294 Volume 26, Number 4

Nurse practitioner offers way to follow upwith positive laboratory results after patientsleave

Dear Editor:The article by Susan Budassi Sheehy, “A Duty to

Follow Up on Laboratory Reports” in the Februaryissue (J Emerg Nurs 2000;26:56-7), offers a thought-provoking and sobering insight into the critical careissues of liability, legality, responsibility, and account-ability. It verifies the need for policies and procedureguidelines regarding a “safety net” for patients whoneed to be contacted with follow-up instructions ontheir medical issues.

As an ED nurse for the past 12 years in a busyManhattan emergency department, I have found thatexperiences like the one described in the article areno rarity. Many times patients are out-of-state visi-tors, traveling tourists from Europe and Japan, or im-patient customers who walk out of the emergency de-partment before all laboratory results are available.Who, then, is responsible for contacting the patientconcerning abnormal laboratory results? Is it theobligation of the physician, the nurse, the medicalsecretary, or whoever stumbles upon the unfortunatefindings? Because the article did not mention an ex-isting hospital policy or any other provisions made forcases like that, it was clear which side the law wouldfavor; hence the quick out-of-court settlement.

There were 3 concerning factors in this situationthat should be addressed. First, it was the physicianwho made the decision to discharge the patient with-out knowing the pregnancy result, but the nurseseemed to be the one getting blamed for inadequatefollow-up. If it is not the policy for most emergencydepartments, so at least the golden rule is to neverdischarge a patient until all laboratory results areavailable, unless the patient is willing to sign outagainst medical advice. Second, was there a super-vising attending physician who oversees the deci-sions made by residents, which is a policy in effect inNew York state since the late 1980s, according toNew York State Health Code? Third, it is high time forthat emergency department to make the quantumleap into the 21st century and have pregnancy kitsavailable for ED staff, not unlike the ones sold in everycorner drug store. They are constantly used in ouremergency department and render an accurate resultwithin minutes.

I would like to offer a permanent cure for problemssuch as this from recurring. Our emergency depart-ment established a “safety net” that is exemplary forNew York City if not the state itself. We have createda position held by a nurse practitioner who reviews

JOURNAL OF EMERGENCY NURSING/Letters

results of every single laboratory test performed on pa-tients in the emergency department. She is responsi-ble for making documented follow-up contact with thepatient by phone, mail, telegram, or if necessary viaforeign embassies. She also contacts patients whosigned out against medical advice or walked out of theemergency department before medical evaluation wascompleted, and she calls in prescriptions and prescrip-tion changes to pharmacies. In addition, she contactsany patients whose final radiology reading differs fromthe initial wet reading and whose EKG reading con-cerned the cardiologist on review, and she instructsthem regarding appropriate follow-up.

This system has worked well for our institution,has spared us similar tragedies, and is well worthcopying.—Johanna Bannert Sica, RN, BSN, NP-student,Queens Village, NY

More on customer serviceDear Editor:

I cried with a sense of relief when I read the mostrecent article on “customer satisfaction” in the Jour-nal (2000;26:174-7).

I remember the day my ED manager told me wewould all be referring to our patients as “customers.”I was shocked. I felt a keen sense of loss. I was notsure, even after 15 years of ED nursing, how I would“satisfy my customers.”

Many years later, I still am not sure. I know I havelimits and cannot solve everyone’s problems, but Ihave tried to serve my patients well and have seldomseen any glowing outward expressions of thanks. I doknow, though, that I have helped. Thank you for car-ing.—Patricia Sanders, RN, CEN, Wauconda, Ill

Organizing in the face of increasing demandson nursingDear Editor:

The June editorial on mandatory overtime andwearing blue ribbons (J Emerg Nurs 2000;26:201-2)raised awareness of the important professional issueof adequate staffing. I used to be strongly anti-unionas a solution. I believed unions represented “blue col-lar” issues, such as hourly wages, while my concern,as a professional, was quality care.

However, throughout my career, I struggled alonewith related difficulties. For instance, one administra-tive edict at a hospital where I worked stated thatnurses must punch out on time, despite a staff reduc-tion and unstable patients. Because the consequencewas being counseled (and possibly disciplined) about“inefficiencies,” nurses frequently just punched outand then finished their work for free. As an ED night

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nurse, I was actually responsible for cleaning thewaiting room’s restrooms and mopping the floor. Aconsultant had determined the ED staff “wasn’t busyenough” and let go the housekeeping staff.

In today’s health care shortages and cutbacks,patient quality of care has now been reduced to basicissues, such as staffing levels. Nurses still expressfeelings of powerlessness, despite the fact that theyare the primary providers of hospital patient care.1

Studies confirm that quality care and patient satis-faction are related to the percentage of RNs in thenursing staff.2,3

Other professionals, such as physicians and pro-fessors, do not accept unrealistic work expectationsor responsibilities at another’s instant command. Sowhy isn’t nursing’s protesting voice reckoned with?

First, I think nurses themselves lack an apprecia-tion of their vital role. The fact is that an admission tothe hospital is a prescription for nursing care.

Second, nurses must unite to command respect.Professional memberships are a part; however, thepercentage of nurses belonging to professional orga-nizations is paltry and declining.

In addition, maybe it is time to consider profes-sional unions. If the American Medical Association al-lows one to deal with physicians’ concerns regarding

HMO patient care, why do nurses believe a union isbeneath them?

I now teach in a nursing program at a college thathas a teacher’s union. Doctorally prepared nursesthere feel no conflict with being both professionalsand represented by a strong union voice. The unionquickly squelched the idea when administration re-cently wanted all faculty to each teach an additionalcourse, without compensation, because financeswere tight. But the nicest part of this story was notbeing a solitary figure saying “No.”

True, I do sometimes squirm at the black andwhite rhetoric from both sides in this union environ-ment. There are flaws in any group. But there is alsoan inherent force in collective numbers. Let us mar-shal it.—Polly Gerber Zimmermann, RN, MS, MBA,CEN, Associate Professor, Harry S Truman College,and Associate Nurse, American Airlines, O’Hare In-ternational Airport, Chicago, Ill

References

1. CareerPath. Nursing 2000 2000;30:86.2. Blegen MA, Goode CJ, Reed L. Nurse staffing and patientoutcomes. Nurs Res 1998;47:43-50.3. Moore K, Lynn MR, McMillen BJ, Evans S. Implementa-tion of the ANA report card. J Admin 1999;29:48-54.

Reviewers’ Acknowledgment

The Journal of Emergency Nursing gratefully acknowledges the time, effort, expertise, and advice donated by thefollowing reviewers of this issue’s content:

June AndreaSue BarnasonCynthia Blank-ReidCarol BonnonoDineke BoyceAudrey BrighentiDeborah Marks CarlsonDianne DanisCathy DickerKathy DolanCatherine FerrarioIris FrankTerry FulmerMaggi Gunnels

Diane GurneyBeverly HartMarlene JezierskiLinell JonesMary KamienskiPatricia KennedyJane Koziol-McLainDiane LapsleyLinda LedrayGenell LeeIrene LoudaBen MelnykovichMathilda MerkerDonna Nayduch

Colleen O’BrienMary O’ShieldsJanet Gren ParkerKathy RobinsonJaye SengewaldSusan ShapiroDeb SmithMarjorie StenbergSuzanne WallRobin WalshPolly Gerber ZimmermannLucy Zuniga