Would like a few answers from ER nurses

missymiss · Jul 15, 2012

It has always been our policy to announce over head chest pains and what room they are going to, if you are in a room with another patient and tied up for whatever reason, how will you know he is in there? I think since it is policy, it is not to much to ask especially considering its a level 1 heart attack facility and there is a time limit for EKG and labs (within 10 min of brining back to room).

missymiss · Jul 15, 2012

Well I guess this isnt the place for me, I cant (well I can) but I wont function, refuse to in an atmosphere like this. If there were enough staff, everyone could have a break. Why should I kill myself for a corporation that dosent give a crap for their employees? It is the law that one gets 30 min. break for a 12 hr shift, (I have learned not to even expect the 10-15 min breaks that ) I have been a nurse alomst 13 yrs and enjoy my patients but am getting so tired of being used and abused by companies who have come to treat nurses as pack mules and want to pay them as little as possible and do as much work as possible. It is not healthy to just cram food in my mouth and all this crap that goes along with working in this department. I can handle stress with the best of them, worked in OR, a jail and med/surg before, what I wont tolerate anymore is being disrespected and plain shown that as an employee no one cares about you and you are seen as nothing more than a plow horse, we are not allowed to have drinks on the floor and they have a hard time keeping help because no one will stay, and neither will I. Do you all have those hospital scores you get a bonus on? The different floors have scores based on patient surveys? Scores range from 1-100, lets just say this, our latest was under 25, LOL

missymiss · Jul 15, 2012

That is a really good idea. It is policy for all CP's to be on monitor, in room EKG, within 10 mins, taken straight back not even triaged labs and protocol, if you have an idiot doing triage who dosent get to the bottom of it and make sure it is really CP and not something else, you do all that for nothing. 90% of what comes through as CP is not cardiac I have found, so we do all this S*** for nothing.

missymiss · Jul 15, 2012

I had ACLS, dosent matter though, I dont care if you can read an EKG in braile, in our dept, it must be taken to any ER doc and signed by him, protocol is automatic, your gonna do labs and ekg anyway, and asa and nitro if you feel its indicated.

missymiss · Jul 15, 2012

I totally agree! with Hagalbel... I am going to paste my answer to a post on next page

, here it is. Well I guess this isnt the place for me, I cant (well I can) but I wont function, refuse to in an atmosphere like this. If there were enough staff, everyone could have a break. Why should I kill myself for a corporation that dosent give a crap for their employees? It is the law that one gets 30 min. break for a 12 hr shift, (I have learned not to even expect the 10-15 min breaks that ) I have been a nurse alomst 13 yrs and enjoy my patients but am getting so tired of being used and abused by companies who have come to treat nurses as pack mules and want to pay them as little as possible and do as much work as possible. It is not healthy to just cram food in my mouth and all this crap that goes along with working in this department. I can handle stress with the best of them, worked in OR, a jail and med/surg before, what I wont tolerate anymore is being disrespected and plain shown that as an employee no one cares about you and you are seen as nothing more than a plow horse, we are not allowed to have drinks on the floor and they have a hard time keeping help because no one will stay, and neither will I. Do you all have those hospital scores you get a bonus on? The different floors have scores based on patient surveys? Scores range from 1-100, lets just say this, our latest was under 25, LOL. I guess what I want to say in a nutshell is I value myself as a person, feel I have alot of offer an employer, my patients like me and voice that (because I am good to them and provide them good care and a listening ear as time allows) and if I cant find a dept. or employer who sees the value in that instead of just wanting new grads cause they are cheap, or nurses who are just there for a pay check, then I will find one who will. I cant go at break neck speed for 12 hrs straight and not do my job and the techs to and never even be asked if I need any help by a charge nurse who knows when her nurses are drowning and wont even offer any help.

Hagabel · Jul 16, 2012

Sorry you are feeling like this. Look at another field within nursing maybe...try PACU or even a clinic/outpts for a total change. I did 13 yrs of ICU and got fed up/bored so that is when I moved to ED.

Good luck.

ecerrn · Jul 16, 2012

Ha! I now know exactly where you work, because I used to work there too! I hear the frustration in your post, and you are doing the right thing, just be careful because it's the only corp to work for in that area ( am I guessing correctly?) And you don't want to burn bridges before you get a new position. The person who asks you how you are doing can be your ally, go to her office and talk some, maybe she can help you transition to a different dept. I wondered how badly the PG scores were, they were dropping into the 70 before I left...wow. too bad...not every er is as bad as that though, so don't give up on er forever....but just know, it's never a controlled environment. I am thankful for the many years experience I got before the change in management, now I am contemplating applying at a smaller better run place. Good luck. You can pm me if you want to. :-)

emtb2rn, BSN, RN, EMT-B · Jul 16, 2012

Staffing is key. You need a float to cover meal breaks. I don't care about the 15 minute breaks as we can eat/drink at the desk, unless jcaho or doh is around. But I do want that 30 minutes of chill time.

EKG's really should be done at triage. I've called codes before they've even printed if the elevations are that obvious. We don't overhead chest pains unless it's a code cause then the door to balloon clock is ticking.

As noted above, it depends on who your co-workers are with respect to how much help you get. And as you gain experience, you'll need less help. But never be afraid to ask. Drowning sucks.

Hang in there.

Christy1019, ASN, RN · Aug 1, 2012

Staffing is key. You need a float to cover meal breaks. I don't care about the 15 minute breaks as we can eat/drink at the desk, unless jcaho or doh is around. But I do want that 30 minutes of chill time.
EKG's really should be done at triage. I've called codes before they've even printed if the elevations are that obvious. We don't overhead chest pains unless it's a code cause then the door to balloon clock is ticking.
As noted above, it depends on who your co-workers are with respect to how much help you get. And as you gain experience, you'll need less help. But never be afraid to ask. Drowning sucks.
Hang in there.

I totally agree with emtb that ekgs need to be done in triage and am quite surprised that noone else has said this sooner. I've been an ER nurse for 4 1/2 yrs in a large, inner city, level 1 trauma center with an avg of 75-120 patients in the ER at any time, and a ridiculously small triage area in comparison to the rest of the dept. We have always had very specific guidelines for how pts are triaged and specific protocols for pts with c/o CP, resp distress, acute CVA etc. The guidelines require that an ekg must immediately be done on any pt over 50y/o with c/o chest pain, nausea and/or vomiting, SOB, syncopal episode, epigastric pain, missed dialysis, and I wanna say dizziness but I'm not positive. They also recommend routinely doing ekgs on pts over 35y/o with c/o non-traumatic chest pain, as we'll as any patient that just "doesn't look right" I.e. diaphoretic, pale etc. The protocol is for the ekgs to be done before anything else and shown to attending physician along w/a copy of an old ekg retrieval if available. If acute STEMI or new LBBB is found, pt is taken to the medical resus room and prepped to go to cath lab. The goal for door to ekg is 10min, so I can't understand why your facilities are sending them to rooms w/out ruling out any acute cardiac issue.

Now before everyone starts telling me how impractical it is to do that many ekgs in triage, I can assure you that for the most part we firmly adhere to our protocol, however if you have a 51y/o pt with c/o upper resp infection type symptoms who states CP is assoc. With yellow sputum productive coughing and feels like his chest is burning, and no know past med hx... no, I'm prob not gonna rush and ekg him b/c my assessment tells me this is a resp infxn/possible pneumonia.

Also, for those who said that ALL chest pain pts must be placed on cardiac monitors and paged overhead so the nurse can hurry in to see them... do you seriously do that for ALL CP pts? Even if they have no cardiac hx, pain is reproduceable, and can be attributed to a non-cardiac cause? Also, in regards to the post about the nurse having to work them up immediately, I don't get the reasoning.. yes, you always want to know about any pts who may be high risk and at least eyeball them if you are busy w/another patient, but if the ekg in triage ruled out a STEMI or new LBBB, and they are stable, there is no need to drop what your doing to get stat labs b/c even if they DO have an elevated trop, you are usually just gonna start heparin drip, monitor ecg and wait for tele admission.

I know that my ER is set up a lil different than most but ill explain how we do things, just to show a different perspective. As I said, its a very large ED/trauma center with approx 110 treatment areas, that is divided into categories based on acuity, as well as triage, 2 resuscitation rooms (medical & trauma), a pediatric area that adjoins cat 3 aka fast track/urgent care type patients. There is also a 6 bed mental health tx area, & a Cdu for 24hr observation. Cat 2 is for acute care pts w/abd pain, stable respiratory complaints etc & is generally the busiest area of the dept. Finally, Category one (cat 1) is a 20 bed area designated for critical, and unstable pts, as well as pts coming from the resus rooms after being stabilized, and chest painers who need cardiac monitoring as this is the only area of the ED with cardiac monitors. It is essentially a mini ICU b/c we frequently have to manage critical pts in the ER for hours until an icu bed opens, leaving us to titrate drips, manage vents & trying to stabilize septic pts etc, plus deal w/acute situations I.e. multiple trauma pts with GSWs just drove up, or cardiac arrests for example. Now if we put every patient who has CP in cat 1 to be monitored, there would be no room for the other critical patients and would a misuse of resources.

So here's some examples of our process which runs fairly smooth b/c we are all on the same page.. (sorry but the whole running around to find a nurse to assess what should've been done in triage, would drive me crazy lol)..

Okay, pt presents to prelim/registration desk (they recently decided that nurses should register walk-I n Pts too, despite registration staff sitting next to us doing ambulance pts, dumb! :confused:

So pt presents c/o midsternal cp radiating to left jaw and shoulder, described as heaviness, with some SOB that started while shoveling snow, & has hx of stents, 2 MIs in past and is noncompliant w/meds. Pt appears pale, slightly diaphoretic, and just "doesn't look right"... so I bring pt back immediately, tell triage Rn he needs ekg, if one isn't avilable I do the ekg myself, even if its with the patient in a chair b/c there's no stretchers. Ekg shows obvious STEMI in multiple leads, pt says last MI was 5yrs ago so I know its not causing these acute changes. We page for resus team (consists of 2 assigned RNs and all cat 1 residents and staff doc) to room 2, er doc faxes ekg to cardiology who confirms pt needs to go to cath lab. While we wat for them to be set up we start 1 to 2 ivs, give ASA, 5,000u Heparin sq, metoprolol, & I wanna say plavix but my brain isn't working lol. Pt is then taken to cath lab by Rn and cardiologist, all within 35minutes, well uner our goal of 60min door to balloon time.

Now if this patient used the system you all have described, as I understand it.. that same patient would have been triaged, then placed in a room, then the nurse had to be found or paged to say pt has CP, and then you'd hope she doesn't assume its yet another non-cardiac chest painer or take her time to eval the patient... which by now 20min may have gone by and that's more loss of heart muscle.

Now if that same pt presented w/same complaints but ekg showed no stemi/Lbbb, but did have slight ekg changes, he would definately go to cat 1 and be on cardiac monitor with full workup.

Next pt is 37y/o, c/o pain to upper chest b/l that radiates toward axilla, reproduceable by lifting arms, and began after heavy lifting. Pt denies n/v/diaphoresis but admits to some SOB that occurred during the heavy lifting. PMH - asthma, moderately obese, borderline HTN & heart murmur, admits to smoking 1ppd & marijuana, denies etoh or drug use. Pt does not appear to be in any acute distress, resps even/non labored with mild expiratory wheeze b/l, VS all WNL, pt given albuterol/atrovent neb for wheezing, states SOB is relieved.

For this particular patient I probably wouldn't do an ekg in triage unless it was really slow b/c all of my clinical experience is telling me that this pts pain is intercostal pain r/t heavy lifting & being out of shape. The wheezes, and asthma/smoking hx explain the SOB, and overall the pt looks good. Also, I would NOT put this pt on a cardiac monitor or page the nurse thing that others described... I would make him ESI 4 and send him to the fast track area. :nurse:

Also, in response to the page overhead for CP pt, that would be going off every 10min in my dept lol. If a nurse receives a pt to cat 1, regardless of the complaint, the triage nurse who brought them there gives a report to the assigned nurse but for other areas in the dept the nurse learns of her new pt by either physically seeing them, or in our EMR when the pt becomes assigned to her. And of course if there is something concerning about the pt the triage nurse or tech will usually talk to the assigned nurse, or it will bedocumented in the EMR's triage note for the nurse to read.