Covering 1:1’s in the ER

JKL33 · Nov 15, 2020

Step 1 based on experience/observation is to use actual discretion in who gets a 1:1, who can be covered with video monitoring, how can patients be positioned differently so that even 1:2 could work, etc. I know no one is fond of that latter idea right now, but something has to give.

If no one is willing to consider anything other than 1:1 and the priority is never "over-staffing" (which I highly doubt is ever seen in an ED with 60k visits/yr)....then I guess it will just keep being exactly what it is right now.

Guest219794 · Nov 25, 2020

1- Adopt a policy that allows discretion, so as to not waste resources. Last night we wasted what will probably end up as 18 hours of 1-1 tech time on a Trazodone OD, who: A-Told her mother so that mom would call 911 to keep her from dying, and B- was zonked on Trazodone. I would guess that the sprained ankle who denied SI was at a higher risk of hanging himself.
That will probably never happen- The amount of stuff that gets missed when you tie up staff members is harder to quantify, and irrelevant to admin.

2- Create a pool of on call sitters- nursing students or whatever. That will never happen because of money. Admin won't want to pay for it.

3- Set up an area in which 1 person can observe more than 1 patient. No doubt somebody in admin will explain why they can't do that.

Sorry. Feeling pessimistic. Any of those would work if the folks running the place cared about nurse morale and patient outcomes.

NurseNelly24, BSN · Dec 3, 2020

This sounds like something you def want to approach management about. Is there a committee within your unit to discuss some of the problems with staffing and behavioral health pts? Just something to consider. But as far as advice, here’s a few things to consider:

-The layout of your ED: Is there an area/room section where psych pts can be cohorted instead of being placed in random spots in the hallway or rooms? At one of the EDs I worked at, whenever there was an overflow of psych, patients, we opened up our “D” section in the back of unit so that they were all placed/or transferred to that area. This was especially beneficial when we closed off certain parts of the unit at 3am, we would keep that area open exclusively for psych patients.

-Piggybacking from the first point, if you have that pop. placed in one spot, it will be better for you to utilize your techs. At my hospital, we have 1:1 for our actively SI/HI who any form of destructive behaviors in the ED. Other patients who are depressed, psychotic, etc. but calm, cooperative for the most part would be placed on a “Line of sight” observation. This means that you’re constantly observing the patient, doing q15 min checks, but we do not have to be side by side with them (e.g. observing them at the nurses station as opposed to the bedside) This allows techs/nurses to observe more than one patient; and this would probably prove benefecial if you have a patient who was chemically sedated.

-Another point: Do your restrained patients still need to be in restraints? I know hospital dictates how long a patient can be in 4 locks, but I’ve had situations where I took over for a nurse who was taking care of an initially combative patient, was given ATI/Haldol combo, restrained, and then kept in restraints for hours despite them being pretty much asleep the entire time. When asked, the nurse had no rationale. If your patient is in 4- points restraints but obviously sedated, you’re wasting a resource by having that patient as a 1:1. I’d say unless, they were failed attempts at calming the patient despite meds/restraints, a patient shouldn’t be in restraints for more than one hour.

-Utilization of Psych nurses to cover in ED: this can be a future convo for your mgmt team, but utilizing psych nurses can be a big win on your department’s end. For one, they’re better at managing psych patients than us ER nurses do, and they are able to address some of their needs, while we take care of our medical pts. Remember why some of these patients get agitated: they spend hours on a stretcher, sometimes no TV, phone, or their belongings, waiting hours to be evaluated by a psych doc, unfamiliar environment, eating cold sandwiches, not on their home meds, etc. Having psych nurses in the ED as a resource to address some of those issues can help with can take a load off for the nurses and techs.

-Collaborating with nurses, techs, management and physicians to create a possible algorithm for evaluating which patients require a 1:1 can also be a future project. This way the process is cohesive and consistent on all days during all shifts.

Hope this helps!

HiddencatBSN, BSN · Dec 3, 2020

My hospital has a float pool of sitters. We use them first, then our techs, then we pull from other units (even if it means they end up having no one on the floor), then we use LONs and then RNs. We’re currently hiring in our sitter float pool because we’ve had to use RNs so much with our increased psych volume- I recently had to sit for 4 hours. We are not allowed to cohort or do video monitoring and don’t have a ton of discretion for initiating it when a patient comes in with SI.

It’s really tough- with inpatient psych beds so hard to come by we can hold patients for several days and in the Winter last year it was not unusual to have half of the department’s beds filled with psych boarders (sometimes we’ll send patients to med surg to wait psych placement but when medical census is high medical patients are prioritized).

JKL33 · Dec 3, 2020

10 hours ago, NurseNelly24 said:

This sounds like something you def want to approach management about. Is there a committee within your unit to discuss some of the problems with staffing and behavioral health pts? Just something to consider. But as far as advice, here’s a few things to consider:

I do like your suggestions; we probably all do. The issue is that practical thinking and problem-solving by staff nurses is often not the part that is lacking in many of these situations. It's more common that the resources and options are purposely restricted. The option left for staff at that point is to "get by." The types of problems in the OP aren't the kind that continue on because the nurses doing the work can't figure out any of the basic solutions. Rather, the solutions are already limited to "none" (or very few and very inadequate) by management.

HiddencatBSN, BSN · Dec 3, 2020

1 hour ago, JKL33 said:

I do like your suggestions; we probably all do. The issue is that practical thinking and problem-solving by staff nurses is often not the part that is lacking in many of these situations. It's more common that the resources and options are purposely restricted. The option left for staff at that point is to "get by." The types of problems in the OP aren't the kind that continue on because the nurses doing the work can't figure out any of the basic solutions. Rather, the solutions are already limited to "none" (or very few and very inadequate) by management.

Sometimes it’s regulatory issues as well. I am pretty sure our practice of cohorting low risk suicide watches was ended because of regulatory requirements.

NurseNelly24, BSN · Dec 3, 2020

10 hours ago, JKL33 said:

I do like your suggestions; we probably all do. The issue is that practical thinking and problem-solving by staff nurses is often not the part that is lacking in many of these situations. It's more common that the resources and options are purposely restricted. The option left for staff at that point is to "get by." The types of problems in the OP aren't the kind that continue on because the nurses doing the work can't figure out any of the basic solutions. Rather, the solutions are already limited to "none" (or very few and very inadequate) by management.

Agreed. I’ve noticed over the years that management, out of the entire “web” are the ones that are least likely to take risks and make changes for improvement the unit. You could hit them with hard-core evidence, and they’ll still find a way to limit resources. The staff nurses will have tons of ideas to improve the unit (many of which are evidenced-based) and they are either never executed or watered down to meet budget requirements or because they’d straight up don’t care.

JKL33 · Dec 6, 2020

On 12/3/2020 at 7:53 AM, HiddencatBSN said:

Sometimes it’s regulatory issues as well. I am pretty sure our practice of cohorting low risk suicide watches was ended because of regulatory requirements.

Yes--or poor interpretation of such. Kind of like how it was supposedly an OSHA violation to have access to a drink at one's workstation.

chare · Dec 6, 2020

24 minutes ago, JKL33 said:

Yes--or poor interpretation of such. Kind of like how it was supposedly an OSHA violation to have access to a drink at one's workstation.

Ain't that the truth. It continues to amaze me how many people, people who should know better, keep spouting this as gospel.

HiddencatBSN, BSN · Dec 7, 2020

2 hours ago, JKL33 said:

Yes--or poor interpretation of such. Kind of like how it was supposedly an OSHA violation to have access to a drink at one's workstation.

I mean, I know we’ve had a lot of practice changes recently regarding our psych patients to correct deficiencies identified by the DNV. I’m pretty sure the cohorting 1:1s was one of those things but I don’t know for sure.

The OSHA issue is that the RN station is considered a “patient care area” and that there’s potential fluid exposure there and with how many patients or residents try to hand me urine or lab samples at the RN station instead of leaving them in the room (or giving me an opportunity to grab gloves)....LOL.

GS ED RN, MSN, RN · Dec 10, 2020

both EDs I work at - have to pool sitters - so sitters will sit w/ 2-3 patients at a time - logistically ensuring visibility of 2-3 rooms at a time is challenging --- also every facility has differing policies - any restrained patients require 1:1 not one sitter wathcing multiple patients - however at times this rule gets bent due to again you guessed it lack of staffing