasthma,andpatientswithCOPD.Pulmonaryfunctionwasassessed by serial FEV1 tests, and respiratory signs and symptoms were assessed.IntheasthmaandCOPDtrials,patientswithrespiratorysymp-toms or FEV1 decrease of ≥ 20% were administered rescue treatment with albuterol (metered dose inhaler or nebulizer) as required. These patientswerenoteligibleforaseconddose;however,theyhadcontinuedFEV1 monitoring in the trial. HealthyVolunteers: In the healthy volunteer crossover trial, 30 subjects received 2 doses of either ADASUVE or placebo 8 hours apart, and 2 doses of the alternate treatment at least 4 days later. The results for maximum decrease in FEV1 are presented in Table 2. No subjects in this trial devel-oped airway related adverse reactions (cough, wheezing, chest tightness, or dyspnea).Asthma Patients: In the asthma trial, 52 patients with mild-moderate persistent asthma (with FEV1 ≥ 60% of predicted) were randomized to treatment with 2 doses of ADASUVE 10 mg or placebo. The second dose was to be administered 10 hours after the first dose. Approximately 67% of these patients had a baseline FEV1 ≥ 80% of predicted. The remaining patients had an FEV1 60-80% of predicted. Nine patients (17%) were former smokers. As shown in Table 2 and Figure 7, there was a marked decrease in FEV1 immediately following the first dose (maximum mean decreases in FEV1 and % predicted FEV1 were 303 mL and 9.1%, respec-tively). Furthermore, the effect on FEV1 was greater following the second dose (maximum mean decreases in FEV1 and % predicted FEV1 were 537 mL and 14.7 %, respectively). Respiratory-related adverse reactions (bronchospasm, chest discomfort, cough, dyspnea, throat tightness, and wheezing) occurred in 54% of ADASUVE-treated patients and 12% of placebo-treated patients. There were no serious adverse events. Nine of 26 (35%) patients in the ADASUVE group, compared to one of 26 (4%) in the placebo group, did not receive a second dose of study medication, because they had a ≥ 20% decrease in FEV1 or they developed respiratory symptoms after the first dose. Rescue medication (albuterol via metered dose inhaler or nebulizer) was administered to 54% of patients in the ADASUVE group [7 patients (27%) after the first dose and 7 of the remain-ing 17 patients (41%) after the second dose] and 12% in the placebo group (1 patient after the first dose and 2 patients after the second dose).COPDPatients:IntheCOPDtrial,53patientswithmildtosevereCOPD(withFEV1 ≥ 40% of predicted) were randomized to treatment with 2 doses of ADASUVE 10 mg or placebo. The second dose was to be administered 10 hours after the first dose. Approximately 57% of these patients had moderateCOPD[Global Initiative forChronicObstructiveLungDisease(GOLD)StageII];32%hadseveredisease(GOLDStageIII);and11%hadmilddisease(GOLDStageI).AsillustratedinTable2therewasadecreasein FEV1 soon after the first dose (maximum mean decreases in FEV1 and % predicted FEV1 were 96 mL and 3.5%, respectively), and the effect on FEV1 was greater following the second dose (maximum mean decreases in FEV1 and % predicted FEV1 were 125 mL and 4.5%, respectively). Respi-ratory adverse reactions occurred more frequently in the ADASUVE group (19%) than in the placebo group (11%). There were no serious adverse events. Seven of 25 (28%) patients in the ADASUVE group and 1of 27 (4%) in the placebo group did not receive a second dose of study medication because of a ≥ 20% decrease in FEV1 or the development of respiratory symptoms after the first dose. Rescue medication (albuterol via MDI or

presyncope or syncope. A systolic blood pressure ≤90mmHgwithadecrease of ≥20mmHgoccurredin1.5%and0.8%oftheADASUVE10 mg and placebo groups, respectively. A diastolic blood pressure ≤50mmHgwithadecreaseof≥15mmHgoccurredin0.8%and0.4%of the ADASUVE 10 mg and placebo groups, respectively.In 5 Phase 1 studies in normal volunteers, the incidence of hypotension was 3% and 0% in ADASUVE 10 mg and the placebo groups, respec-tively. The incidence of syncope or presyncope in normal volunteers was 2.3% and 0% in the ADASUVE and placebo groups, respectively. In nor-mal volunteers, a systolic blood pressure ≤90mmHgwithadecreaseof ≥20mmHgoccurredin5.3%and1.1%intheADASUVEandplacebogroups, respectively. A diastolic blood pressure ≤ 50 mm Hg with adecrease of ≥15mmHgoccurredin7.5%and3.3%intheADASUVEandplacebo groups, respectively.5.6 SeizuresADASUVE lowers the seizure threshold. Seizures have occurred in patients treated with oral loxapine. Seizures can occur in epileptic patients even during antiepileptic drug maintenance therapy. In short term (24 hour), placebo-controlled trials of ADASUVE, there were no reports of seizures. 5.7 Potential for Cognitive and Motor ImpairmentADASUVE can impair judgment, thinking, and motor skills. In short-term, placebo-controlled trials, sedation and/or somnolence were reported in 12% and 10% in the ADASUVE and placebo groups, respectively. No patients discontinued treatment because of sedation or somnolence.The potential for cognitive and motor impairment is increased when ADASUVEisadministeredconcurrentlywithotherCNSdepressants[see Drug Interactions (7.1)]. Caution patients about operating hazardousmachinery, including automobiles, until they are reasonably certain that therapy with ADASUVE does not affect them adversely. 5.8 Cerebrovascular Reactions, Including Stroke, in Elderly Patients with Dementia-Related PsychosisIn placebo-controlled trials with atypical antipsychotics in elderly patients with dementia-related psychosis, there was a higher incidence of cere-brovascular adverse reactions (stroke and transient ischemic attacks), including fatalities, compared to placebo-treated patients. ADASUVE is not approved for the treatment of patients with dementia-related psycho-sis [see Boxed Warning and Warnings and Precautions (5.3)].5.9 Anticholinergic Reactions Including Exacerbation of Glaucoma and Urinary RetentionADASUVE has anticholinergic activity, and it has the potential to cause anticholinergic adverse reactions including exacerbation of glaucoma or urinary retention. The concomitant use of other anticholinergic drugs (e.g., antiparkinson drugs) with ADASUVE could have additive effects. 6 ADVERSE REACTIONSThe following adverse reactions are discussed in more detail in other sections of the labeling:• Hypersensitivity(seriousskinreactions)[see Contraindications (4)] • Bronchospasm[see Warnings and Precautions (5.1)]• IncreasedMortalityinElderlyPatientswithDementia-RelatedPsycho-

sis [see Warnings and Precautions (5.3)]• NeurolepticMalignantSyndrome[see Warnings and Precautions (5.4)]• Hypotensionandsyncope[see Warnings and Precautions (5.5)]• Seizure[see Warnings and Precautions (5.6)]• Potential forCognitiveandMotorImpairment[see Warnings and Pre-

cautions (5.7)]• CerebrovascularReactions, IncludingStroke, inElderlyPatientswith

Dementia-Related Psychosis [see Warnings and Precautions (5.8)]• AnticholinergicReactionsIncludingExacerbationofGlaucomaandUri-

nary Retention [see Warnings and Precautions (5.9)]6.1 Clinical Trials ExperienceBecause clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.The following findings are based on pooled data from three short-term (24-hour), randomized, double-blind, placebo-controlled clinical trials (Studies 1, 2, and 3) of ADASUVE 10 mg in the treatment of patients with acute agitation associated with schizophrenia or bipolar I disorder. In the 3 trials, 259 patients received ADASUVE 10 mg, and 263 received placebo [see Clinical Studies (14)].Commonly Observed Adverse Reactions: In the 3 trials in acute agita-tion, the most common adverse reactions were dysgeusia, sedation, and throat irritation. These reactions occurred at a rate of at least 2% of the ADASUVE group and at a rate greater than in the placebo group. (Refer to Table 1).

S:13.5”

S:9.5”

T:14”

T:10”

B:17”

B:12”

BRIEF SUMMARYADASUVE® (loxapine) inhalation powder, for oral inhalation use The following is a brief summary only; see full prescribing informa-tion, included Boxed Warnings for complete product information.

WARNING: BRONCHOSPASM and INCREASED MORTALITYIN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS

Bronchospasm ADASUVE can cause bronchospasm that has the potential to lead to respiratory distress and respiratory arrest. Administer ADASUVE only in an enrolled healthcare facility that has immediate access on-site to equipment and personnel trained to manage acute bron-chospasm, including advanced airway management (intubation and mechanical ventilation) [see Warnings and Precautions (5.1, 5.2)]. Prior to administering ADASUVE, screen patients regarding a current diagnosis, history, or symptoms of asthma, COPD and other lung diseases, and examine (including chest auscultation) patients for respiratory signs. Monitor for signs and symptoms of bronchospasm following treatment with ADASUVE [see Dosage and Administration (2.2, 2.4) and Contraindications (4)].Because of the risk of bronchospasm, ADASUVE is available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS) called the ADASUVE REMS [see Warnings and Pre-cautions (5.2)]. Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with anti-psychotic drugs are at an increased risk of death. ADASUVE is not approved for the treatment of patients with dementia-related psycho-sis [see Warnings and Precautions (5.3)].

1 INDICATIONS AND USAGEADASUVE is a typical antipsychotic indicated for the acute treatment of agitation associated with schizophrenia or bipolar I disorder in adults.“Psychomotor agitation” is defined in DSM-IV as “excessive motor activity associated with a feeling of inner tension.” Patients experiencing agitation often manifest behaviors that interfere with their care (e.g., threatening behaviors, escalating or urgently distressing behavior, self-exhausting behav-ior), leading clinicians to the use of rapidly absorbed antipsychotic medica-tions to achieve immediate control of the agitation [see Clinical Studies (14)].The efficacy of ADASUVE was established in one study of acute agitation in patients with schizophrenia and one study of acute agitation in patients with bipolar I disorder [see Clinical Studies (14)]. Limitations of Use:As part of the ADASUVE REMS Program to mitigate the risk of broncho-spasm, ADASUVE must be administered only in an enrolled healthcare facility [see Warnings and Precautions (5.2)].4 CONTRAINDICATIONSADASUVE is contraindicated in patients with the following:• Current diagnosis or history of asthma, COPD, or other lung disease

associated with bronchospasm [see Warnings and Precautions (5.1)]• Acute respiratory symptomsor signs (e.g., wheezing) [see Warnings

and Precautions (5.1)]• Currentuseofmedicationstotreatairwaysdisease,suchasasthmaorCOPD[see Warnings and Precautions (5.1)]

• HistoryofbronchospasmfollowingADASUVEtreatment[see Warnings and Precautions (5.1)]

• Knownhypersensitivityto loxapineoramoxapine.Seriousskinreac-tions have occurred with oral loxapine and amoxapine.

5 WARNINGS AND PRECAUTIONS5.1 BronchospasmADASUVE can cause bronchospasm that has the potential to lead to respi-ratory distress and respiratory arrest [see Adverse Reactions (6.1)]. Administer ADASUVE only in an enrolled healthcare facility that has immediate access on-site to equipment and personnel trained to manage acute bronchospasm, including advanced airway management (intuba-tion and mechanical ventilation) [see Boxed Warning and Warnings and Precautions (5.2)].Prior to administering ADASUVE, screen patients regarding a current diagnosisorhistoryofasthma,COPD,andotherlungdiseaseassociatedwith bronchospasm, acute respiratory symptoms or signs, current use of medicationstotreatairwaysdisease,suchasasthmaorCOPD;andexam-ine patients (including chest auscultation) for respiratory abnormalities (e.g., wheezing) [See Dosage and Administration (2.2) and Contraindi-cations (4)]. Monitor patients for symptoms and signs of bronchospasm (i.e., vital signs and chest auscultation) at least every 15 minutes for a minimum of one hour following treatment with ADASUVE [see Dosage and Administration (2.4)]. ADASUVE can cause sedation, which can mask the symptoms of bronchospasm.

BecauseclinicaltrialsinpatientswithasthmaorCOPDdemonstratedthatthe degree of bronchospasm, as indicated by changes in forced expira-tory volume in 1 second (FEV1), was greater following a second dose of ADASUVE, limit ADASUVE use to a single dose within a 24 hour period. Advise all patients of the risk of bronchospasm. Advise them to inform the healthcare professional if they develop any breathing problems such as wheezing, shortness of breath, chest tightness, or cough following treatment with ADASUVE.5.2 ADASUVE REMS to Mitigate Bronchospasm Because of the risk of bronchospasm, ADASUVE is available only through a restricted program under a REMS called the ADASUVE REMS. [see Boxed Warning and Warnings and Precautions (5.1)] Required compo-nents of the ADASUVE REMS are:• Healthcarefacilities thatdispenseandadministerADASUVEmustbeenrolled and comply with the REMS requirements. Certified health-care facilities must have on-site access to equipment and personnel trained to provide advance airway management, including intubation and mechanical ventilation.

• WholesalersanddistributorsthatdistributeADASUVEmustenroll inthe program and distribute only to enrolled healthcare facilities.

Further information is available at www.adasuverems.com or 1-855-755-0492.5.3 Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsy-chotic drugs are at increased risk of death. Analyses of 17 placebo- controlled trials (modal duration of 10 weeks), largely in patients tak-ing atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of 1.6 to 1.7 times the risk of death in placebo-treated patients. Overthecourseofatypical10-weekcontrolledtrial,therateofdeathindrug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the cases of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sud-dendeath)orinfectious(e.g.,pneumonia)innature.Observationalstud-ies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies can be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. ADASUVE is not approved for the treatment of elderly patients with dementia-related psychosis [see Boxed Warning].5.4 Neuroleptic Malignant Syndrome Antipsychotic drugs can cause a potentially fatal symptom complex termedNeurolepticMalignantSyndrome(NMS).Clinicalmanifestationsof NMS include hyperpyrexia, muscle rigidity, altered mental status, and autonomic instability (irregular pulse or blood pressure, tachycardia, dia-phoresis, and cardiac dysrhythmia). Associated features can include ele-vatedserumcreatinephosphokinase(CPK)concentration,rhabdomyoly-sis, elevated serum and urine myoglobin concentration, and renal failure. NMS did not occur in the ADASUVE clinical program.The diagnostic evaluation of patients with this syndrome is complicated. It is important to consider the presence of other serious medical con-ditions (e.g.,pneumonia,systemic infection,heatstroke,primaryCNSpathology, central anticholinergic toxicity, extrapyramidal symptoms, or drug fever). The management of NMS should include: 1) immediate discontinua-tion of antipsychotic drugs and other drugs that may contribute to the underlying disorder, 2) intensive symptomatic treatment and medical mon-itoring, and 3) treatment of any concomitant serious medical problems. There is no general agreement about specific pharmacological treatment regimens for NMS.If a patient requires antipsychotic drug treatment after recovery from NMS, the potential reintroduction of drug therapy should be carefully considered. The patient should be carefully monitored, since recurrences of NMS have been reported. 5.5 Hypotension and SyncopeADASUVE can cause hypotension, orthostatic hypotension, and syncope. Use ADASUVE with caution in patients with known cardiovascular dis-ease (history of myocardial infarction or ischemic heart disease, heart failure or conduction abnormalities), cerebrovascular disease, or condi-tions that would predispose patients to hypotension (dehydration, hypo-volemia, or treatment with antihypertensive medications or other drugs that affect blood pressure or reduce heart rate).In the presence of severe hypotension requiring vasopressor therapy, the preferred drugs may be norepinephrine or phenylephrine. Epinephrine should not be used, because beta stimulation may worsen hypotension in the setting of ADASUVE-induced partial alpha blockade.In short-term (24-hour) placebo-controlled trials of patients with agitation associated with schizophrenia or bipolar I disorder, hypotension occurred in 0.4% and 0.8% in the ADASUVE 10 mg and placebo groups, respec-tively. There were no cases of orthostatic hypotension, postural symptoms,

Table 1. Adverse Reactions in 3 Pooled Short-Term, Placebo-Controlled Trials (Studies 1, 2, and 3) in Patients with Schizophrenia or Bipolar Disorder

Adverse ReactionPlacebo(n = 263)

ADASUVE(n = 259)

Dysgeusia 5% 14%Sedation 10% 12%Throat Irritation 0% 3%

Airway Adverse Reactions in the 3 Trials in Acute Agitation Agitated patients with Schizophrenia or Bipolar Disorder: In the 3 short-term (24-hour), placebo-controlled trials in patients with agitation asso-ciated with schizophrenia or bipolar disorder (Studies 1, 2, and 3), bron-chospasm (which includes reports of wheezing, shortness of breath and cough) occurred more frequently in the ADASUVE group, compared to the placebo group: 0% (0/263) in the placebo group and 0.8% (2/259) intheADASUVE10mggroup.Onepatientwithschizophrenia,withouta history of pulmonary disease, had significant bronchospasm requiring rescue treatment with a bronchodilator and oxygen. Bronchospasm and Airway Adverse Reactions in Pulmonary Safety TrialsClinicalpulmonarysafetytrialsdemonstratedthatADASUVEcancausebronchospasm as measured by FEV1, and as indicated by respiratory signs and symptoms in the trials. In addition, the trials demonstrated thatpatientswithasthmaorotherpulmonarydiseases,suchasCOPDare at increased risk of bronchospasm. The effect of ADASUVE on pulmonary function was evaluated in 3 randomized, double-blind, placebo-controlled clinical pulmonary safety trials in healthy volunteers, patientswithasthma,andpatientswithCOPD.Pulmonaryfunctionwasassessed by serial FEV1 tests, and respiratory signs and symptoms were assessed.IntheasthmaandCOPDtrials,patientswithrespiratorysymp-toms or FEV1 decrease of ≥ 20% were administered rescue treatment with albuterol (metered dose inhaler or nebulizer) as required. These patientswerenoteligibleforaseconddose;however,theyhadcontinuedFEV1 monitoring in the trial. HealthyVolunteers: In the healthy volunteer crossover trial, 30 subjects received 2 doses of either ADASUVE or placebo 8 hours apart, and 2 doses of the alternate treatment at least 4 days later. The results for maximum decrease in FEV1 are presented in Table 2. No subjects in this trial devel-oped airway related adverse reactions (cough, wheezing, chest tightness, or dyspnea).Asthma Patients: In the asthma trial, 52 patients with mild-moderate persistent asthma (with FEV1 ≥ 60% of predicted) were randomized to treatment with 2 doses of ADASUVE 10 mg or placebo. The second dose was to be administered 10 hours after the first dose. Approximately 67% of these patients had a baseline FEV1 ≥ 80% of predicted. The remaining patients had an FEV1 60-80% of predicted. Nine patients (17%) were former smokers. As shown in Table 2 and Figure 7, there was a marked decrease in FEV1 immediately following the first dose (maximum mean decreases in FEV1 and % predicted FEV1 were 303 mL and 9.1%, respec-tively). Furthermore, the effect on FEV1 was greater following the second dose (maximum mean decreases in FEV1 and % predicted FEV1 were 537 mL and 14.7 %, respectively). Respiratory-related adverse reactions (bronchospasm, chest discomfort, cough, dyspnea, throat tightness, and wheezing) occurred in 54% of ADASUVE-treated patients and 12% of placebo-treated patients. There were no serious adverse events. Nine of 26 (35%) patients in the ADASUVE group, compared to one of 26 (4%) in the placebo group, did not receive a second dose of study medication, because they had a ≥ 20% decrease in FEV1 or they developed respiratory symptoms after the first dose. Rescue medication (albuterol via metered dose inhaler or nebulizer) was administered to 54% of patients in the ADASUVE group [7 patients (27%) after the first dose and 7 of the remain-ing 17 patients (41%) after the second dose] and 12% in the placebo group (1 patient after the first dose and 2 patients after the second dose).COPDPatients:IntheCOPDtrial,53patientswithmildtosevereCOPD(withFEV1 ≥ 40% of predicted) were randomized to treatment with 2 doses of ADASUVE 10 mg or placebo. The second dose was to be administered 10 hours after the first dose. Approximately 57% of these patients had moderateCOPD[Global Initiative forChronicObstructiveLungDisease(GOLD)StageII];32%hadseveredisease(GOLDStageIII);and11%hadmilddisease(GOLDStageI).AsillustratedinTable2therewasadecreasein FEV1 soon after the first dose (maximum mean decreases in FEV1 and % predicted FEV1 were 96 mL and 3.5%, respectively), and the effect on FEV1 was greater following the second dose (maximum mean decreases in FEV1 and % predicted FEV1 were 125 mL and 4.5%, respectively). Respi-ratory adverse reactions occurred more frequently in the ADASUVE group (19%) than in the placebo group (11%). There were no serious adverse events. Seven of 25 (28%) patients in the ADASUVE group and 1of 27 (4%) in the placebo group did not receive a second dose of study medication because of a ≥ 20% decrease in FEV1 or the development of respiratory symptoms after the first dose. Rescue medication (albuterol via MDI or

presyncope or syncope. A systolic blood pressure ≤90mmHgwithadecrease of ≥20mmHgoccurredin1.5%and0.8%oftheADASUVE10 mg and placebo groups, respectively. A diastolic blood pressure ≤50mmHgwithadecreaseof≥15mmHgoccurredin0.8%and0.4%of the ADASUVE 10 mg and placebo groups, respectively.In 5 Phase 1 studies in normal volunteers, the incidence of hypotension was 3% and 0% in ADASUVE 10 mg and the placebo groups, respec-tively. The incidence of syncope or presyncope in normal volunteers was 2.3% and 0% in the ADASUVE and placebo groups, respectively. In nor-mal volunteers, a systolic blood pressure ≤90mmHgwithadecreaseof ≥20mmHgoccurredin5.3%and1.1%intheADASUVEandplacebogroups, respectively. A diastolic blood pressure ≤ 50 mm Hg with adecrease of ≥15mmHgoccurredin7.5%and3.3%intheADASUVEandplacebo groups, respectively.5.6 SeizuresADASUVE lowers the seizure threshold. Seizures have occurred in patients treated with oral loxapine. Seizures can occur in epileptic patients even during antiepileptic drug maintenance therapy. In short term (24 hour), placebo-controlled trials of ADASUVE, there were no reports of seizures. 5.7 Potential for Cognitive and Motor ImpairmentADASUVE can impair judgment, thinking, and motor skills. In short-term, placebo-controlled trials, sedation and/or somnolence were reported in 12% and 10% in the ADASUVE and placebo groups, respectively. No patients discontinued treatment because of sedation or somnolence.The potential for cognitive and motor impairment is increased when ADASUVEisadministeredconcurrentlywithotherCNSdepressants[see Drug Interactions (7.1)]. Caution patients about operating hazardousmachinery, including automobiles, until they are reasonably certain that therapy with ADASUVE does not affect them adversely. 5.8 Cerebrovascular Reactions, Including Stroke, in Elderly Patients with Dementia-Related PsychosisIn placebo-controlled trials with atypical antipsychotics in elderly patients with dementia-related psychosis, there was a higher incidence of cere-brovascular adverse reactions (stroke and transient ischemic attacks), including fatalities, compared to placebo-treated patients. ADASUVE is not approved for the treatment of patients with dementia-related psycho-sis [see Boxed Warning and Warnings and Precautions (5.3)].5.9 Anticholinergic Reactions Including Exacerbation of Glaucoma and Urinary RetentionADASUVE has anticholinergic activity, and it has the potential to cause anticholinergic adverse reactions including exacerbation of glaucoma or urinary retention. The concomitant use of other anticholinergic drugs (e.g., antiparkinson drugs) with ADASUVE could have additive effects. 6 ADVERSE REACTIONSThe following adverse reactions are discussed in more detail in other sections of the labeling:• Hypersensitivity(seriousskinreactions)[see Contraindications (4)] • Bronchospasm[see Warnings and Precautions (5.1)]• IncreasedMortalityinElderlyPatientswithDementia-RelatedPsycho-

sis [see Warnings and Precautions (5.3)]• NeurolepticMalignantSyndrome[see Warnings and Precautions (5.4)]• Hypotensionandsyncope[see Warnings and Precautions (5.5)]• Seizure[see Warnings and Precautions (5.6)]• Potential forCognitiveandMotorImpairment[see Warnings and Pre-

cautions (5.7)]• CerebrovascularReactions, IncludingStroke, inElderlyPatientswith

Dementia-Related Psychosis [see Warnings and Precautions (5.8)]• AnticholinergicReactionsIncludingExacerbationofGlaucomaandUri-

nary Retention [see Warnings and Precautions (5.9)]6.1 Clinical Trials ExperienceBecause clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.The following findings are based on pooled data from three short-term (24-hour), randomized, double-blind, placebo-controlled clinical trials (Studies 1, 2, and 3) of ADASUVE 10 mg in the treatment of patients with acute agitation associated with schizophrenia or bipolar I disorder. In the 3 trials, 259 patients received ADASUVE 10 mg, and 263 received placebo [see Clinical Studies (14)].Commonly Observed Adverse Reactions: In the 3 trials in acute agita-tion, the most common adverse reactions were dysgeusia, sedation, and throat irritation. These reactions occurred at a rate of at least 2% of the ADASUVE group and at a rate greater than in the placebo group. (Refer to Table 1).

S:13.5”

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T:14”

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B:12”

nebulizer) was administered to 23% of patients in the ADASUVE group: 8% of patients after the first dose and 21% of patients after the second dose, and to 15% of patients in the placebo group.Table 2: Maximum Decrease in FEV1 from Baseline in the Healthy Volun-teer, Asthma, and COPD Trials

Healthy Volunteer Asthma COPDMaximum% FEV ↓

Placebon (%)

ADASUVE10 mgn (%)

Placebon (%)

ADASUVE10 mgn (%)

Placebon (%)

ADASUVE10 mgn (%)

After any Dose

N=26 N=26 N=26 N=26 N=27 N=25

≥10 7 (27) 7 (27) 3 (12) 22 (85) 18 (67) 20 (80)

≥15 1 (4) 5 (19) 1 (4) 16 (62) 9 (33) 14 (56)

≥20 0 1 (4) 1 (4) 11 (42) 3 (11) 10 (40)

After Dose 1

N=26 N=26 N=26 N=26 N=27 N=25

≥10 4 (15) 5 (19) 2 (8) 16 (62) 8 (30) 16 (64)

≥15 1 (4) 2 (8) 1 (4) 8 (31) 4 (15) 10 (40)

≥20 0 0 1 (4) 6 (23) 2 (7) 9 (36)

After Dose 2

N=26 N=25 N=25 N=17 N=26 N=19

≥10 5 (19) 6 (24) 3 (12) 12 (71) 15 (58) 12 (63)

≥15 0 5 (20) 1 (4) 9 (53) 6 (23) 10 (53)

≥20 0 1 (4) 1 (4) 5 (30) 1 (4) 5 (26)

FEV1categoriesarecumulative;i.e.asubjectwithamaximumdecreaseof 21% is included in all 3 categories. Patients with a ≥ 20% decrease in FEV1 did not receive a second dose of study drug.Figure 7: LS Mean Change from Baseline in FEV1 in Patients with Asthma

Patients with a ≥ 20% decrease in FEV1 did not receive a second dose of study drug and are not included in the curves beyond hour 10.Extrapyramidal Symptoms (EPS): Extrapyramidal reactions have occurred during the administration of oral loxapine. In most patients, these reactions involved parkinsonian symptoms such as tremor, rigidity, and masked facies. Akathisia (motor restlessness) has also occurred.In the 3 short-term (24-hour), placebo-controlled trials of ADASUVE in 259 patients with agitation associated with schizophrenia or bipolar disorder, extrapyramidalreactionsoccurred.Onepatient(0.4%)treatedwithADASUVEdeveloped neck dystonia and oculogyration. The incidence of akathisia was 0% and 0.4% in the placebo and ADASUVE groups, respectively. Dystonia (Antipsychotic Class Effect): Symptoms of dystonia, prolonged abnormal contractions of muscle groups, may occur in susceptible indi-viduals during treatment with ADASUVE. Dystonic symptoms include spasm of the neck muscles, sometimes progressing to tightness of the throat, difficulty swallowing or breathing, and/or protrusion of the tongue. Acute dystonia tends to be dose-related, but can occur at low doses, and occurs more frequently with first generation antipsychotic drugs such as ADASUVE. The risk is greater in males and younger age groups.Cardiovascular Reactions: Tachycardia, hypotension, hypertension, ortho-static hypotension, lightheadedness, and syncope have been reported with oral administration of loxapine.7 DRUG INTERACTIONS7.1 CNS DepressantsADASUVEisacentralnervoussystem(CNS)depressant.TheconcurrentuseofADASUVEwithotherCNSdepressants(e.g.,alcohol,opioidanal-gesics, benzodiazepines, tricyclic antidepressants, general anesthetics, phenothiazines,sedative/hypnotics,musclerelaxants,and/or illicitCNSdepressants) can increase the risk of respiratory depression, hypoten-sion, profound sedation, and syncope. Therefore, consider reducing the doseofCNSdepressantsifusedconcomitantlywithADASUVE.

7.2 Anticholinergic DrugsADASUVE has anticholinergic activity. The concomitant use of ADASUVE and other anticholinergic drugs can increase the risk of anticholinergic adverse reactions including exacerbation of glaucoma and urinary retention.8 USE IN SPECIFIC POPULATIONSIn general, no dose adjustment for ADASUVE is required on the basis of a patient’s age, gender, race, smoking status, hepatic function, or renal function.8.1 PregnancyPregnancyCategoryCRisk SummaryThere are no adequate and well-controlled studies of ADASUVE use in pregnant women. Neonates exposed to antipsychotic drugs during the third trimester of pregnancy are at risk for extrapyramidal and/or with-drawal symptoms following delivery. Loxapine, the active ingredient in ADASUVE, has demonstrated increased embryofetal toxicity and death in rat fetuses and offspring exposed to doses approximately 0.5-fold themaximum recommendedhumandose (MRHD) on amg/m2 basis. ADASUVE should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.HumanDataNeonates exposed to antipsychotic drugs during the third trimester of pregnancy are at risk for extrapyramidal and/or withdrawal symptoms following delivery. There have been reports of agitation, hypertonia, hypo-tonia, tremor, somnolence, respiratory distress, and feeding disorders intheseneonates.Thesecomplicationshavevariedinseverity;insomecases symptoms have been self-limited, but in other cases neonates have required intensive care unit support and prolonged hospitalization.Animal DataIn rats, embryofetal toxicity (increased fetal resorptions, reduced weights, and hydronephrosis with hydroureter) was observed following oral administration of loxapine during the period of organogenesis at a doseof1mg/kg/day.ThisdoseisequivalenttotheMRHDof10mg/dayon a mg/m2 basis. In addition, fetal toxicity (increased prenatal death, decreased postnatal survival, reduced fetal weights, delayed ossifica-tion, and/or distended renal pelvis with reduced or absent papillae) was observed following oral administration of loxapine from mid-pregnancy through weaning at doses of 0.6 mg/kg and higher. This dose is approxi-matelyhalftheMRHDof10mg/dayonamg/m2 basis. No teratogenicity was observed following oral administration of loxapine during the period of organogenesis in the rat, rabbit, or dog at doses up to 12, 60, and 10 mg/kg, respectively. These doses are approximately 12-, 120-,and32-foldtheMRHDof10mg/dayonamg/m2 basis, respectively.8.3 Nursing Mothers It is not known whether ADASUVE is present in human milk. Loxapine and its metabolites are present in the milk of lactating dogs. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from ADASUVE, a decision should be made whether to discontinue nursing or discontinue ADASUVE, taking into account the importance of the drug to the mother.8.4 Pediatric UseThe safety and effectiveness of ADASUVE in pediatric patients have not been established.8.5 Geriatric UseElderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death [see Boxed Warning and Warn-ings and Precautions (5.3)]. ADASUVE is not approved for the treatment of dementia-related psychosis. Placebo-controlled studies of ADASUVE in patients with agitation associated with schizophrenia or bipolar disorder did not include patients over 65 years of age.10 OVERDOSAGESigns and Symptoms of OverdosageAs would be expected from the pharmacologic actions of loxapine, the clinicalfindingsmayincludeCNSdepression,unconsciousness,profoundhypotension, respiratory depression, extrapyramidal symptoms, and seizure.Management of OverdosageFor the most up to date information on the management of ADASUVE overdosage, contact a certified poison control center (1-800-222-1222 or www.poison.org). Provide supportive care including close medical supervision and monitoring. Treatment should consist of general mea-suresemployedinthemanagementofoverdosagewithanydrug.Con-sider the possibility of multiple drug overdosage. Ensure an adequate airway, oxygenation, and ventilation. Monitor cardiac rhythm and vital signs. Use supportive and symptomatic measures.Manufacturedby:AlexzaPharmaceuticals,Inc.,MountainView,CA94043Manufacturedfor:TevaSelectBrands,Horsham,PA19044,DivisionofTeva Pharmaceuticals USA, Inc.Iss.12/2013ADA-40059

S:6.5”

S:9.5”

T:7”

T:10”

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B:12”

nebulizer) was administered to 23% of patients in the ADASUVE group: 8% of patients after the first dose and 21% of patients after the second dose, and to 15% of patients in the placebo group.Table 2: Maximum Decrease in FEV1 from Baseline in the Healthy Volun-teer, Asthma, and COPD Trials

Healthy Volunteer Asthma COPDMaximum% FEV ↓

Placebon (%)

ADASUVE10 mgn (%)

Placebon (%)

ADASUVE10 mgn (%)

Placebon (%)

ADASUVE10 mgn (%)

After any Dose

N=26 N=26 N=26 N=26 N=27 N=25

≥10 7 (27) 7 (27) 3 (12) 22 (85) 18 (67) 20 (80)

≥15 1 (4) 5 (19) 1 (4) 16 (62) 9 (33) 14 (56)

≥20 0 1 (4) 1 (4) 11 (42) 3 (11) 10 (40)

After Dose 1

N=26 N=26 N=26 N=26 N=27 N=25

≥10 4 (15) 5 (19) 2 (8) 16 (62) 8 (30) 16 (64)

≥15 1 (4) 2 (8) 1 (4) 8 (31) 4 (15) 10 (40)

≥20 0 0 1 (4) 6 (23) 2 (7) 9 (36)

After Dose 2

N=26 N=25 N=25 N=17 N=26 N=19

≥10 5 (19) 6 (24) 3 (12) 12 (71) 15 (58) 12 (63)

≥15 0 5 (20) 1 (4) 9 (53) 6 (23) 10 (53)

≥20 0 1 (4) 1 (4) 5 (30) 1 (4) 5 (26)

FEV1categoriesarecumulative;i.e.asubjectwithamaximumdecreaseof 21% is included in all 3 categories. Patients with a ≥ 20% decrease in FEV1 did not receive a second dose of study drug.Figure 7: LS Mean Change from Baseline in FEV1 in Patients with Asthma

Patients with a ≥ 20% decrease in FEV1 did not receive a second dose of study drug and are not included in the curves beyond hour 10.Extrapyramidal Symptoms (EPS): Extrapyramidal reactions have occurred during the administration of oral loxapine. In most patients, these reactions involved parkinsonian symptoms such as tremor, rigidity, and masked facies. Akathisia (motor restlessness) has also occurred.In the 3 short-term (24-hour), placebo-controlled trials of ADASUVE in 259 patients with agitation associated with schizophrenia or bipolar disorder, extrapyramidalreactionsoccurred.Onepatient(0.4%)treatedwithADASUVEdeveloped neck dystonia and oculogyration. The incidence of akathisia was 0% and 0.4% in the placebo and ADASUVE groups, respectively. Dystonia (Antipsychotic Class Effect): Symptoms of dystonia, prolonged abnormal contractions of muscle groups, may occur in susceptible indi-viduals during treatment with ADASUVE. Dystonic symptoms include spasm of the neck muscles, sometimes progressing to tightness of the throat, difficulty swallowing or breathing, and/or protrusion of the tongue. Acute dystonia tends to be dose-related, but can occur at low doses, and occurs more frequently with first generation antipsychotic drugs such as ADASUVE. The risk is greater in males and younger age groups.Cardiovascular Reactions: Tachycardia, hypotension, hypertension, ortho-static hypotension, lightheadedness, and syncope have been reported with oral administration of loxapine.7 DRUG INTERACTIONS7.1 CNS DepressantsADASUVEisacentralnervoussystem(CNS)depressant.TheconcurrentuseofADASUVEwithotherCNSdepressants(e.g.,alcohol,opioidanal-gesics, benzodiazepines, tricyclic antidepressants, general anesthetics, phenothiazines,sedative/hypnotics,musclerelaxants,and/or illicitCNSdepressants) can increase the risk of respiratory depression, hypoten-sion, profound sedation, and syncope. Therefore, consider reducing the doseofCNSdepressantsifusedconcomitantlywithADASUVE.

7.2 Anticholinergic DrugsADASUVE has anticholinergic activity. The concomitant use of ADASUVE and other anticholinergic drugs can increase the risk of anticholinergic adverse reactions including exacerbation of glaucoma and urinary retention.8 USE IN SPECIFIC POPULATIONSIn general, no dose adjustment for ADASUVE is required on the basis of a patient’s age, gender, race, smoking status, hepatic function, or renal function.8.1 PregnancyPregnancyCategoryCRisk SummaryThere are no adequate and well-controlled studies of ADASUVE use in pregnant women. Neonates exposed to antipsychotic drugs during the third trimester of pregnancy are at risk for extrapyramidal and/or with-drawal symptoms following delivery. Loxapine, the active ingredient in ADASUVE, has demonstrated increased embryofetal toxicity and death in rat fetuses and offspring exposed to doses approximately 0.5-fold themaximum recommendedhumandose (MRHD) on amg/m2 basis. ADASUVE should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.HumanDataNeonates exposed to antipsychotic drugs during the third trimester of pregnancy are at risk for extrapyramidal and/or withdrawal symptoms following delivery. There have been reports of agitation, hypertonia, hypo-tonia, tremor, somnolence, respiratory distress, and feeding disorders intheseneonates.Thesecomplicationshavevariedinseverity;insomecases symptoms have been self-limited, but in other cases neonates have required intensive care unit support and prolonged hospitalization.Animal DataIn rats, embryofetal toxicity (increased fetal resorptions, reduced weights, and hydronephrosis with hydroureter) was observed following oral administration of loxapine during the period of organogenesis at a doseof1mg/kg/day.ThisdoseisequivalenttotheMRHDof10mg/dayon a mg/m2 basis. In addition, fetal toxicity (increased prenatal death, decreased postnatal survival, reduced fetal weights, delayed ossifica-tion, and/or distended renal pelvis with reduced or absent papillae) was observed following oral administration of loxapine from mid-pregnancy through weaning at doses of 0.6 mg/kg and higher. This dose is approxi-matelyhalftheMRHDof10mg/dayonamg/m2 basis. No teratogenicity was observed following oral administration of loxapine during the period of organogenesis in the rat, rabbit, or dog at doses up to 12, 60, and 10 mg/kg, respectively. These doses are approximately 12-, 120-,and32-foldtheMRHDof10mg/dayonamg/m2 basis, respectively.8.3 Nursing Mothers It is not known whether ADASUVE is present in human milk. Loxapine and its metabolites are present in the milk of lactating dogs. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from ADASUVE, a decision should be made whether to discontinue nursing or discontinue ADASUVE, taking into account the importance of the drug to the mother.8.4 Pediatric UseThe safety and effectiveness of ADASUVE in pediatric patients have not been established.8.5 Geriatric UseElderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death [see Boxed Warning and Warn-ings and Precautions (5.3)]. ADASUVE is not approved for the treatment of dementia-related psychosis. Placebo-controlled studies of ADASUVE in patients with agitation associated with schizophrenia or bipolar disorder did not include patients over 65 years of age.10 OVERDOSAGESigns and Symptoms of OverdosageAs would be expected from the pharmacologic actions of loxapine, the clinicalfindingsmayincludeCNSdepression,unconsciousness,profoundhypotension, respiratory depression, extrapyramidal symptoms, and seizure.Management of OverdosageFor the most up to date information on the management of ADASUVE overdosage, contact a certified poison control center (1-800-222-1222 or www.poison.org). Provide supportive care including close medical supervision and monitoring. Treatment should consist of general mea-suresemployedinthemanagementofoverdosagewithanydrug.Con-sider the possibility of multiple drug overdosage. Ensure an adequate airway, oxygenation, and ventilation. Monitor cardiac rhythm and vital signs. Use supportive and symptomatic measures.Manufacturedby:AlexzaPharmaceuticals,Inc.,MountainView,CA94043Manufacturedfor:TevaSelectBrands,Horsham,PA19044,DivisionofTeva Pharmaceuticals USA, Inc.Iss.12/2013ADA-40059

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ENA will redefine the idea of a

winning hand next February when

it holds the State and Chapter Leaders

Orientation, a focused two-day event

for all 2015 officers and core

leaders at the Paris Hotel in Las

Vegas — a frequently requested

city for ENA events.

The orientation previously

was known as the State and

Chapter Leaders Conference

and had in recent years been a

lead-in to the ENA Leadership

Conference, the last of which

was this year in Phoenix. ENA switches

to one larger conference, Emergency

Nursing 2015, beginning next fall.

All state council and chapter officers

and core leaders — that includes

government affairs chairs, membership

chairs and any other core leaders —

are strongly encouraged to attend the

orientation Feb. 19-20. Registration

begins in November, with information

to be sent to all 2015 leaders who are

reported in the State Council and

Chapter Online Management System.

Matthew F. Powers, MS, BSN, RN,

MICP, CEN, the 2015 ENA president,

said there’s no better way to

understand the roles, responsibilities

and processes of ENA and how your

state council or chapter connects,

especially if you’re new to the job.

‘‘The No. 1 reason to attend your

state and chapter leaders orientation

would be to learn more about your

professional organization and what

and who ENA is, and what it stands

for,’’ Powers said. ‘‘This orientation is

really focused for our member leaders,

and we’ll be able to focus our time

and energy solely toward the

orientation process vs. previously

concentrating on state leaders and our

leadership conference.’’

State and chapter leaders will learn

about ENA governance guidelines and

the strategic plan of the ENA Board of

Directors to make sure their units and

national ENA are running in

sync. There will be specific

sessions on finances,

association law, meeting

management, conference

planning, member engagement

and social media, along with

dynamic general session

speakers. Advocacy and

government relations will be

key parts of the program — ‘‘how to

get more involved in changing law,

statute and regulation at your local,

state and national level,’’ Powers said.

In short, the orientation is about

resources and, just as important, face

time with the people providing them.

Powers, who attended his first ENA

conference in 2002 and became

president of the East Bay (Calif.)

Chapter the next year before rising

through the California ENA State

Council, knows how important these

resources are to both seasoned and

new leaders. The emergence of new

ENA leaders each year is ‘‘amazing,’’

he said.

‘‘It’s seeing the passion in new

faces, seeing new people that want to

get involved and make a difference,

and to be able to really get the best

out of the best from our members’

talent and experience,’’ Powers said.

‘‘You are able to see their eyes light

up. They get revitalized, they get very

involved, and I think our challenge is

to keep that motivation going

throughout the year.’’

Mari Hoover-McGarry, RN, CEN,

CCRN, is a veteran of ENA orientations

and calls them ‘‘an energizing

environment.’’ As treasurer for the

Palm Beach County (Fla.) Chapter and

a past president and treasurer of the

Florida ENA State Council, she stressed

the importance of networking and

becoming clear on fiduciary rules,

particularly nonprofit tax status and

how it governs advocacy efforts with

politicians.

It’s also great team-building, she

said, both nationally with your board

liaison and within your state.

‘‘It helps put you on the front lines

with the ENA staff and the national

board members,’’ she said. ‘‘And it’s

nice to incorporate some social time

with your state leaders because we all

come from various parts of the state

— we don’t all live in one small

geographic location.’’

State and Chapter Leaders OrientationWhen: Feb. 19-20, 2015 – Paris Hotel, Las Vegas

Signing up: Registration starts in November at www.ena.org; 2015 leaders in the Online Management System will receive a formal invitation. Registration, CE, breakfast and lunch are complimentary. Hotel, airfare and dinner expenses are not covered.

Pre-orientation resources:tinyurl.com/ENAofficers

tinyurl.com/ENAstateschapters

Full program coming soon at www.ena.org.


WHAT HAPPENS IN VEGASBy Josh Gaby, ENA Connection

HELPS EVERYONE

Matthew F. Powers

October 201424


Stacey Cernadas, ADN, RN, EMT, had

traveled the world as an

international flight attendant for almost

nine years when she decided to

quit her job to pursue a career

in nursing. Even though it was

her third career change, the

former pre-med student knew

the nursing profession was

where she belonged.

She had always wanted to

work in the medical field — she

just had to find her way back to

it. She first was drawn to nursing at age

12 when her stepfather suffered a

massive heart attack.

‘‘He had a quadruple bypass when

he was my current age [36],’’ Cernadas

said. ‘‘I remember going through that

experience and seeing the care the

nurses provided to our family and the

patient advocacy. I remember very

vividly how great it was and how

life-changing that event was for my

family and for me at a young age. It’s

one of those things that has been a

very large part of my life.’’

The experience was one of

Cernadas’ main motivators when she

enrolled in nursing school in 2010. She

initially wanted to be a labor and

delivery nurse until her mentor

encouraged her to try emergency

nursing. As soon as she decided to

precept in the emergency department,

she fell in love and never looked back.

‘‘I knew it immediately,’’ she said.

‘‘I’m very calm and collected, and

there’s not much that can get me

flustered or stressed, so being able to

stay calm and relaxed in emergency

situations was something I found really

soothing. It fit me perfectly.

‘‘I really feel like it’s what I was put

here to do. It’s natural to me. I feel at

ease and like emergency

nursing is where I’m supposed

to be. I look forward to the

many years of making a

difference in this profession.’’

Cernadas has now been an

emergency nurse for 16

months and works at Baptist

Medical Center South in

Montgomery, Ala., where she was

encouraged to join ENA by Leigh

Parker, BSN, RN, CEN, the Alabama

ENA State Council president.

‘‘Leigh was one of my charge

nurses, and she took me under her

wing and gave me goals to fulfill,’’

Cernadas said. ‘‘She’s been a really

good mentor and introduced me to

ENA very early in my career.’’

Cernadas attended her first ENA

Annual Conference last year in

Nashville after being selected to

participate in the TNCC pilot course.

‘‘It was amazing,’’ she said. ‘‘I was

so enthralled by everything that was

going on. There were so many sessions

available, and it was really awesome

being able to choose educational

sessions to attend. Everyone was very

receptive. It was a nice brotherhood

and sisterhood of nurses, and I felt like

it was like my family.’’

Parker also encouraged Cernadas to

apply for an ENA Foundation

professional development scholarship

to attend the 2014 ENA Annual

Conference in Indianapolis. There are

19 of these $500 scholarships this year,

intended to reduce the conference cost

and travel expenses for ENA members

who would otherwise be unable to

attend. When Cernadas received the

call that she would be awarded one,

she screamed in excitement.

‘‘I’m really thrilled, and I take this

opportunity seriously,’’ she said. ‘‘I get

to hear amazing speakers all day long,

and at the end of the day, I have great

CE credits. I’m looking forward to the

educational sessions. I also get to see

all of the vendors at the exhibit hall

and the new things that are coming out

on the market that I can take back to

work. I’m just so excited.’’

Cernadas encourages emergency

nurses to give back to the ENA

Foundation to contribute to colleagues’

professional development and growth.

‘‘I think it’s very important to donate

and give back because it lets us create

and evolve our ENA nurses as the

times pass,’’ she said. ‘‘If we don’t give

back, then we are not showing our

appreciation to the incoming nurses,

SENTENA FOUNDATION

Helped by $500 Annual Conference Scholarship,This Emergency Nurse Will Keep Going Places

WITH LOVE

Stacey Cernadas was in Nashville last year for the 2013 ENA Annual Conference and gets to return this year with scholarship assistance.Stacey Cernadas


and we are not willing to help mold

them and make them the best they can

be. You’re only as strong as your

weakest link, so I think it’s very

important for us to carry and put those

values into the newer nurses and the

nurses who want to continue their

education. I really want to make sure

that everyone is pushed to do

everything that they can and be the

best that they can be.’’

2014 Scholarship and Research Grant RecipientsThe ENA Foundation would like to

extend a special thank-you to the

individuals, state councils, local

chapters, industry, ENA staff and

friends of emergency nursing who

have supported the profession through

their generous donations. Because of

your contributions and passion to

promote the advancement of the

profession, our applicants are afforded

the opportunity to receive educational

scholarships and research grants in the

discipline of emergency nursing.

The ENA Foundation is excited to

announce the following 2014

scholarship and research grant

recipients and share how our donors

are making a difference:

Academic Scholarship RecipientsNon-RN Scholarships

•New York State ENA September 11 Scholarships – $2,500 each

Sean Davenport, CCEMT-P, Kentucky Margaret T. Swenson, EMT, Utah

• ENA Foundation Emergency Department Employee Scholarships – $2,500 each

Emily Carle, EMT, Maine Amanda Smith, Florida

•Hill-Rom Scholarship – $2,500

William S. Guban, EMT-B, Vermont

Undergraduate Scholarships•Charles Kunz Memorial Undergraduate Scholarship – $3,000

Pamela D. Bartley, BS, RN, CCRN, CEN, CPEN, South Carolina

•Physio-Control Inc. Scholarship – $3,000 each Jacquelyn Glendinning, RN, New York Linda Murray, RN, Kentucky

Graduate Scholarships•Stryker Masters in Healthcare Scholarship – $5,000 Jody L. Bauer, BSN, RN, Texas

•Teleflex Scholarship – $5,000 Danita Mullins, BSN, RN, CEN, Arkansas

•Judith C. Kelleher Memorial Scholarship – $5,000 Lori Bannon, BSN, RN, Virginia

•Martha C. Wood Scholarship – $6,500 Erin S. Aston, BSN, RN, CPEN, North Carolina

•California State Council – Antoinette Robinson Scholarship – $5,000 Petra Coronado, BSN, RN, CEN, California

As a donor, you can make a difference in the future of emergency nursing. Your donation will help to provide funding for research that can improve the quality of patient care, build future leaders, support education that can change the practice of medicine in the future and much more. If you would like to join others in making a difference in emergency nursing, the ENA Foundation has opportunities for you to become involved. Visit www.enafoundation.org to find out how you can contribute to advancing emergency nursing.

Continued on next page

Learning opportunities at ENA conferences are only the beginning for emergency nurses looking to advance their educations, and the ENA Foundation is here to help.

October 201426

Thank you to the following organizations for

their generous support.

The ENA Strategic Sponsorship Program is designed to create partnerships with leading organizations whose objectives

include supporting the emergency nursing profession.

STRATEGIC SPONSORS

STRATEGIC SUPPORTER

Sponsorship Ad_Connection_half vert_08 2014.indd 1 6/25/14 3:48 PM

•Colorado State Council – Aurora Shooting Victims and Care Providers Scholarship – $5,000 Elizabeth Wolotira, BSN, RN, CEN, CPEN, CFRN, Oregon

•Georgia ENA State Council – Georgia State Council Scholarship – $5,000 Carrie L. Malone, BSN, RN, CEN, Indiana

•Illinois State Council – Illinois State Council Scholarship – $5,000 Susan Remaly, BSN, RN, CEN, Illinois

•Kentucky State Council – Kentucky ENA Founders Scholarship – $5,000 Kathy Tussey, BSN, RN, CEN, Kentucky

•Maryland State Council – Maryland ENA State Council Scholarship – $5,000 Jennifer A. Bishop, BSN, RN, CEN, Pennsylvania

•Michigan ENA State Council – Michigan State Council Scholarship – $5,000 Jo M. Tabler, BSN, RN, CEN, CFRN, Indiana

•Minnesota State Council – “Pathways VI” Scholarship – $5,000 Pamela Sue Jenkins, BSN, RN, CPEN, Pennsylvania

•New Jersey State Council – New Jersey State Challenge Scholarship – $5,000

Valerie Jackson, BSN, RN, FNE, Indiana

•Northern Chapter (NJ) – Mary Kamienski Scholarship – $5,000 Katie M. Bush, MA, RN, CEN, SANE-A, Ohio

•West Central Chapter (NJ) – Jeanette Ash Memorial Scholarship – $5,000 Andrea Helman, BSN, RN, CEN, Illinois

•South Carolina State Council – The Survivor Scholarship – $5,000 Peter Giordano, BSN, RN, CEN, Illinois

• Tennessee State Council – Brent Lemonds Memorial Scholarship – $5,000 Lynette Fair, BSN, Pennsylvania

Continued on next page

ENA Foundation Scholarships and Research Grants Continued from previous page

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October 201428

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•Texas State Council – Vicki Patrick Texas Legacy Scholarship – $5,000

Josie Boyle, BSN, RN, CEN, Oregon

•ENA Foundation State Challenge Scholarships – $5,000 each

Melissa Beans, BSN, Pennsylvania Emma Dragon, BSN, RN, CEN, EMT-B, Massachusetts Debra Kitchens, BSN, RN, CEN, NRP, South Carolina Melissa Kolarik, BSN, CEN, CFRN, Illinois Anne M. LeGare, BSN, RN, Wisconsin

•Gisness Advance Practice Scholarship – $3,000

Kathy Tussey, BSN, RN, CEN, Kentucky

•Karen O’Neil Memorial Scholarship – $3,000

Danita Mullins, BSN, RN, CEN, Arkansas

Doctoral Scholarships•Pamela Stinson Kidd Memorial Doctoral Scholarship – $10,000

Lisa M. Eckenrode, MSN, MBA, RN, NREMT-P, Pennsylvania

•ENA Foundation State Challenge Doctoral Scholarships – $5,000 each

Meredith J. Addison, MSN, RN, CEN, Indiana Tobin Miller, MSN, RN, CEN, CCRN, California Elizabeth R. Tedesco, MSN, RN, CEN, Pennsylvania

•ENA Foundation Doctoral Scholarship – $4,000

Cory Church, MSN, RN, Texas

•Hill-Rom Doctoral Scholarship – $2,500 Meredith J. Addison, RN, MSN, CEN, Indiana

Continuing Education Scholarships•Leadership Tapestry Conference Scholarships – $1,000 each

Erin Aston, BSN, RN, CPEN, North Carolina Danielle Bonca, BSN, RN, Nevada Molly Delaney, PhD, MBA, MNS, RN, CEN, CPEN, Minnesota Angela J. Hodge, MSN, RN, ACNS, CEN, EMT-P, Ohio Kelly Mills, BSN, RN, CEN, Indiana Rebekah Schelhaas, RN, CEN, South Dakota Ann B. Townsend, DNS, RN, ANP-BC, New Jersey Jessica A. Trivett, MSN, RN, CEN, New Jersey

Scholarships and Research Grants Continued from previous page


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•ENA Foundation Annual Conference Scholarships – $500 each Tiffany Alves, MS, CNS, CEN, California Debra Bach, MSN, RN, CEN, Vermont Stacey M. Cernadas, ADN, RN, EM-T, Alabama Kelly Collins, BSN, Maine Lisa Cooley, BSN, RN, CEN, Virginia Tammy Lalmansingh, BSN, Florida Lisa Lietzke, BSN, RN, CPEN, Delaware Stacy L. Maitha, RN, Indiana Emilie Moore, RN, CEN, Ohio Tina Moseley, BSN, RN, Georgia Kara Moyer, BSN, RN, CEN, Indiana Melissa Myers, RN, CEN, Florida Miranda Newberry, BSN, RN, CEN, Indiana

Curtis Olson, BSN, BS, RN, EMT-P, CEN, Nebraska Mary Pargin, BSN, RN, CEN, Illinois Shannon Mays Smith, BSN, RN, CEN, CPEN, Florida Kathryn Taylor, RN, Texas Deborah Villars, RN, Indiana Katie Wade, BSN, RN, CPEN, Delaware

•ENA Staff Sponsored Foundation Annual Conference Scholarships – $500 each

John Becklehimer, RN, Louisiana Katherine Mason, BSN, North Carolina

Research Grant Recipients•ENA Foundation/Sigma Theta Tau International Research Grant – $6,000

Allison Jones, RN, Kentucky

RESEARCH GRANT OPPORTUNITIES

Applications due Oct. 1 for

•ENAFoundation/ANIAResearch Grant – $6,000• IndustrySupportedResearchGrant – Supported by Stryker – $5,000

Applications due Nov. 1 for

•ENAFoundationSeedGrants – $500 each

Applications are available at www.enafoundation.org.

October 201430

T he state of nursing education in

the mid-20th century was quite

different from what it is today. Diploma nursing programs

thrived and were readily available to the emerging high

school graduate seeking a career path in a world of limited

opportunities for young women.1

Students most commonly chose hospital-based diploma

programs offering guaranteed clinical spaces for those

accepted into the program, unlike the ADN and BSN

models.3,5 During a demanding three-year program focused on

the art and science of nursing, students participated in

rigorous coursework in conjunction with ongoing clinical

assignments in a variety of clinical settings with diverse patient

populations and practice areas. Hospital-based diploma

programs, although limited in liberal arts content, provided a

well-rounded education for emerging professionals seeking a

nursing degree and supplied hospitals with needed staff.1,3

Under the strict guidance of nursing faculty and instructors,

students were assigned a variety of clinical roles and advanced

toward assuming independent responsibility for patient-

centered care upon graduation.

During the next few decades, these dedicated bedside

nurses gained further knowledge and experience and honed

their skills while on the job. Those who showed leadership

capabilities were identified by their superiors and offered job

advancement opportunities at their current educational level.

Seeking an advanced degree may not have been thought

necessary unless one desired to move into formal

management or a teaching position. Returning to school was

certainly challenging while balancing both work and family

obligations.

Today, advancements in medical technology, complex

clinical presentations and disease management require

nurses to achieve higher degrees of theoretical knowledge,

and thus diploma nursing programs have been phased out

while newer models emerged.1,3,4 From 1980 to 2008, the

number of new diploma graduates dropped significantly.3

While all might not agree, despite the decline of diploma

programs, some studies suggest that diploma graduates are

as competent in leadership and critical-thinking skills gained

from on-the-job experience as graduates from other

undergraduate nursing programs, and remain a valuable

asset to the nursing profession.2

Students are now strongly advised to enter the nursing

profession at higher levels to appropriately educate the

workforce of the future.4 Advancement through bridging

programs, incentives and online opportunities ease the

process, yet returning to school is still challenging, requiring

both financial investment and time commitment.

How does education differ from experience? The

separation between the two is the source of knowledge.

Education is attaining knowledge and theory through

textbooks. Experience is based on attaining knowledge and

theory and developing proficient skills over time.7 It seems

that education and experience are not mutually exclusive but

go hand-in-hand in charting one’s personal course and

career path. Novice to Expert — the model developed by

Patricia Benner, PhD, RN, FAAN — theorizes that expert

nurses develop skills and understanding of patient care over

time through a sound educational base as well as a

multitude of experiences.8

The current nursing workforce is comprised of a high

proportion of nurses who are nearing the end of their careers,

as well as those who are just entering the profession.3 The

mean age of nursing’s current workforce is estimated to be

well over 45, and as the baby boomers make their exit,

nursing will be faced with a void of thousands of practicing

professionals in the years ahead.3 There exists a tremendous

interest in nursing as a career, yet nursing schools are unable

to handle the volume of applicants.4 How will we fill these

vacancies and promote funding for faculty and programs

needed to educate our workforce of the future?

Future of Nursing Calls for Both Education and Experience

BOARD WRITES | Ellen (Ellie) H. Encapera, RN, CEN


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In response to the Patient

Protection and Affordable Care Act of

2010, the Robert Wood Johnson

Foundation released a comprehensive

report, ‘‘The Initiative on the Future of

Nursing,’’ and a vision for how nursing

will play a critical role in health care.

Recommendations include the removal

of scope-of-practice barriers,

expanding opportunities for nurses to

lead and collaborate in improvement

efforts, higher degrees of nursing

education at entry levels and beyond,

enabling nurses to lead change to

advance health, implementing

transition-to-practice programs,

promoting lifelong learning and the

collection of workforce data and

research.9 Encompassing all these

initiatives, nursing is perfectly poised

to assume a commanding role in the

future of preventive health care,

coordination of care and providing

comfort when cures are not possible.6

We all face personal challenges

along life’s journey, and sometimes we

must make tough choices. At our core,

we are all registered nurses, possessing

unique talents, skills, education and

experiences. As a diverse mixture of

both educated and experienced nurses,

we all can contribute to an exciting

future of opportunities for nursing.

Respecting our differences and

embracing our commonalities is a

recipe for success in meeting the

challenges ahead.

References

1. Scheckel, M. (2009). Nursing education: Past,

present, future. In G. Roux & J. Halstead (Eds.),

Issues and trends in nursing: Essential knowledge

for today and tomorrow (pp. 27-61). Sudbury, MA:

Jones and Bartlett Publishers, LLC.

2. Clinton, M., Murrells, T., & Robinson, S. (2005).

Assessing competency in nursing: A comparison

of nurses prepared through degree and diploma

programs. Journal of Clinical Nursing, 14(1),

82-94.

3. Committee on the Robert Wood Johnson

Foundation Initiative on the Future of Nursing,

Institute of Medicine. (2011). The future of

nursing: Leading change, advancing health.

Washington, DC: National Academies Press.

4. Aiken, L. H. (2011). Nursing education policy

priorities. In Committee on the Robert Wood

Johnson Foundation Initiative on the Future of

Nursing, Institute of Medicine (Eds.), The future of

nursing: Leading change, advancing health (pp.

6-15). Washington, DC: National Academies Press.

5. Undergraduate nursing education. In Committee

on the Robert Wood Johnson Foundation Initiative

on the Future of Nursing, Institute of Medicine

(Eds.), The future of nursing: Leading change,

advancing health (pp. 369-374). Washington, DC:

National Academies Press.

6. Key messages of the report. (2011). In

Committee on the Robert Wood Johnson

Foundation Initiative on the Future of Nursing,

Institute of Medicine (Eds.), The future of nursing:

Leading change, advancing health (pp. 21-46).

Washington, DC: National Academies Press.

7. Difference between education and experience.

(2011). Retrieved from http://www.

differencebetween.net/miscellaneous/difference-

between-education-and-experience/

8. Benner, Patricia E. (2013). From novice to

expert. Retrieved from http://currentnursing.com/

nursing_theory/Patricia_Benner_From_Novice_to_

Expert.html

9. Robert Wood Johnson Foundation. (n.d.). IOM

recommendations. Retrieved from http://www.

thefutureofnursing.org/recommendations

October 201432

Have you heard a good

story lately? A good

story is one that you don’t quickly forget. Stories are

powerful because they show us rather than tell us

about the human condition. Since the beginning of

time, the best of our values have been passed from

one generation to another, often through stories.

Stories provide us with roots to our past. They are

narratives of life that teach us valuable lessons.

At one point in time, tribes gathered around

central campfires to teach these lessons that helped

provide the group with strength and wisdom.

Because they are narratives of life, they encompass

virtually every facet of human behavior. Stories

weave threads of human interaction into our

everyday life and can infuse into our workplace

respect for our work and our peers.

Storytelling has gained great value in the field of

nursing. The stories told by nurses in the form of

case studies translate in our mind the essential role

of healing of body and spirit that nurses play each

day. The work of nursing theorist Patricia Benner1

used storytelling as the basis for a professional

development model. She applies this process to

demonstrate distinctions in the levels of practice for nurses.

These distinctions allow us to understand the relationship

between practice levels and skills in the individual nurse so

that professional development can be focused and move

forward.

Emergency nursing is practiced in a real world with real

constraints, possibilities and concerns. It is within this type of

setting that excellence can thrive and individual professional

practice can grow stronger over time. When any individual

nurse fails to understand the possibilities and potentials that

are present in practice, the profession as a whole suffers. This

brief excerpt of a developing professional in an emergency

department illustrates the approach to clinical judgment used

for her patient, who presented with a non-urgent complaint

one evening:

My patient certainly was not the most complex care I have

ever given, but it illustrated for me the mental work that needs

to go into my practice each and every day. The habit of

nursing observation is one of the most essential things I do

with my patients, and since

I am with that patient more

than any other member of

the team, my observation

may be key to safe and

appropriate treatment.

What I observed and the

conclusion that I drew from

those observations was

essential in defining a very

different course of treatment

than what was anticipated.

I always tell new nurses

coming to the emergency

department to be vigilant,

look for all clues and decide

what those clues may mean

for this patient.

The nurse who wrote

this narrative asked to not

include her name. She

stated that her reason to

remain nameless was to

convey the message that everyone has stories to tell that can

benefit others.

Narrative accounts such as these reveal an aspect of the

nursing role that is never captured in the formal procedures,

skill lists and job descriptions. Expert nurses often use

phrases such as ‘‘gut feeling’’ or ‘‘something just didn’t feel

right.’’ Watching for subtle changes or recognizing those

early-warning signs are a part of the everyday practice for

emergency nurses.

It has been said that storytelling can teach many lessons

as well as have a profound effect on recuperative and

restorative powers. Stories of emergency nurses will be

presented from time to time so that the essential threads

provided by nurses can be woven into the fabric of

emergency care. The new edition of CATN (Course in

Advanced Trauma Nursing) is based on case-study stories in

advanced trauma.

Reference

1. Benner, P. (2001). From novice to expert: Excellence and power in clinical

nursing practice, commemorative edition. New York, N.Y: Prentice-Hall.

The Wisdom in StoriesPRACTICE

By Kathy Szumanski, MSN, RN, NE-BC, Deputy Executive Director, Nursing

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Visit www.physio-control.com/CPRQuality to get the report.

Morrison L, Neumar R, Zimmerman J, et al. Strategies for improving survival after in-hospital cardiac arrest in the United States: 2013 consensus recommendations: A consensus statement from the American Heart Association. Circulation. 2013;127:1538–1563.

Meaney P, Bobrow B, Mancini M, et al. CPR quality: improving cardiac resuscitation outcomes both inside and outside the hospital. Circulation. 2013;128:1–19.

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October 201434

ELECTIONS

Your vote would never swing an

ENA election, right?

If that thought has kept you from

participating during election season,

when only 5 to 7 percent of ENA

members have voted in recent years,

then here’s a number you might want

to consider: Seven. That’s how many

times in the last 11 elections

that an ENA position has been

decided by fewer than 30 votes.

One contest for president-elect

in that span was decided by 18

votes, another by 11. A race for

a director position was decided

by a single vote in 2004.

We’re not just talking close,

said Nominations Committee

member Terry Foster, MSN, RN,

CCRN, CEN, CPEN, FAEN.

“Very, very, very close,”

Foster said.

Driven by this spring’s 6.17

percent voter participation rate

(just under last year’s 6.36 and

not atypical for professional association

elections) and the idea that races

affecting ENA’s direction could easily

go a different way with more voters

involved, Foster looked online for

inspiration. What he found was ‘‘The

Power of One,’’ a variation of an article

celebrating the importance of

democratic voting and citing historical

examples of a single vote affecting an

outcome. That document

(tinyurl.com/

powerofonevote, QR

code at left) has since

become a rallying point for the

Nominations Committee against two

constant questions: How do we get

more ENA members voting? How do

we get them more engaged?

One barrier is obvious.

‘‘There’s often a similar group of

people voting, and I think one of the

big things is people say, ‘We don’t

know who we’re voting for,’ ’’ said

committee member Lucinda Rossoll,

MSN, RN, CEN, CPEN, CCRN.

Wiping out that concern has

become a top priority. Rossoll sees

continued value in the

candidate forums held and

recorded at ENA conferences

(attending one years ago is

what first convinced her to

vote) and in the traditional

candidate biographies

published each spring in ENA

Connection and on the ENA

website. She and Foster agree

that giving candidates more

questions to flesh out their

positions on issues would be a

step forward.

‘‘Tell me how you feel about

mandatory overtime,’’ Foster

said. ‘‘Tell me how you feel

about unions for nurses. Tell me how

you feel about unlicensed personnel in

the emergency department doing some

nursing duties. Tell me some of those

things — like five questions. I think

that would be great. Then you can say,

‘Oh, no, I don’t like what they’ve said

on that,’ or you can say, ‘I really like

what this person said.’ You have a

much better idea, and that’s the power

of one vote.’’

Rossoll envisions ENA state councils

and chapters — themselves no

strangers to close elections —

becoming major difference-makers.

This goes further than simply reminding

members to vote. New Jersey ENA has

posted the national candidates’ pictures

and position statements on the walls for

reference at election time, Rossoll said.

New Hampshire, her home state, once

had a computer set up at its monthly

meeting and encouraged members to

sign in and vote right there.

Challenging states and chapters to have

spirited conversations about national

candidates could get many more

members invested.

‘‘They could have their own little

forum there,’’ Rossoll said.

ENA members already can ask

candidates questions on a dedicated

Facebook page during election season.

Rossoll said another idea would be to

separately record candidates answering

a list of identical questions and then

share those videos for viewing at state

and chapter meetings.

‘‘I think that would be interesting to

compare the answers,’’ Rossoll said,

‘‘and [one candidate] wouldn’t know

what the other [candidate] had said. I’d

like to have it done in front of a group,

too, just to see how composed they

can be.’’

As the Nominations Committee

explores these and other ways of

enhancing the process, there’s one

certainty: Voting has never been more

important. These efforts are crucial.

‘‘I’ve been a nurse for 37 years,’’

Foster said. ‘‘I have never seen it be so

crazy in healthcare as it has been in the

past two or three years — I mean, just

crazy. Every day you work, there’s

something different, there’s a new

directive, there’s something that’s

changed. Now, more than ever, I think

nurses need their professional

association to represent them. Because

of that, you need to vote to make sure

our association is going in the direction

that the majority wants it to.’’

INSIDE THE MARGINSNumbers Say Game-Changing Votes Are Out There For ENA RacesBy Josh Gaby, ENA Connection

Terry Foster

Lucinda Rossoll


If you were to poll a small group of

your colleagues, there is a high

probability that at some point in their

career, most have gotten a new job

through the power of networking.

An April 2013 LinkedIn article

indicates networking as the top source of hire, according to

data obtained from a source-of-hire survey conducted by

best-selling author Lou Adler.

The process of building and maintaining a solid

professional network has multiple benefits. Professional

contacts can be a valuable source of information such as

benchmarking, the sharing of best practices, information on

new career opportunities and an established social network.

Building a professional network does require time and

effort, but it doesn’t have to be a burden. Capitalize on all the

different ways to make and maintain your connections. In

today’s technology-driven world, there are many ways to

build your network without leaving the house. Participate on

a listserv or discussion forum or touch base with contacts via

e-mail. Be sure to supplement the technology-driven

networking with good, old-fashioned personal connections:

Call an old colleague to catch up, attend a professional

networking meeting or have lunch with some current

colleagues.

As your professional organization, ENA is committed to

helping you accomplish your professional goals and build

your professional network. For more resources

and information, visit the career wellness page at

tinyurl.com/ENAwellness (QR code at left) or

e-mail [email protected].

Let’s Do Lunch: Networking Matters

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October 201436

QUALITY AND SAFETY

F or older adults living in

long-term-care, assisted and

independent living facilities, the

transition of care to the

emergency department is

fragmented. Healthcare facilities

and EDs traditionally operate

independently. Thus, the sharing

of information is inconsistent or

missed.

The significant variability in the

amount of information sent with

patients from these types of senior

residences became apparent in

July 2010 when St. Mary Mercy

Livonia Hospital opened

Michigan’s first senior emergency

center for patients age 65 and

older. As exciting as it was to have

this specialized facility for this

population, what wasn’t anticipated was

the disconnect between each patient’s

current chart information and the key

transfer elements, such as reason for

transfer, code status, medical/surgical

history, medication profile and baseline

cognitive and functional status

necessary for emergency decision,

diagnosis and disposition.

Unavailable data when transferring

patients resulted in unnecessary rework,

inefficiencies and emergency healthcare

providers working blindly. Moreover,

incomplete information predisposes the

patient to receive unwanted or less care,

unnecessary tests and even wrongful

resuscitation in some cases.

According to Terrell et al.,

incomplete patient data contributes to a

flawed care plan, safety issues (such as

medication errors) and rehospitalization.

Moreover, flawed executed care

transitions can further lead to overuse of

emergency services and subsequent

unnecessary hospital admissions, thus

increasing healthcare costs.

A smooth patient flow is critical for

ED patients. Any lack of communication

interrupts care as ED staff time and

energy is diverted from primary

responsibilities to calling facilities to

obtain clinical information to treat

transferred patients in a competent

manner. Healthcare professionals are

then removed from the ED patient’s

side, which adds minutes to turnaround

time, affecting throughput and

contributing to ED overcrowding and

eventually patient and staff

dissatisfaction. Overall, instances of

omissions can increase the

possibility of adverse events

associated with long ED wait

times, thereby compromising

quality and safe delivery of

care.

Identifying the ProblemThe ED team (nurses,

physicians, techs, clerks, senior

social worker and case

manager) at St. Mary Mercy

Livonia recognized that efforts

to address these failures would

require systems-based changes

to improve patient safety

during transitions of care in

both directions. ENA’s

‘‘Practical Guide to Safer

Handoff of Older Adult

Patients Between Long-Term

Care Facilities and the ED’’ was

used as a guide to help facilitate the

first meeting. The guide has been

replaced by the new Geriatric

Emergency Nursing Education product,

which can be accessed at

tinyurl.com/ENA-GENE

or by scanning the QR code

at left.

The team then extended an

invitation to long-term care facilities,

emergency medical services and other

providers of care in the area to partner

in improving the transition process.

The response was outstanding. On

Nov. 14, 2011, they held their first

meeting. The energy in the room was

palpable as each member shared his or

her facility’s capabilities, transfer

documents and protocol. It became

clear how little everyone knew of each

MISSION: TRANSITION

By Joan Michelle Moccia, MSN, ANP-BC, CCRN

Alarmed By Information Gaps During Transfers of Older Adults, Michigan ED Team Starts a Coalition to Change the Local System


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Visit www.ena.org and take advantage of all the resources your ENA membership has to offer.

Membership Ad_Connection_half_10 2014.2.indd 1 9/1/14 9:56 PM

other’s scope-of-care capabilities and

transport procedures. Without

hesitation, the group agreed to

continue to meet monthly and focus

on improving transitions of care.

A bond was created, and a name

was selected to reflect the mission.

‘‘STARForUM: Safe Transition of All

Residents For yoU & Me’’ was born.

Making ImprovementsThe group has been meeting monthly.

Two-and-a-half years later, this

grassroots organization has been

responsible for many innovations and

interventions, including the following:

• Process-flow mapping of each facility

(skilled, assisted living, independent,

home health care) and EMS response

to a resident’s symptoms requiring

transport to the ED and return

• Color-coded phone directory to help

identify the facility level of care (red =

skilled; yellow = assisted; green =

independent)

• The facility care nursing capability,

i.e., wound care or IV therapy,

hyperlinked to the directory

• Audit tool (members self-monitor the

information sent to the ED by

reviewing the information sent from

the previous month)

• Transition checklist (list of key

elements needed for ED care)

- Medication assessment record

noting time of last dose given

- Recent antibiotic use

- Reason for stay in facility

- Medical/surgical history

- Family notification

- Code status

- Baseline mental and functional

status

- Last known time normal

- Fall patients: Mechanical or

physiological

• Transition letters from independent

facilities detailing services and/or care

plan detailing purchased support

services, i.e., medication reminders,

assist with ADLs

• Universal transfer form

• ED transition envelope/checklist for

safe return of ED patient back to

facility as a resident, followed by an

ED phone call detailing care received

in the ED and response of resident

• Encouragement of facility to send in

picture ID of their resident

• Discharge instructions including size

and manufacturer of peg tube

replacement

• Discharge instructions including

PICC lumen size and manufacturer

• Sepsis cue card to alert caregivers on

SIRS criteria

Continued on page 44

With the 2014 ENA Lantern Award recipients announced

in August, it would seem the members responsible for

the months-long application review process could kick back

and relax. However, the work of the Lantern Award Review

Committee is ongoing as members continually seek to

improve the process, chairperson Tami Morin, MS, RN,

NEA-BC, said.

The Lantern Award is a recognition award given to

emergency departments that exemplify exceptional practice

and innovative performance in the core areas of leadership,

practice, education, advocacy and research.

Morin, director of emergency services

at the University of Wisconsin Hospital,

leads a group of seven members who

review and score applications

submitted annually. The members’ work

begins in January with a conference call

to discuss the committee’s charges and the

award scoring tool and process. The next step is that

members receive sample Lantern Award applications falling

into each of the scoring bands — low, medium and high

— to try their hand at scoring. These results are reviewed

and compared to see how much inter-rater reliability there is

— whether members are scoring consistently or if there are

gaps that need to be addressed. The committee receives

actual applications in early spring.

‘‘That is where the true work begins,’’ Morin said.

For the 2014 cycle, each committee member was assigned

multiple applications. Each application is scored by more

than one person.

‘‘It takes me about three to four hours to score one

application,’’ Morin said. ‘‘When you multiply three to four

hours by 14, it’s a significant time commitment.

‘‘But when you think about how important it is to the

facilities that have applied, you don’t want to rush it. You

want to do a really good job because they’ve invested a

significant amount of time in preparing their application.’’

The committee meets at ENA headquarters in July to

discuss the selected award recipients, review any issues with

the scoring tool and make recommendations for revisions.

This is also when members draft letters to facilities that did

not receive an award.

‘‘I think this year was the year that we spent the most time

in drafting those letters, trying to give very specific feedback

that is useful to the facilities so if they reapplied, they would

really focus their energies in certain areas,’’ Morin said.

After all applicants are notified, the committee has more

homework. Members conduct literature searches on specific

sections within the application to ensure that the latest

literature is cited. A few members also participate in a Q&A

session at the ENA Annual Conference.

For potential applicants who can’t attend the committee’s

session in Indianapolis, Morin shared the following advice:

‘‘Make sure to read the guide provided by ENA on applying

for the Lantern Award. It really has the tips and tricks to

make sure that you are submitting a strong application.’’

Her second piece of advice is to ‘‘really look at your

department and your data and determine when the right time

to apply is. There are facilities who are doing great things,

but when you look at the requests for data showing tracking

and trending and sustained improvements, there has to be a

time frame on the back end of implementation where they

can really demonstrate those improvements.”

October 201438

Lantern Team Always Has a Light On

THE ENA LANTERN AWARD COMMITTEE: Clockwise, from lower left: Catherine Olson, MSN, RN, staff liaison; Sheryl Bloomer, MA, BSN, RN, CPN; Ellen Siciliano, BA, staff liaison; Tobin Miller, MSN, RN, CEN, CCRN, MICN; Jennifer Davis, MSN, MPH, RN, EMT-P, CEN, NE-BC; Tami Morin, MS, RN, NEA-BC, chairperson; India Owens, MSN, RN, CEN, NE-BC, FAEN. Not pictured: JoAnn Lazarus, MSN, RN, CEN, Board of Directors liaison; Kenneth Grubbs, MBA, RN; Jason Moretz, MHA, BSN, RN, CEN, CTRN.

By Amy Carpenter Aquino, ENA Connection

Details Matter.

October 201440

It’s an exclusive group that accepts

only one new member each year. It

takes years to qualify, including one

final whirlwind year of travel,

meetings, speaking engagements and

high-level decision-making, but once

you’ve gained access to this group,

you are guaranteed a spot for life.

The group is the ENA past

presidents, who reached 42 members

this year. When their latest addition,

JoAnn Lazarus, MSN, RN, CEN, the 2013

president, was conferring with past

presidents during the course of her term

last year, she realized the association

was not taking full advantage of their

wealth of leadership experience.

‘‘I recognized as we were moving

into the changes that were happening

within ENA last year, and even before

that, that we really weren’t tapping

into the wisdom and knowledge of our

past presidents,’’ Lazarus said. ‘‘I

wanted to figure out a way to bring a

group together to find out how they

were feeling about their role as past

presidents, and were they being

acknowledged in their role?’’

Lazarus proposed the formation of

the Past Presidents Task Force, which

the Board of Directors approved in

2013. Lazarus appointed Vicki C.

Patrick, MS, APRN, ACNP, CEN, FAEN,

1981-1982 ENA president and

chairperson; Joanne M. Fadale, BSN,

RN, FAEN, 1990 ENA president;

Benjamin E. Marett, EdD, MSN, RN,

CEN, CCRN, FAEN, 2000 ENA

president; Sherri-Lynne Almeida, DrPH,

MSN, MEd, RN, CEN, FAEN, 2002 ENA

president; and Nancy Bonalumi, MS,

RN, CEN, 2006 ENA president. The

same members are on the 2014 Past

Presidents Work Team.

Lazarus said she intentionally chose

past presidents from different decades

to represent varying years of

experience and service to ENA

‘‘because ENA has changed, and with

that, perceptions have changed,’’ she

said. ‘‘As we prepare for the future, we

can’t forget about how we got where

we are, and that’s through a lot of our

traditions and just the knowledge that

a lot of these past presidents have.’’

In a testament to their legacy as high

achievers, the task force immediately

created a survey for past presidents to

gauge their perceptions of their role

since leaving the board. The survey

helped fulfill the task force’s charge,

which Marett said was ‘‘to make

recommendations to the board of what

the expectations, roles and recognition

of past presidents should be.’’

The survey assessed the past

presidents’ opinions on experiences

such as their first year off the board

and resuming the member role, as well

as whether they thought there should

be an orientation to the past president

role and what roles could be identified

for past presidents, Almeida said.

‘‘This is a rich source of

information, not only about what’s

currently going on in the association

but the history of the association,’’ she

said, adding that it would be a shame

to ‘‘lose that knowledge bank.’’

The group received responses from

33 of the 37 living past presidents, an

impressive 85 percent response rate,

and the overall results were positive.

‘‘I think that most of the group felt

that there was a place for them within

ENA, that there were contributions that

they were able to make and willing to

make and that they wanted to be

involved in the association,’’ Bonalumi

Past Presidents: Their Work Continues

THE ENA PAST PRESIDENTS WORK TEAM: From left: Nancy Bonalumi, MS, RN, CEN; Joanne M. Fadale, BSN, RN, FAEN; current ENA president Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN; Benjamin E. Marett, EdD, MSN, RN, CEN, CCRN, FAEN; chairperson Vicki C. Patrick, MS, APRN, ACNP, CEN, FAEN; and Sherri-Lynne Almeida, DrPH, MSN, MEd, RN, CEN, FAEN. Not pictured: ENA Board of Directors liaison JoAnn Lazarus, MSN, RN, CEN, immediate past president.




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said. ‘‘They felt that while their role

was different, there was still value that

they could bring to the association.’’

Marett said past presidents

expressed interest in varying levels of

ENA involvement, from publishing in

the Journal of Emergency Nursing to

serving as mentors for the Academy of

Emergency Nursing and volunteering

for the ENA Foundation.

Lazarus said the second phase for

the work team is to help prepare ENA

presidents to move into the role of a

past president and to ease a transition

that she compared to ‘‘falling off a cliff.’’

‘‘One minute you’re in the know,

you’ve got all the information, people

are talking to you, and that’s through

Dec. 31,’’ she said. ‘‘And then Jan. 1

— well, now you’re not.’’

Immediate past presidents

experience a ‘‘sudden information

deficit’’ at the end of their term,

Lazarus said, and ‘‘there needs to be

some assistance with that transition.’’

Requesting input from presidents of

different eras ensures that a depth of

experience and collective wisdom will

contribute to creating better transitions

for ENA presidents, Patrick said.

Since ENA has many past presidents

involved at many different levels, there

are ample opportunities to stay active.

The ‘‘transition team,’’ as Patrick

referred to the work team, aims to help

past presidents arrive at how they can

productively make contributions once

they return to the role of the volunteer

rather than the elected official.

‘‘You have to decide what your

level of activity is going to be and how

you can offer to make those

contributions in a constructive manner

for the association,’’ Patrick said.

Fadale said it was surprising to find

in the research that some associations

‘‘put their past presidents out to pasture;

they have no say-so, no activity, no

involvement in their association ever

again, which I feel is very sad. It’s not a

good use of nursing knowledge or

management knowledge.’’

‘‘Or association knowledge,’’ Marett

added.

A literature search revealed that

very little information exists about

transitioning out of an association

leadership role or how to support

people going through that transition,

Bonalumi said.

‘‘I think we’re actually carving out

some new knowledge,’’ she said.

‘‘We’re at least identifying a plan for

our organization that may serve as a

template to others down the road.’’

Lazarus sees the work team

continuing for the foreseeable future

because each Dec. 31 will see a

mentoring opportunity for the newest

past president. Having people who

have been through that experience

will be invaluable. As Almeida said,

‘‘You have to walk in these shoes to

appreciate how difficult it can be to

walk in these shoes.’’

October 201442

Although it’s being sunsetted at the

end of this year, the Emergency

Nursing Technology and Informatics

Work Team has created several

resources that ENA members will be

able to use for years to come,

including some that offer guidance on

how technology can improve

emergency preparedness planning in

the emergency department.

Work team member Jeannette

Jefferies, MS, RN, CCRN, posted a

preliminary article titled ‘‘Preparing for

Disaster – Use of a Patient Tracking

System’’ to the ENA committee shared

documents site, and the complete

paper should soon be available to all

ENA members.

In the paper, Jefferies describes how

using a disaster tracker board can help

ED staff who need to track both disaster

patients who came into the ED and

regular ED patients. The regular ED

patients stay on regular tracker, while

disaster patients could be quickly

assigned to the disaster tracker. Jefferies

shows how to create a quick registration

for disaster patients and includes screen

shots of the quick registration and the

disaster tracker board.

A technology Jefferies has been

exploring is radio frequency

identification, or RFID, which she said

is superior to the more common

barcode scanning technology. While

barcode scanning is simpler and less

expensive, problems can arise with vital

processes such as patient identification;

if the admitting department, for

example, merges records and changes a

patient’s account number that is already

printed on his wristband, someone has

to make sure to switch out the patient’s

wristband. Sometimes a patient can end

up with two wristbands, and the wrong

code can be scanned. Patients also can

become disturbed and remove their

wristbands.

‘‘There are lots of potential risks

when it comes to scanning patients,’’

Jefferies said.

To decrease these and other risks,

some EDs have started using RFID to

track patients and be used for patient

identification. The technology has

been commonly accepted for tracking

equipment, such as monitors and IV

pumps, and even has been used to

track staff, she said. For example, RFID

can tell when a physician enters a

patient’s room to pinpoint exactly

when the medical screening exam

started, Jefferies said.

Her current facility, Mercy Medical

Center in Baltimore, where she works

in nurse informatics, uses a form of

RFID on the inpatient side.

‘‘We have it hooked up to our

call-light system, so when the nurse

walks into the room, it actually turns

Technology For Post-Disaster Tracking

THE EMERGENCY NURSING TECHNOLOGY AND INFORMATICS WORK TEAM: Front row, from left: Dagny S. Scofield, RN, CEN, CPEN; Monica Escalante, MSN, RN, senior associate, IQSIP. Middle row: Jeannette Jefferies, MS, RN, CCRN; Debra Esse, MHA, BS, RN, CEN. Back row: Mitch Jewett, RN, CEN, ENA Board of Directors liaison; David G. Holman, MNSc, RN; Michael Seaver, BA, RN, chairperson; and Leslie Talbert, senior administrative assistant, IQSIP.



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the call light off,’’ she said.

Another advantage RFID has over

barcode scanning for patient

identification is the inability to avoid

the system, said chairperson Michael

Seaver, BA, RN.

‘‘There was actually an article

published on the top 20 ways to work

around barcoded patient

identification,’’ he said.

Not that workarounds are always

negative.

‘‘Nurses, and emergency nurses in

particular, are notoriously adept at

making things work, whether it’s 101

uses for tape, or how do we avoid

delays due to technology, for which

the processes of the new technology

have not been thought out yet,’’

Seaver said.

Sometimes the workaround

provides a better outcome than the

original process, in which case Seaver

suggested people should keep an

open mind and consider making the

workaround the standard process.

‘‘To come up with a decent

workaround typically means that

someone has put in some good,

creative thinking,’’ he said.

Electronic medical record technology

is also being used more in disaster

preparedness planning. The ability to

create virtual care areas, for example,

can help an ED prepare for what

happens when 27 unexpected patients

are brought in after a train accident.

‘‘It’s one thing to be able to

recognize that this is where we’re

going to put all these people, for

instance,’’ Seaver said. ‘‘You may have

the greatest plan in the world —

walking wounded all going to this area

of the hospital — but then how do

you keep them organized? How do

you keep a head count? If you have

them built into the patient tracking, the

more information you have, the more

easily you can recognize that

information and deal with that

information.’’

Another way in which technology

can help in disaster planning is

syndromic surveillance, which is also

addressed in many electronic medical

record systems. Seaver explained

syndromic surveillance as an ED’s

ability to report on a large influx of a

vague gastrointestinal complaint, for

example.

‘‘Is it just coincidence, or is it maybe

something in the water supply?’’ he

said. Monitoring and reporting such

outbreaks to the Centers for Disease

Control and Prevention or the county

health department can help prevent a

biological hazard from becoming more

widespread.

The work team’s EMR handbook,

which also should be available to ENA

members soon, includes information

on patient identification, building

virtual locations and syndromic

surveillance, among other technology

issues.

connection Recruitment & Professional Opportunities

For ad rates and information, contact the ENA Development Department, 847-460-2626 or [email protected].

5 Armstrong Medical www.armstrongmedical.com

11 BCEN www.bcencertifications.org

48 Blue Jay Consulting www.bluejayconsulting.com

17 Chamberlain College of Nursing www.chamberlain.edu/info/ena.org

47 Fraser Health careers.fraserhealth.ca

27 Gebauer Company www.gebauer.com

46 Health Match BC www.healthmatchbc.org

45 Memorial Hermann ENA.MH-jobs.org

45 Munson Healthcare munsonhealthcare.org/recruitment

7 N-Pak www.n-pak.com

47 Nielsen Healthcare www.nielsenhealthcare.com

33 Physio-Control Inc. www.physio-control.com

29 Pinpoint Limited www.pinpointlimited.com

39 Stryker www.stryker.com

15 Teleflex Incorporated www.teleflex.com

18- Teva Pharmaceuticals22 www.tevausa.com

45 Tucson Medical Center tmcaz.com/NursingJobs

47 University of Texas Southwestern jobs.UTSouthwestern.edu

ADVERTISER INDEX

October 201444

• “Plan in a Can” (tennis ball can

innovation) and “Just in Case”

emergency brochure to secure vital

health information,

www.mymercy.us/justincase

• ‘‘Transitions of Care: The Perfect

Storm,’’ a live show consisting of

one-act vignettes showcasing excellent

and poor transitions of care; the show

was recently presented to the Wayne

State University Institute of Gerontology

• A website (in creation) to share

STARForUM’s tools

Reinforced by DataA retrospective quality assurance

review held between Nov. 19, 2013,

and Feb. 14, 2014 (n = 123)

demonstrated that those onboard with

the mission of STARForUM were much

more likely to send in key elements on

a 15-point transfer of information scale

than those who were not invested.

STARForUM members soon will be

testing the response of information

received by using a checklist delivered

by EMS personnel to facility staff when

they arrive to transport their resident

to the ED. Checklists can provide

guidance to paramedics and facility

staff and act as verification following

documentation of the identified key

clinical elements for a safe transition.

Checklists serve to aid in memory

recall, standardization and regulation

of processes, providing an outline for

evaluations or as a diagnostic tool.

ConclusionsThe success of the STARForUM group

is due to the unwavering devotion of

each individual to ensure the safe

transition of the vulnerable older adult.

An opportunity exists for every ED

in the nation to engage and strengthen

relationships with providers involved

in transition of care from nursing

facilities (skilled, assisted and

independent), EMS (interim providers

of care), licensed and nonlicensed

home care personnel, social workers,

case managers and ED personnel.

We hold our patients’ hearts in our

hands. Use your passion, wisdom and

advocacy to help remove barriers and

improve care quality and safety to this

vulnerable subset of older adult patients

through a coordinated care transition

approach that also will impact 30-day

readmissions. Let’s cross this healthcare

quality chasm together.

References

Coleman, E. A., Smith, J. D., Frank, J. C., Min, S., Parry, C., & Kramer, A. M. (2004). Preparing patients and caregivers to participate in care delivered across settings: The care transitions intervention. Journal of the American Geriatrics Society, 52, 1817-1825.

Hales, B. M., & Pronovost, P. J. (2006). The checklist—A tool for error management and performance improvement. Journal of Critical Care, 21, 231-235.

Terrell, K. M., & Miller, D. K. (2006). Challenges in transitional care between nursing homes and emergency departments. Journal of the American Medical Directors Association, 7, 499-505.

Resources

Improving on Transitions of Care: How to Implement and Evaluate a Plan, www.ntocc.org

Better Outcomes by Optimizing Safe Transitions (BOOST), www.hospitalmedicine.org/BOOST

Project RED (Re-Engineered Discharge), www.bu.edu/fammed/projectred

INTERACT (Interventions to Reduce Acute Care Transfers), interact2.net/

Remington Report (Interventional strategies and programs to improve care transitions with supporting evidence), www.remingtonreport.com

Transitions of Care Continued from page 37

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Great ER nursing careers – visit us at Booth #354 at the

ENA Conference to find out more!

memorialhermanncareers @MHTalent

5301 East Grant Road, Tucson, Arizona 85712 EOE Tobacco-free workplace

DREAM JOB.

When you choose a place to work… CHOOSE WELL.

Enjoy Tucson’s wonderful weather and grow your career in an environment that is fun, challenging and rewarding.

Check out all available positions at tmcaz.com/NursingJobs

NOW SEEKING ED, CRITICAL CARE AND ICU NURSES SIGN ON BONUS AVAILABLE!

Love what you do, and where you do it.Check us out. Be inspired.

munsonhealthcare.org/recruitment


The Island The North

JOB #H104-16165CLIENT: HEALTH MATCH BC

PUBLICATION: EMERGENCY NURSES ASSOCIATION ADINSERTION DATE: OCTOBER ISSUE

TRIM SIZE: 8.125" X 10.875"PREPARED BY: ECLIPSE CREATIVE INC. @ 250-382-1103

Fraser Valley

Discover the perfect place to call home.

Enrich your career. Enhance your quality of life.Join the many emergency nurses who have moved to British Columbia (BC), Canada to enjoy a quality of life that is envied around the world. Find out how our nurse services team can assist you in matching your lifestyle interests with exciting career opportunities. Register online today!

TOLL-FREE: 1.877.867.3061 • TEL: 1.604.736.5920 • EMAIL: [email protected] Photo Credit: Picture BC

healthmatchbc.orgHealth Match BC is a free health professional recruitment service funded by the Government of British Columbia, Canada

FIND A JOB IN BC

Emergency Nurses Association

Annual Conference, Booth 650

October 9-11, 2014

Indianapolis, IN

Meet with our team

16165 Emergency Nurses Ass'n Ad Oct.indd 1 Minguo 103-08-27 9:18 AM


Emergency Nurses ~ Meet us at the ENA Conference - Booth #438

Together, we create great workplaces.

Apply online: careers.fraserhealth.caToll-Free: 1-866-837-7099Facebook: /fraserhealthcareersTwitter: @FHcareer

New Challenges, Rewards & Breathtaking Scenery!

In late 2014, the William P. Clements Jr. University Hospital will open its doors at UT Southwestern Medical Center, transforming medical care in North Texas and serving as a model for academic medical centers across the country. Join us now and get in on the ground floor as we build the future of nursing, today.

Join our busy and growing Emergency Department, a 30-bed unit seeing 36,000 patient visits a year and the only Joint Commission Accredited Comprehensive Stroke Center in North Texas.

Assistant Nurse Managers Emergency Department

Requires BSN, BLS, ACLS and 3-5 years current RN experience, of which at least 2 years have recently

been spent in an ED. Leadership experience as a charge nurse, coordinator or team leader is a plus!

Apply online at: jobs.UTSouthwestern.edu Or email [email protected]

All we need is you.

Explore opportunities as we buildthe team to open our new hospital!

UT Southwestern is an Affirmative Action/Equal Opportunity Employer.

Dallas, Texas

We are the future of nursing, today.

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Improve emergency care, improve your career

You know us as recognized ED leaders who guide hospitals toward real and

effective change. Now we would like to get to know you. Blue Jay Consulting is

looking for professionals with the leadership insight and clinical experience to

bring process improvements to our clients, and the passion and commitment to

enhance the overall quality of emergency care. If you consider yourself among

the best in your fi eld, you’ll fi nd yourself in good company at Blue Jay Consulting.

Join the strongest team in the industry and improve your career.

Contact Jim Hoelz or Mark Feinberg at 407-210-6570 to discuss how we can capitalize

on one another’s strengths.

www.bluejayconsulting.com

“ As a Blue Jay consultant, I bring my 30 years of emergency department leadership experience to each client. Every assignment brings a unique set of challenges, but the tools to solve them are similar. We can often shorten the improvement process from years to months and create an environment that is better for patients, families and staff. I leave each assignment with a good feeling that I have left it better than when I arrived. I love being a Blue Jay consultant.”

— B I L L B R I G G S , M S N , R N , C E N , F A E N

Senior Consultant Blue Jay Consulting, LLC

41% 55%28% 68%

Average improvement in time from arrival to seeing a physician.

Typical improvement in patient satisfaction scores and likelihood to recommend

Average improvement in throughput for admitted and discharged patients

Average improvement in LWBS rates, resulting in an additional $1.6 million in collected revenue

13BJAC_ENA_RecruitmentAd 0807.indd 1 8/8/13 1:40 PM

Documents

ENA Connection October 2014