Amber Does the Unthinkable

[Nurse Beth]

Read about Amber's day and see if you agree with what she did.

ED Holding

ED Holding was created as a holding area for patients who have admission orders and are waiting for a bed to open up. They are moved out of ED Main to help with patient throughput. While in ED Holding, which is a kind of limbo, patients receive all their meds, admission assessments, etc. It's like being a patient on the floor but in a temporary location.

The problem is that while it does help alleviate the congestion in ED Main, it also delays the bottleneck. Just as ED Main patients are waiting for a bed in ED Holding, ED Holding patients are waiting for a bed upstairs.

ED Holding has 14 beds with curtains in between the tiny spaces, and one bathroom down the hall. Everything is in close proximity, and feels crowded and miniature, like in a small airplane.

Some days in ED Holding are manageable, even routine. Some days are chaotic and crazy.

A Crazy Day

This particular day, all 14 beds were full. The secretary had called off sick, and there were 3 nurses to run the unit- Amber, Sarah, and Tiffany. Amber was charge, Sarah was experienced, and Tiffany was a new grad just off orientation.

It was 1100 but 0900 meds were not yet passed because Pharmacy missed stocking the Pyxis every time Steve was off. The other pharmacists had not yet hard-wired the fact that ED Holding should be on their radar, because it wasn't open every day.

An elderly woman in Bed 2, kept screaming "Someone help me! HELP ME!! I'm being tortured!" The intermittent screaming punctuated by periods of silence set everyone's teeth on edge. Staff alternated between trying to placate her and trying to ignore her.

A feverish, fretful baby wailed and sniffled loudly but wasn't allowed to nurse because he was NPO. His mother looked on the verge of crying herself.

Next to the baby on the other side of the curtain was a man with a moist, gurgling cough the sound of which brought visions of copious, thick sputum being expectorated into a cup.

Amber's phone in her pocket rang.

"This is Tara in ED Main, we have a patient for you."

"We're full, I have 14 patients already. I have 2 nurses and no secretary today."

"Well, we can't close our doors, you know. You'll have to put them in the hall. We do it all the time."

"OK, give me report"

"It's a COPD, I don't know much, I'm covering for Don who's taking a patient to Cath Lab."

"Who's the doctor?"

"Uh...not sure. You can look it up, alrite. We're slammed."

Within two minutes the patient was being pushed on a guerney to a spot by the nurses station in the hall. He was accompanied by three weary looking family members clutching his belongings. The group took up the narrow hallway and kept dancing around and bumping into each other to try and stay out of everyone's way.

Amber's phone rang again. This time it was the Supervisor.

"Amber, we have a bed on 3W for your patient in Bed 4 so I OKed you getting another patient from ED Main, it's a pleural effusion and you'll need to get ready to put in a chest tube. Tara will call you in a minute, thanks, bye"

Amber flagged Sarah.

"You need to call report on Bed 4 and get the bed clean stat even if you have to do it yourself- I think Housekeeping's at lunch. I'll help you."

"Ok, but the blood just got sent over for the patient in Bed 6 and I have to get it up. I haven't seen the patient in the hall yet."

"Well, maybe Tiffany can help you ...." Amber looked over at Tiffany. With complete tunnel vision, Tiffany was slowly and deliberately doing an assessment on her patient. She had started 15 minutes ago. "Never mind."

Amber's phone rang again. It was Tara.

"I have report on the pleural effusion"

Amber drew a breath and put her hand to her forehead.

"No. Wait. Stop. I am calling a 10 minute Time-Out. No patients, no report, nothing. We need to re-group."

Stunned, Tara did not reply but heard Amber discontinue the call.

---

Amber stuck to her guns and used the next 10 minutes to literally count patient heads and review which nurse had which patients. Together, they figured out where the next 2 patients would go, and who would care for them. After 10 minutes, they resumed and got through the shift.

Amber texted her manager to let him know what she had done as it was not just unorthodox, it was unheard of. She knew she could be in trouble. Her manager responded in a long text which included "all parties have to work together to resolve patient flow issues using approved forms of communication".

Word got around fast and before the day was over, Amber heard through the grapevine that some of the ED Main nurses thought she "couldn't handle the pressure like the other shift leaders". Other nurses applauded her for what she did.

What do you think of Amber's actions? If you had been on duty that day, would you stand with her or criticize her? Or do you think it's surprising that this is even an issue?

[DrVen1]

I would have taken the time out too. I'm surprised this is even an issue considering all she had to deal with. The rudeness was uncalled for though...í ½í¸•

[NurseDiane]

When the supervisor called, Amber should have said that she needs help & ask that the supervisor come to help or things are not going to get done because there were 3 hot bodies working their fannies off with 14 patients and 1 admission coming through the doors that needed a chest tube. Amber should have refused the pleural effusion patient until the chest tube was inserted in the main ED---that is not a procedure to be done in a holding area. Moreover, a pleural effusion patient needs a more controlled environment, like a step-down or ICU. The supervisor should have been told, in no uncertain terms, that that a bad mistake was in the making due to insufficient staff and it was UNSAFE. I probably would have gone over the supervisor's head----to the chief of the ED or the supervisor's boss. And I also would have taken a couple of minutes to put it into writing and send it to the appropriate people so that if anything happened, the appropriate people had already been made aware of it.

One thing I have learned in my 25+ years of nursing is that you have to protect yourself. You want to provide the best care you can, but you can't provide good, safe care when you are overloaded with patients. And, hospital administration is the first to throw a nurse under the bus when something happens. Accepting an assignment that is not safe, accepting inappropriate patients being dumped on you from other units & TRYING to do it all is a recipe for disaster. Hospital administration will take advantage of the nurses all they can, until the nurses start standing firm & refusing to work under those conditions. Historically, nurses have taken the brunt of all problems in a hospital----the fact that the pharmacy failed to stock the Pyxis is somehow the nurses' fault. The unit secretary calling out sick is somehow the fault of the nurses. Then the nurses have to fend for themselves. The nurses are expected to do the work of the unit secretary----are unit secretaries expected to do the work of a nurse if a nurse calls out sick? Why should nurses be expected to do the work of another employee without being compensated for it? If there is supposed to be a whole other person working in the unit, with their own job for an entire shift, then the nurses that have to do the secretary's job should be paid the secretary's salary for the day. An administrator is not expected to do the work of another employee if that employee calls out sick, so why should a nurse be expected to do it?

[Darchangel]

In my humble opinion, she did EXACTLY what was safest for the patients. Continuing on in a flurry is how things fall through the cracks, patients suffer, lawsuits are filed. I applaud her...

[Axgrinder]

Okay - Amber took control of a situation that was quickly spinning out of control. Not only did she do the right thing by taking a deep breath and taking a step back to regroup, she may have prevented a serious error and patient injury that can occur when circumstances rampage out of control. Amber has my respect. Sometimes enough is enough - even for 10 minutes.

[cjcsoon2bnp, MSN, RN, NP]

I don't see anything wrong with what Amber did because it is focused on patient safety and taking that 10 minutes to plan likely will improve the workflow in the minutes and hours following the huddle. I will say that the ED should have been understanding with her about this as long as calling a 10-minute timeout doesn't happen every time that they call her with an admission because then it turns from a "time out" to a stall tactic and an abuse of the system. However, based on the information that we have as the readers it doesn't appear that abusing this timeout is something that Amber has done or will do in the future. As an ED nurse I always like to try and get my patients admitted or discharged in a timely manner in order to avoid bottlenecking in the ED but I can appreciate needed a moment to collect your thoughts and calling a huddle once in a while when things are really hectic just to get control of the situation and improve patient safety.

!Chris

[feelix, RN]

I would have regrouped when they tried to send me a patient without proper report, even no doctor name. What if he was dying? What if orders were needed?

[OneDuckyRN]

I agree with *what* Amber did, but I don't necessarily agree with *how* she did it. Yes, she needed 10 minutes to regroup. However, she should have told the ER nurse she'd call her back in 10 minutes instead of just hanging up. The next move would have been to call the supervisor. The new nurse needs to stop the assessment and come back to it, and help others catch up (yes, I get the tunnel vision thing, but right now she's got to help out where it's most needed). Get the blood hung and the other patient to their assigned bed, then take a deep breath and take the 2 new patients.

For what it's worth, some of these pts sound a little too sick to be in ER holding. Chest tube? Get that person a bed, STAT. Maybe even in ICU...after all, there will probably be some sedation involved. I don't know how many beds or what other resources this facility has, but it seems like if a trauma room is available, that might be another good option for a chest tube. Once the tube's in, MAYBE they can sit in holding for a little while. But now you're asking that one of your 3 already overstretched nurses devote all their attention to this one patient for the duration of the procedure, not to mention afterward. It's inappropriate to expect that this is even OK.

[Idaho_nurse]

I think she did what she had to do in the moment, which is commendable. Would I have handled it that way or would any of us? who is to say unless we have walked in that moment at that time. Without the adequate staffing, I would like to think that I would have called in reinforcements prior to it spinning this far out of control and asking for a back up nurse, or trading out "Tiffany" the less experienced nurse for one with more experience in stressful situations. Its not a dis on "Tiffany" but in this situation, a well experienced staff could have pooled together quicker. As for it being a "holding" area, all critical procedures should have been completed in the ED, and I would not have taken a plural effusion if a chest tube was needed until it was done. Maybe the ED should have been consulted as well and given a heads up on the staffing shortage if they already didnt know, and better communication between the two area's. I am glad she did take a 10 minute pow wow for the benefit of all involved. Good on her for making a command decision.

[nancy nurse 1]

I wish I had the guts to do what she did.

[redbonne]

She considered patient safety first. Bravo.

[paidmydues]

Will you mentor me Amber? A lot of us don't take no krap no more because there are enough studies to prove that it is unsafe! Good girl!

[Tenebrae, BSN, RN]

Amber did the right thing IMO