ENA Connection June/July 2014 by ENA Connection

the Official Magazine of the Emergency Nurses Association

connection

June/July 2014 Volume 38, Issue 6

INCOMING

CLASS Tomorrow’s Looking Even Brighter as ENA Attracts Surge of Students at NSNA Convention

14 - 15

PLUS ... ♦ Record Number of Emergency Nurses at Day on the Hill 8 ♦ How GENE Course Will Help a Hundred Times Over 24

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Dates to Remember

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

Through June 11, 2014, noon CDT Voting for ENA National Elections (www.ena.org/about/elections)

Advocating For Children Who Need Emergency Care

June 13, 2014 Application deadline for Emergency Nursing 2015 Conference Planning Committee

ENA Exclusives PAGE 6 Update From ENA Headquarters PAGE 8 Day on the Hill 2014 PAGE 10 Washington Watch: New Bipartisan Law Expands Access For Mentally Ill PAGES 12 ENA Merging Conferences in 2015 to Create Single Amazing Experience PAGE 14 Student Nurses Swarm Up to ENA PAGE 21 Survey Says! Your Voice Carries PAGE 22 2014 Proposed Resolutions and Bylaws Amendments PAGE 24 Texas Health System Buys GENE Course in Bulk for ED Nurses PAGE 26 ENA Partners With Genentech to Launch Stroke Management Course PAGE 27 Know Your ENA Practice Resources PAGE 34 Military, ED Nurses Not So Different

Regular Features PAGE 4 Free CE of the Month Members in Motion PAGE 25 Future of Your Nursing PAGE 28 ENA Foundation PAGE 36 Academy of Emergency Nursing

recently had the opportunity to represent ENA at the Emergency Medical Services for Children National Resource Center Advisory Council meeting. The mission of EMSC is to reduce child and youth mortality and morbidity caused by severe illness or trauma. Administered through the Health Resources and Service Administration, EMSC funds and supports state grants to improve pediatric emergency care throughout the prehospital and emergency department environments. The EMSC program has provided funding to all 50 states, the District of Columbia and U.S. territories to support pediatric emergency care improvement projects and initiatives. If you are unfamiliar with EMSC, the QR code at left will take you to resources and information.

ENA has made support for the EMSC program one of its top priorities. In fiscal year 2014, ENA worked closely with other national health care groups, especially the American Academy of Pediatrics, to prevent further devastating cuts for EMSC. For fiscal year 2015, which starts Oct. 1, we joined our coalition partners in sending a letter to the House and Senate Appropriations Committee requesting $21.1 million for EMSC. In addition to protecting federal funding for the EMSC program, ENA is actively supporting House and Senate bills (H.R. 4290 and S. 2154) that would continue the EMSC program until 2019. Without the passage of the reauthorization legislation, the EMSC program will expire at the end of the fiscal year on Sept. 30. In 2013, ENA supported two major EMSC initiatives, the National Pediatric Readiness Project (left) and the Pediatric Interfacility Transport Toolkit (below, left). The toolkit was a joint venture between EMSC, ENA and the Society of Trauma Nurses and provides resources to facilitate the safe transfer and transport of a pediatric patient. The National Pediatric Readiness Project was an effort vigorously supported by ENA on the national, state and local levels. The

goal of this project was to measure an ED’s readiness to care for a child in an emergency situation. ENA joined the AAP and the American College of Emergency Physicians as strong supporters of this effort. In 2013, we asked members to identify departmental leaders and encourage their EDs to participate in the survey. We encouraged our members to partner with their state EMSC program manager (left) to identify ways to work together to increase participation in the survey. All of the partnering and support paid off. The results are in, and more than 4,000 EDs participated in the survey. As a nation, the average readiness score was 69. The

Continued on page 11

Official Magazine of the Emergency Nurses Association

Treatment methods for hemorrhagic shock have changed, and the latest free continuing education session from ENA will help you stay on top of the situation.

Available to you starting June 1 . . . ‘‘Stop the Fluid! Permissive Hypotension and Blood in the Shock Room,’’ presented by Elda G. Ramirez, PhD, RN, FNP-BC, FAEN, FAANP. (Credit: 1.0 contact hour.) Ramirez leads a review of the old methods of managing hemorragic shock and the current research that changed the practice. From there, you’ll revisit pathophysiology of shock and coagulation factors and review the rationale for how the new methods save trauma patients’ lives. To take this and other eLearning courses free as an ENA member: •G o to www.ena.org/freeCE, where you’ll log in as a member (or create an account). • Add desired courses to your cart and ‘‘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. Please 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 elearning@ena.org.

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.

Nightingale Honor for Direct Care Donna Gorman, BSN, RN, a staff nurse at Bethesda Butler Hospital Emergency Department in Hamilton, Ohio, shares that colleague David Sens, RN, has received the Florence Nightingale Award recognizing professional nurses in the greater Cincinnati area for their contributions to direct patient care. Sens is co-leader of the ED’s shared David Sens leadership and patient satisfaction committees. He also participates in two to three nursing mission trips per year and recently returned from Haiti. ◆ The emergency department of Terra Haute Regional Hospital in Terre Haute, Ind., was the department with the greatest number of certified nurses — 11, up from two — and was treated to breakfast by the hospital as part of its Certified Nurses Day observance March 19. ED staff nurse Merry Addison, RN, MSN, CEN, FAEN, also reports that the ED staff has reached out to the critical care unit, sponsoring one CCRN exam each

POSTMASTER: Send address changes to ENA Connection 915 Lee Street Des Plaines, IL 60016-6569 ISSN: 1534-2565 Fax: 847-460-4002 Website: www.ena.org E-mail: membership@ena.org

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year for the last three years. The number of CCRN nurses in the intensive care unit has jumped from one to four, with six other nurses studying for the exam. ◆ Kristine Kenney Powell, RN, MSN, CEN, NEA-BC, director of emergency services for Baylor Health Care System, has been appointed to represent ENA on the Joint Commission’s Professional and Technical Advisory Committee (PTAC), which reviews recommendations for the commission’s Hospital Accreditation Program. More than 40 national health care associations and the public are represented on the committee. Powell’s term runs through 2019. Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN, the 2014 ENA president, is the alternate representative, and ENA Chief Nursing Officer Kathy Szumanski, MSN, RN, NE-BC, serves as the ENA liaison. The PTAC’s first call was April 2, with the next scheduled for June 25. Do you have a recent professional or educational success story you want to share about yourself or an ENA member colleague? E-mail it to connection@ena.org with the subject line “Members in Motion.”

Publisher: Kathy Szumanski, MSN, RN, NE-BC Editor-in-Chief: Amy Carpenter Aquino Associate Editor: Josh Gaby Senior Writer: Kendra Y. Mims Editorial Assistant: Renée Herrmann BOARD OF DIRECTORS Officers: 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, CEN Mitch Jewett, AA, RN, CEN, CPEN Michael D. Moon, PhD, MSN, RN, CNS-CC, CEN, FAEN Sally K. Snow, BSN, RN, CPEN, FAEN Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN Joan Somes, PhD, MSN, RN-BC, CEN, CPEN, FAEN, NREMT-P Karen K. Wiley, MSN, RN, CEN Executive Director: Susan M. Hohenhaus, LPD, RN, CEN, FAEN

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Potential complications may include local or systemic infection, hematoma, extravasations or other complications associated with percutaneous insertion of sterile 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. *Research sponsored by the Vidacare Corporation. Teleflex and EZ-IO are trademarks or registered trademarks of Teleflex Incorporated or its affiliates. © 2014 Teleflex Incorporated. 2014-2673

UPDATE FROM ENA HEADQUARTERS | Susan M. Hohenhaus, LPD, RN, CEN, FAEN, Executive Director

There’s No Freezing ENA’s Progress A

fter surviving the coldest and snowiest winter in Chicagoland’s documented history, ENA staff are settled back into the spring and summer seasons, providing the warm and excellent service that ENA members have come to expect. Here are just a few of the highlights of what’s happening at ENA headquarters:

Strategic Partnerships The ENA Board of Directors appointed liaisons to: • The American Academy of Pediatrics Pediatric Education for Prehospital Professionals course steering committee (Jaclynn Haymon, RN, Maryland) • American College of Emergency Physicians Hurricane Sandy Recovery Research Project (Deb Cioffi, MSN, RN, New Jersey) • National Association of EMS Physicians Prehospital Evidence-Based Guidelines Project (Matthew F. Powers, MS, BSN, RN, MICP, CEN, California) • U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response Pediatric Transport Roundtable (Jerri Lynn Zinkan, MPH, BSN, RN, CPEN, Alabama) The ENA Board of Directors also reviewed and commented on the AAP draft policy Updated Guidelines for Palivizumah Prophylaxis Among Infants and Young Children at Increased Risk of RSV Hospitalization. The board also endorsed the ACEP clinical policy Critical Issues in the Evaluation and Management of

open rate also increased significantly in Q1 2014 at 46.6 percent (Q4 2013 was 33 percent), and there were 171,288 unique visits to ENA’s website, with 19 percent as mobile viewers.

Conferences and Meetings Adult Patients Presenting to the Emergency Department with Seizures.

Government Relations ENA’s Government Relations staff focused on the following federal issues in the first quarter of 2014: Poison Control Network Act, Omnibus Appropriation Bill, Excellence in Mental Health Act and Trauma Care Legislation. Government relations staff also monitored and contacted regulators and other stakeholders regarding the shortage of IV saline solution. At the state level, ENA government affairs staff assisted the following state councils: • Idaho ENA, as the state became the 30th to make the crime of assault/ battery on an emergency nurse a felony • Kansas ENA and Louisiana ENA, to assist those states in introducing similar bills • Illinois ENA on issues related to protecting Poison Center funding and legislation related to credentialing vs. licensing for emergency RNs, pre-hospital RNs and trauma nurse specialists.

Social Media ENA’s Facebook page climbed to almost 27,000 ‘‘likes,’’ an increase of 7 percent over Q4 2013; Twitter followers increased to 3,448 (up 8 percent); ENA’s LinkedIn account grew to 3,118 followers. ENA’s e-mail

ENA’s Conferences and Meetings team is working on the negotiations for ENA’s 2016 Emergency Nursing Conference in Los Angeles and the 2017 Emergency Nursing Conference in St. Louis. The team is also finalizing details for the 2014 ENA Annual Conference in Indianapolis and the 2015 Emergency Nursing Conference in Orlando, Fla., as well as the 2015 ENA State and Chapter Leaders Conference, the first time this will be offered as a stand-alone meeting. Details will be available soon for state and chapter leaders.

Institute for Emergency Nursing Research (IENR) IENR staff completed a national behavioral health study which has been submitted to the Journal of Emergency Nursing. A second study on determining the criteria for discharge for patients who receive narcotics in the ED also has been completed. IENR studies in progress include: Acuity Assignment (exploring the minimum data set required to make an accurate acuity decision); Fatigue and Cognitive Ability (exploring how fatigue impacts cognitive ability in calculating weightbased drug dosages); and Moral Distress in Emergency Nursing (exploring what circumstances cause moral distress in emergency nurses).

Institute for Quality, Safety and Injury Prevention (IQSIP) IQSIP staff completed reviewer training for Lantern Award cycle 4. IQSIP staff

June/July 2014

also facilitated committee work related to ongoing development of a community injury prevention toolkit, a primer on implementation of electronic health records in the ED and an ED manager’s survival guide.

Institute for Emergency Nursing Education (IENE) Q1 registration for ENA’s free CE member benefit was 1,357 for three courses. Ninety-nine nurses purchased ENA’s staffing guidelines online tool. ENA’s newly revised Geriatric Emergency Nursing Education program, which launched at the end of 2013, had 86 registrants in Q1. TNCC Seventh Edition launched in Q1 with a total of 1,094 registered for the eLearning modules and 2,423 registered for the instructor update rollout.

Edition, Course Operations is working with course directors and instructors to ship new instructor supplements and provider manuals and to schedule Seventh Edition provider courses. From January to March, the department’s number of phone calls nearly doubled, call time nearly tripled, and we expect to see continued high activity through the instructor update period that runs through June. ENPC Fourth Edition continues to grow, with 12 percent more provider courses already scheduled for this year. Updated copies of the provider manual were sent to all ENPC instructors at the end of March, and updated copies of the instructor supplement will go to them this summer.

Membership

rate of more than 11 percent. More and more emergency nurses are seeing the value of joining their colleagues in this member-centered association focused on providing safe, quality care for patients.

Financial Position ENA’s first quarter 2014 yielded healthy, vibrant financial results. ENA’s revenue growth was 7 percent over the same time period in the first quarter of 2013, and operating income was more than double last year’s first quarter, thanks to growing membership and courses and a successful Leadership Conference. ENA staff have managed expenses well in order to protect and reinvest member dues and education revenue in the profession and the association.

At the end of Q1 2014, 40,870 members were on the ENA membership roster. Course Operations So far this year we’ve added more than With theState launch the TNCC Seventh 1,100 members, an1 annualized growth and of Chapter Ad_Connection_half_0607 2014_print.pdf 5/7/14 9:51 AM

Official Magazine of the Emergency Nurses Association

CAPITAL GAINS

Record Number of Emergency Nurses Attend Annual Day on the Hill

ore than 100 ENA members descended upon Washington, D.C., for the association’s annual Day on the Hill event. On Tuesday, May 6, attendees were briefed by Capitol Hill staff and experts on ENA’s two Congressional requests for their meetings. The next day, they met with their senators and representatives in support of S. 153/H.R. 274, the Mental Health First Aid Act, and H.R. 4080, the Trauma Care Systems and Regionalization of Emergency Care Reauthorization Act. The morning of May 7 started with the ‘‘Coffee with Congress’’ event on Capitol Hill. Reps. Michael Burgess (R-Texas), the sponsor of H.R. 4080, Lois Capps (D-Calif.), a former nurse and co-chair of the House Nursing Caucus, and Diane Black (R-Tenn.), the only former emergency nurse serving in Congress, addressed ENA attendees. In their meetings on Capitol Hill, ENA members met with more than 120 senators and representatives and their staffs. These meetings went a long way toward advancing ENA’s public policy agenda and, specifically, the prospects for enacting significant mental health and trauma care bills. — Marie Grimaldi, ENA communication and PR manager PHOTOS BY JULES CLIFFORD

June/July 2014

ENA President Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN, discusses ENA goals with a staff member for Sen. Kelly Ayotte (R-N.H.).

Mitch Jewett, AA, RN, CEN, CPEN (left), of the ENA Board of Directors chats with Stanley Watkins, chief of staff for Rep. Bobby Rush (D-Ill.). Rep. Leonard Lance (R-N.J.) meets with a group that includes 2014 ENA President-Elect Matthew F. Powers, MS, BSN, RN, MICP, CEN (front, left).

Look for expanded coverage from Day on the Hill in the August issue of ENA Connection.

Official Magazine of the Emergency Nurses Association

WASHINGTON WATCH | Richard Mereu, JD, ENA Chief Government Relations Officer

New Bipartisan Law Expands Access For Mentally Ill A

s emergency nurses know all too â&#x20AC;&#x2030;â&#x20AC;&#x2030;well, the demand for mental health services is greater than ever as untreated mental illness is a major public health concern in the U.S. According to the Substance Abuse and Mental Health Services Administration, more than 41 million U.S. adults experienced mental illness in 2011, and the majority of adults who have mental health or substance use disorders do not get the ongoing care they need. Often, these patients seek treatment in emergency departments. This leads to boarding in EDs, as bed space for psychiatric patients is often difficult to locate, especially for patients who lack insurance. Community mental health clinics attempt to address this crisis by providing comprehensive treatment for children and adults with serious mental illnesses and addictions. These facilities, which treat 8 million Americans each year, are on the front lines of improving health outcomes, providing crisis response and prevention and administering outpatient mental health services. Unfortunately, after decades of budget cuts, these clinics are struggling to meet the ever-increasing demand for behavioral health services. In response to the need for community-based mental health services, Sens. Debbie Stabenow (D-Mich.) and Roy Blunt (R-Mo.) and Reps. Doris Matsui (D-Calif.) and Leonard Lance (R-N.J.) introduced the Excellence in Mental Health Act. The legislation was designed to improve quality standards and expand access to

community mental health clinics. It requires clinics to cover a broad range of mental health services, including 24-hour psychiatric crisis care, full assessments and better integration of physical, mental and substance abuse treatment. The bill also addresses the issue of inadequate funding by allowing community mental health clinics to be adequately reimbursed under Medicaid, just as federally qualified community health centers are reimbursed for comprehensive primary care services. This will give these clinics the financial resources to provide care for a much

wider population. Following its introduction, the Excellence in Mental Health Act received broad, bipartisan support. In the House of Representatives, the bill was co-sponsored by 45 representatives. A similar Senate version of the bill had 24 co-sponsors. The bill also was backed by more than 50 mental health, veteran and law enforcement organizations. ENA was a strong supporter of the Excellence in Mental Health Act and worked closely with both elected representatives and other national health care organizations as it made its way through the House and Senate. In

June/July 2014

March, the Excellence in Mental Health Act was added to a larger piece of legislation dealing with Medicare payments for physicians. Attaching it to a ‘‘must-pass’’ bill greatly improved the chances that these important mental health provisions would become law. On March 27, the physician Medicare payment legislation, which included the Excellence in Mental Health Act, passed the House of Representatives on a voice vote. In the Senate, the bill was approved on a 64-35 vote March 31. It was signed into law by President Obama on April 1. The enacted version of the Excellence in Mental Health Act establishes an eight-state demonstration project to expand mental health services in communitybased clinics. States will be able to apply through the Department of Health and Human Services. The new law could help as many as 750,000 uninsured and low-income Americans with the most serious and persistent mental health conditions, including 100,000 veterans returning from Iraq and Afghanistan. After an initial two-year period, the demonstration program could be extended to additional states. The passage of the Excellence in Mental Health Act is an important milestone in enhancing the treatment options for mentally ill patients. It also represents a significant accomplishment for ENA’s government relations efforts. ‘‘Many ENA members work in emergency departments where behavioral health patients often seek treatment because of a lack of community-based mental health facilities,’’ said ENA President Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN. ‘‘This new law will improve the quality of care and increase access for those who need treatment.’’

From the President Continued from Page 3 survey also provided a national perspective about pediatric patient volume in our EDs. Sixty-nine percent of the EDs surveyed treat fewer than 5,000 pediatric patients per year, or fewer than 14 per day. Why is this information important? Expertise comes with experience. We need to provide tools and resources to help emergency nurses improve pediatric emergency care. There are some great ENA resources that every emergency nurse who cares for children should be aware of. The first is the ‘‘Guidelines for the Care of Children in the ED’’ (below, left). A joint policy statement by ENA, ACEP and AAP, it provides a primer for resources that every ED that cares for children should have. There is a checklist that you can use to identify strengths and opportunities in your own ED. A second resource that directly impacts pediatric patient safety is the ENA position statement “Weighing Pediatric Patients in Kilograms’’ (left). There are two clinical practice guidelines that directly address pediatric emergency care: Noninvasive Temperature Measurement in the ED (above, right) and NeedleRelated Procedural Pain in Pediatric Patients in the ED (left). The EMSC National Resource Center has educational resources, toolkits, disaster preparedness information and many other resources (below, right) available to the public. The National Pediatric Readiness Project website is also a wealth of information and resources.

Official Magazine of the Emergency Nurses Association

How can you help support the national effort to improve pediatric emergency care? I ask you to do two things: 1. Urge your state representatives to co-sponsor H.R. 4290 and your senators to co-sponsor S. 2154. Both of these bills are bipartisan legislation, co-sponsored by Rep. Peter King and Sen. Orrin Hatch. Not sure how to contact your representatives? Visit the EN411 Advocacy Engagement Page (left) and find your elected officials. Let your representatives know how important this program is to the emergency care of children in this country. 2. Find out if your ED participated in the National Pediatric Readiness Survey. Each hospital received its score when it submitted the survey. The EMSC program managers are able to provide comparison data for each state. Talk to your manager about your ED’s strengths and opportunities. Then commit to taking an opportunity to work on a project or initiative to improve pediatric emergency care in your department. Using the resources here, in the Emergency Nursing Pediatric Course or from your local or regional pediatric hospital, I have no doubt you will have the tools to safely care for the pediatric patients in your ED. Each of us has a voice and a role in improving pediatric emergency care. How will you use your voice?

CONFERENCES

From 2 to 1 ENA Combining Conferences in 2015 to Create Single Amazing Experience By Amy Carpenter Aquino, ENA Connection

he land of innovation and celebration is the perfect setting for ENA’s Emergency Nursing Conference. Orlando, Fla., home to seven of the world’s top theme parks, including Walt Disney World, is the host city for the first ENA Emergency Nursing Conference. From Sept. 28 to Oct. 3, 2015, ENA’s two conference experiences — Annual and Leadership conferences — will become one integrated event in Orlando. ‘‘We are all looking forward to providing our members and guests an exciting and innovative Emergency Nursing 2015 Conference,’’ said Matthew F. Powers, MS, BSN, RN, MICP, CEN, the 2014 ENA president-elect. ‘‘A few years back, our members and vendors responded to a survey about combining both our Leadership and Annual conferences into one great conference. We are working diligently to provide you the best experience in 2015, which will address both leadership and clinical topics. There will be opportunities for everyone to learn and grow with new educational offerings and activities planned in Orlando. Please join me and your ENA Board of Directors at our first combined ENA Emergency Nursing Conference.’’ The combined conference will help ENA achieve its goal of promoting safe practice and safe care through education,

networking and advocacy. It promises more education, more hands-on learning labs, more networking opportunities and more fun, all in one conference. Attendees can choose courses from both leadership and clinical practice tracks in an expanded, six-day conference schedule. The ENA General Assembly will still be held at the beginning of the conference, but it will be divided into three half-day formats, giving state leaders and delegates a more flexible schedule. The new format will free up General Assembly attendees to attend afternoon educational sessions or connect and caucus with their states. Authors who need to revise proposed bylaws amendments and resolutions will have more focused time to spend on rewrites. Special-interest groups and networking sessions will be expanded as well, allowing members to visit two or three sessions instead of only one.

June/July 2014

Expanded educational opportunities, formerly called presessions, will be presented differently. Instead of being scheduled before the educational portion of the conference, these longer-format sessions will be held at different times throughout the conference to be accessible to more attendees.

2014 ANNUAL CONFERENCE

Attendees will have more social events for networking with colleagues, including both an opening and closing reception. Beginning in 2015, the ENA Awards Gala will be held in the middle of the conference to give attendees more opportunities to congratulate the award winners throughout the week. The new conference provides all attendees with more time to take advantage of Orlando’s various attractions, activities and nightlife. For ENA staff, the switch to one conference allows more time to explore new options and focus on preparing the best educational and networking opportunities for emergency nurse professionals. For a sneak peek of the ENA Emergency Nursing 2015 Conference, look up “Emergency Nursing 2015 Trailer” at www.youtube. com.

JOIN US INDIANAPOLIS

Indiana Convention Center

October 7-11, 2014

Registration Opens June 5 § Attend a wide range of educational sessions § Learn about innovative products and services § Network with colleagues from around the world

For the latest updates and event details, please visit www.ena.org/AC

AC14_Connection_half_0607 2014.indd 1

Official Magazine of the Emergency Nurses Association

5/8/14 3:36 PM

MEMBERSHIP

Student nurses fill the room to hear ENA President Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN, who snapped this photo from the stage on April 11 and later shared it on her president’s blog (enapresident.wordpress.com).

SWARMING UP TO ENA Message Resonates at NSNA Convention, Leading to More Than 160 New Student Memberships

By Josh Gaby, ENA Connection

ow excited is 23-year-old Carly Campbell to be a new ENA member? She could cry. Campbell, on the verge of graduating May 10 from the Palm Beach Atlantic University nursing program in West Palm Beach, Fla., traveled with three friends to the National Student Nurses’ Association annual convention April 9-13 in Nashville, Tenn. — her first time attending. She already had visited ENA’s booth and applied for a student membership when she heard a capacity-crowd presentation by ENA President Deena Brecher, MSN, RN, APN, ACNS-BS, CEN, CPEN, on what it

means to be an emergency nurse. The ED is the only place in the hospital we don’t say no to people. We take care of every person who comes in the door. That, said Campbell, who did her preceptorship in the emergency department, was ‘‘the highlight of the whole conference for me.’’ ‘‘It totally clicked a lot of things for me in my nursing career,’’ she said, ‘‘and I teared up a little bit, I loved it so much. . . . There’s definitely a specific personality of people that gravitate toward the emergency room. And so to be connected to people who are actually passionate about emergency nursing as a whole, and not just addicted to adrenaline, is really an amazing resource.’’

Carly Campbell

Lines of inspired students agreed. Over three days, ENA signed up 163 new members from 40 states, about double the signups from last year’s convention, and added three more through membership drawings. Traffic spiked after Brecher’s presentations. ‘‘It was just like a mob,’’ said Tennessee ENA State Council President Randy Mitchell, MBA, RN, CEN, who arranged for pairs of council volunteers, himself included, to join Brecher and ENA Member & Course Services supervisor Lindsay Paxton in fielding questions and handing out materials. Answering the call were Barbara Gibson, RN; Mona Kelley, MSN, RN; Holly Kunz, MSN, RN, CEN, CCRN; and Donna Mason, MS, RN, CEN, FAEN.

June/July 2014

‘‘There were so many people [Saturday], they just filled the booths next to us and in front of our booth, and that’s how much of a crowd we had,’’ Mitchell said. ‘‘It’s really nice to see the excitement and the enthusiasm of these young, to-be nurses. A lot of them are in their last semesters, so they’re seeing that light at the end of the tunnel that they’re going to be able to get out and start doing something.’’ One of those students was Jamie Scoff, then a month from graduating from the four-year nursing program at Salisbury University in Salisbury, Md. Though her internship the last seven weeks of school was in an ED, the NSNA convention was her first exposure to ENA. Hearing Brecher sold her on joining. She already is applying what she’s learning. ‘‘[Brecher] had discussed jumping right in and trying to impress and wow everybody that you’re working with, and so I’ve started arriving 15 minutes earlier than they want me to come in and really not holding back at all,’’ Scoff said. Emily Anderson, who will get her BSN in August from the nursing program at Herzing University in suburban Minneapolis, attended her first NSNA convention with three classmates, all of whom joined her in becoming ENA members after hearing about ENA’s courses, continuing education and networking. ‘‘I was kind of in between emergency nursing and ICU nursing, and [Brecher] really cleared up a lot of things about emergency room nursing that I was a little unclear about,’’ Anderson said. What no one should be unclear about is why spreading the word at NSNA matters. ‘‘When we look at membership and our membership demographics, we are starting to see a growth in the under-30 nurse, which is incredibly important,’’ Brecher said. ‘‘So I think we’re starting to really recognize the

Top: Brecher connects with students at the ENA booth in Nashville, which was staffed by a team of ENA enthusiasts that included (left, from left) Mona Kelley, MSN, RN; Brecher; Tennessee ENA President Randy Mitchell, MBA, RN, CEN; and ENA Member & Course Services supervisor Lindsay Paxton. value of engaging nurses while they’re still students.’’ Many of the visitors to the ENA booth wanted to know how they might be included as they start out in emergency nursing. The answer: by making the ED a mutual teaching environment. ‘‘I looked at all of them and said, ‘You guys are all experts at evidencebased practice and doing a lit search, and that’s a skill that a lot of experienced nurses that have been practicing a while don’t have,’ ’’ Brecher said. ‘‘While I, as a new nurse, might not have the experience to pick out the sick patient just by looking at them, I certainly have skills that will help improve the practice in the department.’’ Brecher stressed the importance of ENA state councils and chapters ‘‘harnessing the pixie dust’’ by

Official Magazine of the Emergency Nurses Association

including younger members in their activities. Carly Campbell was already ahead of her. She attended her first meeting with the Palm Beach County Chapter on April 22, less than two weeks after joining ENA, and was welcomed by chapter president Janine Mangold, RN, and about 50 members. Among them were Campbell’s charge nurse and a trauma nurse from the same ED who happens to be on the chapter board. The topic of the night was waveform capnography monitoring — information that came up the next week when Campbell was getting ACLS-certified. ENA is opening doors already. ‘‘As a student getting my footing in emergency nursing in that career choice, I was like, ‘Hey, what can you teach me?’ ’’ Campbell said. ‘‘It was wonderful. I skipped home. I was like, ‘This is the best.’ ’’

® ® ® ADASUVE ADASUVE (loxapine) ADASUVE (loxapine) inhalation (loxapine) inhalation powder inhalation powder 10 mg powder 10 mg 10 mg

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INDICATIONS INDICATIONS AND INDICATIONS USAGE AND USAGE AND USAGE ® ® ® ADASUVE ADASUVE ADASUVE (loxapine) (loxapine) inhalation (loxapine) inhalation powder,inhalation powder, for oral inhalation for powder, oral inhalation for use, oral is a inhalation use, typical is aantipsychotic typical use, is aantipsychotic typical indicated antipsychotic indicated for the indicated for the for the • A acute treatment acute treatment ofacute agitation treatment of agitation associated of agitation associated with schizophrenia associated with schizophrenia with or bipolar schizophrenia orI bipolar disorder orI disorder bipolar in adults. I disorder inEffi adults. cacyinEffi was adults. cacy was Efficacy was l demonstrated demonstrated in 2demonstrated trialsinin2acute trialsinagitation: in2acute trials agitation: inone acute in schizophrenia agitation: one in schizophrenia one and in schizophrenia one and in bipolar one in and I bipolar disorder. one inI disorder. bipolar I disorder. •A Limitations Limitations of Use: Limitations As of part Use:of As of the part Use: ADASUVE ofAsthe part ADASUVE Risk of theEvaluation ADASUVE Risk Evaluation and Risk Mitigation Evaluation and Mitigation Strategy and Mitigation Strategy (REMS) Program Strategy (REMS) Program to (REMS) Program to to •A mitigate mitigate the risk of the mitigate bronchospasm, risk ofthe bronchospasm, risk ofADASUVE bronchospasm, ADASUVE must be ADASUVE must administered be administered mustonly be administered in anonly enrolled in anonly enrolled healthcare in an healthcare enrolled facility.healthcare facility. facility. S b e IMPORTANT IMPORTANT SAFETY IMPORTANT SAFETY INFORMATION SAFETY INFORMATION INFORMATION m a WARNING: WARNING: BRONCHOSPASM WARNING: BRONCHOSPASM BRONCHOSPASM and and and c INCREASED INCREASED MORTALITY INCREASED MORTALITY IN ELDERLY MORTALITY IN ELDERLY PATIENTS IN ELDERLY PATIENTS WITH PATIENTS DEMENTIA-RELATED WITH DEMENTIA-RELATED WITH DEMENTIA-RELATED PSYCHOSIS PSYCHOSIS PSYCHOSIS •A Bronchospasm Bronchospasm Bronchospasm k h ADASUVE ADASUVE can cause ADASUVE canbronchospasm cause can bronchospasm causethat bronchospasm hasthat the potential has that the potential has to lead the potential to torespiratory lead totorespiratory lead distress to respiratory distress and distress and and respiratory respiratory arrest. respiratory Administer arrest. Administer arrest. ADASUVE Administer ADASUVE only inADASUVE an only enrolled in an only enrolled healthcare in an enrolled healthcare facility healthcare that facility hasthat immediate facility has that immediate has immediate n access on-site access to on-site access equipment to on-site equipment and topersonnel equipment and personnel trained and personnel to trained manage to trained manage acuteto bronchospasm, manage acute bronchospasm, acute including bronchospasm, includingincluding •U advanced advanced airwayadvanced management airway management airway (intubation management (intubation and mechanical (intubation and mechanical and ventilation). mechanical ventilation). Priorventilation). to administering Prior to administering Prior to administering t ADASUVE, ADASUVE, screen ADASUVE, patients screen patients regarding screen patients regarding a current regarding a diagnosis, currentadiagnosis, current history, diagnosis, or history, symptoms or history, symptoms of asthma, or symptoms of asthma, COPDof asthma, COPD COPD l and other and lung other diseases, and lung other diseases, and lung examine diseases, and examine (including and examine (including chest (including auscultation) chest auscultation) chest patients auscultation) patients for respiratory patients for respiratory for respiratory •U signs. Monitor signs. Monitor for signs. signsMonitor for and signs symptoms for and signs symptoms ofand bronchospasm symptoms of bronchospasm offollowing bronchospasm following treatment following treatment with ADASUVE. treatment with ADASUVE. with ADASUVE. •T BecauseBecause of the risk Because of of thebronchospasm, risk of of the bronchospasm, risk of ADASUVE bronchospasm, ADASUVE is available ADASUVE is available only through is available only through a restricted only through a restricted program a restricted programprogram c under a under Risk Evaluation a Risk under Evaluation a and RiskMitigation Evaluation and Mitigation Strategy and Mitigation Strategy (REMS)Strategy called (REMS)the called (REMS) ADASUVE the called ADASUVE REMS. the ADASUVE REMS. REMS. •T Increased Increased Mortality Increased Mortality in Elderly Mortality inPatients ElderlyinPatients With Elderly Dementia-Related Patients With Dementia-Related With Dementia-Related Psychosis Psychosis Psychosis a Elderly patients Elderly patients with Elderly dementia-related with patients dementia-related with dementia-related psychosis psychosis treatedpsychosis with treated antipsychotic with treated antipsychotic with drugs antipsychotic are drugs at anare drugs at anare at an increased p increased increased risk of death. risk of ADASUVE death. risk of ADASUVE is death. not approved ADASUVE is not approved foristhe nottreatment approved for the treatment of forpatients the treatment of patients with dementia-related of with patients dementia-related with dementia-related psychosis. psychosis. psychosis. •U •T p •P • ADASUVE • ADASUVE is contraindicated • ADASUVE is contraindicated isincontraindicated patients in patients with the in following: with patients the following: with the following: a — Current — diagnosis Current —diagnosis Current or history diagnosis orofhistory asthma, orofhistory asthma, chronic ofobstructive chronic asthma,obstructive chronic pulmonary obstructive pulmonary disease pulmonary (COPD), disease (COPD), or disease other lung or (COPD), other lung or other lung p disease associated disease associated disease with bronchospasm associated with bronchospasm with bronchospasm — Acute— respiratory Acute — respiratory Acute signs/symptoms respiratory signs/symptoms (eg, signs/symptoms wheezing) (eg, wheezing) (eg, wheezing) •N — Current — use Current of — medications use Current of medications use toof treat medications airways to treat disease, airways to treatdisease, such airways as asthma disease, such as or asthma such COPD asor asthma COPDor COPD •T — History —of History bronchospasm —ofHistory bronchospasm offollowing bronchospasm following ADASUVE following ADASUVE treatment ADASUVE treatmenttreatment Re — Known —hypersensitivity Known—hypersensitivity Knowntohypersensitivity loxapine to loxapine or amoxapine. to loxapine or amoxapine. Serious or amoxapine. skin Serious reactions skin Serious reactions have skin occurred reactions have occurred with have oraloccurred with oral with oral 2. loxapine loxapine and amoxapine loxapine and amoxapine and amoxapine • ADASUVE • ADASUVE must•be ADASUVE must administered be administered mustonly be administered by aonly healthcare by aonly healthcare professional by a healthcare professional professional Pl • Prior to•administration, Prior to•administration, Prior to alladministration, patients all patients must be all must patients screened be screened must for abe history screened for aofhistory pulmonary for aofhistory pulmonary disease of pulmonary and disease examined and disease examined and examined in (including (including chest auscultation) (including chest auscultation) chest for respiratory auscultation) for respiratory abnormalities for respiratory abnormalities (eg,abnormalities wheezing) (eg, wheezing) (eg, wheezing) • Administer • Administer only •a Administer single only 10 a single mg only dose 10 a single mg of ADASUVE dose 10 mg of ADASUVE dose within of a ADASUVE 24-hour within a period 24-hour within by a period 24-hour oral inhalation byperiod oral inhalation by using oralthe inhalation using theusing the single-use single-use inhalersingle-use inhaler inhaler

® ® ADASUVE®ADASUVE (loxapine) ADASUVE (loxapine) inhalation (loxapine) inhalation powder inhalation powder powder

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HELP DEFUSE HELP HELP THE DEFUSE DEFUSE SITUATION THE THE SITUATION SITUATION BEFORE BEFORE BEFORE AGITATION AGITATION ESCALATES AGITATION ESCALATES ESCALATES FURTHERFURTHER FURTHER ORAL INHALATION ORAL ORAL INHALATION INHALATION

For REMSFor Program For REMS REMS Program Program information, information, information, visit visit visit ADASUVEREMS.COM ADASUVEREMS.COM ADASUVEREMS.COM or call 855-755-0492 or call or call 855-755-0492 855-755-0492

Breath-actuated, Breath-actuated, Breath-actuated, single-use, single-use, single-use, ready-to-ready-toready-to1 1 1 use inhaler use use inhaler inhaler

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10 10 10 ONSET ENDPOINT ENDPOINT ENDPOINT SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA BIPOLAR I DISORDER BIPOLAR BIPOLAR I DISORDER I DISORDER FAST ONSET FAST FAST ONSET PLACEBO PLACEBO PLACEBO PLACEBO ADASUVE PLACEBO ADASUVE ADASUVE ADASUVE PLACEBO ADASUVE ADASUVE min min min Statistically signifi cant AT 2 HOURSAT 2ATHOURS Statistically Statistically significantsignifi cant 2 HOURS 49% 33 49%49 % % 3333 % 53%% 27 53%53 % % 2727 % %

(PRIMARY) in agitation reductionreduction inreduction agitation in at agitation at at(PRIMARY) (PRIMARY) AT 10 MINUTES AT 10 ATMINUTES 10 MINUTES 2 improvement hours, with improvement 2 hours, with 2 hours, with improvement 19% 10 19%19 % % 1010 % 23%% 10 23%23 % % 1010 % % (SECONDARY) (SECONDARY) (SECONDARY) rapidly rapidly achieved rapidly achieved at achieved at at 1 1 1 10 minutes 10post-dose 10 minutes minutes post-dose post-dose The mean baseline TheThe mean PEC mean baseline scores baseline PEC in all PEC scores treatment scores in all in groups treatment all treatment weregroups 17.3 groups towere 17.7. were 17.317.3 to 17.7. to 17.7.

PEC=Positive and PEC=Positive Negative PEC=Positive Syndrome and Negative and Negative Scale-Excited Syndrome Syndrome Component. Scale-Excited Scale-Excited Intent-to-treat Component. Component. population Intent-to-treat Intent-to-treat with population last observation population with with last carried observation last forward. observation carried Agitation carried forward. symptoms forward. Agitation Agitation measured: symptoms symptoms tension, measured: excitement, measured: tension, tension, poor excitement, excitement, poorpoor impulse control,impulse uncooperativeness, impulse control, control, uncooperativeness, uncooperativeness, hostility. Each item hostility. ishostility. scored Eachon Each item a scale item is scored is from scored on 1 toa on 7scale (1=absent, a scale fromfrom 1 4=moderate, to 71 (1=absent, to 7 (1=absent, 7=extreme). 4=moderate, 4=moderate, Patient 7=extreme). total 7=extreme). PECPatient scores Patient total ranged total PECfrom PEC scores 14 scores ranged to 31ranged out from of afrom 14 possible to14 31toout 35. 31of out a possible of a possible 35. 35. The efficacy of The ADASUVE The efficacy efficacy 10ofmg ADASUVE ofinADASUVE the acute 10 mg treatment 10 in mg theinacute the of agitation acute treatment treatment associated of agitation of agitation withassociated schizophrenia associated with or with schizophrenia bipolar schizophrenia I disorder or bipolar or was bipolar established I disorder I disorder was in awas established short-term established in (24-hour), a short-term in a short-term randomized, (24-hour), (24-hour), randomized, randomized, double-blind, placebo-controlled, double-blind, double-blind, placebo-controlled, placebo-controlled, fixed-dose trial fixed-dose including fixed-dose 344 trialpatients including trial including who 344met 344 patients DSM-IV patients who criteria who met met DSM-IV for schizophrenia DSM-IV criteria criteria for and schizophrenia for in schizophrenia another study, and and in 314 another in patients another study, study, who 314met patients 314DSM-IV patients who criteria who met met DSM-IV for DSM-IV criteria criteria for for bipolar I disorder, bipolar manic bipolar I disorder, or Imixed disorder, manic episodes manic or mixed with or mixed or episodes without episodes with psychotic with or without orfeatures. without psychotic psychotic features. features.

IMPORTANT IMPORTANT IMPORTANT SAFETY SAFETY INFORMATION SAFETY INFORMATION INFORMATION (continued) (continued) (continued) • After ADASUVE • After • After ADASUVE administration, ADASUVE administration, administration, patients must patients patients be monitored must must bebe monitored for monitored signs for and for signs symptoms signs and and symptoms of symptoms bronchospasm of bronchospasm of bronchospasm at at at least every least 15 least minutes every every 15for 15 minutes minutes at least for1for at hour least at least 1 hour 1 hour • ADASUVE • ADASUVE •can ADASUVE cause can sedation, can cause cause sedation, which sedation, can which mask which can the can mask symptoms mask thethe symptoms of symptoms bronchospasm of bronchospasm of bronchospasm • Antipsychotic • Antipsychotic • Antipsychotic drugs candrugs cause drugs can acan potentially cause cause a potentially afatal potentially symptom fatal fatal symptom complex symptom complex called complex Neuroleptic called called Neuroleptic Neuroleptic MalignantMalignant Malignant Syndrome Syndrome (NMS), Syndrome manifested (NMS), (NMS), manifested manifested by hyperpyrexia, by by hyperpyrexia, hyperpyrexia, muscle rigidity, muscle muscle altered rigidity, rigidity, mental altered altered state, mental mental irregular state, state, pulse irregular irregular or pulse pulse or or blood pressure, blood blood pressure, tachycardia, pressure, tachycardia, tachycardia, diaphoresis, diaphoresis, diaphoresis, and cardiac and and dysrhythmia. cardiac cardiac dysrhythmia. dysrhythmia. Associated Associated Associated features can features features include cancan include include escalatedescalated serum escalated creatine serum serum phosphokinase creatine creatine phosphokinase phosphokinase (CPK) concentration, (CPK) (CPK) concentration, concentration, rhabdomyolysis, rhabdomyolysis, rhabdomyolysis, elevated serum elevated elevated and serum urine serum and and urine urine myoglobin myoglobin concentration, myoglobin concentration, concentration, and renaland failure. and renal renal If failure. NMS failure. occurs, If NMS If NMS immediately occurs, occurs, immediately immediately discontinue discontinue discontinue antipsychotic antipsychotic antipsychotic drugs drugs drugs and otherand drugs and other other that drugs may drugs that contribute that may may contribute tocontribute the underlying to the to the underlying disorder, underlying disorder, monitor disorder, and monitor monitor treat and symptoms, and treat treat symptoms, symptoms, and treat and any and treat treat anyany concomitant concomitant concomitant serious medical serious serious problems medical medical problems problems • ADASUVE • ADASUVE •can ADASUVE causecan hypotension, can cause cause hypotension, hypotension, orthostatic orthostatic hypotension, orthostatic hypotension, hypotension, and syncope. andand syncope. Use syncope. with caution Use Use with with incaution patients caution inwith patients in patients with with known cardiovascular known known cardiovascular cardiovascular disease, cerebrovascular disease, disease, cerebrovascular cerebrovascular disease, or disease, conditions disease, or conditions orthat conditions wouldthat predispose that would would predispose patients predispose topatients patients to to hypotension. hypotension. hypotension. In the presence In the In the presence of presence severe of hypotension severe of severe hypotension hypotension requiring vasopressor requiring requiring vasopressor vasopressor therapy, epinephrine therapy, therapy, epinephrine epinephrine should should should not be used notnot be be used used • Use ADASUVE • Use • Use ADASUVE with ADASUVE caution with with incaution patients caution inwith patients in patients a history with with of a history seizures a history of or seizures of with seizures conditions or with or with conditions that conditions lowerthat the that lower seizure lower thethe seizure seizure threshold.threshold. ADASUVE threshold. ADASUVE lowers ADASUVE the lowers seizure lowers thethreshold. the seizure seizure threshold. Seizures threshold. have Seizures Seizures occurred have have occurred in occurred patients intreated patients in patients with treated treated oral with with oraloral loxapine and loxapine loxapine can also and and occur cancan also inalso epileptic occur occur in patients epileptic in epileptic patients patients • Use caution • Use • Use when caution caution driving when when ordriving operating driving or or operating machinery. operating machinery. ADASUVE machinery. ADASUVE can ADASUVE impair can judgment, can impair impair judgment, thinking, judgment, thinking, and thinking, motor and skills and motor motor skills skills • The potential • The • The potential forpotential cognitive forfor cognitive and cognitive motor and impairment and motor motor impairment impairment is increased is increased iswhen increased ADASUVE when when ADASUVE isADASUVE administered is administered is administered concurrently concurrently concurrently with otherwith CNS with other depressants other CNS CNS depressants depressants • Treatment • Treatment •with Treatment antipsychotic with with antipsychotic antipsychotic drugs caused drugs drugs an caused increased caused an an increased incidence increased incidence ofincidence stroke of and stroke of transient stroke and and transient ischemic transient ischemic ischemic attack in attack elderly attack inpatients elderly in elderly with patients patients dementia-related with with dementia-related dementia-related psychosis; psychosis; ADASUVE psychosis; ADASUVE isADASUVE not approved is not is not approved for approved the treatment forfor thethe treatment oftreatment of of patients with patients patients dementia-related with with dementia-related dementia-related psychosis psychosis psychosis • Use of ADASUVE • Use • Use of ADASUVE ofmay ADASUVE exacerbate may may exacerbate exacerbate glaucomaglaucoma orglaucoma cause or urinary or cause cause retention urinary urinary retention retention • The most • The •common The most most common adverse common reactions adverse adverse reactions (incidence reactions (incidence ≥2% (incidence and≥2% greater ≥2% and and than greater greater placebo) than than placebo) in clinical placebo) instudies clinical in clinical instudies studies in in patients with patients patients agitation with with agitation treated agitation with treated treated ADASUVE with with ADASUVE were ADASUVE dysgeusia, were were dysgeusia, dysgeusia, sedation,sedation, and sedation, throat and irritation and throat throat irritation irritation • Pregnancy • Pregnancy • Category Pregnancy Category C.Category Neonates C. C. Neonates exposed Neonates exposed to exposed antipsychotic to to antipsychotic antipsychotic drugs during drugs drugs the during third during the trimester the third third trimester oftrimester pregnancy of pregnancy of pregnancy are at riskare ofare at extrapyramidal risk at risk of extrapyramidal of extrapyramidal and/or withdrawal and/or and/or withdrawal symptoms withdrawal symptoms after symptoms delivery. after after delivery. ADASUVE delivery. ADASUVE should ADASUVE beshould used should during bebe used used during during pregnancy pregnancy only pregnancy if theonly potential only if the if the potential benefi potential t justifi benefi benefi estthe justifi t justifi potential es es thethe potential risk potential to therisk fetus risk to to thethe fetus fetus • Nursing•mothers: Nursing • Nursing mothers: Discontinue mothers: Discontinue Discontinue drug or nursing, drug drug or taking or nursing, nursing, into taking account taking intointo the account account importance thethe importance importance of the drug of to the of the drug mother drug to the to the mother mother • The safety • The •and The safety effectiveness safety andand effectiveness effectiveness of ADASUVE of ADASUVE ofinADASUVE pediatric in pediatric patients in pediatric have patients patients not been have have not established not been been established established References: 1.References: ADASUVE References: [package 1. ADASUVE 1. ADASUVE insert]. [package Horsham, [package insert]. PA: insert]. Teva Horsham, Horsham, SelectPA: Brands, Teva PA: Teva Select a division Select Brands, ofBrands, Teva a division Pharmaceuticals a division of Teva of Teva Pharmaceuticals USA, Pharmaceuticals Inc; December USA,USA, Inc; 2013. December Inc; December 2013. 2013. 2. Data on file. Clinical 2. Data 2. Data Study on file. onReport Clinical file. Clinical 004-301. Study Study Report Teva Report Pharmaceuticals. 004-301. 004-301. TevaTeva Pharmaceuticals. 3.Pharmaceuticals. Data on file. Clinical 3. Data 3. Data Study on file. onReport Clinical file. Clinical 004-302. Study Study Report Teva Report 004-302. Pharmaceuticals. 004-302. TevaTeva Pharmaceuticals. Pharmaceuticals.

Please see Please Please Briefsee Summary see Brief Brief Summary of Summary Prescribing of of Prescribing Prescribing Information, Information, Information, includingincluding Boxed including Warnings, Boxed Boxed Warnings, Warnings, on following onon following following pages. pages. pages. ©2014 Teva Pharmaceuticals ©2014 ©2014 TevaTeva Pharmaceuticals USA, Pharmaceuticals Inc. USA,USA, Inc. Inc. All rights reserved. All rights All April rights reserved. 2014 reserved. Printed Aprilin April 2014 USA. 2014 Printed ADA-40010 Printed in USA. in USA. ADA-40010 ADA-40010

BRIEF SUMMARY ADASUVE® (loxapine) inhalation powder, for oral inhalation use The following is a brief summary only; see full prescribing information, included Boxed Warnings for complete product information. WARNING: BRONCHOSPASM and INCREASED MORTALITY IN 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 bronchospasm, 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 Precautions (5.2)]. Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. ADASUVE is not approved for the treatment of patients with dementia-related psychosis [see Warnings and Precautions (5.3)]. 1 INDICATIONS AND USAGE ADASUVE 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 behavior), leading clinicians to the use of rapidly absorbed antipsychotic medications 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 bronchospasm, ADASUVE must be administered only in an enrolled healthcare facility [see Warnings and Precautions (5.2)]. 4 CONTRAINDICATIONS ADASUVE 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 symptoms or signs (e.g., wheezing) [see Warnings and Precautions (5.1)] • Current use of medications to treat airways disease, such as asthma or COPD [see Warnings and Precautions (5.1)] • History of bronchospasm following ADASUVE treatment [see Warnings and Precautions (5.1)] • Known hypersensitivity to loxapine or amoxapine. Serious skin reactions have occurred with oral loxapine and amoxapine. 5 WARNINGS AND PRECAUTIONS 5.1 Bronchospasm ADASUVE can cause bronchospasm that has the potential to lead to respiratory 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 (intubation and mechanical ventilation) [see Boxed Warning and Warnings and Precautions (5.2)]. Prior to administering ADASUVE, screen patients regarding a current diagnosis or history of asthma, COPD, and other lung disease associated with bronchospasm, acute respiratory symptoms or signs, current use of medications to treat airways disease, such as asthma or COPD; and examine patients (including chest auscultation) for respiratory abnormalities (e.g., wheezing) [See Dosage and Administration (2.2) and Contraindications (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.

Because clinical trials in patients with asthma or COPD demonstrated that the degree of bronchospasm, as indicated by changes in forced expiratory 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 components of the ADASUVE REMS are: • Healthcare facilities that dispense and administer ADASUVE must be enrolled and comply with the REMS requirements. Certified healthcare facilities must have on-site access to equipment and personnel trained to provide advance airway management, including intubation and mechanical ventilation. • Wholesalers and distributors that distribute ADASUVE must enroll in the program and distribute only to enrolled healthcare facilities. Further information is available at www.adasuverems.com or 1-855-7550492. 5.3 Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at increased risk of death. Analyses of 17 placebocontrolled trials (modal duration of 10 weeks), largely in patients taking 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. Over the course of a typical 10-week controlled trial, the rate of death in drug-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, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies 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 termed Neuroleptic Malignant Syndrome (NMS). Clinical manifestations of NMS include hyperpyrexia, muscle rigidity, altered mental status, and autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmia). Associated features can include elevated serum creatine phosphokinase (CPK) concentration, rhabdomyolysis, 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 conditions (e.g., pneumonia, systemic infection, heat stroke, primary CNS pathology, central anticholinergic toxicity, extrapyramidal symptoms, or drug fever). The management of NMS should include: 1) immediate discontinuation of antipsychotic drugs and other drugs that may contribute to the underlying disorder, 2) intensive symptomatic treatment and medical monitoring, 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 Syncope ADASUVE can cause hypotension, orthostatic hypotension, and syncope. Use ADASUVE with caution in patients with known cardiovascular disease (history of myocardial infarction or ischemic heart disease, heart failure or conduction abnormalities), cerebrovascular disease, or conditions that would predispose patients to hypotension (dehydration, hypovolemia, 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, respectively. There were no cases of orthostatic hypotension, postural symptoms,

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presyncope or syncope. A systolic blood pressure ≤ 90 mm Hg with a decrease of ≥ 20 mm Hg occurred in 1.5% and 0.8% of the ADASUVE 10 mg and placebo groups, respectively. A diastolic blood pressure ≤ 50 mm Hg with a decrease of ≥15 mm Hg occurred in 0.8% and 0.4% 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, respectively. The incidence of syncope or presyncope in normal volunteers was 2.3% and 0% in the ADASUVE and placebo groups, respectively. In normal volunteers, a systolic blood pressure ≤ 90 mm Hg with a decrease of ≥ 20 mm Hg occurred in 5.3% and 1.1% in the ADASUVE and placebo groups, respectively. A diastolic blood pressure ≤ 50 mm Hg with a decrease of ≥ 15 mm Hg occurred in 7.5% and 3.3% in the ADASUVE and placebo groups, respectively. 5.6 Seizures ADASUVE 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 Impairment ADASUVE 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 ADASUVE is administered concurrently with other CNS depressants [see Drug Interactions (7.1)]. Caution patients about operating hazardous machinery, 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 Psychosis In placebo-controlled trials with atypical antipsychotics in elderly patients with dementia-related psychosis, there was a higher incidence of cerebrovascular 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 psychosis [see Boxed Warning and Warnings and Precautions (5.3)]. 5.9 Anticholinergic Reactions Including Exacerbation of Glaucoma and Urinary Retention ADASUVE 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 REACTIONS The following adverse reactions are discussed in more detail in other sections of the labeling: • Hypersensitivity (serious skin reactions) [see Contraindications (4)] • Bronchospasm [see Warnings and Precautions (5.1)] • Increased Mortality in Elderly Patients with Dementia-Related Psychosis [see Warnings and Precautions (5.3)] • Neuroleptic Malignant Syndrome [see Warnings and Precautions (5.4)] • Hypotension and syncope [see Warnings and Precautions (5.5)] • Seizure [see Warnings and Precautions (5.6)] • Potential for Cognitive and Motor Impairment [see Warnings and Precautions (5.7)] • Cerebrovascular Reactions, Including Stroke, in Elderly Patients with Dementia-Related Psychosis [see Warnings and Precautions (5.8)] • Anticholinergic Reactions Including Exacerbation of Glaucoma and Urinary Retention [see Warnings and Precautions (5.9)] 6.1 Clinical Trials Experience Because 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 agitation, 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).

Table 1. Adverse Reactions in 3 Pooled Short-Term, Placebo-Controlled Trials (Studies 1, 2, and 3) in Patients with Schizophrenia or Bipolar Disorder Placebo ADASUVE Adverse Reaction (n = 263) (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 shortterm (24-hour), placebo-controlled trials in patients with agitation associated with schizophrenia or bipolar disorder (Studies 1, 2, and 3), bronchospasm (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) in the ADASUVE 10 mg group. One patient with schizophrenia, without a history of pulmonary disease, had significant bronchospasm requiring rescue treatment with a bronchodilator and oxygen. Bronchospasm and Airway Adverse Reactions in Pulmonary Safety Trials Clinical pulmonary safety trials demonstrated that ADASUVE can cause bronchospasm as measured by FEV1, and as indicated by respiratory signs and symptoms in the trials. In addition, the trials demonstrated that patients with asthma or other pulmonary diseases, such as COPD are 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, patients with asthma, and patients with COPD. Pulmonary function was assessed by serial FEV1 tests, and respiratory signs and symptoms were assessed. In the asthma and COPD trials, patients with respiratory symptoms or FEV1 decrease of ≥ 20% were administered rescue treatment with albuterol (metered dose inhaler or nebulizer) as required. These patients were not eligible for a second dose; however, they had continued FEV1 monitoring in the trial. Healthy Volunteers: 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 developed 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%, respectively). 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 remaining 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). COPD Patients: In the COPD trial, 53 patients with mild to severe COPD (with FEV1 ≥ 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 moderate COPD [Global Initiative for Chronic Obstructive Lung Disease (GOLD) Stage II]; 32% had severe disease (GOLD Stage III); and 11% had mild disease (GOLD Stage I). As illustrated in Table 2 there was a decrease in 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). Respiratory 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

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 Volunteer, Asthma, and COPD Trials Healthy Volunteer Asthma COPD Maximum Placebo ADASUVE Placebo ADASUVE Placebo ADASUVE n (%) 10 mg n (%) 10 mg % FEV ↓ n (%) 10 mg n (%) n (%) n (%) N=26

N=26

N=27

N=25

≥10

7 (27)

3 (12)

22 (85)

18 (67)

20 (80)

≥15

1 (4)

5 (19)

1 (4)

16 (62)

9 (33)

14 (56)

≥20

1 (4)

11 (42)

3 (11)

10 (40)

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)

After any Dose

After Dose 1

1 (4)

6 (23)

2 (7)

9 (36)

N=26

N=25

N=17

N=26

N=19

≥10

5 (19)

6 (24)

3 (12)

12 (71)

15 (58)

12 (63)

≥15

5 (20)

1 (4)

9 (53)

6 (23)

10 (53)

≥20

1 (4)

5 (30)

1 (4)

5 (26)

≥20 After Dose 2

FEV1 categories are cumulative; i.e. a subject with a maximum decrease of 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, extrapyramidal reactions occurred. One patient (0.4%) treated with ADASUVE developed 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 individuals 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, orthostatic hypotension, lightheadedness, and syncope have been reported with oral administration of loxapine. 7 DRUG INTERACTIONS 7.1 CNS Depressants ADASUVE is a central nervous system (CNS) depressant. The concurrent use of ADASUVE with other CNS depressants (e.g., alcohol, opioid analgesics, benzodiazepines, tricyclic antidepressants, general anesthetics, phenothiazines, sedative/hypnotics, muscle relaxants, and/or illicit CNS depressants) can increase the risk of respiratory depression, hypotension, profound sedation, and syncope. Therefore, consider reducing the dose of CNS depressants if used concomitantly with ADASUVE.

7.2 Anticholinergic Drugs ADASUVE 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 POPULATIONS In 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 Pregnancy Pregnancy Category C Risk Summary There 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 withdrawal 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 the maximum recommended human dose (MRHD) on a mg/m2 basis. ADASUVE should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Human Data Neonates 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, hypotonia, tremor, somnolence, respiratory distress, and feeding disorders in these neonates. These complications have varied in severity; in some cases symptoms have been self-limited, but in other cases neonates have required intensive care unit support and prolonged hospitalization. Animal Data In 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 dose of 1 mg/kg/day. This dose is equivalent to the MRHD of 10 mg/day on a mg/m2 basis. In addition, fetal toxicity (increased prenatal death, decreased postnatal survival, reduced fetal weights, delayed ossification, 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 approximately half the MRHD of 10 mg/day on a mg/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-, and 32-fold the MRHD of 10 mg/day on a mg/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 Use The safety and effectiveness of ADASUVE in pediatric patients have not been established. 8.5 Geriatric Use Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death [see Boxed Warning and Warnings 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 OVERDOSAGE Signs and Symptoms of Overdosage As would be expected from the pharmacologic actions of loxapine, the clinical findings may include CNS depression, unconsciousness, profound hypotension, respiratory depression, extrapyramidal symptoms, and seizure. Management of Overdosage For 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 measures employed in the management of overdosage with any drug. Consider the possibility of multiple drug overdosage. Ensure an adequate airway, oxygenation, and ventilation. Monitor cardiac rhythm and vital signs. Use supportive and symptomatic measures. Manufactured by: Alexza Pharmaceuticals, Inc., Mountain View, CA 94043 Manufactured for: Teva Select Brands, Horsham, PA 19044, Division of Teva Pharmaceuticals USA, Inc. Iss.12/2013 ADA-40059

MEMBER FEEDBACK

Survey Says! Your Voice Carries By Amy Carpenter Aquino, ENA Connection

better connect with members and make informed decisions. Member opinions influence and guide NA values its members’ opinions decisions on educational offerings, and provides several organizational issues, strategic opportunities for members to provide planning, national conferences feedback to the organization, and member services. including via social media and directly The majority of surveys will to their ENA Board of Directors state not be sent to all 40,000 ENA liaisons at local and national meetings. members, Jiggens said. ENA Another increasingly effective method realizes its members lead busy of gathering member feedback is lives and aims to minimize the through market research surveys. impact of being selected too ‘‘It is very important to us to frequently for surveys. engage our members,’’ said Laura ‘‘For each study, we will select Jiggens, who joined ENA in February a specific or random sample of as market research manager. members,’’ she said. That makes it Originally from England, Jiggens even more critical that as many came to ENA with more than 16 years ENA members as possible respond “ENA wants members to know when asked to participate. One of market research experience, most recently in the pharmaceutical that we are really listening.’’ ENA member could represent industry. While her involvement with thousands of colleagues. research findings typically concludes LAURA JIGGENS, ENA plans to share some key with the delivery of a final report, ENA Market Research Manager insights from survey results with Jiggens was keen to ‘‘take market members in the pages of research that next step further and ENA Connection, as well as actually implement results and see the results come to life.’’ keep members updated on what the organization is doing A number of ENA market research initiatives planned for with the findings. this year will help Jiggens realize that goal as she creates and ‘‘ENA wants members to know that we are really sends surveys on various topics to ENA members throughout listening,’’ Jiggens said. this year and beyond. Membership satisfaction and national Note: ENA respects members’ privacy and will never divulge conference preferences are two of the topics that ENA a respondent’s identity, personal information or individual surveys will address in 2014. Feedback from member surveys helps ENA headquarters answers unless specifically given permission to do so.

Call for 2015 ENA National Committees Bring your passion for nursing to the national level! ENA 2014 President-elect Matthew F. Powers, MS, BSN, RN, MICP, CEN, would like to invite you as an ENA member to share your knowledge and experience on a national ENA committee in 2015. We will be accepting applications for each of our national committees July 1 - 31, 2014. For a full description of each committee and to apply beginning July 1, go to www.ena.org, then click

on ‘‘Get Involved.’’ National Committee applications must be submitted online by 5 p.m. Central time Thursday, July 31. While not required, a photo is requested with your application. Photos do not have to be professionally done; a quick snap from your smartphone will work. Look for instructions on how to upload your photo in the committee application.

Official Magazine of the Emergency Nurses Association

GOVERNANCE 2014 Proposed Resolutions and Bylaws Amendments

We Have Much to Discuss in Indianapolis T he 2014 ENA General Assembly will be held Oct. 7-8 in Indianapolis. ENA President Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN, will preside. Approximately 700 delegates representing ENA’s state councils and international members will debate and vote on issues that affect the emergency nursing profession. Attending the 2014 General Assembly is a wonderful opportunity for members to understand how decisions are made concerning the direction and stewardship of the association. The General Assembly agenda includes the installation of the 2015 ENA Board of Directors and Nominations Committee, with reports by the president, president-elect, treasurer and executive director. Delegates will also consider and act on proposed resolutions and bylaws amendments. At its May meeting, the ENA Board of Directors reviewed this year’s proposals. Final proposals, including any additional bylaws amendments submitted by the July 10, 2014, deadline, will be posted in August in the online General Assembly Handbook at www.ena.org for viewing by all state councils, chapters and assigned delegates. Summaries of the proposed resolutions and bylaws amendments follow:

ENA Resolutions Update the “Consensus Statement on Definitions for Consistent Emergency Department Metrics”: This resolution recommends

that ENA work with stakeholder organizations to revise and update the ‘‘Consensus Statement on Definitions for Consistent Emergency Department Metrics’’ to minimally include definitions for the terms ‘‘disposition decision time,’’ ‘‘admit decision time’’ and ‘‘boarded admitted patient.’’ ENA’s Role in Firearms Safety: This resolution recommends that ENA advocate for the creation of a national background check before all firearm purchases, a five-day waiting period before purchase and support for evidence-based education on firearm safety. The General Assembly has previously adopted resolutions regarding firearms: GA01-02 and GA10-13.

Emergency Nurses Advocate for Reduction in Prescription Drug Abuse: This resolution recommends that ENA develop resources in the areas of pain management, medication storage and medication disposal; encourage ongoing research on evidence-based pain management strategies; and collaborate with organizations to reduce the incidence of prescription drug recreational use and overdose events. Patient Education for Mild Traumatic Brain Injury/ Concussion: This resolution recommends that ENA update the position statement on Unintentional Sport and Recreational

Injuries to recommend that emergency departments provide 1) patient education on post-concussive syndrome and 2) cognitive rest and return-to-play guidelines, and that ENA explore or develop an educational resource on mild traumatic brain injuries. Use of Orientation Guidelines: This resolution recommends that ENA identify best practices for orientation timelines, delivering content and tracking the progress of new graduate or new-to-the-specialty nurses. Support of Creating a National Trauma System: This resolution recommends that ENA support development of a national trauma system across the continuum of integrated care, including injury prevention, and express support of this endeavor through a position statement. Meaningful Use and Nurse Protocols: This resolution recommends that ENA’s protocol position statement be revised to include identifying emergency registered nurses as licensed health care providers and verbiage regarding the entry of protocols into the electronic health record. ENA Board of Directors Support: This resolution recommends that the 2014 ENA General Assembly acknowledge the ENA Board of Directors’ diligence in performing its leadership role, appreciate its efforts to continue ENA’s growth and

development as a leader among specialty associations and value its efforts in ensuring a clear vision of ENA’s future. Standardization of Emergency Codes Nationwide: This resolution recommends that ENA advocate for and take a leadership role in the development and nationwide implementation of standardized plain language hospital emergency code terminology.

Bylaws Amendments Article VIII – Resolutions Committee Name: The authors offer this amendment to change the committee name to properly reflect its responsibilities. Article VIII – Resolutions Committee Composition: The authors recommend this amendment to add an additional member to the committee for effective leadership succession planning

and increased productivity. Article V – State Captains: The authors propose this language for consistent language throughout ENA documents, with ‘‘state captains’’ in place of ‘‘lead delegate.’’ Articles VIII and XII – Bylaws and Election Rules Submission Deadline: The intent of this amendment is to standardize and streamline the deadlines for submitting materials for the General Assembly meeting. The bylaws, resolutions, election rules and General Assembly Standing Rules of Procedure currently have different timeframes. Standardized submission dates will be clearer for the members. Article III – Dues Waiver Eligibility for Senior Members: The authors offer this proposal to retain member benefits for senior members without cost to the member. Articles IV, VI and VIII —

Eligibility Requirements: Background Checks: The authors want to streamline the election process by eliminating the employment verification and highest academic achievement verification from the background check process. Article VIII – Nominations Committee Chairperson Election: Adopting this proposal will allow the committee to select its chairperson without being attached to a specific event. Articles VIII – Nominations Committee Name: The authors offer this amendment to change the committee name to properly reflect its responsibilities. Article III – Suspension and Termination of Membership: The authors offer this amendment to more clearly define the grounds and procedures for disciplinary action against a member.

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Official Magazine of the Emergency Nurses Association

® PROTECTING PEOPLE AT WORK

COURSES

BETTER CARE x100

Texas Health System Buys GENE Course in Bulk for ED Nurses By Kendra Y. Mims, ENA Connection

totaling $12.4 million. Powell said the grant allowed the purchase of the 100 n an effort to provide its emergency GENE licenses for emergency nurses, nurses with proper training and reflecting about 20 percent of Baylor’s knowledge on caring for the elderly emergency nurse population. population, Baylor Scott & White ‘‘Baylor has been very innovative Health-North Texas ordered 100 and proactive in helping to manage licenses of ENA’s Geriatric Emergency health care for this population,’’ she Nursing Education online course in said. ‘‘We received the grant March, making it ENA’s largest specifically to do work around GENE order to date. elderly care at Baylor, not just ENA member Kristine in the hospital but also out in Powell, MSN, RN, CEN, the community. We’re trying to NEA-BC, director of emergency build subject-matter experts in services at Baylor Scott & our emergency department and White-North Texas, said get them engaged with being a improving care for the elderly clinical resource for frontline Kristine Powell has been a strong focus at staff. We have a definite need Baylor for several years. within the ED for this knowledge, and ‘‘From the ED perspective, we are a focus on ED nursing education is looking at issues such as how to essential.’’ prevent readmissions because a large One of Powell’s priorities is to have number of our elderly patients are at her nurse educators incorporate four of high risk of avoidable readmissions,’’ the GENE licenses into their ED she said. ‘‘We want to improve care internship program so new nurses can and reach out to them out in the receive the course content immediately. community to prevent exacerbations of ‘‘As we continue to do this work, their chronic disease so that they don’t we want to embed this clinical end up back in the hospital. We are information about the care of elderly really looking at patient-centered care patients in the ED as standard practice and want the quality of life for our and standard knowledge,’’ she said. patients as optimal as possible. Part of ‘‘We’re really taking it down two paths that has to do with education in the — one is for nurses who are new to emergency department. It’s one piece the ED, and the other is a refresher for of the larger puzzle.’’ our current nurses.’’ According to the Deerbrook The average age of an Charitable Trust, more than 40 percent emergency nurse at Baylor of hospital patients are over 65, but University Medical Center is 32, fewer than 2 percent of nurses have Powell noted, adding that the ED certifications in geriatrics. Recognizing has a high number of Generation Y the need to improve education for this nurses who haven’t received population, in 2011 the Deerbrook education in geriatric care. Charitable Trust awarded Baylor Powell is looking forward to Health Care System a three-year grant raising awareness of elderly

patients’ special needs and having emergency nurses on the front lines as subject-matter experts and clinical resources for other nurses. But she is also looking to do more. ‘‘I’m also looking to step it up a notch to give a hundred of our nurses that foundational education,’’ she said. ‘‘I want to be able to pull them together to look at how we care for elderly patients in our ED and really start building better workflows.’’ Powell attended the previous GENE pilot program, delivered in a classroom setting at the 2004 ENA Annual Conference in San Diego. She is confident the new online course will be beneficial to emergency nurses. ‘‘I’m an ER nurse, and I am a lifetime member of ENA,’’ she said. ‘‘I have been active in ENA for 25 years. This is an evidenced-based program developed by my professional organization. I am also a TNCC and ENPC instructor and course director, so I know the caliber of the programs that ENA puts out, and I trust ENA’s products.’’ For more information on the new GENE online course or to find out how you can purchase it for your emergency department, e-mail gene@ena.org, call 847-460-4055 or visit www.ena.org/education/ education/GENE.

FUTURE OF YOUR NURSING Bridget Walsh, PHR, Chief Talent Officer

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GENE Ad_Connection_half vertical_0607 2014.indd 1

hen the time for your annual performance evaluation rolls around, do you dread it and consider calling in sick to avoid it, or do you welcome it? Many individuals take a let’s-just-get-it-over-with approach. But I challenge you to welcome your annual performance evaluation, to take it as an opportunity to own your career and take charge of your professional development. Here are a few tips as you enter into your own annual evaluation period: • Spend time on self-assessment; honestly reflect on your accomplishments and your challenges during the year. • Be prepared to have a detailed discussion with your supervisor about your goals, your questions and your opportunities. • Remember that feedback is a gift; be accepting of the gift being given to you and figure out how to make the most of it for your personal and professional development. • Make a plan for the upcoming year and obtain support and guidance from your supervisor and other mentors. • Stay focused on your plan; schedule checkpoints, look for opportunities to accomplish stretch goals and add to your professional experiences. As your professional organization, ENA is committed to helping you accomplish your professional goals. For more resources and information, visit the career wellness page at www.ena.org/membership/Career Center or e-mail careerwellness@ena.org.

5/6/14 1:42 PM

ENA will honor our members who have died in the last year during a special memoriam presentation during the 2014 General Assembly in Indianapolis. If you would like to recognize a member who has died, please complete the request form found in the General Assembly area (members only) at www.ena.org. All requests must be submitted electronically to membership@ena.org.

Official Magazine of the Emergency Nurses Association

ONLINE LEARNING

ENA Partners With Genentech to Launch Stroke Management Learning System By Amy Carpenter Aquino, ENA Connection

troke is a leading cause of death and disability in the United States. ENA and Genentech have joined forces to provide online training, with critical educational resources to help emergency nurses better identify, diagnose and treat stroke. ENA launched the free online training modules on its learning management system at www.ena.org in April. The stroke management learning system will be available for one year until April 2015. The program is divided into three modules designed to introduce emergency nurses to some key concepts surrounding stroke with an emphasis on acute ischemic stroke. Module 1 covers basic stroke education. Topics include stroke epidemiology, ischemic pathophysiology and brain anatomy. Participants will learn how to identify risk factors for stroke as well as potentially modifiable risk factors such as hypertension, diabetes, obesity, high cholesterol and smoking, and

How to Take the Course Members can access the online education modules at www.ena.org/education/ onlinelearning/Pages/Stroke.aspx or learn.healthstream.com/ accesspoint/genentech. Note: No continuing education credits are offered for this course. Participants will receive a certificate of completion. non-modifiable risk factors such as previous stroke, family history, age and hypercoaguable states. The modules also cover the two different types of stroke. Module 2 focuses on in-hospital diagnosis of acute ischemic stroke. Learners will discover effective ways to rapidly recognize stroke symptoms, apply time-saving recommendations and determine treatment options. Vibrant graphics illustrate the differences between what happens to the body during a large vessel ischemic stroke and during a transient ischemic attack. Participants also will

learn how delays in medical management of acute ischemic stroke patients can affect their outcome. Module 3 teaches stroke treatment and management of acute ischemic stroke, with an emphasis on the management of confirmed acute ischemic stroke. It includes review of patient eligibility for treatment, potential risks and benefits of therapy, dosing and administration, and post-treatment monitoring and care. The modules provide a variety of teaching techniques, including videos and an option to click on new or unfamiliar terms for pop-up definitions. “This program will provide an overview of stroke basics; review the assessment of a patient with suspected stroke; and comprehensive treatment guidelines with fibrinolytic therapy for a patient with an ischemic stroke,’’ said Alyssa Kelly, MSN, RN, CNS, CEN, senior associate, ENA Institute for Emergency Nursing Education. ‘‘It will assist the learner in meeting the NINDS in-hospital time goals for patients with suspected stroke, thus improving patient outcomes.’’

June/July 2014

ENA PRACTICE RESOURCES

A Toolbox of Tips For Success By Monica Escalante, MSN, RN, Senior Associate, Institute for Quality, Safety and Injury Prevention

he influence of evidence-based practice resonates throughout nursing, impacting education, practice and research. The demand for evidence-based quality improvement and performance requires nurses to have the best tools and resources for success. Applying research evidence and integrating the knowledge into clinical practice is now the expected standard of performance for a majority of health care organizations. Understanding the various levels of evidence assists nurses in evaluating and determining its relevance and how it can be incorporated into best practices. EBP is a systematic and scientific approach that is constantly changing but is compulsory for safe practice, safe care and clinical decision-making. As stated by Baker, et al.,1 emergency nurses are in an exclusive position to not only improve care but also improve nursing practice by implementing and using several forms of scientific inquiry. However, finding the right tools and resources can be daunting; the overwhelming amount of information available can make it difficult to know what is authoritative, current and scholarly. Fortunately, ENA has developed user-friendly clinical resources and publications that provide electronic and print materials to support nursing education, practice and research. A variety of essential information can be obtained from ENA’s practice website: www.ena.org/practice-research/ Practice/Pages/PracticeResources.aspx. Among these practice resources are clinical practice guidelines, position statements, emergency nursing scope and standards of practice, ENA’s translation into practice, toolkits, topic briefs and white papers. These tools and resources provide current, scholarly and evidence-based information which supports emergency nursing practice. Practice resources have substantial supportive information that can be used to not only guide practice but also to improve health care delivery.2 The information obtained from the practice

Continued on page 31

Clinical Practice Guidelines • Evidence-based; assist in translating research into practice • Recommendations based on systematic review and critical analysis of current and scholarly literature • Formerly known as Emergency Nursing Resources

Position Statements • Statements of beliefs that reflect ENA’s stance on issues relating to safe practice, safe care and patient outcomes • ENA position statements, including joint statements and supported statements • Archived position statements

Emergency Nursing Scope and Standards of Practice • Benchmark guide for professional emergency nursing • Resource for practice, standards and competencies expected • Establish nursing professional performance standards

ENA’s Transitions into Practice • Quick reference with level of evidence recommendations • Assist in facilitating and applying current evidence into practice • Examine current topics in everyday emergency nursing practice and make recommendations for transition into practice

Toolkits • Collective resources that include education, forms, links and valuable material useful in implementing change and improving practice • Contain documents that will assist an individual to champion a project or implement a program

Topic Briefs • Supportive documents that provide detailed information on a given subject of importance, particularly to safe practice and safe care • Examine relevant issues: adult immunizations, the bariatric/obese patient, health literacy, health information technology and the health work environment

White Papers • Distinctive and authoritative reports focused on specific topics • Presentation of research with a specific purpose, audience and organization • Current white papers address care of the psychiatric patient in the ED and nurse fatigue

Official Magazine of the Emergency Nurses Association

ENA FOUNDATION | Seleem Choudhury, MBA, MSN, RN, CEN, 2014 ENA Foundation Chairperson

Be the Ultimate Colleague “Appreciation is a wonderful thing. It makes what is excellent in others belong to us as well.”

ould Voltaire’s words be applied to the ENA Foundation and its ongoing journey toward building a strong foundation? Since January, I have spoken with and written to many ENA members to share my appreciation for their contribution to our mission of enhancing emergency care through education and research. We know and celebrate our differences — various values, motivations and passion. However, we are all linked inextricably by a common thread of emergency nursing. The fact that you are drawn to emergency nursing makes you committed to excellence, and excellence is never an accident — it is a standard to which we hold ourselves and others. We should all be involved in building a strong foundation so that we can ensure the integrity of not just the ideals of excellence for ourselves, but also for our colleagues who work in the triage room, the nurse who covers our break, the educator who teaches us, the charge nurse who runs interference and the manager who helps lead us inside and outside the ED. Virtually every aspect of emergency care is entwined in the excellence of those around us. If they perform well, we all perform well. When we appreciate and help those around us, we all succeed. Let me share how scholarship recipients — and your colleagues — praised your ENA Foundation at a recent Maine ENA State Council meeting. ‘‘I am very proud to be a part of an organization that supports and promotes its members through continuing higher education,’’ said ED educator Lauren Vickerson, BSN, RN, CEN. ‘‘I owe success to those who support the ENA Foundation and who support emergency nurses throughout the country . . . I am proud to be a part of such a professional and well-respected group of peers,’’ said Jennifer Granata, MSN, RN, CEN, an ED manager. In Colorado, emergency physician Lee Shockley, MD, described why he donates to the ENA Foundation: ‘‘Effective emergency care requires teamwork and highly skilled professionals. . . . As an emergency physician, I believe that support for emergency nurses is one of my duties. The ENA Foundation’s scholarships for emergency nursing education

are a way that I can help provide that support.’’ I would like to let you in on a badly kept secret: It’s not only your peers who want to see you succeed. We receive gifts from members of the public (yes, your patients) who donate simply because they wish to pay it forward and they see the benefit of having a highly educated emergency team. On the ENA Foundation Board of Trustees, highly engaged corporate trustees participate to ensure that you can continue to learn and that you get an opportunity to grow. Ken Craig, MBA, corporate trustee-at-large from PhysioControl Inc., shared an experience with me: ‘‘I recently sat next to someone at dinner that had benefited from an ENA Foundation academic scholarship that helped her complete her master’s degree and advance her hospital career. It was heartwarming to hear how grateful she was to the ENA Foundation and to those companies that provide funding for those scholarships. The ENA Foundation really does make a difference!’’ John Proctor, MD, MBA, FACEP, FAAP, American College of Emergency Physicians Emergency Medicine Foundation representative, said, ‘‘I know the foundation to be committed to the welfare and success not only of the nursing providers of emergency care, but to the patients we serve.’’ I hope you can see what is happening here: It’s Voltaire’s excellence in motion. It is us appreciating our job, our practice and each other by helping us become better at what we do. This is a movement that you are either part of or not. If you believe in it, donate today. You can become the ultimate colleague by making a conscious decision to help your team by making a donation. It’s you who is defining our practice, it’s you who is creating the increase in knowledge, it’s you who should also be donating to help those who help you every day. I believe that you want to continue to work with the best, so let’s give the best a chance by supporting the ENA Foundation so it can keep providing scholarships and research grants. This is building a strong foundation, this is emergency nursing, this is excellence in motion, this is your ENA Foundation and this is why you should get involved and make a donation. For the sake of excellence and your colleagues, please make a donation at www.enafoundation.org or call the ENA Foundation at 847-460-4100.

June/July 2014

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EMERGENCY NURSING RESEARCH

Better Care Through the IENR By Paul R. Clark, PhD, MA, RN

very day, in every emergency department throughout the United States, emergency nurses are faced with questions about how to provide the safest, best-quality care to patients. Nurses already adjust their practices based on the latest evidence and practice experience to deliver better care to emergency patients. However, what happens when nurses seek answers to questions and find there is no current evidence to answer these questions? Working with emergency nurses to unearth evidence answering these The 2014 IENR Advisory Council: Front row, from left: Gail Lenehan, EdD, MSN, questions is the goal of the Institute for RN, FAEN, FAAN; Board of Directors liaison Michael Moon, PhD, MSN, RN, CEN, CNS-CC, FAEN; IENR senior administrative assistant Leslie Gates; middle row: IENR Emergency Nursing Research. The IENR senior associate Cydne Perhats, MPH, IENR; Kathleen E. Zavotsky, MS, RN, CEN, seeks knowledge through research ACNS-BC, CCRN; Kathy M. Baker, PhD, RN, NE-BC; back row: Margaret J. Carman, studies that answer questions about DNP, MSN, RN, CEN, ACNP-BC; IENR senior associate Altair Delao, MPH; Paul R. improving the safety and quality of Clark, PhD, MA, RN; IENR director Lisa Wolf, PhD, RN, CEN, FAEN; Kevin Langkiet, patient care. MSN, RN. The mission of the IENR is to other assistance. conduct and facilitate research and evidence-based practice On April 22-23, the IENR advisory council met at ENA in emergency nursing, with a vision to be a source of headquarters in Des Plaines, Ill., to discuss burning questions research and information for evidence-based emergency in emergency nursing. Studies carried out under the leadership nursing practice and care. Our mission and vision are active of director Lisa Wolf, PhD, RN, CEN, FAEN, include: in our many activities, such as authoring a series of research • Understanding current ED discharge processes for articles in the Journal of Emergency Nursing and research patients receiving Schedule II and III pain medications (study projects, such as seeking answers to help emergency nurses in data analysis phase). deal with violence in the emergency department, identifying • Investigating the relationship between emergency educational needs in rural hospitals and recognizing issues nurses’ reported sleep and their perceived fatigue and with behavioral health patients. cognitive ability (study in preliminary development phase). The IENR also organizes and staffs the Research Lounge • Seeking out the nature of moral distress/despair at the ENA national conference. The Research Lounge is experienced by emergency nurses (study in preliminary staffed with doctorally prepared emergency nurses who help development phase). stretcherside nurses develop research projects. Research IENR members were also updated on the March 2014 Lounge attendees receive support creating research National Nursing Research Roundtable at the National questions, developing strategies to sample a target population, developing a specific research methodology and Institutes of Health, sponsored each year by the National

June/July 2014

ENA Practice Resources Continued from Page 27

2014 ED Operations Committee The Emergency Department Operations Committee convened at ENA headquarters for an onsite meeting March 27-28. Members focused on committee charges by reviewing and recommending topics for the Key Concepts in ED Management program and developing content for an ED manager survival guide. The ED Operations Committee charges for 2014 are as follows: 1. Provide subject-matter expertise related to emergency department operations. 2. Identify and recommend resources for emergency department operations/management. Committee Members Fred Neis, MS, RN, CEN, FACHE, FAEN, chairperson Frances Damian, MS, RN, NEA-BC Mark Mayes, MHA, BSN, RN, CEN Kristine Powell, MS, RN, CEN, NEA-BC Maryfran Hughes, MSN, RN (not pictured) Board Liaison Kathleen Carlson, MSN, RN, CEN, FAEN

Institute of Nursing Research. We also discussed ways to improve ENA members’ access to research tools through the research section of the ENA website and how to develop the Research Lounge at the 2014 ENA Annual Conference in Indianapolis. The IENR encourages emergency nurses to seek answers to questions that are not answered by current evidence. If you have questions about initiating a research project in your emergency department, contact Lisa Wolf at IENR@ena.org and visit the IENR website: www.ena.org/practiceresearch/research.

resources can be used as references for research, educational purposes and to assist in implementing change. For example, reviewing CPGs may influence further investigation into an organization’s procedure for using capnography during procedural sedation/ analgesia. Reviewing CPGs for prevention of blood culture contamination might impact hospital policies and protocols. TIPs can act as a quick reference to simplify applying current evidence in emergency nursing. ENA’s available toolkits are valuable materials that can assist individual champions to implement a program or function as support for projects. Position statements, the Emergency Nursing Scope and Standards of Practice, topic briefs and white papers are also essential practice resources with detailed evidence that may serve as a reference or inspire change. Diane Gurney, MS, RN, CEN, 2010 ENA president, shared how ENA’s practice resources have helped her provide safe care to her patients. ‘‘The ENA website is my ‘go-to’ place for emergency nursing practice information,’’ Gurney said. ‘‘For years I have relied on ENA for current, evidence-based knowledge to support my emergency nursing practice. The clinical practice guidelines have been invaluable in assisting me with current scientific knowledge regarding such practice issues as orthostatic vital signs, non-invasive blood measurement and gastric tube placement verification. As a manager, I used the ENA position statements to help justify the need for trauma nursing education, standards for triage nursing and the importance of a hospital-wide multidisciplinary approach to implementing strategies for holding and crowding. It is all in one place, easy to use, comprehensive and evidence-based.’’ References 1. Baker, K.M., Clark, P.R., Henderson, D., Wolf, L.A., Carman, M.J., Manton, A., & Zavotsky, K.E. (2014). Identifying the differences between quality improvement, evidence-based practice, and original research. The Journal of Emergency Nursing, 40(2), 195-197. doi: 10.1016/j.jen.2013.12.016 2. Peterson, M.H., Barnason, S., Donnelly, B., Hill, K., Miley, H., Riggs, L., & Whitemand, K. (2014). Choosing the best evidence to guide clinical practice: Application of AACN levels of evidence. Critical Care Nurse, 34(2), 58-68. doi:10.4037/ccn2014411

Official Magazine of the Emergency Nurses Association

CERTIFICATION

Emergency Nurse Practitioner Portfolio Credential Available E NA collaborated with the American Nurses Credentialing Center in 2012 on a new methodology for assessment of emergency nurse practitioners with the development of certification by portfolio. A portfolio contains evidence of professional practice. The ANCC portfolio program contains requirements in four domains of practice: professional development, professional and ethical nursing practice, teamwork and collaboration, and quality and safety. No examination is required. All portfolios submitted in this certification program are subject to peer review. If the APRN application is approved and passes the peer review program, the certification of ENP-BC is awarded. Nurses credentialed through the ANCC program are established as experts in their specialty. Advanced practice nurses practicing within an institution are required to comply with the credentialing and privileging process in their facility, which includes the common elements documented in this ANCC portfolio certification. This certification is renewable every five years. As the momentum proceeds toward full implementation of

the Consensus Model for APRN Regulation, dialogue is occurring in many states on aligning the necessary elements of the model. Discussion on professional portfolios occurred this year in Nevada, where a regulation passed in February indicates all Nevada APRNs must maintain a professional portfolio subject to audit by the board. Nevada further explains that it may deny the renewal of a license to practice if it finds an APRN has failed to maintain the portfolio required. In a ‘‘President’s Blog’’ posted last fall, JoAnn Lazarus, MSN, RN, CEN, the ENA 2013 president, announced the launch of the ANCC ENP-BC credential. ‘‘For advanced practice RNs, credentialing by portfolio is an opportunity to be recognized for meeting the criteria established by emergency nurse practitioner peers as having the skill and knowledge to practice,’’ Lazarus wrote.

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June/July 2014

The Consensus Model for APRN Regulation: Status 2014

Clinicians Advised to Watch for MERS

pathogenic potential and the transmission dynamics of MERS-CoV but note that the incubation period is often five days, with an outer limit of 14 days. CDC recommends collecting multiple specimens from different sites after symptom onset. The CDC guidelines for collecting, handling and testing clinical specimens from suspected cases can be found at www.ded. gov. Many state health departments are approved for MERS-CoV testing.

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he Consensus Model for APRN Regulation was crafted five years ago to address issues related to practice for advance practice registered nurses. The model provided a framework for creating a uniform structure of APRN regulation for use across the United States. It also aimed to align the relationships among licensure, accreditation, certification and education. This alignment would allow APRNs to practice to the full extent of their education and to move easily from state to state in order to increase access to much-needed care for many patients. The model was endorsed by ENA as well as 47 other nursing organizations. The four APRN roles defined in the Consensus Model are: • Certified Registered Nurse Anesthetist • Certified Nurse Midwife • Certified Clinical Nurse Specialist • Certified Nurse Practitioner Since the publication of the Consensus Model, organizations representing licensure, accreditation, certification and education have strived to make the changes required to align with the Consensus Model, with an intended full implementation target of January 2015. The January publication of the Journal of Nursing Regulation noted there are 229,955 individuals in the U.S. who currently hold advanced practice nursing licenses, Maureen Cahill, MSN, RN, APN-CNS, associate director of nursing regulation at the National Council of State Boards of Nursing, said at a LACE meeting in Chicago in April. The APRN Campaign for Consensus initiative is focused on assisting states in aligning their APRN regulation with the major elements of the Consensus Model. Those major elements are: • State recognition of each of the four described roles • Licensure and title of APRN in the roles • Graduate or post-graduate education from an accredited program • Certification at an advanced level from an accredited program that is maintained • Independent practice • Independent prescribing Cahill acknowledges the journey is 69 percent complete. The status of individual states related to full implementation of the consensus model can be found on the National Council of State Boards of Nursing website at www.ncsb.org/aprn. htm. The National Council 2012 document, A Health Care Consumer’s Guide to Advanced Practice Registered Nurses, can be downloaded for free from the website.

he appearance of the Middle East Respiratory Syndrome in the United States has prompted emergency clinicians to take a critical look at patients who have a recent history of travel to the countries in the Saudi Arabian peninsula and are presenting to emergency departments with respiratory illness. MERS-CoV is caused by a coronavirus. To date, the Centers for Disease Control and Prevention have limited information on the

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MILITARY NURSING

VETERAN OF TWO FRONTS

Member Finds Military Nurses, Emergency Nurses Not So Different in Their Roles By Kendra Y. Mims, ENA Connection

t. Col. Kathleen Richardson still remembers seeing her first explosive injury during her first deployment in Iraq. Although she had seen amputations and partially injured limbs before, this particular injury pattern was unlike anything she had ever witnessed during her 18-year Army nursing career. ‘‘It was very graphic to me,’’ she said. ‘‘I remember looking at that leg and thinking that the bone reminded me of slivers of wood.’’ Richardson, DNP, RN, ARNP, CNS, NP-C, CEN, deployed to Iraq in 2007 for 15 months with a forward surgical team. As the emergency medical treatment officer in charge, she was responsible for the entire management and oversight of the 102nd Forward Surgical Team emergency treatment section. During the first part of the deployment, her team was co-located with the 86th Combat Support Hospital during the troop surge, where they worked alongside the hospital’s physicians and nurses to treat various traumas and illnesses, including a high number of patients with appendicitis and tuberculosis. Richardson and her team found themselves treating soldiers, coalition forces and insurgents in the emergency area at the same time. ‘‘We cared for everybody who came into the hospital, and that was an interesting thing to deal with,’’ she said. ‘‘Some of the patients who came in were afraid that we were going to hurt them instead of treat them. You could tell they were apprehensive and hypervigilant until they realized that

Lt. Col. Kathleen Richardson, DNP, RN, ARNP, CNS, NP-C, CEN. we weren’t going to hurt them, and then you could visibly see them relax. It was an ongoing process to gain their trust. They got the same standard of care that we gave to everyone else.’’ Richardson discussed the danger of having the interpreters there to help them communicate. Sometimes the interpreters had to hide from the insurgents to protect their identities. ‘‘If one of the insurgents came in, we made efforts to ensure that the interpreters’ faces were not seen so that they wouldn’t be identified, because if the interpreters were identified, their families could be at risk,’’ Richardson said. ‘‘As we were there longer, we started learning the language so that we could communicate without the interpreters.’’ Richardson described her

experience in Iraq as both rewarding and challenging. ‘‘It was a growth experience, both personally and professionally, and the first time I had the opportunity to do what I had joined the military to do and what I was trained for,’’ she said. ‘‘I had the chance to meet a lot of people from different walks of life, whether they were from Iraq or the coalition forces. We were able to learn from some of the other health care providers, and we taught trauma training to some of the doctors and nurses in Iraq who were going to be stationed in hospitals out in the population. That was very rewarding.’’ When Richardson returned from Iraq she became the emergency and critical care career manager/U.S. Army Human Resources Command for

June/July 2014

several years. She enjoyed her role as the assignment officer and career manager for emergency and critical care nursing officers in the U.S. Army. ‘‘In the Army, you are managed by an individual who looks at all of the assignments across the world,’’ she said. ‘‘We would make visits to different hospitals to talk to individuals face-to-face to learn more about their personal and professional goals and pair their goals with the training they needed to be successful. We would help them plan their careers, whether it was moving up or getting out of the Army and help them work through making those decisions. We worked closely to make sure that we had the right people in the right places at the right times, while ensuring that the hospitals could still run efficiently during their leave of absence. Balancing that was the hard part.’’ Today, Richardson is the Uniformed Services University, Doctor of Nursing

Practice phase II Residency director and a practicing nurse practitioner at Madigan Army Medical Center. Looking back at her career, she says becoming an Army nurse gave her the opportunity to do things she wouldn’t have accomplished if she had worked in the civilian sector, such as transporting patients via helicopter as a flight nurse and developing flight protocols. ‘‘I’ve had the opportunity to teach and meet people from different branches of the service,’’ she said. ‘‘Every time that I’ve met a new person or went to a new facility, it’s helped me grow and understand what my role as a military nurse really means. ‘‘I think being an Army nurse is really looking at what you want to do, who you want to be and what you want to contribute. Being an Army nurse has helped me continue to strive to reach my full potential and give back to the nurses who are coming up behind me

to ensure they are getting the support they need. They are going to take care of me and my family someday, and if they can use what I’ve learned to grow even further, then we are bettering nursing and health care as a whole.’’ Richardson believes the roles of emergency and military nurses go hand in hand. ‘‘The emergency nurse is that frontline health care provider who is there to ensure that individuals get the support and care that they need, whether it’s for a trauma or a cold,’’ she said. ‘‘I think the goal of the military health system is to make sure that soldiers are healthy and get the care they need to do their jobs. When it comes down to it, the army nurse and emergency nurse are both there to help the individual who is in need right now get back to their life. Whether it’s being a nurse in the ED in the civilian sector or in the military sector, it’s the same mission.’’

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Official Magazine of the Emergency Nurses Association

4/9/14 11:52 AM

Find a Perfect Pairing Through EMINENCE By Kendra Y. Mims, ENA Connection

he Academy of Emergency Nursing launched the EMINENCE (Establishing Mentors InterNationally for Emergency Nurses Creating Excellence) program in 2008 to pair ENA emerging professionals with experienced AEN fellows to work on specific projects for one year. Previous project topics have included writing for publication, professional presentation, research, program development, advanced practice role development, injury prevention and educational conference planning. ENA member Charlann Staab, MSN, RN, CFRN, CHC, CHPC, clinical services manager for Phi Air Medical, LLC, always had wanted to write an article for a publication but didn’t know where to begin. In 2012, she was one of 15 mentees selected to participate in the EMINENCE program. That gave her an opportunity to learn from an emergency nurse who had expertise in writing and editing for publication. She was paired with Carole Rush, RN, M.Ed., CEN, FAEN, clinical nurse educator at Okotoks Urgent Care, who has more than 20 years of experience in writing and editing for publications. Rush was a co-section editor, with Patricia Clutter, for the ‘‘International Nursing’’ column in the Journal of Emergency Nursing from 2007 to 2013 and is the case study section editor of the International Emergency Nursing Journal, based in the United Kingdom. Several years ago, Staab developed an interest in writing on the challenges of pain management for patients taking methadone. Once she became a mentee in the EMINENCE program,

she discussed her aspirations with Rush, who supported Staab’s goal and provided her with writing guidance. Staab is grateful for the support and direction and said the EMINENCE opportunity allowed them to build a lasting relationship beyond the program. ‘‘I was attracted to the EMINENCE program because you could be matched with someone who is skilled and is willing to give you that push, direction and feedback,’’ she said. ‘‘That was the part I was interested in, and Carole did that and so much more. Carole is an editor and has been for years, along with many other things, and she was a natural to give me insight into the writing process. She gave me the pros and cons and helped me learn the writing guidelines for publications. She’s very honest, and you need a mentor who can be honest with you, who knows the ropes and the process and who will help your project be successful.’’ Rush also participated in the 2010-2011 program as a mentor for an educational conference-planning project topic. ‘‘It is challenging to start and complete a project on one’s own,’’ Rush said. ‘‘The EMINENCE mentoring program is a good opportunity to work with emergency nurses who have common interests and experiences and who are willing to share their knowledge and experience, time and contacts. Everyone can benefit from both being a mentor and a mentee, so seek out those opportunities for a specific project/goal.’’ As Staab’s mentor, Rush said she learned a lot about the article’s focus, methadone, and its impact on pain management in emergency care.

Charlann Staab

Carole Rush

‘‘By helping Charlann through the writing process, I improved my editing skills,’’ Rush said. ‘‘Working with another nurse who is keen to learn and complete a project is very motivating. The most satisfying part is giving back and helping another emergency nurse, as I have been helped by many nurses throughout my career.’’ Staab’s article has been accepted for publication and will appear in the ‘‘Toxicology’’ column of JEN. She also presented the article at the Arizona ENA State Council’s ‘‘Hot Topics’’ conference in April. Staab encourages members to share their knowledge through the mentoring program. ‘‘I highly recommend the EMINENCE program to anyone who has interest,’’ she said. ‘‘This program provides you with networking opportunities and resources, and it matches you with a knowledgeable mentor who is accessible and has the expertise to help you reach your goal. ‘‘I think sharing knowledge is crucial to our profession. There are a lot of ENA members who have expertise in a certain area, or they’ve had an experience that other members can learn from, but we’ve got to get it into a medium where we can share it. Whether it’s writing for publication, prepping you to do a dynamite presentation or helping you to achieve another goal, this program has the best networking resources of experts and members.’’ For more information on the program, please visit www.ena.org/ about/academy/EMINENCE.

June/July 2014

Standards Changing for State Council Achievement Awards

ENA will launch a new application

recognition of the states for their

work team is charged with developing

efforts to 1) improve networking

the application and evaluation tool

and professional development

and ultimately will be reviewing and

opportunities for members and

ratifying the applicants.

or more than six years, ENA has administered a State Council Achievement Award program, designed to assist ENA state organizations in developing best practices and to recognize the states that have met or exceeded the necessary requirements. This summer,

program to reward accountability and

The ENA Board of Directors

recognize state councils for achieving

appointed the ENA State Council

best practices and organizational

Achievement Award Work Team to

excellence beyond basic compliance.

review and recommend the new

The new program will improve

2) conduct state council affairs in a

application objective. Additionally, the

State councils must meet basic

sound business manner. State Council

compliance requirements to be

Achievement Award recipients will be

eligible to complete the award

honored based on their outstanding

application.

40th Anniversary Celebration for NERS Truly Something to Sea By Renée Herrmann, ENA Connection

performance and accomplishments.

he New England Regional Symposium celebrated its 40th anniversary April 16-18 in Mystic, Conn. Each year, a different ENA state council plans the event, and this year was the Connecticut ENA State Council’s turn. Kara Cleveland, BSN, RN, CEN, and Mary Davis, BS, RN, CEN, were co-chairs of the event. The theme was ‘‘Navigating Change,’’ inspired by the seaport setting of Mystic along with trends in the current industry. ‘‘Change is all around, and everything is changing in health care with the Affordable Care Act, high reliability and hospitals becoming more transparent,’’ Cleveland said. ‘‘We then focused on the nautical theme.’’ The planning committee worked diligently to create a successful event. Cleveland noted that one unforeseen issue was that the conference fell during Easter week. ‘‘We booked the venue in October 2012 and were hoping that since it was during April break, people could bring their families. When we realized it was Easter, it put pressure on us to get the attendees,’’ she said. Because of the committee’s efforts and a strong push during the weeks leading up to the event, about

160 nurses registered for the 2014 NERS. For NERS’s ruby anniversary, the planning committee focused on the color red. Bags and conference materials were colored red, and attendees were entered into a raffle for a ruby necklace. The committee also worked to bring in presenters who have spoken on a national level, including ENA President Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN, who delivered the keynote address, and ENA Secretary/Treasurer Kathleen Carlson, MSN, RN, CEN, FAEN. Feedback for the symposium has been positive, Cleveland said. A highlight for her was Brecher’s keynote presentation. ‘‘It set the tone for the event,’’ she said. ‘‘The title was ‘My Patients Are Fine, I Am Going to Lunch,’ and it focused on high reliability, transparency and patient safety.’’ Two events were held for attendees to take in the sights of Mystic and network with colleagues. A welcome ‘‘Mystic Pizza Party’’ was well received. ‘‘Drop Anchor at the Aquarium’’ featured catered hors d’oeuvres and access to the aquarium at night. ‘‘I think when you’re planning, it takes a whole team,’’ Cleveland said, ‘‘and we had a fantastic committee. They say ‘it takes a village,’ which may be a cliché, but it was our whole team that pulled together [to make the event a success].’’ Brecher agreed: ‘‘To have an emergency nursing conference that spans 40 years is a tremendous accomplishment. From the emergency nurses who planned the events to the nurses who attended, the focus on safe practice and safe care was clear. It was exciting to be with ENA members from New England as they celebrated this great achievement.’’ The Maine ENA State Council will host the 2015 event.

connection

Recruitment & Professional Opportunities

For ad rates and information, contact ENA Sales Representative Maureen Nolimal at 847-460-4076 or Maureen.Nolimal@ena.org.

ADVERTISER INDEX These advertisers support ENA Connection. Let them know you saw their ad in this issue.

40 Blue Jay Consulting LLC www.bluejayconsulting.com 33 Chamberlain College of Nursing www.chamberlain.edu 29 Gebauer Company www.gebauer.com 38 JPS Health Network www.JPSNursing.org

39 New Hanover Regional Medical Center www.newhanovered.com 23 Pinpoint Inc. www.pinpointinc.com

5 Teleflex Incorporated www.teleflex.com

16- Teva 20 www.tevausa.com 38 University of Virginia Health System www.uvajobsbeyondmeasure.com

“Every day brings an opportunity to see cutting edge trauma care. Nurses are the bedrock of our Emergency Department. It is our duty to provide the highest quality care.” - Meg Bryant, Director, Emergency Services A major employer in the Fort Worth area, JPS is a teaching hospital and Level I Trauma Center. If you’re interested in joining our team, please visit www.JPSNursing.org

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June/July 2014

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Average improvement in throughput for admitted and discharged patients

Average improvement in time from arrival to seeing a physician.

Typical improvement in patient satisfaction scores and likelihood to recommend

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B I L L B R I G G S , M S N , R N , C E N , FA E N

Senior Consultant Blue Jay Consulting, LLC