ER New Grad- ICU holds in ER - Is this a normal situation in the ER?

[rlunay21]

Hello Everyone,

My employer plans on cross training me to be in ER, ICU, and Telemetry Units. My first stop is the ER. I finished 2 months of RN orientation and am currently on my own in the ER. This one particular busy day in the ER--we were short in resources. our Charge Nurse functioned both as a Charge Nurse AND Triage Nurse. Our only ED tech was unable to help any nurse because they had to watch 51/50s the whole shift. WE had no ICU nurses or beds available and so if we had an ICU pt- we would have to hold them in ER--amongst other things. (We do not have Unit Secretaries in my facility)

So I basically received an ICU patient who we ended up diagnosing and admitting the pt for- renal failure, pneumonia, dehydration, abd pain --and of course when labs came back - septic protocol was initiated- and so came a whole stream of antibiotics, blood work, exams, etc, etc. (Pt was relatively stable).

In addition, The Admitting physician had written orders for this patient and had ordered to get consults from 3 different specialties (Cardiology, Nephrology, and Pulmonology). So, I had to call and get a hold of all these 3 different MDs and Look (and decipher) through all four MD's orders and try to carry out ALL their orders! A few of these orders included - Antibiotics, fluids, regular meds, labs (which the MD states to CALL THEM for the result), v/q scans, doppler studies, CT w/ contrast, and the list goes on and on. Sometimes you get orders that cancel each other out. One MD states they want NS while another MD states they want D5W as maintenance fluid. So the rule of thumb is to take the orders from the most recent MD who wrote the orders most recently...

I had all these orders from different doctors and so I tell my Clinical Director (who was nice enough to come down and help us out) " I need help, i got all these antibiotics ordered from 3 different Physicians..and shes in renal failure already!..and i have all these other orders..can you help me determine what I need to do and how I should go about doing this?" She tells me to basically do not worry about any other orders except the "STAT orders"..She reviewed the MD notes very briefly and saw that I did quite a few of these orders (even the non stat orders- i wanted to be nice to the ICU nurses!) and emphasized again to just do the STAT orders and ICU will have other orders dealt with. I also keep in my mind that this pt is ICU-which means as much as possible --be treated as an ICU pt--v/s and check up on them every hour- ekg strips every hour--thorough charting---pressure ulcer checks--i tried my hardest -- i didn't take a lunch break AND i stayed 2Hours OT! [Pt eventually got transferred to a proper ICU holding place]

Keep in mind that I am constantly getting patients in my other rooms--SOB, lethargic, weakness, helping with intubations, Chest pains, overdoses...who are also getting discharged or admitted or transferred out - so that means a whole new set of calling MDs for consults, calling ambulances, dealing with insurance people, case managers, and talking to accepting hospitals etc. etc.

@ the same time --the ERmd is throwing order after order..and sometimes they verbalize orders to nurses who are NOT the primary RN for a certain pt and sometimes the memo doesnt get passed to the proper RN.

Anyway, I went home 2H after I was supposed to actually go home--then I get a phone call from the night shift nurse who i gave report to for that ICU pt...she tells me that the Admitting MD for the ICU pt got super mad at me for not putting in certain labs in the system and not getting a hold of the cardiology MD, and told the night shift nurse to specifically tell me "an ICU hold in the ER means that they be treated as an ICU patient.......just think about how your loved one would want to be treated..don't let this happen again or else I am going to have a fit"..

Then the night shift nurses tells me that they will have to file a incident report and that my charge nurse and the clinical director is informed of this incident.

OMG,after i hung up..i couldn't help but cry mainly because Im a New Grad and I know I am on probation just because i am new to this company!...I didnt know what to think and I do not know what is going to happen to me! Will i get fired? My boyfriend (who also works in ER) tells me he gets to be 1:1 when he gets a critical pt. I almost never see that happen in my ER...How are things supposed to be run when someone gets this kind of patient load?

IF the Admitting MD really wants me to treat this pt as an ICU pt ..doesn't that mean I should be 1:1 or even 1:2?

Can any shed some insight? Any advice would be greatly appreciated!

[canoehead, BSN, RN]

If I was your boss I'd congratulate you for making it through. There are a lot of systems issues I see in your post, and nursing can't be expected to pick up the slack for everyone. Docs need to make their own phone calls, the middle man just introduces errors, and they KNOW that. If they hold an ICU patient and you're still covering ER beds, then all the in depth ICU niceties aren't gonna happen. As a new grad, you're still learning about what is and acceptable load, and you did more than your share on this shift.

[prep8611]

ICU nurse here, in my hospital we would have had to triage somebody out to take the septic patient. Otherwise we would be bringing an icu nurse down there to take care of the patient in ER holds. Not to be an ******* but you guys are good at codes and rapid treatment, you really have no idea how to manage a critically ill patient. Why didnt a more veteran nurse take the intensive care hold?

[Lunah, MSN, RN]

Not to be an ******* but you guys are good at codes and rapid treatment you really have no idea how to manage a critically ill patient.[/quote']

With the number of ICU holds many EDs experience, I have to beg to differ on this one. Most ED RNs with whom I've worked are very versatile by nature and can manage critically ill patients with great skill. Not to mention many of my coworkers have experience outside the ED. :-) Of course, your mileage may vary!

[ChristineN, BSN, RN]

ICU nurse here in my hospital we would have had to triage somebody out to take the septic patient. Otherwise we would be bringing an icu nurse down there to take care of the patient in ER holds. Not to be an ******* but you guys are good at codes and rapid treatment, you really have no idea how to manage a critically ill patient. Why didnt a more veteran nurse take the intensive care hold?[/quote']

We have boarders (ICU and otherwise) frequently in my ER and we rarely get ICU nurses to take care of boarders. Occasionally we will get med-surg or step-down nurses, but we can not expect them to take ICU pts. Nor can we expect the ICU to work short just because the ER is boarding. Instead we are good about making sure the nurse that has the ICU pt only has 1-2 pts. Many of our ER nurses have done ICU in the past, and, even those that have not are perfectly capable of taking care of ICU pts. To say we have no idea we have no idea how to manage ICU pts is very insulting.

[prep8611]

With the number of ICU holds many EDs experience, I have to beg to differ on this one. Most ED RNs with whom I've worked are very versatile by nature and can manage critically ill patients with great skill. Not to mention many of my coworkers have experience outside the ED. :-) Of course, your mileage may vary!

I'm sorry your correct, im actually generalizing for my ER that hires mainly new grads or have only done ER.... They know you give fluids and pressors but dont know why. CVP, SVR, SVV, SV are all things they don't understand which are so important for a sepsis patient. I work in ED once and a while and its hell, ER nurses have a tough job and many are extremely skilled and knowledgable in what they do but most ERs cant do hemodynamic monitoring so they shouldn't be expected to care for such a critical patient while juggling other patients.

[prep8611]

We have boarders (ICU and otherwise) frequently in my ER and we rarely get ICU nurses to take care of boarders. Occasionally we will get med-surg or step-down nurses, but we can not expect them to take ICU pts. Nor can we expect the ICU to work short just because the ER is boarding. Instead we are good about making sure the nurse that has the ICU pt only has 1-2 pts. Many of our ER nurses have done ICU in the past, and, even those that have not are perfectly capable of taking care of ICU pts. To say we have no idea we have no idea how to manage ICU pts is very insulting.

Not that you don't have any idea but you don't have A lines, cvps, and hemodynamic monitoring systems so you shouldn't be expected to really understand whats going on. You guys get basic vital signs that shows you 5 values so how can you possibly take care of a patient who if in the icu we would be monitoring up to 10 values.

[NurseOnAMotorcycle, ASN, RN]

How about we not start another Specialties War?

[prep8611]

Agreed, ER works extremely hard and there is no way i could do it everyday. Just stating the facts of how dangerous it is having a septic icu holding in the ED for reasons stated above. I think the OP did a commendable job for what he/she was challenged with, i think its the institutions protocols that have failed.

[NJnewRN]

If you are smart please heed my advice. Please do a yr there and get the heck out. Please go back to school or find a easier job. That sounds unsafe. You are working like a dog. MD's should consult with each other. Crazy. If you are smart you will try to advance your degree or find something easier. Best of luck to you in the mad house.

[JBudd, MSN]

Not that you don't have any idea but you don't have A lines, cvps, and hemodynamic monitoring systems so you shouldn't be expected to really understand whats going on. You guys get basic vital signs that shows you 5 values so how can you possibly take care of a patient who if in the icu we would be monitoring up to 10 values.

I agree with Nurse onaMotercycle, lets not start a whole different fight. Its just you need to know that not all ERs are alike, in mine we do often have A lines, the CVP etc.; and we do titrate all sorts of drips. Just sayin'. Many of us also have critical care experience. We respect our ICU nurses! but if we wanted to be doing that all the time, we would't be in the ER.

This is about the OP being given far more to do than reasonable or safe, rising to the task, doing a magnificent job, and getting yelled at for a missing lab draw.

[happyinillinois]

Welcome to the ER. It's a dumping ground. The flow of patient's never stop. Unless you've done it, you have idea. To answer another's post maybe a more seasoned nurse didn't take the patient because she had a couple of her own ICU holds.

[Dpeterson777]

Let me just say, IT GETS BETTER!! I am going on 6 months as a new grad without healtcare experience in a busy ER. We FREQUENTLY hold ICU patients in our ER because we don't have beds available. I'd say this... If you feel overwhelmed, tell your charge nurse. Ask her/him to review your charting/orders to make sure you have done as much as possible in the ER. In our ER we do STAT admission orders (Antibitoics, breathing txs, BP meds if needed, tests, labs, etc). I wouldn't worry too much. You are not expected to get all the admission stuff done! I'd say make sure the pt is stable, chart sedation and basic stuff that shows pt care is being provided. Make sure tests needed are ordered by ward clerk (EKG's, labs, wounds, cultures, influenza swabs, ua, etc). I would verbalize to admitting Doc things that need to be adressed like wound consults, etc. We don't acutally initiate these consults in our ER... Just remember, you are new and learning, and dont be expected to know EVERYTHING. I feel SO MUCH better after 6 months exp and it gets better each shift. I ALWAYS tell my charge if I feel overwhelmed or out of my scope of practice and ask them to review pt charting, nursing notes, and orders to make sure I have what is needed. I CHART THIS TOO. Sometimes you can only do what you can do... I remember going home one night after having an ICU pt and realizing I never had "orders" for the NGT I placed, never charted "sedation scale" (IE Ramsey, etc), BUT, I did an excellent job of charting pt status, vitals, sedation according to protocol, ER and admission orders, etc. I talked to my charge and was praised for such an excellent job. Just remember, you will get better with time! In the meantime, do what you need to protect your license and ask for help when needed! Hope you find the transition gets easier!