New to ER - tips, tricks, recommendations & prioritization?

  1. 2
    So, after 6.5 yrs as RN/shift charge on a step down unit, I moved to the ED! Very excited to work with the excellent team!

    Though I know how to be a nurse, being an ER nurse is a whole new world to me... different processes, different resources, and different expectations. These things are stressing me a little bit... I hope that I eventually adjust to the process... like what is expected and when...

    Last night in the last 30 mins of my shift, I had a stable NSTEMI admitted (needed to transport her to floor), and back to back ambulances (relatively stable COPD resp distress/tachy & a pneumonia with god knows what drugs in her system).... I decided to try my hand and triaging the COPDer... I was halfway through getting my quick history and trying to enter it in T system when the pneumonia came in. I hadn't gotten labs or checked orders on COPD by the time the next pt was in her room, needing triage/assessment. Went to pneumonia patient's room, let my preceptor triage her as I collected blood/hooked her up to monitor, etc. Got that done and tried to call report on admitted pt so I could take her up since the next shift was already there and I didn't want to dump a transport on them... meanwhile COPD lady is climbing all over the stretcher bc she has to pee! (not to mention, I still haven't collected labs on her... by then I think I had forgotten!)... oncoming RN got her off the bedpan and I kind of mentally checked out... a little bit of shell shock? maybe. I had a sudden and overwhelming feeling of incompetence! I do realize some situations are just overwhelming, no matter how experienced you are...

    So I'm wondering... how do you guys prioritize these things? Triage has to go into the computer right away... but I'm inclined to line/lab/problem solve before getting to the computer. I get that this will come with time, especially as I get better at charting in Tsystem... but.... woah. I guess that's what orientation is for...

    How long did it take you to get used to the flow/process/your resources?
    Any words of wisdom? I know I am an ED nurse at heart and I look forward to getting the hang of it... I just hope it doesn't take me too long... :-P
    jrsRN07 and Joe V like this.

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  2. 21 Comments...

  3. 4
    If getting the patient seen by a provider is dependent on getting the triage done ... get the triage done.

    And relax -- you're in a whole new environment -- you're going to flounder a bit.
  4. 1
    I agree with Altra, relax. Our system sounds like its different from yours, but your floor experience will do wonders for your time management and prioritization. I find new grads have the stars in their eyes look alot of the time and take some coaxing to come out, but more experienced nurses usually start out running and continue to do so the whole time.

    I think i was there about 5 months (4 months were orientation) before I became more confident and realized that yes, I can do it. I have to give credit to my awesome coworkers, who jump in when needed or see me start to slow down when I dont mean to.
    acuariaRN likes this.
  5. 2
    Congrats on your new position. Hope you are liking it so far. You pretty much hit the nail on the head- it takes time.

    When I first started using T-system as an RN I found it a mess and blessing all at once. Now, I have come to love T-system because it is very well laid out. A recommendation I can make to assist you in faster triage is to type the medication names, dosing and frequency rather than clicking and clicking- such as, Metoprolol 25mg BID. I find this approach saves much time of looking up at the screen and down on the paper the information is written on. You can also expedite your entry by focusing on only entering what you need to. If you are concerned of getting the info in for the provider to see, if the provider even looks at your notes, enter only the C/C, pain, vitals, PMH and medications- that is all they really care about. Social history, assessment, and interventions can be added later if your busy with the late entry or manual clock entry feature. I use the following process when I'm getting my butt kicked- prepare the gown, turn on and ready the monitor, pull out all IV equipment and have pen and paper ready for EMS report. As report shouldn't take more than 2minutes at most, immediately use the following time to undress, place on monitor, dress and IV your patient. This can all be done in 10minutes with preparation for EKG. If your patient is a tough stick and can wait a few minutes, enter your info and come back for blood- literally

    Orders are a big deal because all ER stuff is *STAT*, but that does not mean each order carries the same level of urgency. You mentioned you had a NSTEMI, resp distress/COPD and pneumonia. Use your nursing judgement to pick your most urgent. I'm assuming the NSTEMI was "stabilized" since she/he could be transferred. The NSTEMI is of priority, but can wait if stable. The pneumonia person will probably get placed on the monitor, blood and cultures gathered, given antipyretics if applicable, and placed on abx, xrayed, CT'd, and admitted. O2, antipyretics and abx are the most beneficial thing for this patient. Get blood, give tylenol, and wait for abx to come up. This person can wait also. I would probably focused all my efforts on the respiratory distress person and worried about getting back to others when my resp distress was "stable."

    Hope that helps,
    Regards.
    cheethaj and acuariaRN like this.
  6. 2
    Just remember that you are only one person with only two hands, and you can only care for one pt. safely at a time.
    turnforthenurseRN and acuariaRN like this.
  7. 4
    Even experienced nurses take about 6 months to acclimate to the ED. This is a whole new ball game.......every aspect is different. Give yourself a break and realize it will only come with time. If the triage in the computer in dependent on the patient seeing the MD if they aren't blue, hemorrhaging or coding....get the information in the computer.

    Who is the sickest, who will be admitted and who may be transferred out/to the floor. If my stuff for the NSTEMI was done and they were pain free waiting transport...they are finished.........and the the COPDer was "stable" (decent 02 sat) I'd check on the new pneumonia triage, get it in the computer and go back to the COPDer line and lab then go back and line and lab the pneumonia. Then called report. As long as all vitals are stable.

    NOW, with 30 mins left to your shift? The NSTEMI was all set...waiting to go to the floor. The COPDer, I would triage and get the stuff in the computer....I would then triage the Pneumonia get it in the computer then go back to the COPDer line and lab abd then try to line and lab the pneumonia...or let the oncoming shift know they need to line and lab the pneumonia while I call report and get the NSTEMI out of the department.

    YOu'll be fine!!!! It will all come in time. The biggest hurtle you over came???

    Is that at the end of the shift you still felt the ED is where you need to be. Welcome!
  8. 0
    Thank you all SO much for the input!
    Looking forward to having a go at another 12 hr shift tomorrow...
    Bring it on! hahah! And I'll do my best to take it easy on myself.... :-P
  9. 1
    I love T-system. Welcome to the ER. Always remember to stop and take a breath. If you don't breathe, you'll drown. It's a stupid analogy, but it's true.

    As far as triage needing to be done right away... that's a big negative, in my opinion. Getting the patient stabilized is priority, not charting. That's not to say you should put off charting for hours, I'm just saying that when you get an EMS pt that is kind of a mess (especially when you're slammed in other rooms), that triage screen can wait until you've got your line, blood, etc. You are definitely right in wanting to get your basic stuff done to get things cooking before trying to chart.

    Being a charge nurse in step down for 6.5 years will definitely be valuable experience for the ER. Hope you enjoy it!
    acuariaRN likes this.
  10. 0
    I'm not familiar with the T system, does it mean pts aren't initially triaged while in triage??? I've just never worked anywhere that pts were triaged after being placed in a room, nor have I seen anyone that's being oriented to their first ER position be responsible for triage period. So I'm just wondering if this method works differently or if t system is another form of EMR?
  11. 1
    Christy,
    I think I would refer to Tsystem as a type of EMR program... it's where all the charting gets done in the ED. We have a rapid assessment unit in the ED where most of the triages take place prior to being sent back to the main ED --- however ambulances usually get placed in the rooms in the main ED and it is the responsibility of the primary RN (or the pod leader, if there is one) to complete the triage assessment in a timely manner.

    Yesterday I had a productive 12 hr shift, I got to manage several ambulances & post-rapid assessment pts back in the main ED (9 total)... I got to try to keep up the pace between assessing, treating & even managed to do a stable ambulance triage (took me forever haha... still clumsy with T system... gotta practice practice practice!)

    I've learned so much in the past two weeks... and so much more to learn! Despite the sometimes overwhelming simultaneous demands, I am truly enjoying myself thus far... So happy I made the change!
    silverbat likes this.


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