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?

[Doumbia]

IMO she did the right thing, as the one responder mentioned, the hospital is quick to throw the individual nurses under the bus, often after staffing is inadequate and workflow too overwhelming for patient safety. Cripes, this kind of stuff can cause PTSD in staff, this is also why nurses leave the profession, and patients get hurt. Also wonder why a brand new graduate would be working in this area. Often nurses who speak up are reviled by admin, even other nurses who should know better. Why would any millenials want to go into a profession where this is now the norm?

[BuckyBadgerRN, ASN, RN]

Amber should know that an exclusively breastfed baby CAN nurse, even if NPO

[whichone'spink, BSN, RN]

Why would any millenials want to go into a profession where this is now the norm?

Yeah, this. And this millenial is working on getting out, or at least away from the bedside. When I make money and make a college fund for my children, I will list conditions for them to be able to draw from the fund. No useless liberal arts major, and absolutely NO nursing major. That's how strongly I am against nursing. I wish my parents imposed that condition on me, for my own good.

[klcrn1987]

I have done exactly what Amber did.... I was asked to come in on my day off to man the "overflow" unit for the main Med-Surg unit. They were holding patients in the ER and needed to clear them ASAP so within 15 mins of me hitting the floor at 7PM, I had 4 admissions... by myself, not even a CNA to take vitals and help settle the patients... luckily, none of them were critical. Each admission from start to finish takes about 45 mins if you really push (mostly paperwork ) so that was 3 hrs right there, plus meds, IV's etc. It was getting to be about 9PM with the next nurse coming in at 11PM. I still had one more patient to admit and they called and wanted to send 3 more patients up ASAP (wanted to have them admitted by 12AM so they could charge the extra day!!) I flat out told them NO!!! I felt I could not properly admit and handle 7 patients without help and the safety and well being of my patients came first. The Supervisor and ER staff were not happy with me but they also knew that I wasn't a "slacker" and if I said I couldn't do it that I was truly doing the best I could. I finished my last admission and had them send 1 of the new patients up and was working on it when the next nurse came in.... I stayed to help and we had everything cleared up and settled by about 12:30am..... 7 full admissions in 5-1/2 hrs.... I thought we did pretty good!!

[Kooky Korky, BSN, RN]

I don't think this is really an unusual situation; as others have said, it just depends on how you word it. I think as a charge nurse I've probably said "Okay, give me a few minutes to figure this out and I'll call you back" multiple times. Not frequently, but occasionally. And knowing those five or ten minutes were possibly hellish for the people waiting; you don't want to overdo it.

As for the ED Main nurses gossiping about her--that's going to happen. The floor nurses give it right back to the ED. You have to let it go. We complain about "seriously, the ED nurses couldn't find two minutes to change the patient's bloodsoaked linen?" and that kind of thing. But when it comes to the patients and families complaining that (for instance, I heard this yesterday) no one in the ED cared about cleaning out the patient's abrasion, no one touched it the whole time they were there--we all stand up for the ED nurses, trying to explain (without alienating the patient/family) that the ED responds to the urgent problems knowing we'll have more time to take care of the rest of it on the floor.

It does sound like she was in a little over her head, which happens as a relatively new leader--and occasionally happens to everyone. Nothing to do but use it as a learning experience.

Sounds like a 3rd world country.

I know God is watching and sees all and He judges fairly. He will punish administrators and managers who create these ridiculous working conditions, who seem to care so little about people, only about $$$$.

But Amber and whoever she represents in real life need to demand a replacement secretary and nurse and pharmacist. She should have notified the manager immediately and had him get himself there to work the floor, get better staffing, get the ER shut down until things were more manageable, something. Even having a CNA would have helped.

Even with 3 nurses, the setting would have been like Dante's Inferno.

[Kooky Korky, BSN, RN]

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?

It isn't just the secretary's pay. The nurses might not know HOW to do the more technical aspects of the secretary's job, what with all the newfangled equipment and computer programs in use today.

[memarc1120]

I think she absolutely did the right thing!!! Like a run on sentence, it keeps on going and going if you don't stop it. Screw the other people that say she is not leadership material. They just don't have the balls to do what she did!!

[Nursingisalifestyle]

I think Amber did the responsible thing. I learned long ago in Nursing management....STAR Stop, Think, Act and Review. When things are the craziest we need to take a moment to stop and think. Nursing is about critical thinking but we have to be able to know when we need a moment to be able to think.

[erniefu, BSN, RN]

What was learned was that the supervisor was the one who couldn't handle the pressure and did not prioritize properly. It seems that the supervisor had no idea what was going on in the holding area (already causing the hold to be over census) and sending an inappropriate patient to the hold (I doubt a hold has proper monitoring equipment and supports like the ER main to do a chest tube insertion). Amber was right to reassess the situation and figure out what to do next. Surgeons take time out during surgeries to ensure that fewer errors are commited.

[LVN fresno]

You sound like some one that never has worked i a ED . Amber should be supported by all nurses

[canoehead, BSN, RN]

She did exactly what was needed. I would not have accepted any patient without a report. Plus having two patients in the hall while being short staffed...no way. Amber, the ER charge and the supervisor need to get together and work this out safely, calling a halt to all movement seems fair until that gets done.

[OscarTheOwl]

I learned a long time ago that you can only do what you can do. I can't do 10 things at once, you have to prioritize. She prioritized organization in order to make everything that followed flow more smoothly. It shows leadership and responsibility to look forward and anticipate what's going to need to be done first. You can not do that when your brain is slammed. She took 10 minutes to figure out how to use the time more efficiently. Good for Amber.