ER nurse/pt. ratio,triage times, & EHS pt. responsibility?

pkapple · Nov 5, 2004

20 patients!!!!!!!!!!!!!!! 6-7 ambulances backed up??????????

y'all needed to go on divert----------

rjflyn, ASN, RN · Nov 5, 2004

And hire a whole lot more nurses. There is no way in h@%^ I would take care of that many patients. The first time would be the last. Personally 5 patients at times is too many.

:angryfire Rj

20 patients!!!!!!!!!!!!!!! 6-7 ambulances backed up??????????
y'all needed to go on divert----------

Sarah8714 · Nov 5, 2004

In the state of Texas - That is a major liability waiting to happen to the hospital! Once paramedics are within a certain distance of the hospital, i.e. ambulance dock and into your door (100 yard parameter or so), the patient is the hospital's responsibility and the protocols that paramedics work under are null and void. Even though the patient is technically in the paramedic's "possession" it is the hospital's responsibility if they are standing in triage. As a paramedic we have in the past stood in triage for up to 8 hours but the state has regulated that to 30 minutes. If you are longer than 30 minutes the hospital could get fined a lot of money if they are not on ER divert. They also monitor hospitals that go on divert. We use a website database that the hospital House supervisors update and can be viewed by the local EMS services. As a nurse it is way too unsafe to handle that many people. The highest patient ratio around our area is 5 to 1 for medical and minor trauma.

Sarah, RNBScN · Nov 5, 2004

Depends on the acuity in the ER and how many RN's are staffed on days and nights.

Dayshift

-----------

1 RN trauma 2 beds (3rd) if required

2 RN obs/exam/gyn/eye - 10 beds

1 RN triage

1 RN for amb/minor/consult/family room/fracture - 8 beds and 4 chairs

1 RN charge nurse (who assist when possible)

1 ward clerk (answers the phone, etc...)

2 porters

Nightshift

------------

1 RN trauma 2 beds

1 RN charge (who is responsible for triage after 23:00 hrs. and amb/minor/consult/family room/fracture - 8 beds and 4 chairs after 03:00 hrs_

1 RN obs/exam/gyn/eye - 10 beds

We have a 10 -22 hrs. shift that is assigned usually until 19:00 hrs. in obs area then reallocates to triage. We have a 19:00 - 03:00 shift which is assigned on amb/minor/consult/family room/fracture - 8 beds and 4 chairs

So really, after 11:00 p.m. on a night shift, we have 3 RN's which is really unsafe and they hospital doesn't have enough money to hire another RN. Dayshift is stacked rather well. Can you see the difference?

As well, we use a CTAS level (Canadian Triage Acuity Level Scale) system to assess our patients according to their presentation.

Level 1 - stat MD assess Life threatening, VSA

Level 2 - CP (*Seen by MD within 15 mins)

Level 3 - SOB with good sats, febrile child, (*Seen by MD within 30 mins)

Level 4 - ABD pain less than 5/10 on scale (*Seen by MD with 60 mins)

Level 5 - Prescription refill, minor laceration (*Seen by MD with 120 mins)

Re: CTAS an RN is responsible for reassessing the patient if the MD has not had the opportunity to do so. We also have advanced orders to implement treatment. We can always upgrade a CTAS level BUT never downgrade.

Hope this helps.

nursegoodlove · Nov 5, 2004

Depends on the acuity in the ER and how many RN's are staffed on days and nights.
Dayshift
-----------
1 RN trauma 2 beds (3rd) if required
2 RN obs/exam/gyn/eye - 10 beds
1 RN triage
1 RN for amb/minor/consult/family room/fracture - 8 beds and 4 chairs
1 RN charge nurse (who assist when possible)
1 ward clerk (answers the phone, etc...)
2 porters
Nightshift
------------
1 RN trauma 2 beds
1 RN charge (who is responsible for triage after 23:00 hrs. and amb/minor/consult/family room/fracture - 8 beds and 4 chairs after 03:00 hrs_
1 RN obs/exam/gyn/eye - 10 beds
We have a 10 -22 hrs. shift that is assigned usually until 19:00 hrs. in obs area then reallocates to triage. We have a 19:00 - 03:00 shift which is assigned on amb/minor/consult/family room/fracture - 8 beds and 4 chairs
So really, after 11:00 p.m. on a night shift, we have 3 RN's which is really unsafe and they hospital doesn't have enough money to hire another RN. Dayshift is stacked rather well. Can you see the difference?
As well, we use a CTAS level (Canadian Triage Acuity Level Scale) system to assess our patients according to their presentation.
Level 1 - stat MD assess Life threatening, VSA
Level 2 - CP (*Seen by MD within 15 mins)
Level 3 - SOB with good sats, febrile child, (*Seen by MD within 30 mins)
Level 4 - ABD pain less than 5/10 on scale (*Seen by MD with 60 mins)
Level 5 - Prescription refill, minor laceration (*Seen by MD with 120 mins)
Re: CTAS an RN is responsible for reassessing the patient if the MD has not had the opportunity to do so. We also have advanced orders to implement treatment. We can always upgrade a CTAS level BUT never downgrade.
Hope this helps.

Thank you to ALL of you who have so kindly responded. "Diversion" is now a thing of the past d/t "gridlock" everywhere on the Lower Mainland (where I live), and "patient overrride". The nurse in the back - on top of triaging those who come in by foot or ambulance - are also responsible for maintaing scheduled IV/DVT therapies. (That whole system is utterly bizarre to me and "should" be done either out in the community by an IV nurse/team, or added staff to do this "should" be implemented. Fiscal restraints!).

The one pt. I mentioned that got overlooked by the ambulance attendant...had been charted by same to have a pulse of 123 but failed to report it to the nurses. The pt. was having an MI and had been there a full 2 hours... One pt. went into cardiac arrest and because they were in one of the 6 -7 ambulances (no room at the Inn), the nurse had to do CPR in the doorway of the ambulance. Two trauma victims came in at the same time (a fall off a ladder and a MVA), a certified pt. was in the lock down area, apt. came in with a sheered off kidney and bowl, as the nurse put it, "it was chaos reigning", and it went on... They pulled the one experienced ER nurse to transport a pt. via ambulance to a cath lab on the east side of the river...removing her from the floor 4-6 hours and this is happening routinely at least 6 times a week. The nurses that were left were - one experienced (in-charge) RN, a new grad. RN and an RN who was new to the unit. The nurses are running in and out of the ambulances, hanging blood, doing lab work and admin. meds.

When we point blank asked the manager of the ER "who" would be liable for these ambulance people it was said, "There is no nurse assessment. Once the pt. comes to us, we have a "duty to care". But, BC Ambulance has an agreement with us to do the v/s, charting and reporting. No one person is assigned to these pts., it may be the triage nurse if she isn't too busy, it may be the nurse in front if she isn't too busy, etc. I don't know who is responsible. It's a parking lot issue. Everyone kind of walks by and takes a gander. I doubt the nurse would be liable because "who" are they going to blame? No one is assigned to them. " [and then she laughed*].

It was said that BC Ambulance wait times have had a large increase & we are about 4th for waiting time in B.C. Our ER admissions are up 30% as of the March-Sept. period from last year. 40% of the time our ER is operating above capacity. The avg. occupancy rate for our hospital is 126%.

I have seen PRF's that would make your hair stand straight up like: a nurse that had a pt. on conscious sedation and d/t her extreme workload...the only thing she could do to asses them was to "kick the foot of their bed as they ran past to see if they would rouse." Because we are in such "gridlock"...pts. are being put L to R @ the nrsg. stn, in hallways, linen room (no suction/no o2) and treatment (i.e.: cast room) on stretchers & gerichairs...where they are out of "vision" for the nurses to assess/monitor. We have had an example of a pt. being unconscious in one of these rooms, lying flat on their back...vomitted, requiring full code & intubation.

There are "more" stories I could tell, but, I think you get the jist.

The morale, chronic stress is taking a major toll on these nurses. The management/admin. have been told these stories over and over. Everything comes to the "bottom line"....no $ to hire more staff.

My heart goes out to these nurses - they have expressed (in tears), fear for their pts. safety and their licenses.

What a SICK environment to work in - going against everything a nurse believes and stands for...which is the promotion of wellness.

Thanks for letting me vent and for all your help. You are true hereos for the work you do! :nurse:

rjflyn, ASN, RN · Nov 5, 2004

ANd that my friends is why we dont want Canadian style medical care in the USA.

Rj:rolleyes:

Thank you to ALL of you who have so kindly responded. "Diversion" is now a thing of the past d/t "gridlock" everywhere on the Lower Mainland (where I live), and "patient overrride". The nurse in the back - on top of triaging those who come in by foot or ambulance - are also responsible for maintaing scheduled IV/DVT therapies. (That whole system is utterly bizarre to me and "should" be done either out in the community by an IV nurse/team, or added staff to do this "should" be implemented. Fiscal restraints!).
The one pt. I mentioned that got overlooked by the ambulance attendant...had been charted by same to have a pulse of 123 but failed to report it to the nurses. The pt. was having an MI and had been there a full 2 hours... One pt. went into cardiac arrest and because they were in one of the 6 -7 ambulances (no room at the Inn), the nurse had to do CPR in the doorway of the ambulance. Two trauma victims came in at the same time (a fall off a ladder and a MVA), a certified pt. was in the lock down area, apt. came in with a sheered off kidney and bowl, as the nurse put it, "it was chaos reigning", and it went on... They pulled the one experienced ER nurse to transport a pt. via ambulance to a cath lab on the east side of the river...removing her from the floor 4-6 hours and this is happening routinely at least 6 times a week. The nurses that were left were - one experienced (in-charge) RN, a new grad. RN and an RN who was new to the unit. The nurses are running in and out of the ambulances, hanging blood, doing lab work and admin. meds.
When we point blank asked the manager of the ER "who" would be liable for these ambulance people it was said, "There is no nurse assessment. Once the pt. comes to us, we have a "duty to care". But, BC Ambulance has an agreement with us to do the v/s, charting and reporting. No one person is assigned to these pts., it may be the triage nurse if she isn't too busy, it may be the nurse in front if she isn't too busy, etc. I don't know who is responsible. It's a parking lot issue. Everyone kind of walks by and takes a gander. I doubt the nurse would be liable because "who" are they going to blame? No one is assigned to them. " [and then she laughed*].
It was said that BC Ambulance wait times have had a large increase & we are about 4th for waiting time in B.C. Our ER admissions are up 30% as of the March-Sept. period from last year. 40% of the time our ER is operating above capacity. The avg. occupancy rate for our hospital is 126%.
I have seen PRF's that would make your hair stand straight up like: a nurse that had a pt. on conscious sedation and d/t her extreme workload...the only thing she could do to asses them was to "kick the foot of their bed as they ran past to see if they would rouse." Because we are in such "gridlock"...pts. are being put L to R @ the nrsg. stn, in hallways, linen room (no suction/no o2) and treatment (i.e.: cast room) on stretchers & gerichairs...where they are out of "vision" for the nurses to assess/monitor. We have had an example of a pt. being unconscious in one of these rooms, lying flat on their back...vomitted, requiring full code & intubation.
There are "more" stories I could tell, but, I think you get the jist.
The morale, chronic stress is taking a major toll on these nurses. The management/admin. have been told these stories over and over. Everything comes to the "bottom line"....no $ to hire more staff.
My heart goes out to these nurses - they have expressed (in tears), fear for their pts. safety and their licenses.
What a SICK environment to work in - going against everything a nurse believes and stands for...which is the promotion of wellness.
Thanks for letting me vent and for all your help. You are true hereos for the work you do!

RNin92 · Nov 7, 2004

ANd that my friends is why we dont want Canadian style medical care in the USA.
Rj:rolleyes:

Amen my friend...Amen.

tiredfeetED · Nov 7, 2004

lets see..

1=charge RN/MICN

2 RN in 5 bed trauma bay

then RN/LVN 4 beds to 1 nurse

1 RN in triage and LVN in fast track

for our 18 bed ED we start with 7 lic. then get a 11-11 and a 3-3 person...this helps with lunches and hall beds (OH that dont exist)

time from sign in to Doc is around 15min...our doc is really trying to cut out the triage process all together except for days of complete saturation. The one thing that travelers or new hires like is that we have great team work.

If i have less staff than this I will close beds to piss off the supers and Docs...Cali= Ratio!!

RNin92 · Nov 7, 2004

lets see..
1=charge RN/MICN
2 RN in 5 bed trauma bay
then RN/LVN 4 beds to 1 nurse
1 RN in triage and LVN in fast track
for our 18 bed ED we start with 7 lic. then get a 11-11 and a 3-3 person...this helps with lunches and hall beds (OH that dont exist)
time from sign in to Doc is around 15min...our doc is really trying to cut out the triage process all together except for days of complete saturation. The one thing that travelers or new hires like is that we have great team work.
If i have less staff than this I will close beds to piss off the supers and Docs...Cali= Ratio!!

Exactly how do you "close beds" in the ED??!!??

I'ld LOVE to know.

:coollook:

tiredfeetED · Nov 7, 2004

Exactly how do you "close beds" in the ED??!!??
I'ld LOVE to know.

Cali ratio laws!!!!

We must have a min. staff, but like every ED we fill the halls and hold many MS/ICU..but we must have more staff...

nursegoodlove · Nov 7, 2004

Cali ratio laws!!!!
We must have a min. staff, but like every ED we fill the halls and hold many MS/ICU..but we must have more staff...

Thank you everyone for your help! The more I read of what is "normal"...the more "abnormal" I am feeling we are in our ER dept. I am going to make some notes & take them to our nurses to help give them some idea of what's going on elsewhere! I doubt there aren't too many ER's that have pts. seeing a unit clerk 1st...and then the triage nurse? It's scary! :uhoh3: Thanks again - I am taking all this down - it's a great help! :)