Comparing ERs

Lev, MSN, RN, NP · Dec 27, 2015

I can only speak for my own ER in a community teaching hospital which sees about 110,000 patients a year.

For patients who walk in, the first person they talk to is registration. Registration gets their information and a quick one liner about why they are coming in. Then, the patient is directed to a triage room where the Triage RN triages the patient and the tech gets vital signs. Depending on how they are triaged they will be sent back out the main waiting room, to another waiting room, will sit in the waiting room or hallway across from triage, or will go straight back to a room in the main ER. When a patient comes in via ambulance, they are sometimes triaged in triage, but many times are brought back straight to a room in the main ER (especially if critical) and the primary RN triages the patient on arrival to a room. If they are come back via ambo and do not need to be seen right way, they will be loaded into a stretcher in one of the triage rooms.

The Adult ED (where I work) has 46 beds in the main ER, there are 10 fast track beds, and 10 ED obs beds. There are 4 areas in the main ER each with a large central work station. There is also a computer in each room.

The nurse to patient ratio in the main ER is 1 nurse to 3 or 4 patients at a given time. It does go up to 5 on rare occasions.

We do not have a requirement to obtain the CEN, but there are quite a few certified nurses.

Our respiratory therapists obtain ABGs. We do not have standing orders for xrays, but we often put orders in to confirm line placements etc.

We are required to charge vital signs in the main ER for a priority 1-3 patient at a minimum of every 4 hours. However, this is typically done every 2 hours or more often depending on the patient. Vitals signs are an RN responsibility. We document on arrival to the room and with any changes. We also put a note in the computer before patients go upstairs to med-surg or telemetry. For critical care patients we give a verbal report.

Until a patient goes back to a room, there is no main RN who cares for them. In the main waiting room, we have a "greeter" who is staff member or volunteer. There is also security in the waiting room.

The charge nurse is responsible for a lot of different things. The charge nurse helps out with critical patients and codes, coordinates with the supervisor to make sure we get beds for patients, helps triage patients as needed, responds to patients who have any concerns related to care or treatment, helps with difficult IV starts, and helps with difficult/psych patients.

If there are no beds available for patients who are admitted, they will board in the ED until a bed becomes available. Typically, an ER nurse is assigned to them, but sometimes we get floor nurses to come down to the ED to care for them. If we have a lot of "boarders" we move them to one part of the main ED. There is no ER doctor assigned to the these patients. Typically, these patients are med-surg or telemetry patients.

Nalon1 RN/EMT-P, BSN, RN · Dec 27, 2015

about 95% the same where I work as Lev

Kristenlaurenw · Dec 28, 2015

I work in a small ER (14 beds). After registration, the first person a patient sees is the triage nurse who obtains vitals at the time of triage. Each nurse is typically assigned to about 4 rooms. There is no requirement for CEN but there is a differential paid if you have it. Our respiratory therapists do ABGs but our manager is wanting to start having RNs checked off on it. X-rays are ordered by providers (if a nurse knows a pt needs one, they will put in the order for the provider). Vitals are charted based on acuity (a non urgent patient with a cold might not have them checked again until discharge but a chest pain might have them at least every 30 minutes). Each facility should have a policy on this. Each patient room is assigned to a nurse so every patient who has been roomed should have a nurse who is responsible for then. The charge nurse makes room assignments, controls patient flow, handles any patient complaints, helps with triages, and is the go-to resource person for anything the nurses need during the shift. Since we have such a small hospital, if no beds are available in house, they are transferred to a larger facility. If they must wait, they pretty much stay and tie up their room and their assigned nurse is still taking care of them.

turnforthenurse, MSN, NP · Dec 28, 2015

This is going to depend on the ER you're working with because I've worked in ones who have very different flow patterns. I currently work in a 25 bed ER (5 of those beds are hallway beds and aren't always in use either due to staffing or census)

First to talk to the patient: Registration actually does it because they have to get the patient into the system before we can start charting on them...and then we just ask all of our additional questions from there. There is always a nurse in triage and that nurse has eyes on everyone in that waiting room and everyone who walks through that door. Vitals are usually obtained right there in triage unless the patient has no vital signs or needs to be brought back immediately for whatever reason.

Where I work we have a main ED side and a fast track side. The main ED side also includes our hallway beds and the critical rooms which are larger than the standard ER rooms and have a crash cart as well as extra supplies. Then of course there is triage.

Our ratios vary from 1:3 to 1:4, but it depends on staffing as well. We have an acute ER side where we try to keep the sicker patients and the ratio there is USUALLY 1:3 but due to staffing some days it will be 1:4.

CEN isn't a requirement but it is strongly encouraged.

RNs CAN obtain ABGs but we have a dedicated respiratory therapist in our ER so they do that. There is a lot of autonomy in my ER and we have a lot of protocol order sets based on a patient's chief complaint. I will go ahead and order XRs but never a CT or US unless a provider verbally tells me to put an order in for them. We can order basic meds like Tylenol and ibuprofen based on protocol orders as well as fluids and zofran.

VS should be charted at least every 2 hours unless something warrants more frequent monitoring. Patient status depends on what the patient is there for. Are they a CVA with t-PA on board? I'll be doing neuro checks every 15 minutes, etc.

For patients in holding, the ER nurses are responsible. Sometimes (if staffing allows) we'll get lucky and get an ICU or med-surg nurse to help handle the admission holds. I really hate holding because ERs aren't really designed for that and there have been studies showing that patients (especially ICU patients) can have increased mortality rates or complications the longer they are held in the ER.

Our charge nurse is responsible for traffic control and serves as a resource person on the unit. They typically assist in critical situations such as codes. They're also my go-to person when I'm having one heck of a time trying to start an IV on someone. :)

PAEMT · Dec 28, 2015

It looks like my ER is a little different so I'll give you a run down of how it works here

we have a nurse up front next to registration who gets the chief complaint while registration is putting the patient into the system, then that nurse will either triage the patient or the nurse right behind them will triage them. The patient then goes out to the waiting room (unless in acute distress). If a patient comes in by EMS they get triaged by the RN and then wait in the ambulance bay (you don't get to the back quicker if you come by ambulance).

My ER has a fast track area , an area where patients from that fast track area wait for results of tests/consults, an observation area, Psych ER, and a main ER with exam "rooms", hallway spots and Resus/trauma rooms (which are used for non critical a who would get pulled out for a critical).

Our ratio is usually maxed out at 8:1 in the main ED, though we have gotten up to 10:1. The ratios in the fast track areas are variable the highest I've seen is 15:1

no requirement for CEN but a bonus is paid and test costs are refunded

providers put in X-ray orders and do ABGs

vitals and charting are q2 for ED patients and q4-8 on admits

the charge RN is in charge of assigning rooms, assigning ancillary staff to constant observations, troubleshooting and keeping the flow going

every patient in the ED has a nurse assigned to them except those in the waiting areas who the triage RNs are responsible for

if a patient is admitted and there are no beds they usually board in the ED until there is a bed. The ED RN is responsible for carrying out their impatient orders. Getting to a room within 2 hours of admission is considered very quick at my facility, it usually takes 4 hours or more

turnforthenurse, MSN, NP · Dec 29, 2015

PAEMT - 8-10:1??? :wideyed: How the heck do you manage that? What's your patient population like? What's your average acuity per shift?

PAEMT · Dec 29, 2015

Our patient population is very very diverse, many immigrants, some people get off the plane and come right to our hospital. Our population has for the most part very low health literacy and little to no access to primary care. Acuity is variable though it has been pretty high as of late.

As as for how we deal with it. When it's all you know, you get used to dealing with it. You obviously can't give the care you can with a 4:1 ratio but we try our best

emtb2rn, BSN, RN, EMT-B · Dec 29, 2015

PAEMT - 8-10:1??? How the heck do you manage that? What's your patient population like? What's your average acuity per shift?

Wow! That's horrendous as an average ratio. What happens during a code or if the pt is a 1:1? How do you divide 7-9 pts among nurses that already have at least 8 each?

Lev, MSN, RN, NP · Dec 29, 2015

Forgot to mention that there is a separate psych ER. The psych patients sometimes have to come to us first to be medically cleared.

PAEMT - care to share which state you are from? I have heard of certain ERs in NY (such as Methodist) having horrendous ratios like that...

turnforthenurse, MSN, NP · Dec 29, 2015

I also forgot to add that we have two rooms for psych patients who are either suicidal or homicidal.

Emisa · Dec 30, 2015

Thank you for all of your replies :-)

I envy your ratios - our ratios an average day are 1:10, but on really bad days they are 1:20 and above... Reason for this is that every patient who is admitted to the ER by triage has to have a team nurse responsible for them regardless of acuity. We have no psych patients but pretty much every other category and those patients are divided equally between 3 different teams in the main ER, regardless if a room is available or not. Each team consists of 1 RN and 1-2 techs, and maybe 3 physicians.

One thing I do like is that we have a separate so called alarm team - a team consisting of 2 nurses and one tech along with an emergency physician. They take care of all incoming priority 1 patients, like cardiac arrests, traumas etc. in a separate alarm room in the ER.