ER vs ICU, how did we get there?

Specialties Emergency

Published

Ok...

In my hospital the lines have been drawn.

I don't like them...the lines I mean.

Somewhere along the way the ED has become the enemy of the ICU and I am not sure how that happened.

So I am looking to see how things are in other hospitals.

I SOOOOO wish we could work as a team!

(I know I'm kind of dorky that way...my kids keep telling me!)

:chuckle

But all kidding aside...any ideas?

Specializes in Emergency/Critical Care Transport.
Now Tom,

I am sure that you knew the exact minute that lady was going to code and timed it just perfect to make sure that you had her in ICU just at the right minute.

Us ER Nurses are crafty little devils!

The other day i get this pt who comes in being bagged by EMS. Doc tubes him, goes on a vent etc. Now I have tried to learn to what the ICU likes in their patients and get it all done for them. So I get the Doc to put in a triple lumen subclavian central line, the pt get's a foley, all labs and cultures done, he's on three drips the doc wants another, and puts in a femoral line for rapid fluids,pt's blood glucose was above 1200, he was also septic. We get his BP up to 66/40 which was great since had no bp earlier. I'm told there is a "ready bed" for him in ICU. I call up and give the report. ICU nurse tells me "Oh you have to get that BP up to 100 before we can take him." Naively I ask why that matters. "Oh it's dangerous for him to have the low bp up here." I reply, "No more dangerous than it is for him down here." And I think and maybe less dangerous because his primary nurse will have only one other pt in the ICU instread of three others down in the ED. And since I do both Critical Care Transport and EMS, I'm of the philosphy that some BP is better than none and 66/40 is respectable when you're in shock.

So I explain to her that we are flowing fluids and have a norepi drip running and the doctor has offered to accompany the patient to the floor to ensure his safety. She replies "He's too unstable." So I say. " Where do you think unstable people go? If he was stable he could go to PCU or med/surg."

She finally accepted the patient, but I really get a pain from these people. They look down on us in the ED because we don't grasp all the nuances of critical care (supposedly), but when we punt to them for help we get a thousand reasons why the pt is too unhealthy to come up. I mean if they are the "best care" in the hospital, isn't that where the pt is going to have the best rate of survival? I just don't get it. If you're so proud to be a critical care nurse, shouldn't you want to take care of a critical patient? Or is it all about low pt to nurse ratios?

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Specializes in Emergency room, med/surg, UR/CSR.

When I worked nights, I called up to the ICU one night at about 6:20 and was asked if I could hold off for another 15 minutes or so until the day shift nurse got there. Needless to say, I said no. I gave report and got the patient up right about 7am.

You're right, I have never been a floor nurse so I really do have no clue as to what is involved in doing an admit, but on the other side of the coin, there are times we have our frustrations too.

I always try to be nice to the nurses I am calling report to and if they have to call me back, I don't give them any grief. I know admits at shift change are a pain so if I have an admit that occurs within a half our of shift change all I ask is that the nurse take report and the patient can come up later. I don't like to dump an admit on my relief since I am the one that can give the best report on the patient rather than leaving it for someone who hasn't spent any time with the patient.

JMHO, :)

Pam

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and as far as there being a trauma...well that is quite possible, however, it kinda irks me when that is used as an excuse because where do you think the traumas go after their initial stabilization... to the ICU....... and just because they leave the ER doesn't mean they magically become stable and a cake walk..... and if a trauma is an excuse for not calling report for almost 6 hours... fine, but then understand that a hypotensive, multiple pressors, multiple blood products, swan numbers every hour, CVVH, hgb 6 patient is also quite time consuming. Are you forgetting the fact that I called down twice to get report?? I mean no disrespect, but the excuse that "maybe she didn't get to eat that night" kinda hit a chord because she wasn't the only one.

Ah, well....I will agree there's no excuse to be snotty when you're calling report and attemtping to transfer pt to ICU at 0645 is bad manners too. Also not giving an explanation....even a really simple "I got a really unstable pt down here.....guess what you'll getting in a couple of hours...." goes a long way towards maintaining good relations with the ICU.

Without knowing the ER nurse's side of the story....I can't really say why she kept 'em down there 6 hrs. I hate keeping admits any longer than I have to...."get along little gomers...rolling, rolling.....rawhide!" But maybe that's just me.

And I understand that critical ICU pt is a lot of work....but man, can't we all just get along? :rotfl:

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Specializes in Emergency/Critical Care Transport.
When I worked nights, I called up to the ICU one night at about 6:20 and was asked if I could hold off for another 15 minutes or so until the day shift nurse got there. Needless to say, I said no. I gave report and got the patient up right about 7am.

That's another thing. If you got the request to hold off on a pt every once in a while, that would be okay. I held one off till after shift change last night without even being asked. But there seems to be this aggravating ritual that you have to go through with every admit. First when you call up the ICU nurse is with another pt and will call you back in five minutes. That never happens. So fifteen minutes later you call up and this time the nurse is in the bathroom, eating lunch (I love that one!), still in report (30 minutes after shift change and the obligatory 30 minute grace period). Call #3 you finally get to talk to the ICU RN who then pretends she's your fourth semester nursing instructor a proceeds to grill you about the pt's H&H, K, and other things, even though she has a copy of the the report I faxed up to her over an hour ago right in front of her. Then finally when she runs out of questions, can you bring the pt up? Oh no, you see the room hasn't been cleaned yet. Can you call back in another half hour, or better yet, she'll call you back when the bed is ready.

:angryfire

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someone mentioned earlier about communication between the two units is most important. I agree totally. We've recently started having charge nurse meetings with ER and ICU with our directors, nursing supervisors and CNO. I think it has helped some. But plans only work as well as the people that implement them. Some ER charge nurses are better and more cooperative and experienced than others, the same with ICU. We can only do so much, the other 'side' has to agree and try as well. It's amazing how smoothly things can work, or how awful it can be if it doesn't. I've suggested to my manager and it's been mentioned to 'step' into the other charge nurses shoes for a while so that we can understand where the other person is coming from. Unfortunatly that hasn't happened yet. Maybe......in a perfect world....frustrating as all get-out isn't it

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and as far as there being a trauma...well that is quite possible, however, it kinda irks me when that is used as an excuse because where do you think the traumas go after their initial stabilization... to the ICU....... and just because they leave the ER doesn't mean they magically become stable and a cake walk..... and if a trauma is an excuse for not calling report for almost 6 hours... fine, but then understand that a hypotensive, multiple pressors, multiple blood products, swan numbers every hour, CVVH, hgb 6 patient is also quite time consuming. Are you forgetting the fact that I called down twice to get report?? I mean no disrespect, but the excuse that "maybe she didn't get to eat that night" kinda hit a chord because she wasn't the only one.

Ah, well....I will agree there's no excuse to be snotty when you're calling report and attemtping to transfer pt to ICU at 0645 is bad manners too. Also not giving an explanation....even a really simple "I got a really unstable pt down here.....guess what you'll getting in a couple of hours...." goes a long way towards maintaining good relations with the ICU.

Without knowing the ER nurse's side of the story....I can't really say why she kept 'em down there 6 hrs. I hate keeping admits any longer than I have to...."get along little gomers...rolling, rolling.....rawhide!" But maybe that's just me.

And I understand that critical ICU pt is a lot of work....but man, can't we all just get along? :rotfl:

I agree w/ the why can't we all just get along attitude. That is the approach I try to take... and I do understand how difficult it can be at times to call report on a patient....... we in the ICU are kinda in the middle b/c we get em from the ED then send em to the stepdown/tele.....and some days calling report can be VERY FRUSTRATING.......... and the reason why you are trying to get the patient out is cuz there is a helicopter on the way with a critical patient from an outside patient needing that ICU bed or there was a code on med-surg and somehow bed management assigned the code bed...so I do understand.... I guess my point of that story is that it goes two ways... Really ICU nurses and ER nurses have a lot in common......like excitement, critical patients, chaos, great critical thinkers, morbid sense of humor......I could go on........ peace ER nurses......... :balloons:

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I love the battles we have with ICU, I really do. Ever since they got mad at me last year. We resuscitated a lil ole lady what little was left on dopamine and isuprel, I even went out of my way to keep her in the ER for 3 extra hours to see if she would go to heaven so they wouldnt have to admit her and do all their work there. Of course wouldnt you know it I finally take her up and 10 minutes after I leave the unit she finally expires.

The ICU charge nurse wrote me up for dumping a terminally ill pt on them, and a very unstable one. My nurse manager stood up for me and I didnt get in trouble. But the lines have been drawn by them.

Let the rumble begin!!!!!!!!!!

I'll make a guess here and say that Grandma probably went to Heaven right around shift change. Being written up for "dumping" by the charge nurse? I'll say this charge nurse is an idiot. I thought ICUs were supposed to care for unstable patients, but, Tom, perhaps I've been wrong all these years.

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I can't really ever remember any issues between our ICU and the ED.....

It's probably because most ED patients either go to CCU, the floor, or MICU..The only thing that comes from our ED to us, in a roundabout kind of way are the traumas. We have a seperate trauma room and trauma team that consists of one ER nurse, one SICU nurse (where I work), a surgery nurse, Respiratory therapy, two surgery residents, anesthesia, radiology, lab tech, chaplain, security, house supervisor, Trauma RN.... and then whoever else thinks they can squeeze into the room.... attendings show up to the Level I traumas....

However, when those units are full, we'll sometimes get some overflow from the ED.

The nurses we work with in the trauma suite are almost always smart and easy to work with.

Sorry you guys have such a hard time working with eachother!

It might be somewhat the same type of story from anesthesia, who calls us report after surgery and recovery room..... although, I've never actually had any issues there myself.

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Someone said earlier that communication is key, and I would agree.

I think part of the problem is personality. To work in either ED or ICU you have to be assertive and strong. So two people with those attributes can be a dynamic team...or horrific adversaries. I'm sorry that so much of the time we seem to be the latter.

Sometimes I think that the administration LIKES it this way...

If we are fighting with each other...we certainly cannot be fighting with them!

If the reason we are overworked and underpaid is the ED/ICU (depending on which floor you live!) then the REAL issues do not have to be addressed.

Kind of makes you think a bit!!!

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Someone said earlier that communication is key, and I would agree.

I think part of the problem is personality. To work in either ED or ICU you have to be assertive and strong. So two people with those attributes can be a dynamic team...or horrific adversaries. I'm sorry that so much of the time we seem to be the latter.

Sometimes I think that the administration LIKES it this way...

If we are fighting with each other...we certainly cannot be fighting with them!

If the reason we are overworked and underpaid is the ED/ICU (depending on which floor you live!) then the REAL issues do not have to be addressed.

Kind of makes you think a bit!!!

Great point.....does make ya ponder..... :coollook:

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Specializes in CCU/CVU/ICU.

Seems this is a common thing. At my place of employement, the biggest issue with the ER is when they try to give report at innapropriate times...ie. during shift change.(can i get a big DUHHHH). Or, the ER nurse who thinks we're lying when we say we're busy and need to call back in a few minutes. This really pisses the ER nurses off...however these same nurses can hold on report until they're ready (and able). (can i get a bigger DUHHH).

A familiar ICU sentiment is this: On days when an ER nurse has to care for a critically ill or unstable patient it can really throw a wrench into her schedule and impact report calling times, etc. These same ER nurses

sometimes fail to realize that ICU nurses ALWAYS have critically ill and/or unstable patients. ER nurses have more 'control' over when report is called...they do it when they can. The ICU nurse has no such control and may receive a call when she's dealing with Mr. unstable, etc. If she ever said 'i'll receive report when i can', you'd surely see an ER nurse slamming the phone and cussing us out.

I think ER nurses should have a little more patience with the ICU...as so many (speaking soley of the place where i'm employed) ER nurses are too quick to complain about being inconvenienced. As if their time were more valuable than any other nurses time....These chicks (and a few fellows) are dorks.

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Okay, this is the first time I've replied since the new system went into place, so here goes:

I'm not sure this can ever be resolved. Although I go agree with the poster who said that both ICU and ER nurses have strong personalities, I think we are fundamentally quite different. I've worked both, and found that I'm much more of an ER kind of gal.

ER people deal with the unexpected all day long, the unexpected is the expected. ICU nurses deal with the unexpected all day long as well, but in a framework which is much more controlled. As one poster said, ICU nurses take care of critically ill and unstable patients, so of course they expect their patients to be critically ill and unstable. However, in the ER the very stable guy with the toothache can code 10 minutes after he arrives (oh, so the tooth pain was heart related), the teenage girl who complains of constipation ruptures her ectopic while waiting to see the doctor, the guy the ambulance just brought in pulls a gun on the doctor (all of these have actually happened in various ERs where I've worked).

So I think we're on different wavelengths. The best we can do is to care for the patients the best we can and respect each others' strengths and differences.

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