What do you do first, besides "ABC"?

[BSNbeauty]

My biggest challenge in the ED is prioritizing. I always use the ABC as a rule of thumb, however I still feel overwhelmed with the other tasks such as discharging, admitting, and receiving patients.

For an example: When I have a patient to discharge and a new patient to see which one comes first?

Should I finish my discharge,then see the new stable patient? Or should I assess the new patient then discharge?

I guess it'll take time.... sigh.

[whichone'spink, BSN, RN]

Thanks. I'm an over achiever. Sometimes I hate asking for someone to help but I know I have to. Thanks for the advice.

I'm a new grad too, and this is also something I struggle with. One night, for some reason, I had 3 patients and my pod buddies had only one each. I was running around and they could see that, yet I guess because of tunnel vision I didn't ask for help. My pod buddies had to prod me to ask for help. As for d/c vs new patient, if you're buddies aren't busy, I'd personally delegate the d/c, and see the new patient myself. I haven't developed the nurse spidey sense to know from eye balling a patient who can wait a few minutes and who needs attention now.

[sunflrz321]

I agree, always at least put eyes on the new patient first, just to CYA. After all, how do you know the patient is stable if you haven't even looked at him or her? The triage vitals and assessment that may have been taken two (or more) hours ago don't telling you how the patient is doing now. You don't have to do a full assessment at that time. Just go in, do a very quick set of vitals, put them on monitors if need be, look for any apparent distress (pallor, diaphoresis, altered mental status, alertness and posture, clear speech, guarding/ grimacing in pain, tachypnea, dyspnea, or retractions etc- all of these are pretty easily apparent in a 2 min conversation w/ the patient without a more thorough assessment, and they are much of what constitute the experienced nurse's "spidey sense") and quickly check the cap refill to confirm good perfusion or catch sepsis early. Introduce yourself and let them know what to expect (that you & the doc will both do assessments and histories, etc), tell them not to eat anything until doc gives the okay, etc. All told this should take 2-3 minutes, 5 minutes max. Don't ask too many questions here, they will suck up your time. Then go do your discharge, and come back to this patient for the full assessment and interventions when the discharge is done.

I agree with the poster above that if you discharge first, you will immediately get another patient in that place that might be less stable and might keep you from the first admit. Also, if something should start to happen to the first admit (e.g. desat, HR goes tachy, etc), if they are at least on monitors then it will be apparent to everyone at the nurses' station, even if you aren't there to catch it.

I think your instinct to do at least some assessment/eyeballing of the patient is spot on, so don't be afraid to follow those instincts. When making decisions like this in the future, you can always weigh the risks and benefits of each scenario. The risks of seeing the discharge first without even putting eyes on the admit are that the new patient could deteriorate and you wouldn't know it and that you could also get two back-to-back new patients at almost the same time, which can be tricky. The benefit is that you can "move the meat" faster. These decisions are all about weighing risks and benefits of multiple situations, and deciding which risks you feel comfortable with and which you are not. You will be making risk-benefit decisions like these throughout your entire nursing career.

[Larry77, RN]

Some of the comments here kind of make the hair on the back of my neck stand up. You would delay discharge to avoid getting a new patient? Ugh... You would like to wait to see your patient after the doc eval's them? Ugh

Not good ED practice in my opinion.

2 things should drive your decision...stability of the patient and if they have been seen by an RN already (i.e. in triage). To delegate the DC is a great idea but to delay it is not. To be interrupted by the MD does slow you down but I have frequently taken notes or charted while the doc was interviewing a patient.

The unstable patient that might have to go in your room after you DC has to go somewhere...is your mindset to hope they go somewhere else? ick, the patient needs treatment and a good charge nurse would have them treated before you were done with your DC....

I'm not trying to pick a fight but I do disagree and want to make sure newbies don't think this is good practice for all.

[Altra, BSN, RN]

Agree with Larry77's post above ... and make sure to utilize your resources such as your department's tracking board ... before rushing in to assess a dental pain because, OMG I have a new patient.

[BSNbeauty, BSN, RN]

Thanks SunFLRZ, larry, and Altra... you all gave great valid points.

[JessiekRN]

Larry.. With all due respect here I wasn't talking about "delaying discharge".. In the sense that I don't let discharged patients sit around for hours so my rooms don't get filled. Rather, if we are talking pure and simple prioritization, the discharged, stable patient can wait five minutes while the new, possibly unstable patient is seen. It's not "delaying discharge". It's safer for the new patient, and it's good time management. Sorry but your post rubbed me wrong a little bit.

[JessiekRN]

Also I don't think the above poster was talking about hanging out doing nothing till the dr sees the patient to save herself some work. What I think you missed was that she said sometimes you simply can't be faster than the dr, and if the patient is being seen, and in good hands, then the RN can be assured she has a few extra minutes while a practitioner assesses the patient. Not sure what kind of ideal ED you work in, but mine is less than perfect most of the time. And you do the best you can. The OP asked for advice and different perspectives were given. I don't appreciate the comment "ugh" in regards to what was well intentioned advice. Also not sure if you realize your post is somewhat contradictory. You wouldn't "delay discharge" by seeing a brand new patient. But you also wouldn't let a dr get in your room before you. So while you're busy not delaying discharge, how do you prevent the dr from getting in the new room ahead of you? Not sure I understand the logic. We all have our own ways of doing things. But I found your post a bit disrespectful.

[sunflrz321]

Yes, I want to clarify as well. I wasn't suggesting you should intentionally delay discharges to avoid getting new patients. That would not be ethical. Like Jessie, I was just talking about prioritization- addressing a potentially higher acuity situation very briefly before the lower acuity situation of a discharge. I did say that eyeballing the patient and taking a quick set of vitals should take 2-3 minutes, 5 minutes max. 5 minutes to ensure a patient's general safety and cover one's own tail as a nurse is not going to delay anyone's discharge, or create any problems in "moving the meat."

[Larry77, RN]

So you guys are answering specifically to a situation without specifics. Is the new patient unstable? We don't know. Has the new patient been seen by an RN? We don't know. Is the discharge ready to go (ie dressed)? We don't know. Is the department slammed and the CN desperate for rooms? We don't know. Is there a pod buddy that could discharge your patient real quick? We don't know.

My concern and the reason for the "ugh" was what sounded like bad practice to me and you are defending it using specifics we don't know. Should you always wait for the MD to see the patient...you agree no right? Should you always wait to discharge so not to receive a new patient...you agree no right? That was my point, not that in this specific example without the needed details is it the right thing to do...we don't know.

I hope this makes a little more sense and in no way was I trying to offend anyone...

[JessiekRN]

Okay- I agree with you completely. You're right in the sense that prioritization is not clear cut and entirely dependent on the situation. But I think the OP is aware of that. Patient in respiratory distress, or discharge? It's clear cut. I think OP was asking for help in the situations that are not so black and white. And so maybe I should have been clearer. It's the "in between" patients where I think new ER RNs can get lost. And so- when in a situation where you're facing the known (discharged patient) vs the unknown (patient either triaged or not- but you yourself have not seen)- I always go with seeing the unknown first. Triage helps, sure. But not every nurse does a great job at triaging. Vitals only tell you so much. The triage could be three hours old. Abdominal pain could be a ruptured app or a bellyache. You see where I'm going. In a case where you simply don't know what you're going to walk into- that comes first. I think when I started in the ED I had a tendency to take things for granted. Triage note looks good- patient can wait. But I've learned the hard way that things in the ED are not always what they seem. And that things can change on you in a millisecond. So Larry I apologize and we can agree that learning ER judgement is something that comes with time and experience. Until then, the OP needs to err on the side of caution. Which means discharging your patient, while maybe the charge nurses first priority, is not and should not be the primary nurses priority. Obv there are exceptions. Asthma attack and not a single room in the ED? Get em out. But I think u get my point.

[Altra, BSN, RN]

Again agree with Larry77 ... this "new patient" scenario/fear is too vague for meaningful discussion and meaningful guidance for the OP. If this new patient has come through triage -- unless your ED is horribly dysfunctional and unsafe, you will be given a heads up if the patient is presenting with something potentially unstable or has an immediate need. Otherwise, they can likely wait.

On the other hand, is the new patient arriving via EMS and EMS is standing there waiting so that they can give you report and hand off the patient? It is a priority to get report from them and get them back out into service.

The OP needs specific guidance on how to refine her thought processes.

[dollparts13]

so I've been a nurse for a year and a half.. first year spent at a small hospital, and I've been at a huge level 1 trauma center for 6 months now. I still feel like a new grad most of the time. .. One good approach that I think works well is when a patient gets put in your room, if you have something else you have to do, go introduce yourself, give them a hospital gown and tell them to change. This give you a chance to do a quick "across the room" assessment and to figure out why they are there. then tell them you'll be back in.

Moving the meat is right, as terrible as it sounds. in one way, because most EDs track how long it takes you to d/c your patients, and secondly, where I work, the charge nurses put your next patient outside your room within 10 minutes of your patient being up for discharge. There isn't time to dilly-dally around.

I still try to pay attention to get tips on prioritization and just keeping up wtih a massive, fast load, but I figure being with my sickest patient that needs me the most can't fail me.