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, feeling of fist in throat and... Read More

  1. 2
    Quote from tami101481rn
    I have to disagree with all of you saying 15 minutes is not a long wait time. If EMS brought in a patient from a dialysis clinic with these symptoms, he would be high priority. Dialysis can cause to quick of a shift in electrolyte imbalances, namely K+. That would be the best explanation for rapid heart rate, the feeling in his throat etc. A shift in k+ leads to cardiac problems, MI etc. I have an issue with any high level acuity patient going to triage, whether it be chest pain, difficulty breathing, or a patient with ESRFbwith a rapid heart rate. I understand busy, trust me, but there is always a stable patient who can be shuffled.
    Maybe the 15 minute wait was due to shuffling.

    We have hall beds in our ER that get used when we are totally full (as was the case tonight). However, I'd rather have a pt hang out in triage/waiting room for 10 minutes while I move someone non-emergent from a room to a hall bed instead of putting an emergent pt in a hall bed immediately. My rationale is that it's much more unsafe to put an emergent pt in the hall where you don't have a monitor or supplies. I'll hold that pt for ten minutes while I shuffle a non-emergent out. Who knows, maybe that was the case. Like I said.. lots of variables we don't know.
    psu_213 and Daisy Doodle like this.

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  2. 2
    Quote from tami101481rn
    I have to disagree with all of you saying 15 minutes is not a long wait time. If EMS brought in a patient from a dialysis clinic with these symptoms, he would be high priority. Dialysis can cause to quick of a shift in electrolyte imbalances, namely K+. That would be the best explanation for rapid heart rate, the feeling in his throat etc. A shift in k+ leads to cardiac problems, MI etc. I have an issue with any high level acuity patient going to triage, whether it be chest pain, difficulty breathing, or a patient with ESRFbwith a rapid heart rate. I understand busy, trust me, but there is always a stable patient who can be shuffled.
    Really, I have to agree with this. This is a pt who may very well be a ticking time bomb. So then the ED becomes like the casino. ????If EDs would stopped being used like clinics or urgent care centers so much, people like the student's father would get seen right away. Dude you know if he had been considered a VIP, he'd been seen in a few minutes flat or less with such symptoms.
    Akewataru and sheilahdee like this.
  3. 3
    sorry for not responding back yet. been quite busy and i am actually about to head out for clinicals. First i wanna say that I really appreciate your responses. I am used to forums where people just beat each other up, are down right mean, and make you feel stupid for even posting. I appreciate the kind and informative responses you all gave me.

    It was indeed A-fib. When they finally got him back his HR was 179 and that's when things went into action. I was more dissapointed in the attitude the one nurse gave. the other nurse's eyes totally bugged out like whoa we should do something, and the other one was pretty rude. I do get it that sometimes you can have a bad day and maybe you came across wrong. So i didn't dwell too much on it. I jsut wanted to try to understand. You can actually see back into where they do your vitals and triage patients, and there was noone in there. my mother likes to talk to everyone and meet knew friends, even in the ER lol (i get on her case about it sometimes lol) and she said one person was in for their shoulder, another was throwing up, and one had a bloody nose. now for the Peds cases She doesn't know. and you all are right, I don't know what else was going on.

    Everything is okay now. They were FINALLY able to stabalize his HR with meds, no need for the shock. (he was worried about that lol). He is being observed in cardiac stepdown.

    Again, that you all for your responses!
    TJ'sMOM, NRSKarenRN, and Esme12 like this.
  4. 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 ~*Stargazer*~ like this.
  5. 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.
  6. 0
    OP, glad to hear your father had a good outcome.
  7. 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.
  8. 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.
  9. 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
  10. 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.
    ~*Stargazer*~ likes this.


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