research abstracts from the ena 1997 annual meeting

T he fol lowing original r e s e a r c h pro jec ts we re pre- s e n t e d a t ENA's 1997 Sc ien t i f i c A s s e m b l y ,

S e p t e m b e r 5-7, in At lanta , Georgia . A b s t r a c t s are n u m b e r e d in the i r p r e s e n t a t i o n order, wi th oral pre- s en t a t i ons (1 t h rough 10) followed by pos te r p r e sen - t a t ions (11 t h rough 15). Pos ter p r e sen t a t i ons m a y re- flect r e sea rch in progress . The author who p r e s e n t e d each a b s t r a c t is i n d i c a t e d b y i tal ics a n d their a d d r e s s is p rov ided to faci l i ta te co r re spondence . I wou ld like to a c k n o w l e d g e the work of t he nurses on the ENA S t a n d i n g C o m m i t t e e for Resea rch and Susan M a c L e a n for fac i l i ta t ing the se lec t ion and pub l i ca t ion of t h e s e abstracts.--Jane Koziol-McLain, RN, PhD(c)

1. Attitudes Toward MDS and Perceived Climate. Frank Cole, Cindy Abel. Univers i ty of Texas -Hous ton , School of Nurs ing, 1100 Ho lcombe Blvd., Fifth Floor, Houston, TX 77030.

Purpose: Nurses a t t i t udes t oward AIDS (AA) are k n o w n to i m p a c t care p rov ided to pe r sons wi th AIDS (PWAs); however , little r e s e a r c h exis t s in th is a rea wi th ED nurses . The concep tua l f r amework i n d i c a t e s tha t A A and the p e r c e i v e d c l imate t o w a r d p rov id ing care to PWAs i m p a c t s o u t c o m e s of care. Therefore, th is s tudy e x a m i n e d the re la t ionsh ips a m o n g AA, p e r c e i v e d c l imate , and d e m o g r a p h i c var iables .

Design: A cross-sec t ional , correlat ional d e s i g n w a s used .

Setting: Two level I t r a u m a cen te r s wi th a large n u m b e r of PWAs in Southern u rban a reas were used .

Sample: The c o n v e n i e n c e s amp le c o n s i s t e d of 66 r eg i s t e r ed nurses , the major i ty were female (n = 47), mar r i ed (n = 38), wi th a m e a n age of 36 and e i ther an a s soc i a t e d e g r e e (n = 30) or BSN (n = 26). No exclu- s ion cr i ter ia w e r e used .

Methodology: A ques t ionna i r e w a s u s e d tha t con- t a i ned d e m o g r a p h i c ques t ions , an A A sca le wi th

J Emerg Nurs 1997;23:399-406. Copyright © 1997 by the Emergency Nurses Association. 0099-1767/97 $5.00 + 0 18/65/84533

e s t a b l i s h e d rel iabi l i ty (0.80 to 0.96) and va l id i ty and an AIDS Cl imate (AC) scale. The A A scale m e a s u r e d a t t i t ude a c c o r d i n g to the m o d e (heterosexual , blood t rans fus ion [blood], IV drug use [IV], and homosexua l ) by w h i c h the pa t i en t a c q u i r e d AIDS. The AC scale, c o n s t r u c t e d for th is project , m e a s u r e d nur ses ' per- cep t ion tha t admin i s t r a t i on s u p p o r t e d care to PWAs.

Results: Cronbach ' s a lpha w a s 0.95, 0.96, 0.84, 0.90, for he te rosexual , blood, IV, and homosexua l sub- scales , respect ively , and 0.70 for AC. Ev idence of fac- torial va l id i ty w a s ob ta ined . The following m e a n scores ex i s t ed for he te rosexual , 17.6; blood, 18.3; homosexual , 16.1; and IV, 11.7; and 31.6 (possible 7 to 42) for AC. Us ing Pearson p r o d u c t - m o m e n t correla- t ions, no s ign i f ican t re la t ionsh ips ex i s t ed b e t w e e n A A s u b s c a l e s and AC or b e t w e e n A A and demo- g raph ics . AC w a s re la ted only to p e r c e i v e d risk of AIDS (r = 0.27, p = 0.03).

Conclusions: A A var ied by m o d e of acqu i r ing HIV wi th the mos t pos i t ive a t t i t ude for blood. A d m i n i s t r a - t ive suppor t ex i s t ed to p rov ide care and p e r c e i v e d suppo r t w a s g rea te r for t hose who felt less risk of con- t r ac t i ng HIV. Add i t iona l r e s e a r c h is n e e d e d to examine t he effects of A A and AC on o u t c o m e s of care.

2. Post-code Stress in Emergency Nurses. Janine Catalano. Unive r s i t y of T e x a s - H o u s t o n , M e d i c a l School, 1100 Ho lcombe 6.630, Houston, TX 77030.

Purpose: Stress in e m e r g e n c y nurses m a y lead to phys i ca l and psycho log ic s y m p t o m s and i n c r e a s e d turnover. Role theory s t a t e s t ha t s t ress occurs w h e n one feels unab le to m e e t in terna l or ex terna l behav- ioral expec ta t ions . For e m e r g e n c y nurses CPR s i tua- t ions m a y p r o d u c e feel ings tha t e x p e c t a t i o n s have not b e e n m e t resu l t ing in p o s t - c o d e s t ress . The purpose of th is s t u d y was to m e a s u r e p o s t - c o d e s t ress and ident i fy d e m o g r a p h i c var iab les tha t affect it.

Design, Setting, and Sample: This desc r ip t ive s tudy occur red in four e m e r g e n c y d e p a r t m e n t s wi th v is i t s r ang ing from 1700 to 3500 per month . A s a m p l e of c o n v e n i e n c e cons i s t ed of 53 nur ses who repor ted

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anonymously. Females composed 81% of the sample with a mean age of 39.7 years (SD = 7.5). The majority reported a BSN with an average of 8 years emergency nursing experience (SD = 5.6). Religious beliefs were important or very important to 71% of the respondents. Subjects had participated in an average of 23 codes in the past year (SD = 16).

Methodology: The Post-code Stress Scale (PCSS) (Cole et al., 1991) and demographic data forms were distributed at a. scheduled staff meeting. Respon- dents returned the forms anonymously by U.S. mail. The response rate was 60%. The PCSS has evidence of content and construct validity and an internal consistency of 0.84 in this sample.

Results: Scores on the PCSS had a mean of 68 and a range of 37 to 83. Possible scores are 18 to 90, with higher scores indicating higher levels of post-code stress. Of all the possible demographic variables, only religious beliefs were found to have an influence as determined by ANOVA [F(3,48) = 3.14, p <0.05]. Subjects who reported that religious beliefs were "very important" to them demonstrated higher levels of post-code stress.

Conclusion: High levels of post-code stress were found in this population and scores were greater than 67 for 58% of participants. Thus, post-code stress is a significant phenomenon of concern to nursing. Post- code stress, not properly diffused, may lead to a variety of undesirable outcomes for nurses, emergency departments, and, ultimately patient care. Implica- tions for emergency nurses include the need for nurses to be aware of stress engendered by codes and the need for a mechanism to diffuse this stress.

3. Identifying the Roles, Activities, Skills, and the Cost-Saving and Revenue-Generating Activities of Master's--Prepared Nurses Who Function in Tradi- tional Clinical Nurse Specialist Roles in the United States. Rhonda Adams Scott. South ~F~it6n Medical Center, 1170 Cleveland Avenue, At lanta . , [~ 30344.

Purpose: The purpose of this s tudy was to describe the roles, activities, skills, and the cost-saving and revenue-generating activities of master's- prepared nurses who function in traditional clinical nurse specialist (CNS) roles in the United States.

Methodology: The study used a descriptive research design and was guided by role theory. The data were measured by a 64-item instrument developed by the principal investigator, using Likert-type, fill-in-the blank, and closed-ended questions. The tool was pretested and used in two pilot studies. Content validity was supported by three experienced CNSs. Instrument reliability was 0.89. Surveys were mailed

to all individuals who subscribed (n -- 2279) to the Clinical Nurse Specialist Journal. The sample included 724 master's-prepared CNSs providing a margin of error of _+4 percentage points with a 99% confidence level.

Results: Respondents were from 49 states and represented 25 clinical specialities. The majority of the CNSs were female, between the ages of 30 and 49, worked full-time, earned $40,000 to $60,000, active in professional organizations, hospital based, and employed 1 to 8 years. Respondents reported (listed from frequently to less frequently) spending time in the role of expert practitioner, educator, con- sultant, administrator, and researcher. The results indicated a trend toward increasing administrative responsibilities and performing advanced skills that have traditionally been considered medical practice. A small number of CNSs were able to identify cost- saving and revenue-generating activities, including the monetary value.

Conclusions: Implications from this study can be used to (1) identify and clarify roles, activities, and advanced skills, (2) recognize all CNSs as advanced practice nurses, (3) recommend the educational prepara- tion, curriculum changes, and clinical experiences needed to prepared CNSs, and (4) conduct research regarding the effects of CNSs' interventions on nursing practice, patient care, and health care costs.

4. Patient Acuity, Nurse Cultural Acceptance, and Patient Satisfaction with Triage Nursing in the Emergency Department. Barbara Davis, Jim Raper, Linda Scott. Marshall University, School of Nursing, 400 Hal Greer Blvd., Huntington, WV 25755-9500.

Purpose and Design: Utilizing Strasser's Model of Patient Satisfaction and Lenninger's Model of Cultural Sensitivity and Nurse Caring Behavior this descriptive, correlational study determined relationships between patient satisfaction and: (1) nursing care provided during ED triage; (2) patient's intention to return to emergency department; and (3) triage nurse's demonstrated level of cultural acceptance.

Sample: Convenience sample of triage nurses (N = 81) and urgent/delayed category patients (N = 378) undergoing ED triage in an academic medical center and two nonprofit hospitals.

Methods: Following informed consent, triage nurses completed the 18-item cultural sensitivity survey (Henderson/Primeaux) (reliability/validity unde- termined). Forty-eight hours post-ED visit, patients were contacted by telephone and following informed consent, were administered Caring Subscale of Con- sumer Emergency Care Satisfaction Scale (r = 0.92);

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and two scales measuring satisfaction with triage nurse (r = 0.94) and subjects' intent to return to emergency department (r = 0.87). Two open-ended questions regarding what subjects liked best and what "could have been better" also were posed.

Results: Analysis of variance revealed higher levels of satisfaction with care at triage and with triage nurses at the academic medical center, while highest levels of intent to return were reported by subjects from the nonprofit community hospital. Content analysis of open-ended questions revealed positive nurse behaviors and "less time to be seen" as domi- nant patient satisfaction themes. Nurse data revealed a positive relationship between nurse's cultural sensitivity and highest level of education (r-- 0.30, p < 0.01), but failed to demonstrate a statistically significant relationship with either level of nursing education or overall patient satisfaction with triage nursing.

Conclusions: Results were consistent with patient satisfaction studies and the model proposed by Strasser. The findings suggested the importance of ED nurse-patient relationship, but failed to support the concept of higher levels of nursing education translating into increased levels of nurse cultural sensitivity. In an era of managed care, pat ient satisfaction remains an important variable in suc- cessful health care delivery requiring further inves- tigation.

5. A Comparison of Techniques for Measuring ED Patient Satisfaction. Jane Koziol-McLain, Steven Lowenstein, Leslie Beasley. Box B-211, UCHSC, 4200 E. Ninth Avenue, Denver, CO 80262.

Purpose: Patient satisfaction is inconsistently defined and its measurement fraught with method- ological problems. The results of a recently mailed survey at our hospital showed low patient satisfaction. Recognizing the limitations of mailed surveys, we conducted a study to examine the consistency of patient satisfaction responses across three survey techniques: a mailed survey, a face-to-face interview, and, a telephone interview.

Design, Setting, and Sample: This prospective study surveyed patients at an urban, university emergency department. All English- or Spanish-speaking adult patients discharged during 20 randomly selected 4- hour time blocks during a 2-week period were eligible to participate.

Methods: A trained research assistant (not employed by the hospital) verbally administered a subset of 15 questions from the mailed Emergency Depart- ment Patient Satisfaction Survey (Picker Institute) to eligible, consenting patients. A subset of eligible

patients were contacted 2 weeks later and asked the same questions in a telephone interview.

Results: Response rates were much higher in face-to-face interviews (95%, 185/195) and telephone interviews (87%, 40/60) compared with the mailed survey (26%, 135/514). Face-to-face interviewees were typically female (55%), young (mean age = 37 years), and without insurance (63%). The proportion of patients that would "Definitely recommend this emergency department to friends and families" var- ied from 46% (95% CI = 0.37, 0.55) for those complet- ing the mailed survey, to 78% (95% CI -- 0.72, 0.84) and 85% (95% CI = 0.70, 0.94) for those surveyed face- to-face and by telephone, respectively. The most frequently cited problem areas were similar between face-to-face interviewees and mailed survey respondents: waiting time (48% mailed, 38% face-to-face), causes of problem explained well (44% mailed, 20% face-to-face), and depar tment cleanliness (39% mailed, 13% face-to-face).

Conclusions: Satisfaction ratings based on mailed surveys significantly underestimate the degree of patient satisfaction, yet they accurately identify problem areas. The cost and feasibility of various survey techniques needs to be weighed against the repre- sentativeness of the sample achieved when monitor- ing patient satisfaction among ED patients.

6. Pain Management Practices in the Emergency Department. Paula Tanabe. Northwest Community Hospital, Emergency Department, 800 West Central Road, Arlington Heights, IL 60005.

Purpose: A conceptual model consist ing of patient and system variables that affect pain in the ED patient was developed for use in this study to describe the experience of pain from the ED patients' perspective and identify patient and system variables that affect pain management in the emergency department.

Design and Setting: A descriptive design was used to collect the data in a level I trauma center emergency department.

Sample: The sample consisted of 203 patients who were more than 18 years of age, spoke English, and were not disoriented, physiologically or psycho- logically unstable, or intoxicated.

Methodology: All eligible patients who presented with pain during the 8-day, 10 hours per day, data collection period were approached, consent was obtained, and they were interviewed using a structured questionnaire that included 15 questions describing pain, including the numeric rating scale and verbal descriptor scale to rate pain intensity. Both

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measures have established validity and reliability. All ED staff were blinded to the purpose of the interviews. Charts were reviewed retrospectively for the use and timing of analgesics.

Results: Seventy-nine percent of the total census had a chief complaint related to pain and 47% received an analgesic. The average time to analgesic was 73 minutes. Only 15% of the patients received an opioid despite the average pain rating of 6 on a 0 to 10 scale. Multiple logistic regression was used to identify predictors of treatment. The location of chest pain was the only variable that was found to be an independent predictor of treatment of pain, (R = 0.14, df = 1, p < 0.05). Independent variables examined included pain rating, location of pain, age, gender, ethnicity, and fear of addiction. Only 23 of 160 patients with pain expressed a fear of medications.

Conclusions: Pain in the ED setting is underiden- tiffed and poorly managed for a variety of reasons. ED nurses need to further develop pain assessment skills and increase the implementation of all pain management strategies.

7. Evaluation of Pulse Oximetry in Smokers. Julie Miller, Arthur Pancioli. St. Luke's Pediatric Hospital, Bellevue, KY 41073.

Purpose: To determine the accuracy of pulse oximetry in persons who smoke presenting to the emergency depar tment for evaluation. Recently, spectrophotometric analysis and bedside use of pulse oximetry to monitor patients' arterial oxygenation has become a standard of care in the emergency department. However, in persons who smoke, elevated carboxyhemoglobin levels may result in erroneous pulse oximetry readings.

Sample: A convenience sample of 21 adults aged 18 to 78 years who presented to the emergency department for evaluation was u s e d - m this pilot study. Patients requiring pulse oxi-rn6¢ry-~menitoring and concurrent arterial blood gas all"alysis were included. Exclusion criteria were: recent or current oxygen therapy, pulse oximetry saturation less than 70%, shock, methemoglobinemia, and hemoglobin less than 5 gm/100 ml. Based on current smoking his- tory, 10 subjects were assigned to the smoker group and 11 subjects were assigned to the nonsmoking group. Subject confidentiality and anonymity were assured following institutional review board approval.

Methodology: Pulse oximetry was measured using a Nellcor N-200 oximeter (Nellcor Incorporated, Hayward, Calif.). Co-oximetry, which measures absorbencies of oxyhemoglobin, is considered the "gold standard" for establishing pulse oximeter accu-

racy. Reliability and validity of pulse oximetry when correlated with co-oximetry analysis is r = 0.98. Comparison analysis on the arterial blood sample was performed using OSM 3 Hemoximeter (Copenhagen, Denmark). Carboxyhemoglobin levels, obtained as part of the co-oximetry analysis, was utilized to confirm smoking status.

Results: A strong, statistically significant relationship between pulse oximetry and co-oximetry mea- surements in nonsmokers (r = 0.87, p = 0.001; mean difference 1.7%, SD of difference +_1.6%) was demonstrated. However, in smokers, the relationship was moderate and nonsignificant (r = 0.47, p = 0.172; mean difference 2.1%, SD of difference +_2.2%).

Conclusions: Although sample size was small, the data suggested that pulse oximetry is a more accu- rate reflection of arterial oxygenation in nonsmokers that in smokers.

8. Fosphenytoin (Cerebyx ®) Loading Dose Admin- istration in the Emergency Department. Patricia Fischer, Susan Henkin. University of Illinois at Chicago, College of Pharmacy, 833 South Wood Street, Room 164, Chicago, IL 60612.

Purpose: Administration of IV phenytoin (PHT) in the emergency department requires significant nursing resources. Fosphenytoin (FOS; Cerebyx®), a phenytoin prodrug, overcomes many of the clinical complications associated with parenteral phenytoin providing greater flexibility (IM and IV routes), conve - nience (faster rate of IV infusion~ IV fluid compatibility), and patient comfort (improved injection/infusion tolerance). Injection/infusion tolerance, general safety, and pharmacokinetics results from six prospective, multicenter clinical studies with fosphenytoin were reviewed, with particular emphasis to ED nursing practice.

Methods: Data from 543 patients from 3 double- blind IV and 3 open-label (1 IV; 2 IM) studies conducted at 43 facilities were reviewed and summa- rized. Patients enrolled in these studies had status epilepticus (n = 85 FOS), seizures (n = 189 FOS, n = 35 PHT), or neurosurgical/head injury (n = 206 FOS, n - 28 PHT), and required a phenytoin loading dose for the treatment/prophylaxis of seizures. Target loading doses for fosphenytoin and phenytoin ranged from 10 to 20 mg/kg phenytoin equivalents; target IV rates ranged from 50 to 150 mg/min with fosphenytoin and up to 50 mg/min with phenytoin.

Results: Therapeutic plasma phenytoin concentrations (>10 [tg/ml) were rapidly achieved following IV and IM fosphenytoin loading doses. Intravenous fosphenytoin resulted in less pain/burning at infusion



site than phenytoin (9% of patients vs. 90%, respectively), fewer disruptions to the infusion (14% vs. 48%), and was safely infused in less time (21 vs. 42 minutes). Fosphenytoin provided improved IV fluid compatibility/stability. Larger than typical IM vol- umes (10 to 20 ml) were well tolerated, and 95% of fosphenytoin injections were without irritation. Central nervous system related adverse events were similar for both fosphenytoin and phenytoin. Transient groin itching/burning occurred occasionally with IV fosphenytoin. No clinically significant hypotension or arrhythmias were seen following either fosphenytoin or phenytoin.

Conclusions: Intramuscular and intravenous fosphenytoin loading doses are safe and significantly better tolerated by the patient than parenteral phenytoin. Therapeutic plasma phenytoin concentrations are rapidly achieved. Improved safety/tolerability pro- file and faster administration of fosphenytoin enhances the delivery of care the emergency nurse provides.

9. Delay in Accessing Stroke Healthcare (DASH) Study. Wayne Rosamund, Rebecca Gorton, Dexter Morris, Albert Hinn, Susan Hohenhaus. University of North Carolina, School of Public Health, Chapel Hill, NC 27514.

Purpose: Delay in Accessing Stroke Healthcare (DASH) Study was designed to quantify components of delay in responding to stroke symptoms and to identify factors associated with short delay in presenting to the emergency department.

Design: A longitudinal prospective study design was used.

Setting and Sample: ED nursing staff, who attend- ed training sessions given by the study investigators, identified patients presenting to the emergency depar tment of the University of North Carolina Hospitals with any of the following symptoms of stroke: sudden weakness or numbness of face, arm, or leg on one side of the body, sudden dimness or loss of vision, loss of speech, or sudden severe headache, or unexplained dizziness. Men and women of any age were eligible. Between July 1995 and February 1996, 152 patients were enrolled.

Methods: A 32-question, standardized, structured investigator-developed questionnaire was administered by trained ED nurses to every patient with stroke symptoms. The data collected included time of onset of symptoms, actions taken in response to symptoms, and perceived urgency of symptoms. To obtain content validity, the tool was reviewed by a panel of expert emergency nurses.

Results: More than 50% of study participants were women, 33% were African-American, with an average age of 67 years. Having someone else in their sur- roundings identify stroke symptoms (47%), having known someone who had a stroke (70%), and the use of an ambulance to arrive at the emergency department (52%) were associated with ED arrival times within 3 hours of onset of symptoms. Having a histo- ry of stroke (37%) and making the decision to seek medical care themselves (24%) were associated with a greater than 3-hour delay to arrival in the emergency department.

Conclusion: The importance of a "stroke-educated" public to reduce the time it takes for patients experi- encing stroke to rapidly respond and access medical care is needed for the benefits of evolving acute treat- ments to be more fully achieved. Emergency nurses, as well as the public, should be actively involved in educat ing high-risk patients and families about stroke recognition.

10. Hidden Scars: Experiences with Practicing Pro- cedures on the Newly Dead. Kathleen Oman. Univer- sity Hospital, Emergency Department, 4200 East Ninth Avenue, Box A021-610, Denver, CO 80262.

Purpose: Teaching hospitals have the mission and responsibility to teach, train, and educate health care providers. Lifesaving invasive procedures are taught and practiced in order to develop and maintain competency. In some instances, these procedures are taught and practiced on newly dead patients. The purpose of this study was to gain an understanding of the health care provider's experience with the phenomenon of practicing procedures on the newly dead in the emergency department.

Design, Setting, and Sample: Human science provided the framework for this qualitative descriptive study conducted in the emergency department and associated flight program. Eight consenting participants consisting of four nurses, three physicians, and one hospital minister (chosen with the intent of obtaining a nonclinical opinion) were selected based on their personal range of experience, their views about the phenomenon, and their willingness to be interviewed.

Methodology: Unstructured interviews lasting 30 to 50 minutes began with the question "I'd like you to tell me about your experience with practicing or teaching medical procedures on newly dead patients in the emergency department." The interviews were audiorecorded, transcribed, and analyzed to uncover themes. Participants were asked to validate the results to establish credibility and confirmability.

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Results: Four major themes emerged from the data: (1) The Real Thing: the reality of practicing on a human body versus a mannequin or animal model; (2) Moral Conflict: the issue of consent and the lack of respect and dignity that was perceived during the practicing; (3) Secrecy: not disclosing the practice and misrepresenting the procedures in the medical record; (4) Hidden Scars: procedures that won' t dis- figure the patient are more tolerable.

Conclusions: Practicing procedures on the newly dead without consent or disclosure is advocated by some emergency care providers as necessary for assuring and maintaining competency. Others find this "Don't Ask, Don't Tell" practice (Goldblatt, 1985) troublesome. We need to find a way to eliminate the secrecy, acknowledge what we do, and deal with the issue of consent.

11. Rural Enhancement of Access and Care for Trauma Patients. Sallie Gough, Herbert Garrison, Kathleen Dunn, Paul Cunningham. Eastern Carolina Injury Pre- vention Program, PO Box 6028, Greenville, NC 27834.

Purpose: The Rural Preventable Mortality Study (RPMS) conducted in 1995 in rural eastern North Carolina suggested that approximately 29% of deaths due to trauma were preventable. Primary concerns in the prehospital setting included airway management, oxygenation/ventilation, and fluid resuscitation. Major ED issues included delays in definitive care, airway management, and oxygenation/ventilation. The purpose of the National Highway Traffic Safety Administration (NHTSA)-funded Rural Enhancement of Access and Care for Trauma (REACT) project is to decrease the preventable mortality rate in trauma through implementation of a continuous quality improvement system.

Design: Descriptive.

Setting: Twenty-nine counties in ~ural eastern North Carolina served by one levei I-t~'um~a center.

Sample: Participants include ED nu[ses, physicians, and prehospital care providers of all levels in the 29-county area of eastern North Carolina.

Methodology: Trauma care guidelines were developed based on the RPMS-identified deficiencies. Tools developed for the collection of data assessing prehospital and ED care were used in a pilot study to determine reliability. A system is being implemented consisting of education directed at ED and prehospital care providers; data collection assessing the quality of trauma care; and feedback based on the data collected. Community ED nursing staff will assess prehospital trauma care, and level I trauma center personnel will assess care delivered at outlying emer-

gency departments. Concurrent education and data collection with feedback to the care providers will be conducted from July 1, 1997, through June 30, 1998. Beginning July 1, 1998, the Rural Preventable Mor- tality Study will be repeated to assess the effective- ness of this continuous quality improvement system on preventable mortality outcomes.

Results: Preliminary data on trauma care guide- line compliance will be presented.

Conclusions: The REACT project provides an opportunity to test outcomes after instituting a model system for continuously improving trauma care.

12. Pediatric Sledding Injuries in Pennsylvania. Lisa Bernardo, Mary Jane Gardner, Kenneth Rogers. University of Pittsburgh, School of Nursing, 415 Victoria Bldg., Pittsburgh, PA 15261.

Purpose: The purpose of this study was to analyze demographic and other factors associated with pediatric sledding injuries. Application of the agent-host- environment model of injury prevention was applied to this study's findings to develop education strategies for preventing pediatric sledding injuries.

Design: A retrospective, descriptive review of reg- istry data from the Pennsylvania Trauma Outcomes Study (PTOS).

Setting: Accredited trauma centers in Pennsylvania.

Sample: Injured children ages 2 to 18 years (mean = 10.6 years, _+3.9 years) admitted to the 25 accredited Pennsylvania trauma centers from 1989 through 1994 whose E-codes (external causes of injury and poisoning) and injury descriptions indicated sledding activities.

Methodology: PTOS data elements extracted for analysis were age, gender, intensive care unit (ICU) and hospital length of stay (LOS), and discharge status. Injury Severity Score (ISS) and ICD-9-CM [International Classification of Diseases-ninth revi- sion-Clinical Modification] codes were obtained. Descriptive and inferential statistical analyses were performed.

Results: Two hundred twenty-six patients were admitted for sledding injuries. Sixty-nine percent were male. The mean ICU LOS was 3 days _+ 2.9, and the mean hospital LOS was 7 days + 7.2. Ninety-six percent were discharged alive. Forty-seven percent of the ISS scores were classified as moderate (ISS 7 to 15). There was no association between age and ISS (r= 0.04), but there was a moderate correlation between ISS and length of ICU stay (r = 0.47). Hitting trees and stationary objects (n = 121) was the most common injury descriptor. Patients struck by moving



vehicles (n = 18) had the highest proportion of head (34%) and chest (18%) injuries, the highest mortality rate (33%), the highest median ISS score (22), and highest mean ICU LOS (6 days), compared with pat ients hi t t ing stationary objects or falling.

Conclusions: Most children were injured from col- lisions with objects or moving vehicles. Patient education based on the agent-host-environment tr iad of injury prevention should emphasize the safe s ledding pract ices of s ledding on obstacle-free hills with adult supervision and avoidance of s ledding in s t reets or driveways.

13. The Effect of the MorTan Device on Ear Ir- rigations in Children. Cindy Ebner, Adele Webb. Children's Hospital, One Perkins Square, Akron, OH 44308.

Purpose: Cerumen removal is often necessary to visualize the tympanic membrane in order to accurately d iagnose acute otitis media . The current method of cerumen removal is irrigation of the audi- tory canal. The purpose of this s tudy was to examine the safety and efficacy of the new MorTan (MorTan Inc., Missoula, MT) device in comparison with other irrigation and aural medicat ion delivery systems.

Sample: The 300 subjects were be tween 4 and 46 years of age, with a mean of 14 years. Fifty-three percent were male and 47% were female. Part icipants were randomly ass igned to one of three groups: WaterPik (Teledyne Water Pik, Fort Collins, CO) alone, MorTan on WaterPik, or MorTan on syringe.

Methodology: Ears were visualized to determine the percent of occlusion. Following a s tandardized protocol, carbamide peroxide (Debrox) was instilled and the ear irrigated until the tympanic membrane was visualized. A FACES Pain Scale was used to assess the comfort level of subjects. A quest ionnaire was developed to assess nurse satisfaction with the MorTan for irrigation and Debrox administration.

Results: A comparison of the t ime to clear the cerumen be tween groups was analyzed using analysis of variance (ANOVA). It took significantly longer to clear the cerumen using the WaterPik alone. An ANOVA was performed to analyze the pain difference be tween the groups. There was no significant difference in discomfort for those who had their ears irrigated with the MorTan on the WaterPik and those who had the MorTan on a syringe. There was a significant difference be tween the WaterPik alone and the WaterPik with the MorTan, and the WaterPik alone and the MorTan on syringe. The most discomfort was reported with the MorTan on the syringe (mean = 4.34). One hundred cultures were done on

the WaterPik following irrigations and cleaning. Only 1% were positive.

Conclusions: The majority found the MorTan easi- er to use for aural medication, but the nurses reported that the MorTan with the WaterPik was harder to use than the WaterPik alone. Ninety-eight percent of the nurses identified a need for a bet ter device, but only 40.3% felt the MorTan met that need.

14. Evaluation of the Use of an Emergency De- partment Domestic Violence Protocol and its Associ- ation with the Attitudes, Knowledge and Skills of Clinicians. Kristen Smith, Anna Waller, Susan Hohenhaus. University of North Carolina Hospitals, Depar tment of Emergency Medicine, CB #7594, Chapel Hill, NC 27599-7594.

Purpose: In recent years, domest ic violence has been in the spotlight as a major public health issue. As part of the evaluation of a domest ic violence protocol, this study, utilizing the framework of social-learning theory, looked at the relationships be tween the implementat ion of the protocol, and the knowledge, attitudes, and screening/referral skills of ED clinicians.

Design: A comparat ive design was used to conduct this study.

Setting and Sample: Thirty-four ED clinicians (nurses and physicians) at the University of North Carolina Hospitals, a tertiary care and teaching facility, were surveyed prior to the implementat ion of a domest ic violence protocol and after 1 year of its use.

Methods: A se l f -admin is te red ques t ionna i re developed by experts in domest ic violence issues, consist ing of c losed-ended questions regarding attitudes and knowledge and open-ended quest ions regarding screening and referral skills was used. The evaluators a t t e m p t e d to survey every clinician. Clinicians were educa ted about domest ic violence issues and trained to use the protocol. To assess screening and referral skills, clinicians were asked what they do when they suspec t and confirm a woman to be a domest ic violence victim. Pre- and postsurvey data were analyzed using Student 's t test for continuous variables and chi-square tes ts for cat- egorical variables.

Results: High comfort levels regarding talking to pat ients about domest ic violence were associa ted with more familiarity with the protocol. Clinicians surveyed after the protocol was in place for a year repor ted more comfort than cl inicians surveyed before implementat ion (69% reported discomfort with the subject in the pretest, and 35.4% in the posttest). Knowledge about domest ic violence was not associ- a ted with training or protocol use (27% reported iden-

October 1997 405


tification of a domestic violence case before training, and 72.2% after training). Screening and referral skills were associated with specific protocol training.

Conclusions: Training specific to domestic violence screening and referral skills is important to both increase clinicians' comfort level, and increase iden- tification of domestic violence victims in the emergency department. More training is recommended to increase the quality of care given to women in the emergency department.

15. The Option of Family Presence During a Re- suscitative Code of a Loved One. Lana deRuyter, Judi Gawlikowski, Dianne Lanham. Chester County Hos- pital School of Nursing, 701 East Marshall Street, West Chester, PA 19380.

Purpose: To determine if family presence during the code of a loved one facilitates the family mem- ber's grief resolution process. Rando's Concept of the Death Surround, which suggests that the environment and circumstances immediately surrounding death influence the grief resolution of surviving family members, will serve as the study's theoretical framework.

Subjects: Family members of ED patients who sustain a terminal cardiopulmonary arrest either in the prehospital or ED setting. Family of patients who are successfully resuscitated will be excluded.

Design: Utilizing a quasi-experimental design, family members will be approached on arrival in the emergency department by specially trained staff members who will offer the option to stay during the resuscitation. Family members choosing not to stay will be supported in their decision and provided with grief support in the usual manner. Telephone follow- up will be conducted with all families 4 weeks postevent, at which time study participation will be sought. Confidentiality and anonymity will be assured. Enrolled subjects will be mailed: Consent, Subjective Questionnaire and the Grief Experience Inventory (GEI). The GEI consists of 135 true-false items covering somatic and emotional content associated with the process of bereavement. The items yield three validity scales and nine symptom scales that measure tile intensity and severity of grief reac- tion. It is a well-validated tool and demonstrates high test-retest reliability. Differences between subjects' scores on the GEI will be analyzed using the t test. The Subjective Questionnaire, designed for use in this study, will inquire about subjects' reactions to being present during the resuscitation and its impact on grief resolution. Content analysis of questions will be reported, along with demographic data.

Implications for Nursing: It is anticipated that the results of this study will enhance the knowledge base of ED staff, resulting in a more supportive and nurtur- ing environment for families during this difficult time.


research abstracts from the ena 1997 annual meeting

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