Just a question to understand the ER better - page 2

so a quick run down. just wanted opinions. 59 yr old male patient in ESRF comes into the ER. wife signs him in and describes that he is "finishing dialysis (home hemodialysis), rapid heart rate,... Read More

  1. Visit  Esme12} profile page
    2
    I am glad your Dad is feeling better. I agree about other forums....Come hang out with us........Here at AN we try very hard to keep a flame free atmosphere. It is a part of the Terms of Service.


    Our first priority is to the members that have come here because of the flame-free atmosphere we provide. There is a zero-tolerance policy here against personal attacks. We will not tolerate anyone insulting other's opinion nor name calling.

    Our call is to be supportive, not divisive. Because of this, discrimination, racial vilification and offensive generalizations targeting people of other races, religions and/or nationalities will not be tolerated.
    I'm sending prayers and positive healing vibes for your Dad...Good luck in school.
    Akewataru and Anna Flaxis like this.
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  3. Visit  Anna Flaxis} profile page
    5
    Quote from samadams8
    People with afib have a good chance of having a stroke, among other serious/critical problems. Some folks don't tolerate rapid Afib for very long.

    Sorry guys. Unless there were mass casualties going on, I'd get that pt at the least on a monitor ASAP. Call me crazy.
    If it's full in the back, the triage nurse will call the charge nurse on the phone and let them know there is a "2" in the lobby, and where does the charge nurse want them?

    The charge nurse then has to figure out where they CAN put them (Is there anyone discharging? Can they get dressed and go wait in the lobby for their paperwork? Is there anyone being transported to the inpatient unit? Can we get that done NOW and get another stretcher in the room? Are there any empty rooms I don't know about? Wait, Medic 410 is on the radio with a Cath Alert; I gotta take this radio call. Okay, now I have a "2" in the lobby and a Cath Alert coming. Wait, my phone is ringing. It's the ICU charge nurse letting me know that they're not going to be able to take that post cardiac arrest for another hour because they don't have any patients stable enough to move out, and they have to call and find a nurse to come in so they have enough staff. Okay, is there anyone else that can go? We need a room for the Cath Alert! Joe, does that GI bleed have admitting orders? Good, get him up to the medical floor NOW. We need the bed. What? The floor says they're still cleaning the room? Too bad, take the patient up now and wait in the hallway if you have to. Hey, Dr. Payne, can the patient in bed 15 go home? Great, if you could write up those DC orders ASAP, that would be great. Oh, you've just sedated a kid for a fracture reduction? Okay, well could you do the DC as soon as you're done there? Jane, is 16 gone yet? They just left? Great, can you please go grab that "2" out of the lobby?).

    It's actually safer for the patient to wait in the lobby while all this is taking place so that the triage nurse can keep an eye on them. Now granted, it would be a good idea to at least start the triage and registration and get an EKG while the patient is waiting for a bed, but I don't know if this particular ED has the resources to do that.

    Putting them on a monitor in the meantime is more easily said than done. On a busy shift with many cardiac and/or ICU admits, all of the portable monitors may be in use, transporting patients to the inpatient units so that we can empty rooms and room more patients who are waiting in the lobby or coming in by ambulance.

    The national average ED wait time, which is time of triage until time the doctor is in the room, is six hours. Ours is much lower than that, and yet still I can see how a person in rapid A-Fib could wait longer than 15 minutes to be seen. It happens with frightening regularity.

    This is not necessarily a failure on the part of ED staff; they may be doing everything in their power to work as fast as they can, but due to the factors already mentioned, there are limits to what they can do and how quickly they can do it. Many hospitals are deliberately under staffing EDs in order to cut costs. If you don't think this has a direct impact on patient safety, think again.

    The attitude by the one nurse in triage could easily have been an attitude of frustration, not necessarily a lack of concern for the patient or a failure to recognize the urgency of his condition. It is indeed very frustrating to work under these conditions. I think I can speak for many ED nurses who really want to be able to provide the very best emergency care, but don't have the support and resources to do so.
  4. Visit  Anna Flaxis} profile page
    0
    OP, glad to hear your father had a good outcome.
  5. Visit  samadams8} profile page
    0
    Quote from ~*Stargazer*~
    If it's full in the back, the triage nurse will call the charge nurse on the phone and let them know there is a "2" in the lobby, and where does the charge nurse want them?The charge nurse then has to figure out where they CAN put them (Is there anyone discharging? Can they get dressed and go wait in the lobby for their paperwork? Is there anyone being transported to the inpatient unit? Can we get that done NOW and get another stretcher in the room? Are there any empty rooms I don't know about? Wait, Medic 410 is on the radio with a Cath Alert; I gotta take this radio call. Okay, now I have a "2" in the lobby and a Cath Alert coming. Wait, my phone is ringing. It's the ICU charge nurse letting me know that they're not going to be able to take that post cardiac arrest for another hour because they don't have any patients stable enough to move out, and they have to call and find a nurse to come in so they have enough staff. Okay, is there anyone else that can go? We need a room for the Cath Alert! Joe, does that GI bleed have admitting orders? Good, get him up to the medical floor NOW. We need the bed. What? The floor says they're still cleaning the room? Too bad, take the patient up now and wait in the hallway if you have to. Hey, Dr. Payne, can the patient in bed 15 go home? Great, if you could write up those DC orders ASAP, that would be great. Oh, you've just sedated a kid for a fracture reduction? Okay, well could you do the DC as soon as you're done there? Jane, is 16 gone yet? They just left? Great, can you please go grab that "2" out of the lobby?). It's actually safer for the patient to wait in the lobby while all this is taking place so that the triage nurse can keep an eye on them. Now granted, it would be a good idea to at least start the triage and registration and get an EKG while the patient is waiting for a bed, but I don't know if this particular ED has the resources to do that.Putting them on a monitor in the meantime is more easily said than done. On a busy shift with many cardiac and/or ICU admits, all of the portable monitors may be in use, transporting patients to the inpatient units so that we can empty rooms and room more patients who are waiting in the lobby or coming in by ambulance.The national average ED wait time, which is time of triage until time the doctor is in the room, is six hours. Ours is much lower than that, and yet still I can see how a person in rapid A-Fib could wait longer than 15 minutes to be seen. It happens with frightening regularity. This is not necessarily a failure on the part of ED staff; they may be doing everything in their power to work as fast as they can, but due to the factors already mentioned, there are limits to what they can do and how quickly they can do it. Many hospitals are deliberately under staffing EDs in order to cut costs. If you don't think this has a direct impact on patient safety, think again.The attitude by the one nurse in triage could easily have been an attitude of frustration, not necessarily a lack of concern for the patient or a failure to recognize the urgency of his condition. It is indeed very frustrating to work under these conditions. I think I can speak for many ED nurses who really want to be able to provide the very best emergency care, but don't have the support and resources to do so.
    OK, but I stand by my position. Just bc this pt lucked out, so to speak, does not mean ,it was necessarily handled OK.I don't agree w how some eds are structured and run. It's not a restaurant. Sure there are other cases that may trump others, but I have seen a lot of license taken with that position.Her father was probably rapid upon initial vs. Why so fast? I'd take a quick listn to the heart. Afib is highly irregular ...a controlled rate is one thing, but rapid afib is another.
  6. Visit  Daisy Doodle} profile page
    6
    As a triage nurse I am looking at Stable or Unstable. Many people are living in chronic A-Fib. We do the best that we can with the resources at hand. It is all about perception and expectation. 15 minutes is equivalient to urgent treatment in my ED. I am not surprised by the positive outcome because that is what we do. We face multiple "sick" patients with multifaceted challenges. Had that patient showed any sign of instablility there would have been a gurney.

    Also going straight back to a bed does not equate being tended to immediately. My patients rountinly are direct bedded only to wait 45 minutes for my first opportunity to to complete a focused assesment.

    Welcome to healthcare, its only getting worse. We have seen a 7% increase in total patients every year since 2007. Do the math........ Our bed numbers remain the same and our staff is leaving.
  7. Visit  samadams8} profile page
    0
    Quote from Daisy Doodle
    As a triage nurse I am looking at Stable or Unstable. Many people are living in chronic A-Fib..
    Not uncontrolled afib. There's a difference between controlled and uncontrolled, rapid afib . Focused assessment could include a quick assessment of heart. His was a rapid rate by more than 30 beats...related to stress. Why so rapid? Is it regular, etc?

    I believe you about healthcare. My issue is that fundamentally, this patient may well have been able to be taken and put on a monitor or given an EKG sooner. Of course none of us has all the information. But I am betting it went down in ways that I have witnessed before. I have seen so many unjustified things--like a patient from car accidents with head injuries sitting in ED waiting rooms for hours--all while he continued to bleed internally. Why makes these folks wait until they hit the floor before they are seen.

    I think the triage nurse could have evaluated this man in a more, thorough focused way. If his tolerance for the rapid atrial rate, and complications associated with it, had caused him to get in real trouble, which, make no mistake about it, it very well could have gone down that way, someone's butt would and should be required of them.
    Last edit by samadams8 on Sep 20, '12
  8. Visit  NurseOnAMotorcycle} profile page
    1
    We have a "PIT" team (Provider In Triage) who works just between triage and the exam rooms who's responsible for anyone in triage or waiting area. She sees acute cases in triage and starts orders for them while they are waiting for a bed. Also in triage is a bed for very acute cases, code cart and EKG machine. They try to get the bloodwork and start IVs if they can, but they at least get started easier.Sometimes they are seen and discharged from the waiting room. Sometimes the only thing they need when they come back is a diagnosis. It has it's problems like every system, but I like that we have that immediate assistance as needed.
    Anna Flaxis likes this.
  9. Visit  That Guy} profile page
    0
    Quote from samadams8
    Not uncontrolled afib. There's a difference between controlled and uncontrolled, rapid afib . Focused assessment could include a quick assessment of heart. His was a rapid rate by more than 30 beats...related to stress. Why so rapid? Is it regular, etc?
    While this is true, in the initial post the first thing the pt states is the pt has "rapid heart rate" well, what is rapid. It is very broad answer. They then go on to say that turns out it is Afib with RVR. The wife couldnt state this because she did not know and of course that changes things the minute you find that out. I have had people walk in and say my heart feels like its beating out of my chest and their Pulse is 90. SO to them that was rapid. Afib RVR isnt though. This is one reason I hate triage and avoid it like the plague.
  10. Visit  samadams8} profile page
    1
    Quote from That Guy
    While this is true, in the initial post the first thing the pt states is the pt has "rapid heart rate" well, what is rapid. It is very broad answer. They then go on to say that turns out it is Afib with RVR. The wife couldnt state this because she did not know and of course that changes things the minute you find that out. I have had people walk in and say my heart feels like its beating out of my chest and their Pulse is 90. SO to them that was rapid. Afib RVR isnt though. This is one reason I hate triage and avoid it like the plague.
    It is reasonable to consider that if the patient was found to be w/ a rapid rhythm--> say >130's, which, for someone that is not an infant or child is by definition abnormal, it requires the very basic assessment step of auscultating at least for regularity of rhythm along with a rate. This is basic nursing and medicine--> assessment.

    Upon auscultating, one could appreciate irregularity--which is a hallmark of AFIB. A tech or nurse's aid could do basic VS, but this is why someone with an expectation of higher skills--at least basic assessment--must be in the role of triage.

    The nursing process, which begins with assessment, is the nursing process, period.

    Afib w/ RVR is tricky. Some tolerate it for a bit, while others do not.

    The judgment call can't be based on guesswork anymore than a person would guess, "Hey? This person is c/o angina? Should I take this seriously?"

    This is an ESRD pt, just completing hemodialysis with a rapid heart rate, and a feeling of fist in throat and constant burping.
    Upon taking his CC, at least a focused assessment is required from a cardiopulmonary perspective.

    Often a more serious event occurs with this condition before it's recognized, but the initial encounter/assessment here gives the opportunity to prevent a seriously problematic outcome.
    It's imperative that this pt get evaluated and tx'd as soon as possible.

    Also refer to:
    http://www.clevelandclinicmeded.com/...-fibrillation/
    Last edit by samadams8 on Sep 21, '12
    Susie2310 likes this.
  11. Visit  Anna Flaxis} profile page
    7
    samadams8, I mean this in the very best possible way, but you are thinking like a critical care nurse.

    The very first step in triage is the rapid visual assessment. This is even before you elicit the chief complaint. In the rapid visual assessment, you basically "eyeball" the person and determine how sick they are; do they need immediate assistance, or can they wait a few minutes?

    This person was apparently alert and oriented and perfusing his vital organs. He was conscious, breathing, and had a pulse. He was not in respiratory distress. He was not bleeding. Therefore, he could wait a few minutes.

    The triage nurse's role is not to do a focused assessment and start treatment. The triage nurse does a rapid visual assessment, takes some vitals, gathers a history, and determines the level of acuity, i.e. the order in which patients need to be seen, based upon all the information gathered.

    As for A-Fib with RVR, to be honest with you, it doesn't freak me out. A-Fib with RVR *rarely* deteriorates into a lethal arrhythmia, and people can generally tolerate it and compensate for a great deal of time. What the person needed in the ED setting was a 12 Lead EKG, some supplemental O2, a peripheral line, and some medication for rate control, such as Diltiazem. It sounds like he got all of that.

    Whether he needed any further treatment would be based upon the physician's exam and decision making process to determine whether the patient needed hospital admission or outpatient follow up. People do not stay in the ED.

    The OP was more concerned with one nurse's attitude, that her eyes did not "bug out" and that she *appeared* unconcerned. I'm here to tell you, my eyes would not "bug out" either, and it might appear as if I am unconcerned. I've taken care of a lot of people with arrhythmias, and I have a very calm exterior. To me, the fact that the one employee (we don't know that it was a nurse; she could have been a CNA or a Tech) appeared frightened tells me that that person is inexperienced and not very knowledgeable about cardiac arrhythmia. I'd rather have the experienced crusty old nurse out there in triage (and working triage often enough can make even the nicest, sweetest person crusty, LOL!) than the fresh, green one.

    We don't really know why he waited 15 minutes from the time he entered the lobby until he was officially triaged (I say officially, because the moment the triage nurse laid eyes on him, the triage process had started), despite the triage rooms being empty, because we don't know what was going on in that ED at that time. It could be that the triage nurse had been specifically instructed to hold off with the exception of anything emergent because they had something going on in the back. They were full, they were on divert, they were coding a child, they had just received a trauma, who knows. We don't.
    Last edit by Anna Flaxis on Sep 21, '12 : Reason: formatting
    canoehead, psu_213, flyingchange, and 4 others like this.
  12. Visit  Susie2310} profile page
    1
    Quote from samadams8
    It is reasonable to consider that if the patient was found to be w/ a rapid rhythm--> say >130's, which, for someone that is not an infant or child is by definition abnormal, it requires the very basic assessment step of auscultating at least for regularity of rhythm along with a rate. This is basic nursing and medicine--> assessment.

    Upon auscultating, one could appreciate irregularity--which is a hallmark of AFIB. A tech or nurse's aid could do basic VS, but this is why someone with an expectation of higher skills--at least basic assessment--must be in the role of triage.

    The nursing process, which begins with assessment, is the nursing process, period.

    Afib w/ RVR is tricky. Some tolerate it for a bit, while others do not.

    The judgment call can't be based on guesswork anymore than a person would guess, "Hey? This person is c/o angina? Should I take this seriously?"

    This is an ESRD pt, just completing hemodialysis with a rapid heart rate, and a feeling of fist in throat and constant burping.
    Upon taking his CC, at least a focused assessment is required from a cardiopulmonary perspective.

    Often a more serious event occurs with this condition before it's recognized, but the initial encounter/assessment here gives the opportunity to prevent a seriously problematic outcome.
    It's imperative that this pt get evaluated and tx'd as soon as possible.

    Also refer to:
    Atrial Fibrillation
    I agree. In the OP the patient's wife reported the patient had a rapid heart rate, feeling of fist in throat and constant burping, and was finishing dialysis. Sheehy's Manual of Emergency Care, 6th edition, published by the ENA, states on page 73 that "The triage nurse performs a focused physical assessment related to the patient's chief complaint . . . Inspection, palpation, and (occasionally) auscultation can be used to gather information related to the chief complaint."
    Last edit by Susie2310 on Sep 21, '12
    samadams8 likes this.
  13. Visit  samadams8} profile page
    1
    No one asked the triage RN to start tx. Someone tells you those symptoms and rapid hr, you take a look and listen. It doesn't take that long. I am not even asking you to listen foe murmurs or other untoward hear sounds.Look at it this way. If the client stated he has chest pain, you don't bloe if off, even if it tired out to be an anxiety attack. It's the same thing in this instance. No excuses. This gets a fail from me as well as some ED docs I know.Sorry.I have been a nurse in adults and critical care and you name for over two decades. Rapi AF doesn't necessarily frak me out either. That is not the point.This is suboptimal screening. The exception would be if there were numerous traumas or the like.This bull, and if it were my parent, you better believe I'd have something to say.
    Susie2310 likes this.
  14. Visit  samadams8} profile page
    0
    Quote from Susie2310
    I agree. In the OP the patient's wife reported the patient had a rapid heart rate, feeling of fist in throat and constant burping, and was finishing dialysis. Sheehy's Manual of Emergency Care, 6th edition, published by the ENA, states on page 73 that "The triage nurse performs a focused physical assessment related to the patient's chief complaint . . . Inspection, palpation, and (occasionally) auscultation can be used to gather information related to the chief complaint."
    THank you Susie. Hugs and kisses. You can take care do me and my family anytime!


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