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Amber Does the Unthinkable

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Nurse Beth Nurse Beth, MSN (Columnist)

Specializes in Med Surg, Tele, ICU, Ortho. Has 30 years experience.

Her name is Amber and she’s been a nurse for 3 years. Recently while working as Shift Leader in the ED Holding unit on a crazy day, Amber did the unthinkable.

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?

rearviewmirror, BSN, RN

Specializes in ER.

Amber's action is rational and very proper coming from former main ed. However, I remember snorting in arrogance when things like these happened and complained that non-ed nurses can't handle pressure and hard ball work like ed nurses do.

Either ways amber shouldn't even have come to the point she did, but the hospital administration treats staff like dirt and insects, therefore this kind of situation is rampant, including in ed. I left this abusive environment and work for insurance company. For all fairness, I hate administration.

iluvivt, BSN, RN

Specializes in Infusion Nursing, Home Health Infusion. Has 32 years experience.

God forbid that a nurse should ask for 10 minutes to regroup at a moment when she is overwhelmed.The fact that this is even a question demonstrates just how powerless we can become on tbe workplace.There is nothing wrong with taking ten minutess to get organized as long as no harm came to any patient.

God forbid that a nurse should ask for 10 minutes to regroup at a moment when she is overwhelmed.The fact that this is even a question demonstrates just how powerless we can become on tbe workplace.There is nothing wrong with taking ten minutess to get organized as long as no harm came to any patient.

Are unions or employee negotiations for non-union states helping with this at all? I'd like to hear about this from people responding to this article (along with answers to questions in the article).

I completely understand where Amber was coming from- but I think she should have handled it better. Just hanging up on the other nurse was quite rude. I think she should have explained her situation to the other nurse and told her she would call back in ten minutes. Or she should have pulled Tiffany from her assessment to help with the more urgent patients.

I just don't think she communicated as professionally as she should have.

Nonyvole, BSN, RN

Specializes in Emergency.

I'd do exactly what Amber did. It's all about patient safety. And staff safety, too, really.

On top of that, I would also be making enough noise so that the right people had to listen. Of course, I'm also the sort that would hand patients and their families review cards and contact information for the patient advocates and the C-suite. Although...I'm also known as a bit of a rabble-rouser.

Also, the ED needs to decide...an extension is part of the ED and so shouldn't be subject to an "us vs them" mentality, or they're more of an inpatient unit, who doesn't put patients in the halls.

While Amber's reaction shows concern for patient safety and she takes action, this is a too late reaction in my opinion.

Hospitals have to have plans in place to manage fluctuating census without jeopardizing patient safety. If nurses are out sick, the unit coordinator is out and medications have not been passed 2 hours late it is time to inform the supervisor/manager about the situation. Unsafe patient assignments or conditions should not be accepted. Hospital leadership is accountable to provide sufficient staffing, contingency plans, and need to have plans in place to manage fluctuating census.

Floor like a ER holding area can not turn into a zoo because the hospital fails to manage throughput. Nurses need to speak up and this nurse used the emergency break so to speak, which should result in leadership evaluating how they manage patient flow.

My only critique is that she did not realize early on in the shift that the staffing situation will lead to chaos and the increased stress, multitasking, and workload would most likely lead to questionable safety as evidenced by late medication. Charge nurses need to provide leadership and also provide guidance to newer nurses, which is impossible in that situation.

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.

sallyrnrrt, ADN, RN

Specializes in critical care, ER,ICU, CVSURG, CCU.

I want to be on Ambers team, I want to work with Amber

I think Amber is awesome! Patient safety comes first, and this chaos was a medical error in the making. By taking time to regroup she made sure each patient was being cared for by someone, and everyone was on the same page. Kudos, Amber!!!

Pixie.RN, MSN, RN, EMT-P

Specializes in EMS, ED, Trauma, CNE, CEN, CPEN, TCRN. Has 12 years experience.

This is why we sometimes have a midshift huddle in the ED when the fecal matter is about to hit the rotary blades and we need to regroup. Nothing wrong with the holding unit doing it too, but communication is key. It always comes back to communication.

dudette10, MSN, RN

Specializes in Med/Surg, Academics. Has 9 years experience.

It saddens me that this is even a controversy. If this is supposed to be "floor lite," it's anything but. Everyone knows that when someone is admitted, the patients are at their sickest. On the floor, patients are naturally varying acuity--some are close to being discharged, some are improving, and some are at their sickest. This section should be staffed to the ED ratio, not the floor ratio, and certainly not at or above the floor ratio.

She did what she had to to make sure everyone had their ducks in a row to manage patients safely.

The floor needs to do their jobs too. Take report ASAP on an empty bed. (Getting report is no longer than a few minutes; the only time I've made the ED wait is when I'm in a patient room, and I call back as soon as I walk out--none of this sitting on report crap.) Get discharges out as fast as humanly possible, but unfortunately, some patients hold up emptying their beds because they are waiting on their rides.

Edited by dudette10

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¸•

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?

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

Specializes in Adult MICU/SICU.

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

Specializes in Emergency Nursing.

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 :specs:

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?