Would like a few answers from ER nurses - page 3
by missymiss 3,529 Views | 20 Comments
I just started in the ER about 3 months ago and I had a pretty smooth transition because I came from the floor and also worked in OR before. I liked the job at first, when you had a chest pain come in, you had help come to your... Read More
- 3Aug 1, '12 by Christy1019Quote from emtb2rnStaffing 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!
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.
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.