[Kinky Slinky RN]

Sorry if this is a repeat thread, I tried searching but couldn't find anything..

I was at work the other day and was being slammed with some sick pts...

I had a conscious sedation on a 13 yr old femur fx for traction/fx reduction... 13 yr old tib/fib fx, both of which needed to be transported to our childrens hospital next door...

80 yr old ETOH withdrawal going into DTs/electrical burn/shoulder dislocation/hyponatremia...

female s/p open hysterectomy that was febrile, tachy, needed CLC placement, NGT, foley and was on the way to MICU when they realized admit orders hadn't been fully completed so pt was reverted back onto my team..

another pt just dx with colon CA/SBO that needed NGT, foley, all kinds of things with life expectancy of 1 month and pt crying asking if shes going to die... also had to teach med student how to insert foley and NGT

not to mention all of the less acute pts i had... one gen. abd pain/nausea, one T12 fx pt that MAEW, i had more but they werent even near as sick...

So my question......

I OVERHEARD charge RN talking about a possible AAA from jail that was going to be mine... but charge was not directly talking to me... so when am I legally responsible for that possible AAA pt? I never received report, was never notified of pt arrival, etc...

Thankfully the pt was ruled out AAA immediately upon arrival so he wasn't even fully evaluated by MD until 5 hrs after arrival... but if something HAD gone wrong... would I have been legally responsible? Pt was on a bed that we did not have a nurse to staff so the bed became mine... Am I legally responsible simply because he was on MY bed even though I never received repor or notification of arrival?

Thanks for yalls help!!

[grandee3]

I sure hope that pt was not going to be yours, if I counted right, you already had 7 or 8pts. If CN did not tell you directly that the pt was going to be yours, I don't think you would have been responsible.

[alkaleidi]

Hmm. We have McKesson Tracking Board that, on the front page, shows all patients in the ED with their names/dx/age/sex, room #, MD assigned, and RN assigned. We are not always told that we have a new patient -- we are expected to be checking that regularly to see if we've been assigned a new pt. I don't necessarily agree with the whole not notifying you, but I can see how it gets busy and they just assign it if they know you are low on the totem pole or if you haven't had a new one in awhile. MOST of our leads have been good so far about telling me "hey you have a new one in room such-and-such," but there have been times that I've looked at the computer and found, "Oops, I have a new patient!" without being told. I would say that in my case, when my name is assigned to someone, I become responsible -- regardless of whether someone physically pulled me aside to tell me they're mine. This is definitely something I would clarify with your NM, though, because it could turn into a dangerous situation if you're tied up elsewhere and something critical arrives... yikes!

[cmo421]

Did u have all these pt's and less sick ones at the same time, or was this what u had through ur shift up untill the possible AAA came in? At 22 u must be a fairly new grad also,so the ER is very over whelming at times. But for anyone, all those pts at once is alot. Legalities can be a grey issue. In a court of law,unless obvious neglect,it would all come down to what a similar educated nurse would do in the same situation. Whoever is assigning beds in triage should know somewhat what the acuity is in that nurses assignmentand assign accordingly. Also, whoever is supervising the ER should have been called. Just because they are ur pt's does not mean u can not ask for help. That is what the charge person and ER management is for. When in doubt, always pass the puck up! If u do not say u need help,then the burden is yours.

[NREMT-P/RN]

OKAY.

You had your hands full.

Overhearing that you are getting a patient is generally NOT going to be enough to make you legally responsible.

BON's have often taken a position of shared responsibility. IF the Charge Nurse puts a CRITICAL patient in a room and you are not available or notified and this CN just leaves 'em there - I think that it will an IMPOSSIBLE situation for the the CN to be able to escape RESPONSIBILITY - now, will that mean that you are NOT responsible at all?

I think that there may be some internal guidelines (check your facility) - but, if the CN places a patient in a room and this patient is in NEED of CRITICAL INTERVENTION then expecting that this intervention will take place via MAGIC (meaning I'm tied up with another critical patient, off the unit with an ICU admit or committed to recovery of a conscious sedation AND I never actually get report AND get to the patients bedside) will not bring good things to ANYONE.

I had some issues with a CN that would document that I was given report at say 1515 - and I would NOT even be on the unit - I was away with a ICU admit. I returned at 1540 to find a CP in a room, clothed - no EKG, O2, IV, monitor - NADA. Well, my documentation reflected my arrival on unit - how I found patient and no report received from CN at the indicated time. Remainder of documentation of assessment and interventions that were done. Well, this pt had a big MI that was evolving with positive markers and in need of a cath lab. Hmmm...I will be accountable for what I am responsible for - but, I will NOT be placed in a position that can hurt me due to convenience.

Lesson learned.

Now, if this is a NORMAL patient load for you - I think you may have some serious problems. I see that you are 22 and I suspect that you may only have limited experience - the time to speak up is NOW. I know that it will be difficult. Please don't be offended - but, if this situation is NORMAL you are on a course that will eventually have consequences. BAD ONES.

When I CANNOT accept ANY patient for SAFETY reasons - I will refuse. The problem from the BON's will ONLY take place when you ACCEPT a patient. IF I have multiple other patients with life threats - I will NOT accept another patient - ANY PATIENT. I am ONE nurse (a good one most of the time - but still just ONE!) that can do ONE thing for ONE patient at ONE time. (That does not mean I have just one patient, but I know my limits!)

Now, will my "refusal" of a patient create a problem? Yep - probably. But, it will be an administration problem - not a problem where I am wanton or neglectful. It will not be a liability problem that I own. And I will not have the problem of facing a distraught family when something does not go right.

I encourage you to address this (in writing if necessary to protect you!) with ED admin and nursing admin. Wow, this is not a new issue - but, most facilities will push you as far as you let them - and if they are without staffing (as you note) on a regular basis then they are playing Russian Roulette with patients lives AND your license/livelihood. The one thing I know for certain about Russian Roulette is that there is a near CERTAIN fatal outcome if you play it long enough. For your sake - STOP now!

I think you MAY have some ammo with some internal policies regarding conscious sedation recovery (RN's have to generally be dedicated - not an additional patient load - due to risk of CS patient airway compromise) and critical patients/ICU admissions. Most facilities have written policies - and when they violate these - safety for patients IS compromised. You likely signed receipt and did competencies for these policies - so if you don't follow 'em - the facility could push it ALL back to you. Not a good situation. Think it over. Check it out. Protect yourself and your patients. Also, JCAHO can and does cite facilities that violate their own standards - anyone can report the "problems".

Good Luck.
Practice SAFE.

[Dolce]

Oh wow. Please tell me you weren't caring for all of those patients at once.... Yikes!

I thought standard patient load for ER was 4:1. I think if it were me I would be filling out the Safe Harbor forms every shift until I found a new job.

[loricatus]

A while back, when I was pretty much new to the pit I work at now, I posed a very similar question. Thought you might be interested in a link to the thread

http://allnurses.com/forums/f18/what...ty-242836.html

OHHHHH I can feel your pain {{{{{}}}}}. And, from experience, it will only get worse. Rather than go into identifiable details of what I am planning to do, I'll just say that you will have to consider leaving there before you or a patient gets hurt. This is just passing on some advise I received.

The best responses to my prior question might help you out. One was that whoever placed that person in the room would be responsible for them until you can get to them.
But, that will not help you if you get something like I did last week. I was paged overhead by the charge nurse, while I was attending to a critical patient. I came out of that patient's room to be told "Person just syncopized in the waiting room, take care of him...I don't know his name...think he c/o SOB" She pointed over to a man slumped in a wheelchair, left in the hall just outside of the room at the opposite end of the ER. Mind you, in the amount of time it took to go over and page me & then wait for me to come out of the room, this man could have been put in the bed and not dumped outside of it. Now, because of this tactic she used, I became responsible for the patient who happened to be an acute GI bleed, unstable (he coded) & needing 6 units PRBC just to keep him alive for surgery. Of course, my other 7 patients, including the other ICU admit, were neglected. I didn't get one bit of nursing related assistance, even after overhead paging for help. Residents and med students had to actually come to help. I charted something to the effect of: As per charge nurse instructions, pt left & found unconcious in wheelchair outside room @ 1300...attempted x 8 to page for assistance, MDs aware... The assistant manager later handed me back my notes and told me to revise them. Of course, I said no-so I found that the whole record disappeared upon transport to the OR. After that episode, another patient's visitor came over to me with a cup of coffee and tried to comfort me for what he (and my other patient's) had seen what I went through-----HOW SAD IS THAT.

So, I can only adivise you to make plans to leave that place because it will only get worse. They will find a way around things to make sure that the patient becomes your legal responsibility. Thank goodness I have malpractice insurance and patients who would be kind enough to come to my defense if I were to be accused of malpractice for a set-up event.

[USIJurgy]

Hmmmm, I think an interesting sidenote to this post would be: when are you no longer legally responsible for a pt?
I think we have all heard the horror stories of people coding in the waiting room with no one noticing.
But lets say I have a pt that is discharged- a CP pt with normal markers, d/cd to follow up with cardiac doctors within the next week for stress testing- so, I d/c the IV, wheel him out to the waiting room, where he is awaiting a ride. Is that it? Am I done? Or does my responsibility for that pt remain until he is out the front door and into a ride with his family? What if he asked to wait outside for his ride so I wheeled him out the front door to wait for his ride?
I love playing EMTALA games =)

[grandee3]

ok, I'm not an ER nurse but any nurse that tell another nurse to rewrite the notes needs to be reported to BON, YESTERDAY!http://allnurses.com/forums/f18/what...ty-242836.html

OHHHHH I can feel your pain {{{{{}}}}}. And, from experience, it will only get worse. Rather than go into identifiable details of what I am planning to do, I'll just say that you will have to consider leaving there before you or a patient gets hurt. This is just passing on some advise I received.

The best responses to my prior question might help you out. One was that whoever placed that person in the room would be responsible for them until you can get to them.
But, that will not help you if you get something like I did last week. I was paged overhead by the charge nurse, while I was attending to a critical patient. I came out of that patient's room to be told "Person just syncopized in the waiting room, take care of him...I don't know his name...think he c/o SOB" She pointed over to a man slumped in a wheelchair, left in the hall just outside of the room at the opposite end of the ER. Mind you, in the amount of time it took to go over and page me & then wait for me to come out of the room, this man could have been put in the bed and not dumped outside of it. Now, because of this tactic she used, I became responsible for the patient who happened to be an acute GI bleed, unstable (he coded) & needing 6 units PRBC just to keep him alive for surgery. Of course, my other 7 patients, including the other ICU admit, were neglected. I didn't get one bit of nursing related assistance, even after overhead paging for help. Residents and med students had to actually come to help. I charted something to the effect of: As per charge nurse instructions, pt left & found unconcious in wheelchair outside room @ 1300...attempted x 8 to page for assistance, MDs aware... The assistant manager later handed me back my notes and told me to revise them. Of course, I said no-so I found that the whole record disappeared upon transport to the OR. After that episode, another patient's visitor came over to me with a cup of coffee and tried to comfort me for what he (and my other patient's) had seen what I went through-----HOW SAD IS THAT.

So, I can only adivise you to make plans to leave that place because it will only get worse. They will find a way around things to make sure that the patient becomes your legal responsibility. Thank goodness I have malpractice insurance and patients who would be kind enough to come to my defense if I were to be accused of malpractice for a set-up event.[/quote]

[grandee3]

Sorry about above, tried to quote, just a little upset.