Complications of Femoral Artery Sheath Insertion in Non-Fluoroscopic Resuscitation: A Single-Center Observational Study.

Hemodynamic changes in the distal arteries during transfemoral catheterization in children have not been documented. To evaluate arterial flow changes of the lower extremities ipsilateral to the puncture site using Doppler US during transfemoral cerebral angiography in children. Twenty-seven children who underwent transfemoral cerebral angiography at our institution between April 2013 and August 2013 compose our study population. Doppler US was performed to evaluate diameters and peak systolic velocities of the common femoral artery and superficial femoral artery before and after femoral sheath insertion. Children were classified into three groups based on the spectral waveform changes of the superficial femoral artery after femoral sheath insertion. Thereafter, one-way ANOVA followed by the Bonferroni post-hoc comparisons test were performed to compare values among the groups. Mean common femoral artery and superficial femoral artery baseline diameters were 4.10 mm and 3.32 mm, and mean baseline peak systolic velocities were 218.26 and 166.51 cm/s, respectively. Fourteen of 27 children showed persistent triphasic flow in the superficial femoral artery (group 1); 7 children showed altered flow of biphasic (n = 3) or monophasic (n = 4) waveforms (group 2); and 6 children showed pulsus tardus et parvus pattern (group 3) after femoral sheath insertion. Mean baseline diameter of the common femoral artery and mean subtracted value between common femoral artery and femoral sheath size were significantly smaller in group 3 than the other groups. Size discrepancy between common femoral artery and femoral sheath was <1 mm in all cases of group 3. Superficial femoral artery diameter and peak systolic velocity significantly decreased after femoral sheath insertion in group 3 compared to groups 1 and 2. A significant skin temperature drop after sheath insertion in the ipsilateral lower extremity was noted in group 3 (-1.83°C), compared to groups 1 and 2 (+0.42 and -0.86°C, respectively). Changes in the spectral waveforms of superficial femoral arteries frequently occur in children during transfemoral cerebral angiography (13/27, 48%). Significant arterial flow disturbance was noted on Doppler US in children with a common femoral artery <1 mm larger than the femoral sheath diameter.

Background: The use of heparin in coronary angiography (CAG) through radial route is a well-known practice. However, the prophylactic use of heparin following the femoral arterial sheath insertion is still controversial, so we aimed to assess the safety of CAG without the use of heparin through femoral approach by minimizing fluoroscopy time. Methods: All patients undergoing diagnostic CAG through femoral approach were enrolled in our study. Heparin was not given after femoral sheath insertion contrary to the usual practice. Depending on the fluoroscopy time, patients were divided into three groups: (a) group with fluoroscopy time 10 min) were excluded from the study as well as those who received heparin. Results: Altogether, 1550 patients were enrolled in the study over a period of 3 years. The mean age of the study population was 57.0 ± 12.5 years; 71% of the patients were male. Fluoroscopy time was <2 min in 63% of the patients, 2–5 min in 33% of the patients, and 4% of the patients had fluoroscopy time of 5–10 min. No thromboembolic clinical events were recorded in the entire population during the study. Femoral sheath thrombus was seen in only 2.9% of the patients, and all of these cases had a fluoroscopy time of &#88055 min. Conclusion: CAG can be safely performed through femoral route without the use of heparin and without any associated thromboembolic complications if fluoroscopy time is <10 min.

BackgroundImpairment of endothelial function is an independent predictor of coronary events. The aim of this study was to clarify the influence of arterial access and coronary angiography on endothelial function.MethodsEighteen...

Efficacy of a single dose intravenous heparin in reducing sheath-thrombus formation during diagnostic angiography: A randomized controlled trial

Anatomically correct graft positioning at the femoral insertion site is a key factor in surgical reconstruction of the medial patello-femoral ligament (MPFL). Basically there are two techniques to define this point in fluoroscopy during surgery. The role of the anatomical femoral torsion on the accuracy and reproducibility of both procedures has not been clarified. Twenty human anatomical leg specimens were dissected. The femoral insertion of the MPFL was marked by two K-wires. The position of the ligament insertion was determined fluoroscopically in the true lateral view as used in routine clinical practice. The anatomical MPFL insertion was compared to the radiographic landmarks which were recommended by two previous studies. The anatomical femoral torsion of the specimens was assessed by computed tomography scans. In true lateral view fluoroscopy, the mean distance of the femoral MPFL insertion was -0.2 mm distal to the vertical reference line intersecting the posterior point of Blumensaat's line. In the anteroposterior direction, the mean distance was -2.0 mm posterior to the femoral cortex reference line. There was no correlation between anatomical femoral torsion and the distance of the femoral MPFL insertion to the posterior cortex. The results of this study strongly recommend use of a vertical line intersecting the most posterior point of Blumensaat's line as a reference to identify the MPFL insertion in the craniocaudal direction. In the anteroposterior direction, the femoral MPFL insertion showed distinctive variation and was found -2.0 mm posterior to the femoral cortex reference line without being influenced by the anatomical femoral torsion.

The central tenet of any professional field of study is its well-established body of research, its ethics, and general public benefit. The role of the nurse practitioner (NP) in emergency care is supported by consistent research that underscores the excellent care quality provided by these professionals. Decades of scholarly literature attests to the safety, efficacy, patient-centricity, efficiency, equity, and evidence-based nature of NPs working in emergency care, with several studies showing that the outcomes achieved by NPs are similar to those achieved by their physician counterparts. It is clear that NPs provide comprehensive emergency care that is not only safe and effective but also patient-centered, timely, and based on the latest evidence-based practices. The evidence for nurse practitioners in emergency care may be found among several exemplars of empirical and peer-reviewed works as outlined in the following text, organized as an annotated bibliography: Carter, A., & Chochinov, A. (2007). A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department.Canadian Journal of Emergency Medicine, 9(4), 286–295. doi:10.1017/s1481803500015189 This comprehensive 36-article review evaluated the impact of NPs in the emergency department (ED) on wait times, patient satisfaction, and delivery of cost-effective, high-quality care. Hiring and utilizing NPs were associated with shorter waiting times, leading to greater patient satisfaction. Carter and Chochinov found that NPs possess an equal level of expertise to physicians in interpreting radiographs but proved to be more proficient at patient follow-up, conducting physical assessments, and making appropriate referrals. Fowler, L. H., Landry, J., & Nunn, M. F. (2019). Nurse practitioners improving emergency department quality and patient outcomes.Critical Care Nursing Clinics of North America, 31(2), 237–247. doi:10.1016/j.cnc.2019.02.010 The authors performed a literature search using the EBSCOhost and CINAHL databases with key words related to ED NP outcomes. Six hundred nineteen articles met the inclusion criteria, eight of which were selected for content review, including four systematic reviews, one randomized controlled trial, one qualitative study, one descriptive study, and one longitudinal cohort study. This analysis revealed that NPs provided enhanced patient satisfaction, reduced wait times, provided care similar to physicians, spent more face-to-face time with each patient, adhered to evidence-based guidelines, and collaborated effectively as a team. Jennings, N., Gardner, G., O'Reilly, G., & Mitra, B. (2015). Evaluating emergency nurse practitioner service effectiveness on achieving timely analgesia: A pragmatic randomized controlled trial.Academic Emergency Medicine, 22(6), 676–684. doi:10.1111/acem.12687 "A randomized controlled trial was conducted" to investigate the efficacy of NP-led emergency care as opposed to the standard medical care provided in the ED of a major referral hospital. "Patients presenting with pain were randomly assigned to receive either standard ED care or NP care." The NP service proved far more effective in quickly providing analgesia to ED patients. Mafi, J. N., Chen, A., Guo, R., Choi, K., Smulowitz, P., Tseng, C. H., ... & Landon, B. E. (2022). US emergency care patterns among nurse practitioners and physician assistants compared with physicians: A cross-sectional analysis.BMJ Open, 12(4), e055138. doi:10.1136/bmjopen-2021-055138 Using 8 "years of data from the National Hospital Ambulatory Medical Care Survey," a retrospective cohort study of adult patients compared three provider groups: NP/PA (physician assistant) alone, NP/PA with physician, and physician alone. After adjusting the data to account for observable patient characteristics, this study found the NP/PA-only group used fewer medications, diagnostic tests, procedures, hospitalizations, and low-value CT/MRI studies than physicians. Roche, T. E., Gardner, G., & Jack, L. (2017). The effectiveness of emergency nurse practitioner service in the management of patients presenting to rural hospitals with chest pain: A multisite prospective longitudinal nested cohort study.BMC Health Services Research, 17(1), 445. doi:10.1186/s12913-017-2395-9 This study recruited 61 adult patients with chest pain, with a nested cohort of 41 participants suspected or confirmed to have an acute coronary syndrome. Outcomes included adherence to guidelines, diagnostic accuracy, service indicators, "satisfaction with care, quality of life, and functional status. Data were examined and compared for differences for participants managed by emergency nurse practitioners and those managed in the standard model of care." The emergency nurse practitioner service model demonstrated high adherence to clinical guidelines and diagnostic accuracy and was as effective as the standard care model in evaluating service indicators and patient-reported outcomes. Woo, B. F. Y., Lee, J. X. Y., & Tam, W. W. S. (2017). The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: A systematic review.Human Resources for Health, 15(1), 63. doi:10.1186/s12960-017-0237-9 This review was composed of randomized controlled trials, "quasi-experimental studies, prospective and retrospective cohort studies," and excluded "cross-sectional studies" and those "without comparison groups." This investigation incorporated 15 studies, covering 23,681 participants "from five countries—Australia, Canada, New Zealand, the United Kingdom, and the United States." Based on the narrative synthesis of the accessible data, NPs demonstrate "outcomes comparable to those of physicians in emergency settings," indicating that the implementation of NPs in emergency care settings may result in improved patient outcomes. Wu, F., & Darracq, M. A. (2021). Comparing physician assistant and nurse practitioner practice in U.S. emergency departments, 2010-2017.The Western Journal of Emergency Medicine, 22(5), 1150–1155. doi:10.5811/westjem.2021.5.51988 This study examined the comparison between PA and NP practice in EDs in the United States, utilizing the data collected from ED visits reported by the National Hospital Ambulatory Medical Care Survey (NHAMCS). From 2010 to 2017, there has been a considerable rise in the number of visits attended to by PAs and NPs in the US EDs. Although emergency medicine has traditionally been a specialty of PAs, NPs have grown over the last few years. This increase is highlighted by the "greater than twofold increase in the number of visits" conducted by NPs during the same period. These visits bear a striking resemblance in many ways, "such as patient age, gender, insurance status, arrival by ambulance, diagnostic screening, procedures performed, imaging ordered, admission rate, and ED length of stay." CONCLUSION Although clinical research and evidence are used daily by medical professionals to make informed decisions, the repercussions of poorly informed or executed studies can be far-reaching and dangerous. Violations of scientific integrity and publication ethics are especially problematic when results not only negatively impact the practice of advanced practice nurses but also carry the potential to remove patient access to quality care in areas where it is most needed. The practice environment and care provided by NPs in emergency care are unique. There is significant variation among practice standards, training, and clinical expertise between NPs in emergency care and those caring for different patient populations. Furthermore, the specialty of emergency medicine and the role of the NP in emergency care are rapidly evolving. Therefore, scientific inquiry into the discipline should be led by those with current expertise in the field. Although understanding emergency nurse practitioner (ENP) practice and how it affects health outcomes requires a broad range of content and methods experts, ENPs are uniquely positioned to lead research that is relevant to their complex practice settings. As clinicians educated in graduate-level research and scholarly methods, we must promote a critical approach to evidence appraisal. For educators, researchers and NPs in clinical emergency care, additional studies demonstrating NP outcomes are needed. Just as nurses have done for centuries, our ability to offer and implement evidence-based solutions in care delivery may well be what keeps our health care system intact. —Wesley D. Davis, DNP, ENP-C, FNP-C, AGACNP-BC, CEN, FAANP, FAEN Family and Emergency Nurse Practitioner Program Coordinator and Assistant Professor, College of Nursing University of South Alabama Mobile, Alabama —Jennifer Wilbeck, DNP, RN, FNP-BC, ACNP-BC, ENP-C, FAANP, FAAN Emergency Nurse Practitioner Program Director and Professor Vanderbilt University College of Nursing Nashville, Tennessee

Advanced vascular access skills are an essential component of all critical care specialty curricula. However, common femoral artery (CFA) cannulation and sheath insertion has thus far not been emphasised within emergency medicine training. The advent of life-saving endovascular resuscitation techniques in both medical and traumatic disease, along with the inherent advantages of central arterial pressure monitoring in the severely haemodynamically compromised patient, mandates the prioritisation and deliberate practice of this procedure.CFA access facilitates central invasive arterial pressure monitoring as well as Seldinger-guided sheath insertion through which a number of resuscitation devices may be inserted further into the arterial system and left heart-termed 'endovascular resuscitation'. Arterial line placement is considered core to emergency medicine training by Australasian College for Emergency Medicine (ACEM) and Royal College of Emergency Medicine (RCEM), but this is not specific to the skill of CFA access. Extracorporeal Membrane Oxygenation (ECMO) CPR is likely to become increasingly common in refractory cardiac arrest. ECMO is listed as a scope of practice skill for emergency medicine by ACEM. ECPR is now an American Heart Association (AHA) Class 2 recommendation for cardiac arrest. The ELSO registry reports indicate a steady increase in ECPR globally in the last 5 years. ECMO technology development and increasingly procedural and indication refinements will also likely mean this intervention will become simpler to perform and manage. There is an increasing focus on perfecting this skill prior to embarking on training programmes for endovascular resuscitation or ECPR in both the prehospital and in-hospital emergency medicine environment. We describe the key technical steps in performance of this procedure, discuss acquisition and maintenance of competency, and describe pitfalls. CFA access in emergency medicine has an increasing relevance to practice. It is imperative that this procedural skill is given diligence in training, process, governance and relevance to emergency medicine practice.

Patellar dislocations occur at a much higher rate in military than civilian populations. Past population-level studies have shown that surgical management is as good as or superior to conservative care and may reduce future reoccurrences. Although in acute cases and in civilian clinics, patellar dislocations are usually managed first in an emergent care setting, previous work suggests this can lead to increased costs. This study compared differences in downstream care type and intensity of services based on whether initial care occurred in emergent or non-emergent care settings. In our sample of 1,523 Military Health System (MHS) beneficiaries with patellar dislocation and 2-year follow-up, we found non-significant differences in costs, intensity of services, and rates of surgical repair regardless of whether the patient was initially seen in an emergent versus non-emergent care setting. Although we found significant increases in the use of imaging, patellar dislocation-related medical visits, and frequency of closed treatment approaches in emergent care settings, these values were very small and likely not clinically significant. These findings, which included all the patellar dislocations reported across the entire MHS in a 24-month period, suggest that neither emergent nor non-emergent care settings are likely to influence the long-term care received by the individual.

Laparoscopic rectal cancer surgery has technical difficulties with a higher complication rate than colon cancer. However, few studies have examined whether postoperative complications are associated with oncologic outcomes. The aim of this study is to evaluate the impact of postoperative complications on long-term oncologic outcomes after laparoscopic low anterior resection for rectal cancer.Between January 2005 and December 2012, we evaluated 686 consecutive patients who underwent laparoscopic low anterior resection for stage I-III rectal cancer. Patients were divided into complication (n = 175) and noncomplication (n = 511) groups. The median follow-up period was 38 months (range, 2–118). We compared perioperative clinicopathologic outcomes, 5-year survival, and local recurrence between groups and evaluated prognostic factors.Five-year overall survival rates were 91.4% and 89.2% (P = 0.234) and 5-year disease-free survival rates were 83.2% and 77.7% (P = 0.002) in the noncomplication and complication groups for all stages, respectively. For stage I cancer, both the 5-year overall survival and the 5-year disease-free survival rate of the complication group were lower than the noncomplication group. Local recurrence rates were 3.1% and 7.8% in the noncomplication and complication groups, respectively (P = 0.002). In multivariate analysis, the presence of postoperative complications was a significant predictor of 5-year disease-free survival (hazard ratio, 1.65; P = 0.012).Postoperative complications had a negative impact on 5-year disease-free survival after laparoscopic low anterior resection for rectal cancer. The rate of local recurrence in the complication group increased more than the noncomplication group. In particular, postoperative complications were associated with poorer oncologic outcomes for stage I cancer. Laparoscopic surgery is preferred for early-stage rectal cancer so careful attention should be paid to avoid postoperative complications.

Arteriographic and Pathologic Evaluation of Two Suture-mediated Arterial Closure Devices in a Porcine Model

3:10 PM Abstract No. 381 Percutaneous ultrasound-guided insertion of distal perfusion sheaths for patients with limb ischaemia during femo-femoral venoarterial-ECMO: a retrospective study of 92 cases

Toward Patient-Centered Care: A Systematic Review of Older Adults’ Views of Quality Emergency Care

Review Questions/Objectives The systematic review objective is to synthesise the best available research evidence related to the effectiveness of femoral arterial closure devices as compared to traditional compression methods post femoral sheath removal in the cardiovascular patient. The specific review question to be addressed is: • What effects do femoral arterial closure devices, as compared to traditional compression methods, have on outcomes post femoral sheath removal in the cardiovascular patient? Inclusion Criteria Types of participants This review will consider studies that included all types of cardiovascular adult patients (18+ years old) with post femoral sheath removal following endovascular procedures regardless of previous treatments. The femoral artery is preferable access site due to the larger diameter of the artery compared to the radial or brachial arteries. Due to the larger diameter of the femoral artery, time to hemostatis and complications are significantly different than that of the brachial or radial arteries.For accurate comparison, patients undergoing procedures using radial or brachial access will not be included. Types of interventions The interventions of interest are arterial closure devices and traditional compression methods used following femoral arterial sheath removal. Studies that compare arterial closure devices and compression methods post endovascular procedure will be included in this review. Similarly, studies that compare various compression methods post endovascular procedure will be included in this review. Studies that compare radial or brachial access to femoral access and hemostasis will not be included in this review to allow for accurate comparison. Femoral access has significantly differing times to hemostatis and complication rates than radial or brachial access. Types of outcome measures The primary outcome of interest is the difference in effectiveness of femoral arterial closure devices and traditional compression methods on patient outcomes. Studies meeting criteria for participants and intervention which include outcomes related to bleeding risks and vascular complications, such as hematoma, bleeding at the site, retroperitoneal bleeding, pseudoanuerysm, and AV-fistula creation will be considered for inclusion in this review. In addition, studies describing attainment of hemostasis following femoral sheath removal will be considered.

Introduction: Aggression is a professional hazard for those who are employed in the psychiatric setting. There is evidence that 52% of the nurses working in the emergency department experience physical or other violence from clients. There are not many studies conducted in India regarding the application of aggression management training in a psychiatric setting. Material and Method: A quantitative method was used for implementing a participatory training programme. There were 44 trainer group nurses and 138 trainee group nurses from psychiatric, emergency and intensive care settings. The trainer group nurses were trained by the investigator and the trainee group nurses were trained by the trainer group nurses. An interpretive exercise was developed and validated to assess the competency of the nurses on aggression management and violence prevention. There were two posttests for the trainer group nurses and there was one posttest for the trainee group nurses. Results: Among the trainer group nurses, majority (93.2%) of the nurses were non-competent during the pre-test. But all the nurses (100%) were competent during the post-test one and the post-test two. Among the trainee group nurses, majority (97.1%) of the nurses were non-competent during the pre-test and all the nurses (100%) were competent during the post-test. Majority of the key personnel (82%) opined that, their staff perform better aggression management practices after the training programme. Conclusion: An aggression management and violence prevention (AMVP) training programme based on participatory approach was found to be more effective to empower the nurses to work in psychiatric and emergency settings.

Nurse practitioners (NPs) are certified within a population-focused specialty area, practice in a variety of settings, and treat a wide range of patients. Little is known about what agreement exists between certification obtained and actual site of practice. Keough, Stevenson, Martinovich, Young, and Tanabe (2011, p. 195) There is an ongoing debate about which qualifications are necessary to work in emergency care settings. BACKGROUND Statistics There are currently more than 205,000 NPs in the United States and 9,000–12,000 are employed in emergency departments (EDs) and related areas (e.g., urgent care centers; American Association of Nurse Practitioners [AANP], 2015). Last year NPs cared for approximately 4% (5.4 million) of the 136 million patients seen in EDs in the United States (Centers for Disease Control and Prevention, 2015). Consensus Model In 2008, the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education developed by the American Nurses Credentialing Center (ANCC; 2008) became the framework for NP licensure, accreditation, certification, and education. The model delineates advanced practice nursing based on role (NP, clinical nurse specialist, nurse midwife, or nurse anesthetist) and population-focused competencies (family/individual across the life span, adult-gerontology, pediatrics, neonatal, psych/mental health, and women's health/gender specific; ANCC, 2008). Specialty practice encompasses additional competencies, and it is at the specialty level within the Consensus Model that concerns about scope of practice reside. Primary Certification Upon graduation, primary certification for NPs is achieved by the successful completion of the board examination at the population level: Family nurse practitioners (FNPs) are awarded board certification as a Family Nurse Practitioner, Board Certified (FNP-BC), through the ANCC or the American Academy of Nurse Practitioner Certification Program that awards an FNP-C; Acute care NPs are awarded an Acute Care Nurse Practitioner Certification from the AACN Certification Corporation or an Acute Care Nurse Practitioner, Board Certified (ACNP-BC) from the ANCC; Pediatric NPs may have ANCC certification as a pediatric primary care nurse practitioner or certification by the Pediatric Nursing Certification Board as a pediatric acute care nurse practitioner. Once certified, a pediatric, family, or an adult-gerontology NP may be hired to work in an ED. Because the educational preparation of pediatric and adult-gerontology NPs does not include the care of patients across the life span and because many EDs see patients of all ages, the pediatric and adult-gerontology NPs are limited to practicing in EDs within larger metropolitan areas that see only older adults or children. Competencies/Specialty Certification Competencies for emergency nurse practitioners (ENPs) were initially published by the Emergency Nurses Association (ENA) in 2008 in the Nurse Practitioner Delphi Study: Competencies for Practice in Emergency Care (ENA, 2010). In conjunction with the AANP, individuals on this committee led stakeholders to develop entry-level competencies for NPs in emergency care. The competencies were also endorsed by the American Nurses Association and by the National Organization of Nurse Practitioner Faculties. These competencies are the basis of ENP curricula in the United States. The ANCC established emergency nurse practitioner board certification (ENP-BC) via portfolio in 2013 (ANCC, 2013). To obtain ENP-BC, the NP applicant must have obtained certification in a population focus, 2 years or 2,000 hr of emergency care practice (within the past 3 years), 30 hr of continuing education in emergency care, and exemplary performance in two of five professional development/leadership areas. Submission of self- and peer performance evaluations is also required. Finally, the applicant must complete a written exemplar demonstrating expertise as an emergency care provider. REQUIREMENTS TO WORK IN AN ED The ability of an FNP and/or ACNP to work in an ED is based on the (1) regulatory agency (state board of nursing [BON]), (2) academic preparation, (3) additional preparation, and (4) credentialing. Regulation The BON in each state determines the scope of practice and is the final authority on whether an NP can work in an ED. Currently, there is limited consensus among state BONs on the interpretation of the Consensus Model related to the scope of practice for NPs providing care within EDs. Academic Preparation Formal educational programs to prepare NPs to work in EDs have been available since the 1990s. The domains in emergency care include critical care, urgent care, primary care, behavioral medicine, public health, and social medicine (Chan & Garbez, 2006). Nurse practitioners prepared as primary care providers have competencies different from those prepared for acute care roles. These unique educational differences govern an NP's scope of practice (American Academy of Emergency Nurse Practitioners, 2015). Recently, several FNP programs have revised their curricula to incorporate didactic and clinical content in emergent and urgent care. Nurse practitioners educated as acute care providers are prepared with didactic and clinical practice in acute care settings; they do not have the academic preparation to care for pediatric patients in emergency care settings. Additional Preparation Emergency Care Fellowships Both FNPs and ACNPs may obtain additional education in emergency care by completing an emergency care fellowship program. Pediatric and adult-gerontology ACNPs who receive additional educational preparation in emergency care and acute stabilization and resuscitation of medically unstable patients across the life span are prepared to provide safe, high-quality care in their respective EDs. Emergency trained FNPs or ACNPs graduating from academic ENP programs and fellowships should be recognized as having the knowledge, skills, and competencies to practice in the ED and be considered board-eligible for ENP certification. FNPs can obtain knowledge and skills in the acute resuscitation and critical skills required for safe practice in an ED either by completing an ENP graduate program or by attending a structured emergency fellowship program. Continuing Education/On-the-Job Training Continuing education is one method of obtaining the competency, knowledge, skills, and behaviors necessary to practice in an ED setting. On-the-job training can also teach NPs valuable skills (e.g., ultrasound technique). Credentialing Regardless of each state BON's authority to regulate practice or the educational preparation of an FNP or ACNP, the ability to work in an ED is ultimately granted by the medical staff of the hospital through a process called credentialing. Credentialing or obtaining privileges is the process of establishing the qualifications of an individual to work in a specific environment. This generally includes a background check along with an assessment of academic and certification credentials, work history, recent continuing education, and current licensure. FNPs OR ACNPs IN THE ED? In a study conducted by Keough et al. (2011), FNPs, adult NPs, and ACNPs were surveyed regarding certification, demographics, practice setting, routine responsibilities, and additional preparation (2011). The FNP, adult nurse practitioner (ANP), and ACNP respondents (5%, 7%, and 42%, respectively) reported practicing in a nontraditional practice setting. Of the NPs practicing in a nontraditional setting, 74% were ACNPs, with 90% of those ACNPs practicing in a nontraditional, ambulatory care setting. Sixty-five percent of the FNPs who were practicing in a nontraditional setting worked in a high-acuity ED, whereas 56% of the ANPs working in a nontraditional setting were employed in intensive care units. Additional training and education for these NPs included, but were not limited to, pharmacology, laboratory interpretation, and the ordering of diagnostic tests. The authors concluded that “while greater than 90% of ANPs and FNPs practice in settings consistent with their certification, a proportion of NPs practice in nontraditional settings may benefit from additional education (formal, on-the-job, and continuing education) and mentoring” (Keough et al., 2011, p. 195). Among NPs working in emergency care, a snowball sample of 164 NPs surveyed found that 78% reported were certified as an FNPs whereas only 10% reported certification in acute care (E. Ramirez, oral communication, August 20, 2015). Current initiatives to help prepare NPs to attain the ENP core competencies include establishing educational standards for graduate education of ENPs and appropriate postgraduate continuing education. Other important activities to support and promote ENP practice include updating the ENP core competencies and exploring partnerships with nursing and medical organizations to improve continuing education, recruitment, and retention of qualified ENPs. Nurse practitioners will continue to work in EDs, whereas state BONs strive for congruence with the Consensus Model. Ultimately, all NPs working in emergency settings must demonstrate ENP competencies because certification for ENPs is in the best interest of patient safety. That's the bottom line. —K. Sue Hoyt, PhD, RN, FNP-BC, CEN, FAEN, FAANP, FAAN Emergency Nurse Practitioner St. Mary Medical Center Long Beach, CA —Jean A. Proehl, RN, MN, CEN, CPEN, FAEN Emergency Clinical Nurse Specialist Proehl PRN, LLC Cornish, NH