Help! Dysfunctional ER in Small Town. 1000 Visits/Month

  1. My first day in the ER......
    I have been a nurse for 6 years working in ER, ICU, OR, and nursing supervision. I have just signed on as the ER manager and was shocked at the mess i walked into.

    Any input from others, especially small town ER's that see 950 to 1200 patients per Month, would be greatly appreaciated.

    I found that my new office is the chart break down room. Usually 3 to 4 days of charts waiting to be taken apart, t sheets copied, pt charges put into meditec,pt discharged from meditec ect. We then sort the charts (take them apart) and put them into three stacks. One copy for the referred to MD, one copy to the emergency md billing services and finally the medical record. How is it done everywhere else????

    Another question is about staffing. Is there any minimal staffing requirements?? We generally see 25-45 pts per day. My FTE's show I need to staff 3 on days, 3 on evenings, and 1 on nights. (1.68 per visit)Is anyone staffing only one RN on nights?? I feel its to dangerous and have refussed. I'm looking for justification for being over my FTE's because of low volume on 11-7 shift.

    Finally, does anyone have any hints on finding missing stats. ie blood pressure checks, triage of OB patients, Breath-a-lizer tests, trama codes (level 3) doing EKG's & breathing tx's after 6:00pm, calling in the x-ray tech on call after hours ect..

    Any comments or suggestions will be greatly appreaciated.

    [ May 31, 2001: Message edited by: catalyst ]
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  2. 6 Comments

  3. by   CEN35
    Ok well where to start? Your situation is so much different than ours? we are a level II Trauma center in Cleveland Ohio.
    We see from 90 - 156 a day. We have 6 and a medic on days, 7 and a medic on evenings, 5 and a medic on nights till 3:30am, and then 3 Rn after 3:30am till 7am.
    Paperwork? We have a registration person 1,2 or 3 at times. they are responsible for preparing all the billing issues and chart breakdown after discharge. We have two secretaries in back that out in orders, call attendings and break down charts for admissions.

    CEN35 (Rick)
  4. by   LerRN95
    Originally posted by catalyst:
    <STRONG>My first day in the ER......
    Any input from others, especially small town ER's that see 950 to 1200 patients per year, would be greatly appreaciated.

    I found that my new office is the chart break down room. Usually 3 to 4 days of charts waiting to be taken apart, t sheets copied, pt charges put into meditec,pt discharged from meditec ect. We then sort the charts (take them apart) and put them into three stacks. One copy for the referred to MD, one copy to the emergency md billing services and finally the medical record. How is it done everywhere else????

    Another question is about staffing. Is there any minimal staffing requirements?? We generally see 25-45 pts per day. My FTE's show I need to staff 3 on days, 3 on evenings, and 1 on nights. (1.68 per visit)Is anyone staffing only one RN on nights?? I feel its to dangerous and have refussed. I'm looking for justification for being over my FTE's because of low volume on 11-7 shift.

    Finally, does anyone have any hints on finding missing stats. ie blood pressure checks, triage of OB patients, Breath-a-lizer tests, trama codes (level 3) doing EKG's & breathing tx's after 6:00pm, calling in the x-ray tech on call after hours ect..

    Any comments or suggestions will be greatly appreaciated.</STRONG>
    I am a ED nurse supervisor of a rural hospital we average 25-30 patients a day. We have only one RN at all times in the ER. They work from 7-7. There is an LPN that comes in to work 11a-11p. This is the only time there is help assigned to to assist the RN in the ED. We do not have a triage nurse.

    Over all our department runs fairly smoothly, but there is many areas to improve on. I will be glad to help if I can. Just email me.

    Lisa
  5. by   denicke
    Have you thought about flex staffing?? Have 2 RN's 7a-7p, 1 RN 11a-p, and 2 7p-7a. That may save enough $ to justify a clerk to do paperwork and maybe some tech type duties. Good luck!!
  6. by   kaycee
    First of all I don't understand your pt. visit numbers, they don't add up. If you see 950-1200/yr that's approx 3-4 pt's / day unless you have days where you see 25-45pt's/day and lots of days that no one comes in. If you see 25pt's/day that's over 9000pt's/yr. I'm not great at math but what is your usual daily census knowing that in an ER it can vary a great deal? We see approx 18-19000pt's/year. It's a community hospital. We staff 3 RN's an ER tech and a secretary on days, the same on evenings and on night's there are 2 RN's and a secretary. On days and evenings there is a registration clerk. On nights the secretary registers pt's. The secretaries do all the charges and tearing apart of charts to go to their designated areas. We have X-ray in the dept. at all times. Our tech's do blood draws, ekg's, foleys, splinting, assisting with suturing and do basic vs. We have a nurse in triage at all times except on nights. We work 12hrs shifts and 8's depending on the nurse and dept's need. The 12hr shifts are usually 7a-7p & 7p-7a. Occasionally 11a-11p if the need is there. We don't always have techs so when they are not there and even when they are, the RN's do all their own blood draws, resp treatments, splinting, ecg's ect.
    I agree 1 RN on nights is not good. As denicke said maybe some creative shifts would help fill the holes without going over budget. Also the addition of a secretary on whatever shift is your busiest may help with the paper work.
    Let us know how things go. Good luck.
  7. by   LANA
    I, too, work in a small rural hospital. 4 ER beds with 2 extra for minor, minor overflow (actually, pt rooms not in use by hospital). Have one MD & RN around the clock. One LPN comes in 12 to 16 hours of the 24 hours and one clerk to register 16 of the hours. Eight hours (night shift) there is only one RN, who registers, triages, wakes the doctor (if he is fortunate to be asleep), orders, treats, & discharges the patient or patients.

    If it is possible, we do the EKGs and breathing treatments. Will call respiratory, if the help is needed. Will start the IV and obtain blood, if the situation permits. Otherwise respiratory and lab will perform the jobs. X-ray tech is either staying in house or live near hospital for call ins (they have 30 mins to respond). They always respond faster in codes.

    We have a Meditech system. The nurse enters all the orders, unless she has a clerk available and has no time to do the job. We have computers in 3 of our 4 ER rooms.

    Lab prints out results to our dept. We are able to access all labs that the pt has ever had at our hospital, as well as X-ray reports, History/Physicals, visit histories, medication histories, etc. Also, linked with larger local Columbia/HCA hospitals, so as to obtain same info, if the pt was ever treated there. Absolutely, love MediTech!

    Upon discharge, we put our charges in MediTech, copy the charts ourselves or, if the clerk has time or is available she will help us. We make a copy of the face sheet, T-sheet, nurse's note, and prescriptions for our benefit. Kept in our station for quick access for returns. Only keep them for 6 months. We make a copy of face sheet & T-sheet for radiology and the pt's local doctor. Main chart goes to Medical Records. Copy of face sheet with drugs administered goes to pharmacy for them to charge.

    We put out our own supplies, including linen.

    We average 30 to 35 patients a day and are growing. Currently, in process of building a new ER and adding a new full time RN. We don't like working at night alone. At current time, at night, we are completly isolated from the rest of the hospital. Various employees will come and check on us & lend a hand. The local police will come and check on us. We have no security, other than cameras and a silent alarm necklace.

    In case of codes, we have buttons in the exam rooms that alarms in MedSurg. If you know your job, you only need a handful of employees for a code. If we get backed up with serious to critical, we depend on ICU &/or the ER manager (who is willing to come in to our rescue anytime). If need be another doctor is just a phone call away.

    Just set up your policies and utilize them. Hope I have helped.
  8. by   ok-rn
    I am an RN in rural Oklahoma. I have been in ER 11 years and have seen LOTS of changes!
    We see on an average of 1200 a month, the most of which is on the day shift, 7A-7P. However, we staff 2 RN's each shift, around the clock. We have admissions clerks who register the patient and do all the chart break down and copying.

    Lab and respiratory care are in house and Xray is in house 3 nights a week(weekends). The rest of the time, they are on call and all live fairly close.

    We do not have a triage nurse or a ward clerk and I think we need them, especially on the day shift!
    Myself and another RN do all the QA and the trauma registry.

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