Time Management in ER

[MAL, RN]

Hi All,

Im on of those "Forbidden" new-grad's in the ER. I wasn't given very good training, but nonetheless learned alot during my weeks of orientation.

My concern is adjusting to the fast-pace in the ER. Im on my first few days by myself, and the challenge of learning to handle 5 patient rooms of documentation/orders/etc is overwhelming. I work with a great team, but they are all so busy too that its hard to ask them for help!

I'm just not sure if its because Im a new graduate or just new to the ER.

Any insight on this? Tips/suggestions on how to keep my head above water these first few weeks of orientation?? How long until you ER nurses became comfortable with your workload??

I just dont want to get fired because I am drowning in my workload from poor time management!!

Thanks Evereyone!

[Anna Flaxis, BSN, RN]

I've been watching my fellow nurses in the ED, and I think the ones with ADD (it's only my opinion that they must have ADD, based upon their observable behaviors) are some of the most successful. They are the ones who are able to quickly shift their focus as priorities change. I'm sort of the opposite, and it's the area with which I struggle the most. I tend to zone in on details, and don't feel ready to move on until I have all my ducks in a row. I want to be meticulous in whatever task I'm doing and make sure all of my Ts are crossed and all of my Is dotted before I can move on to the next thing. Interruption is constant in the ED, with all the phone calls, new orders, changing priorites, etc., and interruption is something I struggle with. The nurses that really seem to thrive in the ED are the ones who move easily from one thing to the next and don't get drawn in to making sure everything is perfect before moving on to the next thing.

From the way I describe myself, I think I'd be an excellent ICU nurse, but what I really like about the ED is the detective work aspect, and I think I'd miss that too much in ICU. In the ED, whenever that patient walks or is brought through the door, you're taking their chief complaint, presenting s/s, your own assessment, and rolling it all into a clinical picture. There is no diagnosis yet. All of your efforts are aimed at finding the diagnosis. Admits to the ICU come with a diagnosis, and your interventions are aimed at addressing that diagnosis. While I think I'd be great at managing complex medical situations because of my ability to be meticulous, I think I'd really miss the detective work aspect of the ED.

Anyway, I don't mean to hijack, but the topic of nurses with a certain amount of ADD has come up in my ED, and as I said, I think they are the most successful in that specialty, due to the nature of the beast.

[Rob72, ASN, RN]

True "ADD/ADHDs" don't do well, and I've worked with a few. Invariably, they loose the trees for the forrest.

Developing a high level of compartmentalization helps- being able to quickly find a stopping place in the immediate task, switching tasks, and coming back to what you left. This is where the Strong Personality comes in- sometimes you have to tell others, firmly, "Not now...I'll be with you in a moment."

Clustering is another biggie. As soon as you open a med/device/etc., throw the wrapper away immediately. Trash is in the trash before you do anything else. Push a med- while waiting 2-5 minutes in the room to observe your pt., do your charting.

Most of this falls under developing a practice framework, or an abbreviated decisional tree (heuristic). Once you find an operational model that you are able to consistently follow, you are more capable of "switching gears" because your interventional processes are more efficient.

As a tech, you'll learn that individual nurses have different heuristics, and learning these will allow you to anticipate their needs- it becomes an X=Y formula. E.g., Nurse Kathy + Chest pain= EKG, IV, Labs in that order. Once your interventions are done, you know that labs need to be tubed/called/whatever, so you step away from the immediate process, and on your return, you re-evaluate what is going on in the room, and what your next pathway will be.

[TinyRNgrl]

I to was a new grad in the ER. Although I had EMS experience and a year as a extern in an ER/level 1 trauma, it is a whole new ball game with RN after your name.

AT LEAST 6-12 months until we feel comfortable is what everyone told me. I am not going to repeat the obvious ABC's but I always try and stay one step ahead of the game. In the ER where I work we have protocols that gives the RN a lot of autonomy as well as 98% of our docs have a lot of trust in us and good working relationship which is awesome. So, before the doc even gets in to see the pt I go in and do my nsg assessment and while I am doing that I am starting an iv and drawing labs so it is done (only for pt's who I know are going to need it, abd pain, cp, n/v/d, etc). Time doesn't always allow it, but I do always try and stay ahead of the game if possible.

But as we all know in an instant, all ---- can break loose and these are the times we all get overwhelmed. Sometimes you just have to take a second and just BREATH. In your head, do a quick run through and see what needs done now, what can wait and what to delegate. If your feeling overwhelmed chances are, others are too. And it is OK to say to the charge nurse, Hey, I'm overwhelmed. Don't ever hesitate to ask for help. Heck one day it was a full ring circus and I needed someone to help hold a kid while I put in an IV. Nobody was around at that moment so the Dr. came in to hold for me. (rare, I know) but like I said, we have an awesome crew.

And just some things I personally do too, just because it is who I am. I can never sit around yapping when another nurse is running around with multiple things to do. When I am caught up and have the extra time I always ask others if they need help. I try and always vital my own pt's and try to delegate as little as possible if I can. Techs are overworked and underpaid and I try and help them out too if I can. I see us as a team, and the more we work together, the better life is. :) Unfortunatly, there are those people who sit around talking when things can be done. And that drives me NUTS! When I do delegate something I always thank the tech. But I find out when you help out the tech's or other nurse's they are always there when you feel like your drowning or they always offer help back.

OK, I am rambling. I am sure your a wonderful nurse. And each day you will feel a little bit more comfortable. Always ask questions if your not sure, ask for help when you need it, thank the techs when they help ya out, don't take anything personal from a hostile pt or family member, remember your ABC's, take your pee breaks and love being an ER nurse because it takes a special person to do what we do everyday.

[MAL, RN]

I've been watching my fellow nurses in the ED, and I think the ones with ADD (it's only my opinion that they must have ADD, based upon their observable behaviors)... due to the nature of the beast.

I agree with you!! Its hard to stop what Im doing to take orders, and I have a tendency to want to finish something if it only takes a few minutes, even if there is something higher on my priority list..Its definetly something to get use too..

[Roy Fokker, BSN, RN]

Here's my take on the issue (keep in mind I'm still new in the ED). I work a Level II 50 bed (including hallways) ED averaging 200 - 250 pts. a day.

- Always document as soon as possible. It's one thing I have difficulty with sometimes but as my preceptor kept drilling into my head during orientation: you never know what's coming down the pipeline and before you know it, in the blink of an eye and you're at least 2 hours behind on documentation!

- Prioritize, prioritize and re-prioritize. And this rule applies every minute of your shift. Sure an ambulance may come in bringing in a new asthmatic patient ... but don't forget about that borderline chest pain you've been working up who starts to show changes in the ST on the monitor (who is the priority now?)

- Learning to delegate is crucial. In my ED techs do transport (to x-ray/CT/Ultrasound/to floor) as well as certain tasks (blood draws-not IVs/EKGs/fingersticks). So if you have two tasks: Transport "A" to CT for abdomen/pelvis and get EKG on "B" for chest pain - what should be the course of action?

- Somethings can absolutely wait: and sucks as it does sometimes, comfort measures fall into this category. Despite all the glares and "my husband is a diabetic and hasn't eaten all day" etc. - nobody is going to crunk and code because they waited an extra half hour for a meal tray or a blanket. Urgent needs come first.

- I've gotten into the habit of hooking practically ALL my patients onto the monitor (unless they are an ESI 4/ESI 5 or I'm working track). That way I can set up the monitor to automatically take vitals (say every 30 minutes) - not only do I have a ready trend of vitals on my patients, the monitor can also catch a patient heading south sooner.

- DO NOT feel shy/embarassed about asking fellow nurses and/or charge nurse for help. If you feel like you're drowning, there is no shame in asking for help. Patient safety first.

This kinda applies to the doctors too (depends on who you work with) - I work with a bunch of awesome docs for the most part and if they see that the nursing staff is getting murdered - they'll take verbal orders from admitting docs, or they'll start IVs/foleys... heck, I've had docs wheel patients down to X-ray, take 'em to the bathroom or get 'em a sandwich! If you're super busy and can't find a nurse to take the telephone admit orders, ask the doc if they can spare two minutes and take 'em.

cheers,

[360jRN]

Prioritization is key. You can have all the time management skills in the world but if youre accomplishing all your tasks in the wrong order then you're urinating into the wind. Sometimes it's easy to get lost in the moment where all you hear is a constant roar and youre walking around not knowing where youre going or what youre trying to do. In those instances stop, take a deep breath, and reset. Prioritize...Re-Organize...Act! If you need help dont be afraid to ask the worst thing someone can say is No, I cant help you right now.

You're going to have patients get mad at you and cuss you and tap their feet wondering what's taking so long and complain about this and about that. Just remember the guy with the sprained ankle and entourage of visitors doesnt have to have you in the room every five minutes. That will only lead to you receiving verbal abuse or saying something you dont need to say.

Prioritize...Practice safely...Soak up as much information and teaching from your senior nurses....And find a cold adult beverage that you like! LOL!

[Cath90]

I'm in my 8th week and have found the same thing. Days where you feel ran off your feet but look back at what you've done and feel you have not gotten anywhere.

I think its just part part of the new environment.

Ive been told not to focus on this and accept that I won't get everything done. I have also been told to focus on ABCD and my secondary survey. They said nursing assessments are really important so we can detect deterioration.

My ANUM also said it's ok to ask the doctor to take some blood ect when you literally cannot get to the pt, or another nurse of course.

I found everybody in the team are generally happy to do this as it speeds the time in ED and aids in getting to a diagnosis.

i suppose we just do what we can do, focus on the task at hand and prioritise once we finish that task.

[Susie2310]

- Somethings can absolutely wait: and sucks as it does sometimes, comfort measures fall into this category. Despite all the glares and "my husband is a diabetic and hasn't eaten all day" etc. - nobody is going to crunk and code because they waited an extra half hour for a meal tray or a blanket. Urgent needs come first.

You are absolutely incorrect that providing a snack /oral carbohydrates to a diabetic patient who is hypoglycemic, or any patient who suffers from hypoglycemia, is not an urgent concern and is a comfort measure that can wait. I suggest that you review hypoglycemia; symptoms of mild to severe hypoglycemia along with what the outcomes can be if the patient doesn't receive glucose quickly. I'm sure you know that hypoglycemia can be deadly, and that patients can deteriorate quickly. Not having eaten all day can cause big problems, and now you know why the patient's wife was glaring at you.

Yes, with severe hypoglycemia they definitely could crunk and code - have a serious arrhythmia that leads to cardiac arrest, or suffer permanent neurological impairment from lack of glucose to their brain. Keep in mind that patients often have multiple co-morbidities, and multiple body systems can be affected. Why would you dismiss someone who said that their family member was diabetic and hadn't eaten all day? I have to add that more than one nurse actually did wrongly dismiss my concern about my family member being hypoglycemic and needing to eat when they were an inpatient.