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Professional Time is defined as activity performed outside of direct patient care such as committees, work groups, performing audits, gathering research data, or any activity that is sanctioned by the ED leadership team, as it will contribute to quality and safe patient care as well as a positive department culture. Team members on Professional Time will work in collaboration with the leadership team conserving work, time, money and resources while producing cost-efficient and high-quality project outcomes.

In the United States, trauma is the leading cause of death for persons ages 1 to 44 years.1 According to 2015 statistics from the Centers for Disease Control and Prevention, the annual costs of health care and lost productivity were higher in trauma care than for any other major disease process: cancer cost the US economy $216 billion, diabetes $245 billion, heart disease $313 billion, and trauma $671 billion.1 Four years ago, my level I trauma center had a trauma program manager just starting in her new position. All the mannequins breathe, blink, and have pupils that react, but the adult mannequins can have surgical airway procedures performed and chest tubes inserted, and with the help of the simulation specialist, they actually speak, answer questions, and demand the team’s attention (Figure 3). In discussing the possibility of working together on a mock trauma alert case, Suzanne suggested presenting a particular case because she believed it was an excellent example of the team’s efforts resulting in a good patient outcome.Mock Trauma Neurologic Case A 21-year-old female, unrestrained driver in a rollover single car crash was thrown from the vehicle. [...]our goal is to continue to move forward, advance our scenarios, and increase the expectations of our team.

[...]for the first time, all 4 categories of APNs in Florida will be recognized! In 1993, the National Council of State Boards of Nursing began investigating and acknowledging the differences and barriers in access to education, certification examinations, and licensure facing APRNs throughout the United States. The groups’ dedication and commitment to resolve differences and remove barriers continued, and in July 2008, the Consensus Model for Advanced Practice Registered Nurse Regulation: Regulation, Licensure, Accreditation, Certification and Education was released.1 This important and comprehensive document was the result of collaboration among representatives from multiple professional nursing organizations and the National Council of State Boards of Nursing APRN Advisory Committee.

In our first case study, we looked at a patient who presented with symptoms appearing to be positional vertigo, but, after observation and a change in status, the patient was diagnosed with a cerebellar stroke.4 The author brought our attention to recent literature that has found a HINTS (HI: head impulse testing, N: nystagmus, TS: tests of skew) exam to be more sensitive in identifying central vertigo versus peripheral vertigo than magnetic resonance imaging (MRI) or computed tomography angiography (CTA). In our second case study, we heard from an APN whose specialty focus is in an oncology emergency department.7 The Spotlight here showed us that fully integrated emergency departments with a focus on hematology and oncology patients allowed these patients to be better served, as they were treated by specifically trained physicians, APNs, ED nursing staff, and ancillary personnel who could specifically direct comprehensive emergency care for these immunocompromised patients. With an ever-expanding role for APNs in the emergency-care setting, the Emergency Nurses Association (ENA) created The Institute for Emergency Nursing Advanced Practice (IENAP) Advisory Council.8 This dedicated group is focused on increasing continuing education that is relevant to the clinical practice of the APN in emergency-care settings.

[...]of your role-registered nurse, physician, or advanced practice registered nurse-everything we do for our patients depends on support from many other departments, such as pharmacy, spiritual care, radiology, respiratory therapy, security, and environmental services, to name just a few. At the beginning of my career as a clinical nurse specialist for emergency services, it was suggested to me that a collaborative practice team be developed. The purpose of the group was to develop an interdisciplinary and synergistic approach to clinical care rendered to patients in the emergency department. Chaplains work collaboratively with the trauma team, the ED team, the respiratory department, the radiology department, patient access (the business office), guest services, security, media relations, and our local and state law enforcement agencies, along with many other resources, to help care for our patients. The commitment of chaplains to patient care and the patient experience is on a different level than that of our fellow members of the health care team. Family members thirst for some kind of information when they first with the law enforcement agency investigating the crash, I was provided with a tentative ID of the patient, as well as some information they had available regarding this patient. In collaboration with our clinical team, I was able to contact the other facility and have all the appropriate forms completed in order to obtain the patient’s previous medical records.

Cindy Kumar is a dual-certified nurse practitioner in adult-gerontology acute care (AG-ACNP) and family practice (FNP). With 17 years of experience as an acute care nurse with adult and pediatric populations, she currently provides emergency care in both pediatric and general emergency departments.

Migraine headaches are classified as a primary headache syndrome.Migraine Headache Migraine headaches are the fourth to fifth most common complaint in the emergency department, accounting for 3 million to 5 million ED visits annually.1,4 Although tension headaches are the most common primary headache disorder, migraines tend to be the most disabling and are more likely to present to the emergency department.1 Migraines have a 3:1 female to male ratio.5 Currently, there are several different treatment combinations available, which will be discussed further.Diagnostic Criteria The diagnostic criteria for migraines include those detailed in Table 1.5 Of note, the International Headache Society 2019 update further distinguishes migraines into aura and nonaura.6 According to the American College of Emergency Physicians 2019 Clinical Policy regarding evaluation and management of adult patients presenting to the emergency department with acute headache, subarachnoid hemorrhage should be ruled out using the Ottawa Subarachnoid Hemorrhage Rule (Table 2).7 Additional clinical findings such as pregnancy, postpartum women, fever, trauma, and severe back pain may warrant further evaluation before considering a migraine diagnosis.7Treatment Options Several different treatment combinations are available for migraines, including triptans, dihydroergotamine mesylate (DHE), 100% oxygen inhalation, ergotamine tartrate, opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), antihistamines, acetaminophen, dexamethasone, ketorolac, and metoclopramide, to name a few.5,8 These treatments can be used as solitary treatments or in conjunction with other treatments listed, as appropriate. The adverse effects include increased blood pressure, chest pressure, dizziness, flushing, neck tightness, tingling, and limb heaviness.9,10 The contraindications to triptans are pregnancy, vascular disease, coronary artery disease, and uncontrolled hypertension.Dihydroergotamine Mesylate DHE can be given through several different routes, such as intramuscular (IM), intravenous (IV), subcutaneous, or intranasal. The contraindications include pregnancy, hypertension, angina, peripheral vascular disease or poor circulation, liver or kidney disease, serious infection, and arteriosclerosis.Opioids Opioids are certainly an option for treatment of migraines, although, considering the opioid epidemic, the American College of Emergency Physicians recommends preferentially using nonopioid medications for migraine treatment in the emergency department.7 Opioids should not be considered as first-line treatment. The contraindications include hypersensitivity to this class of medications and latex allergy; it has not been studied in pregnant or pediatric patients.Botox Injections Onabotulinum A (Botox) is thought to relax musculature secondary to blocking acetylcholine release at the neuromuscular junction, which reduces inflammation of the meninges and blocks pain signals coming from the brain.19 It was approved by the Food and Drug Administration in 2010 as a prophylactic therapy for chronic migraines in adults.18 Botox is given as an injection for migraines and is divided into 31 different sites approximately every 3 to 6 months.20 The adverse effects include toxin-effect spread, hypersensitivity reaction, anaphylaxis, injection-site reaction, and muscle weakness.

There is a significant gap in the provision of care for transgender or gender-nonconforming patients. This population experiences a multitude of disparate health outcomes. Studies have demonstrated a clear knowledge gap among ED clinicians regarding the care for transgender or gender-nonconforming patients. A significant number of ED clinicians reported caring for transgender or gender-nonconforming patients during their careers. Currently, many ED clinicians report receiving minimal or no training in the care of transgender or gender-nonconforming patients. This lack of competency contributes to ED care avoidance in this population. This quality improvement project aimed to evaluate the effectiveness of improving clinicians’ knowledge and skills, openness and support, and oppression awareness in transgender or gender-nonconforming patients through a targeted educational intervention. This study included 4 community hospital-based emergency departments. Performance in the domains of knowledge and skill, openness and support, and oppression awareness was measured using the Ally Identity Measure questionnaire and a paired t test analysis of scored results. The intervention for this quality improvement project was a synchronous, in-person education session delivered once in each of the respective hospital-based emergency departments that addressed key components of understanding transgender or gender-nonconforming patient care. These topics include relevant terminology, assessment recommendations, common gender-affirming therapies, and local resources for follow-up. It also incorporated audio/video testimonies of transgender or gender-nonconforming patients and a case study. Improvement was demonstrated in all 3 domains when comparing the pre- and postintervention Ally Identity Measure scores. Knowledge and skills demonstrated the most significant increase from pre- (mean, 25.3) to postintervention (mean, 34.6). Openness and support and oppression awareness demonstrated almost equal improvement when comparing pre- (openness and support mean, 27.0; oppression awareness mean, 16.9) and postintervention performance (openness and support mean, 29.2; oppression awareness mean, 18.4). Transgender or gender-nonconforming patients represent a unique clinical cohort that requires specialized knowledge to provide competent patient care. ED clinicians demonstrated knowledge deficits regarding transgender or gender-nonconforming patient care. These findings support the need for formalized training in the care of transgender or gender-nonconforming patients and its effectiveness in addressing the existing ED clinician education gap.

Emergency department (ED) health care personnel (HCP) are at risk of exposure to SARS-CoV-2. The objective of this study was to determine the attributable risk of SARS-CoV-2 infection from providing ED care, describe personal protective equipment use, and identify modifiable ED risk factors. We hypothesized that providing ED patient care increases the probability of acquiring SARS-CoV-2 infection. We conducted a multicenter prospective cohort study of 1,673 ED physicians, advanced practice providers (APPs), nurses, and nonclinical staff at 20 U.S. centers over 20 weeks (May to December 2020; before vaccine availability) to detect a four-percentage point increased SARS-CoV-2 incidence among HCP related to direct patient care. Participants provided monthly nasal and serology specimens and weekly exposure and procedure information. We used multivariable regression and recursive partitioning to identify risk factors. Over 29,825 person-weeks, 75 participants (4.5%) acquired SARS-CoV-2 infection (31 were asymptomatic). Physicians/APPs (aOR 1.07; 95% CI 0.56-2.03) did not have higher risk of becoming infected compared to nonclinical staff, but nurses had a marginally increased risk (aOR 1.91; 95% CI 0.99-3.68). Over 99% of participants used CDC-recommended personal protective equipment (PPE), but PPE lapses occurred in 22.1% of person-weeks and 32.1% of SARS-CoV-2-infected patient intubations. The following factors were associated with infection: household SARS-CoV-2 exposure; hospital and community SARS-CoV-2 burden; community exposure; and mask non-use in public. SARS-CoV-2 intubation was not associated with infection (attributable risk fraction 13.8%; 95% CI -2.0-38.2%), and nor were PPE lapses. Among unvaccinated U.S. ED HCP during the height of the pandemic, the risk of SARS-CoV-2 infection was similar in nonclinical staff and HCP engaged in direct patient care. Many identified risk factors were related to community exposures.

APRNs have existed for more than 50 years and are established members of emergency care teams throughout the United States (US) and in many countries worldwide.2-6 Nearly a decade ago, the Institute of Medicine identified APRNs as necessary for the future of health care delivery in the US.7,8 Since then emergency departments (EDs) in the US and abroad have become increasingly overcrowded, in part due to their status as a health care safety net for those who cannot access a primary care provider.9,10 It is estimated that EDs provide more than 47% of all hospital-associated health care in the US.9 As a result, there is currently a substantial mismatch between the need for emergency services and the available resources to provide that care.10 APRNs have been identified as particularly important for bridging this gap in both urban and rural settings.11-14 The regulatory landscape for APRNs in the US continues to evolve, and APRNs who work in the emergency care setting face a few unique licensing and certification challenges. The Consensus Model’s licensing paradigm could create barriers to APRN practice in the emergency care setting because it would require APRNs who treat the full population of the emergency care setting to complete three courses of graduate study and to obtain and maintain three certifications (eg, Family Nurse Practitioner, Adult-Gerontological Acute Care Nurse Practitioner, and Pediatric Acute Care Nurse Practitioner).1,17 CNSs, for whom there are fewer courses of study than for NPs, would be required to have and maintain 2 licenses (Adult-Gerontology CNS and Pediatric CNS), but they would be restricted to either primary or acute care.18ENA Position The following are the positions of the Emergency Nurses Association (ENA): APRNs are established members of the emergency care team and are critical to the future of quality health care across the US and worldwide. Background The emergency care setting is unique when compared to most other practice settings in that its patient population consists of all ages and all combinations of medical history and chief complaint, rather than a narrow subset of them, as is the case with most other specialties (eg, pediatric oncology, adult cardiology, etc).19 Although some APRNs only treat a subset of the patients in the emergency care setting, for example, only pediatric patients or only adults with urgent or chronic needs, other APRNs are called upon to treat all patients and conditions, from nonemergent, episodic chronic care to acute, complex, life-threatening traumatic and medical conditions.2,20-23 APRNs are licensed and regulated by state law, and reciprocity across state lines is determined by each state. The Consensus Model’s proposal that US states license APRNs as “primary care” or “acute care” APRNs, along with its stipulation that an APRN only be allowed to expand his or her scope of practice by completing another graduate program of study, stands in contrast to how APRNs are currently licensed and regulated today.24-29 In nearly all states, APRNs are licensed at the role level, and the scope of practice is determined not only by formal education and national certification but by clinical experience as well.30 Degree-granting programs are designed to prepare APRNs for entry-level competency, and postgraduate training after one’s formal course of education confers clinical expertise.6,29,31-34 It is, therefore, no surprise that APRNs who are currently providing safe and effective primary and acute care across the country are certified as family nurse practitioners (FNPs), acute care nurse practitioners (ACNPs), Adult NPs, Pediatric NPs, Adult-Gerontological NPs, Adult-Gerontological CNSs, and Pediatric CNSs, among others.15,21,35,36 The Consensus Model has been a powerful force for raising the quality of APRN education and training in the US and has successfully championed full practice authority for APRNs in all states.15 Regardless of the outcome of these and future discussions over whether and how to implement the Consensus Model’s definitions of primary care, acute care, and scope of practice, APRNs will continue their long tradition of providing safe, effective care in the emergency care setting, and ENA will remain committed to interprofessional collaboration and advocacy on their behalf.Resources Advanced Practice Registered Nursing Consensus Work Group, The National Council of State Boards of Nursing APRN Advisory Committee.