Best tips for RN changing specialty to ED

On 12/22/2022 at 1:55 AM, Valcorie34 said:

I was just hired in ED. I have worked Med/Surg and post acute rehab and as a nurse manager running a rehab. I would love some tips for starting in an ED. I am going to get a preceptor but I know this is a whole new beast. 

I've never worked med-surg, so keep that in mind.

1.  You need to do your best to try to look at your patient, get a picture for what's going on, and anticipate what assessments/labs/treatments you'll probably end up doing - this can do wonders to help you prioritize and stay on top of your patients.  I know this happens on the floor too, but the difference is that in the ED we're not entirely sure what the diagnosis is yet..

2. Stay on top of epic and watch for orders/results.  Once you start to get behind, it can take a good bit of energy to get caught back up.

3. Don't be in such a rush to move your soft level 3's and your 4s.  Sometimes having one of your beds tied up with a nothing patient can do wonders to keep you caught up on the one or two really sick patients you have.

4. Enjoy the freedom of the ED!  I convinced myself during nursing school that I could do med-surg.  I decided during med surg 2 in my last semester to apply for an ED job and I'll never go to the floor.  No more 2 hour morning med pass, no endless charting of IV and safety checks, no more detailed skin checks, just none of that.  Go do nursing stuff, chart the best you can, stabilize and move the patients through the system.

Just prepare yourself, it's fast paced and can be overwhelming.  In a typical shift I'll turn my beds over multiple times and I'll have anywhere between 1 and several sick patients that need stabilized.  Oh, and there's none of this "sorry I can't take report right now I'm busy" or "the unit can't take any more patients, we're bumping this patient to 2 south".  You're the ED, the squads don't stop coming and they don't stop driving themselves into the front door.  You may be bogged down with 2 sickies, a drunk, and a toe pain, and when that cardiac arrest comes through the door, you gotta manage that too.  Don't get be wrong, you'll have help, but there is no telling the patients they can't come.

I was on the M/S floor 2 years then went to ER. I did my senior capstone in ER and absolutely loved it, it was always my goal to get into ER as a licensed nurse. I've been here a little over a year now, technically, but I was also out a few months with injury (unrelated to work). So I have the perspective from both M/S and ER. 

1: ER is a lot more autonomy. We do need orders for lots of things, and it's a group effort but it's a lot more autonomy than on the floor. The doctors/PAs/NPs value your input, generally speaking. When someone gets roomed with abdominal pain, chest pain, sore throat, whatever -- we have a typical set of things we usually do. It also depends on the provider too, but you get a feel for how they each do things after a while. So if I get a chest pain roomed, they've had an EKG in triage unless they're direct bedded. I then get them on the monitor, do a line AC or above, get all my standard rainbow of labs, do my assessment, and anticipate what we might need for them. Even things like sore throat I know we'll do a covid/flu swab and maybe strep so I can get that done. If they're female and any remote chance of preg, I have them pee and get a preg. It helps speed everything along. Then when Dr puts in orders you can collect and send it down. 

2: Be kind to yourself and give yourself grace. I was a good M/S nurse. But it's a whole different world in ER. And the focus is different. You have to dissect what info is important vs. what isn't. You'll learn so much every day. Learn from your fellow nurses, techs, and providers. Patients can teach us too! Be confident to a degree for patients to trust, but humility is important as well. Safety comes first. Use your resources: charge nurse, float nurse, doctors, techs, other nurses, etc. It's major teamwork in ER, rightfully so. As you get your footing, help out others too when you safely can! 

3: Agree with previous poster on keeping an eye on Epic for new orders. We communicate with comments on our board so everyone's aware of what's happening with the patient (ex. Need XR, Labs > Need CT, PO challenging, wants pain meds 7/10, etc.). I love this, so charge can see who may be approaching soon d/c and who may end up needing admission. Don't delay doing orders if you can do them right then. You never know what can come in the door anytime. You're constantly prioritizing who could die fastest, who's most critical, who can wait, etc. You can't plan out a day like you can on the floor here. There's no brain sheet. It's all in the computer, and people are constantly coming and going. In the beginning when I got overwhelmed, I'd grab a post-it and write my rooms down and who needed what. I didn't acknowledge orders until I did it. Now I work faster and can keep up better for the most part and know in my head what I'm doing. But every now and then I need my little notes so I keep a folded paper in my pocket all the time just for that. Don't be afraid to ask for help! We do nebs all the time in ER, but on my M/S floors, RT did them. When I started I felt silly I didn't know how to do one. But I told my preceptor I just hadn't done them before, she showed me, and now I know. Had I pretended and not done it correctly, that asthma exacerbation maybe wouldn't have gotten their albuterol/atrovent neb correctly.  

4: It's a good vibe. It's the most chill place I've worked as far as personalities. You get all kinds of people in the ER, and it can be fun to just be yourself around these patients and make them feel comforted after a long wait, make a joke with them to try to lighten a mood, be silly with them. But never dismiss a patient's concerns. Even the frequent faces. You never know. 

Good luck!!