Professional Issues Study Guide for the CEN

System

The system refers to the broad healthcare system in which a healthcare worker is employed and the one in which a patient receives care. For some systems, this comprises only a single hospital, but most systems have multiple hospitals, outpatient and urgent care facilities, and ambulatory clinics.

Delegation of Tasks to Assistive Personnel

Delegating tasks means to direct assistive personnel to complete a task that both nurses and assistive personnel can do. It is appropriate to delegate certain tasks to nursing assistants or other assistive personnel, including assisting patients with activities of daily living, eating, hygiene tasks, and ambulation. However, a task should only be delegated if the nurse has another task that only they can complete. Never delegate a task to assistive personnel that is outside of their scope of practice. The nurse should not delegate simply to avoid “unpleasant” tasks such as assisting with toileting.

Disaster Management

There are three levels of crisis: emergency room, hospital-wide, and community-wide. All healthcare facilities are required to have a disaster management plan in place for these crises. The plans should include four phases: prevention, preparedness, response, and recovery. All staff members need to receive annual training on disaster management in various scenarios to ensure they function effectively in an emergency and maintain both staff and patient safety.

Mass Casualty

Mass casualty protocols establish a plan to handle a sudden influx of patients that overwhelms normal resources. It allows for calling in additional staff, transitioning alternative hospital areas into temporary ER space, working with first responders to transport patients to other hospitals, setting up ORs for emergent surgeries, and transferring inpatients to other facilities. An incident command structure will coordinate the response. All hospital facilities are legally required to have such plans.

Federal Regulations

The primary federal regulations governing treatment in the emergency room are the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Emergency Medical Treatment and Labor Act (EMTALA). HIPAA sets strict standards for patient privacy that staff must follow and gives patients the right to their medical information and the right to request medical records. EMTALA requires all Medicare-participating hospitals offer a screening medical exam and treatment to anyone who presents to the ER, regardless of whether or not they can pay.

Patient consent must always be obtained, regardless of how minor the treatment, procedure, or surgery appears. The only exception to this is when the patient is having a life-threatening medical emergency and needs to have emergent surgery. Even then, an effort should be made to have the patient sign the consent if they are able to do so. Prior to consenting to a procedure, patients need to have a comprehensive discussion with the doctor about what the procedure entails and the risks and benefits of the procedure.

Patients must be consentable, meaning that they are alert, oriented, and understand the nature of the procedure. If the patient is not considered to be consentable, an alternate person, such as a spouse or designated healthcare power of attorney, may sign the form.

Performance and Process Improvement

Performance and process improvement are other essential parts of healthcare. Because healthcare and the treatments available are constantly evolving, healthcare systems must be prepared to perform self-reviews regularly. If these reviews reveal changes are needed to improve staff and patient experiences and safety and/or save the healthcare facility money, they should be implemented. Performances and processes can be tracked through employee surveys, debriefing after emergent situations, evaluating spending dollars, annual reviews for all staff, and other techniques that depend on the services offered at the healthcare system.

Risk Management

Healthcare risk management is a systematic approach to recognizing, assessing, and mitigating potential hazards within the healthcare system. These hazards can range from medication errors to patient falls to physical, emotional, or mental violence directed at healthcare workers. Good risk management needs to be a comprehensive process to assess all of the threats that a healthcare system faces. Effective risk management will reduce the healthcare system’s legal liabilities and enhance the staff and patient experience, as well as overall safety, while also improving the treatment offered at that facility.

Symptom Surveillance

Symptom surveillance is the process of monitoring sudden clusters of diseases that appear locally, such as measles or the flu. County health departments follow symptom surveillance with assistance from the state and federal authorities. Infectious disease departments can also follow trends inside the facility. Specific reporting laws vary by state. It is often mandatory that healthcare workers notify both the state and the patient if the patient tests positive for certain communicable diseases, such as the human immunodeficiency virus (HIV).

Triage

Triage is the practice of quickly assessing a patient to determine how sick they are. The nurse can perform a rapid visual assessment, get vitals, and assign a triage acuity level to the patient to ensure that the sickest patients receive treatment first. This can be a challenging process to explain to not-so-sick patients who want to receive rapid treatment.

Rapid Visual Assessment

The triage nurse can perform a rapid visual assessment of the patient to see if they appear to be sick or not. Evaluate the patient’s orientation, level of consciousness, and mobility, and look for any signs of bleeding. Are they writhing in pain or relatively calm? Are they pale or diaphoretic? Are they vomiting? Are they able to walk? These visual cues help to assess the urgency of their condition.

In trauma patients, a rapid visual head-to-toe assessment can help to locate injuries. There are tools for identifying a stroke in a patient, including the FAST scale, which stands for facial drooping, arm weakness or numbness, speech difficulties, and time. The Rapid Assessment of Avoidable Blindness (RAAB) is used to assess emergent eye problems. Checking all of these symptoms and asking the patient to describe their situation will allow them to receive appropriate care and ensure that the sickest patients receive treatment first.

Pediatric Assessment Triangle (PAT)

The PAT is a rapid visual assessment tool designed to specifically assess children in emergency settings. The three primary components are appearance, work of breathing, and circulation.

Appearance evaluates the child’s color, tone and interaction, and level of consciousness. Work of breathing assesses the respiratory rate, checks for retractions, and evaluates for stridor or wheezing. Circulation includes checking the heart rate, capillary refill time, and temperature. When evaluated together, the components of the triangle allow for a rapid but comprehensive evaluation of the child’s physical condition and help to determine the urgency of their treatment.

Triage Acuity Levels

Triage acuity levels are assigned to patients in the ER after they have been initially triaged. These levels guide the urgency of the treatment and determine who receives treatment first. Patients are not simply treated on a first-come, first-served basis in the ER.

Simple Triage and Rapid Treatment (START)

The START system is a classification system most commonly used by first responders in mass casualty events. This system will identify who the first responders start treating first and who is transported to the hospital via ambulance (or helicopter, if needed) first. A rapid visual assessment and vital signs assessment will help determine the patient’s condition. Specific colors are assigned to each victim and then written in an obvious place, usually on their forehead. The classification system is as follows:

red (immediate)—victims requiring immediate-life saving care
yellow (delayed)—victims who can wait a little while for treatment
green (minor)—victims with minor injuries who can wait for lifesaving care
black (expectant/deceased)—victim who is deceased or expected to be so shortly

Levels of Triage

There are five triage levels in the ER used to classify the urgency of a patient’s condition; each patient who arrives at the ER is assigned a triage level. The levels are as follows:

level 1: resuscitation—The patient requires immediate lifesaving treatment. Examples include patients experiencing cardiac arrest, respiratory arrest, or severe trauma.
level 2: emergency—These are high-risk situations that can become life-threatening without prompt intervention. Examples include patients experiencing stroke, chest pain, head trauma, or an asthma exacerbation.
level 3: urgent—This patient requires quick attention but can wait as long as 30 minutes for treatment. Examples include patients experiencing abdominal pain, moderate bleeding, or a possible fracture.
level 4: semi-urgent—The patient needs prompt treatment, but the condition is not life-threatening and can wait a little while. Examples include patients with migraines, sprained ankles, or cuts that require sutures.
Level 5: non-urgent—The patient can wait for a while and be treated when time allows. Examples include patients with a rash, minor aches, or the common cold.