ED to ICU CCU Transition

londonflo · Sep 11, 2022

4 minutes ago, Lipoma said:

At times it's more work caring for the stable belly pain versus the intubated and unstable patient.

Yes the intubated cannot ask you for anything.

JBMmom, MSN, NP · Oct 7, 2022

I'm a bit late answering your post, but I've worked with nurses that transferred from the ED to the ICU (and vice versa) and it's hard to know whether you will like it or not. Be prepared, even in busy ICUs, chances are you will still have patients that can ask for things. We all love a good intubated patient, but the goal is to eventually extubate them whether we want to or not.

I know that from my own experience, I could not work in the ED. The varying levels of acuity would make it hard for me to prioritize. And I like knowing ALL the things about my patients. By the time they come to me in the ICU I have diagnoses, I have labs, I have results and I can get busy labeling my lines. (just kidding, sort of- it is a compulsion) The nurses that can hustle and bustle in the ED and take care of 6, 10, 20 patients in a shift boggle my mind- in an admiring sort of way. I would want to know more about many of them, and probably less about some.

You may very well enjoy many aspects of ICU care. As I said, I have 2-3 patients in my 8-12 hours so my goal for a shift is to put the story together. Why am I seeing what I'm seeing in my patient and what can I do, if anything, to fix it. The ED is about stabilizing and the ICU is about moving the care forward. It's a great place to see improvements, or unfortunately, declines, and figure out what needs to be done next. Good luck if you make the move, I think it's a great place to work.

Lipoma, BSN, RN · Oct 8, 2022

3 hours ago, JBMmom said:

I'm a bit late answering your post, but I've worked with nurses that transferred from the ED to the ICU (and vice versa) and it's hard to know whether you will like it or not. Be prepared, even in busy ICUs, chances are you will still have patients that can ask for things. We all love a good intubated patient, but the goal is to eventually extubate them whether we want to or not.

I know that from my own experience, I could not work in the ED. The varying levels of acuity would make it hard for me to prioritize. And I like knowing ALL the things about my patients. By the time they come to me in the ICU I have diagnoses, I have labs, I have results and I can get busy labeling my lines. (just kidding, sort of- it is a compulsion) The nurses that can hustle and bustle in the ED and take care of 6, 10, 20 patients in a shift boggle my mind- in an admiring sort of way. I would want to know more about many of them, and probably less about some.

You may very well enjoy many aspects of ICU care. As I said, I have 2-3 patients in my 8-12 hours so my goal for a shift is to put the story together. Why am I seeing what I'm seeing in my patient and what can I do, if anything, to fix it. The ED is about stabilizing and the ICU is about moving the care forward. It's a great place to see improvements, or unfortunately, declines, and figure out what needs to be done next. Good luck if you make the move, I think it's a great place to work.

I appreciate your feedback. I'm not sure if I was conveying my thoughts clearly when I made the comment about patients asking for things.

I enjoy talking to patients (one of the first reasons I went to the ED as a new grad instead of the ICU - I like walky talkies) and educating them about the process of their care.

What's mentally exhausting is me being elbow deep in a code or caring for someone needing 1:1 attention because they're circling the drain and another patient stalking me outside said room and barking orders/requests when they clearly see me busy. I've even had family members walk outside their room and walk into another patients room to ask me "what's going on with my mom/dad/sister/any results yet?"...or yelling "I'm hungry" while we're doing compressions in the other room.

I'm just tired of telling adults how to behave when half of them are older than me. I'm also exhausted from being blamed for their sickness when they refuse to take accountability for the position they're in - AKA the dialysis patient who frequents the ED because they refuse to go to their dialysis center and when we try to help, they chew staff out because they're not feeling well. Being told its my responsibility to find transport for them to go back home when they're discharged...but it was a relative who dropped them off.

...Sorry, I started to rant off because boy o boy was today awful.

Susie2310 · Oct 11, 2022

On 10/7/2022 at 8:00 PM, Lipoma said:

What's mentally exhausting is me being elbow deep in a code or caring for someone needing 1:1 attention because they're circling the drain and another patient stalking me outside said room and barking orders/requests when they clearly see me busy. I've even had family members walk outside their room and walk into another patients room to ask me "what's going on with my mom/dad/sister/any results yet?"...or yelling "I'm hungry" while we're doing compressions in the other room.

I'm just tired of telling adults how to behave when half of them are older than me. I'm also exhausted from being blamed for their sickness when they refuse to take accountability for the position they're in - AKA the dialysis patient who frequents the ED because they refuse to go to their dialysis center and when we try to help, they chew staff out because they're not feeling well. Being told its my responsibility to find transport for them to go back home when they're discharged...but it was a relative who dropped them off.

I hear your frustration in your first paragraph, but in my experience the family members are usually just trying to do their best for their relative (the patient). There are helpful notices placed in some patient rooms advising the patient/their family member to inform their nurse if they have any concerns about the patient's condition or for varied other reasons including if they are hungry, and so they do that. They believe they're doing what they're supposed to do. I've found it very frustrating when I've been a family member and I've tried to find the nurse to report important information about my relative (the patient) such as a change of condition and the nurse is no-where to be found (albeit with good reason as he/she is taking care of other patients). The family member doesn't know the very important things the nurse is doing in other patient rooms; they just know that they have a very important reason for needing to find the nurse, but they can't find him/her, and they look for the nurse where they reasonably expect to find him/her; in the hallway, at the nurses' station, or try to find which room the nurse is in so they can talk to the nurse when they come out of the room. So while it's frustrating for you, it's very frustrating for them also.

I think part of the problem with the patients not following their treatment plans (your second paragraph) and not taking accountability for their situation is that more time needs to be spent in primary care settings educating the patient on their condition. It's difficult for providers to provide all the necessary patient care and patient education in the time allotted for the appointment. Also, without a good support system, I think it's very difficult for a patient who needs dialysis. Being seriously ill is very difficult without a good support system.

Lipoma, BSN, RN · Oct 11, 2022

13 hours ago, Susie2310 said:

I hear your frustration...not taking accountability for their situation is that more time needs to be spent in primary care settings educating the patient on their condition. Being seriously ill is very difficult without a good support system.

I agree that being seriously ill is difficult without a good support system...but if a patient has been fired by multiple dialysis center due to their abusive nature towards their care team then this patient failed themselves. This is what I mean by refusing to take accountability. No amount of education will make a difference. Also, there is no need for a patient/family to exit their designated ED room to enter into another ED patient's room to demand I feed them or to request results. That's what the call light is for. The ED is dynamic and someone is always around to assist if the nurse is unavailable. These are the types of patients that have exhausted me.

But I hear you.

Susie2310 · Oct 12, 2022

4 hours ago, Lipoma said:

I agree that being seriously ill is difficult without a good support system...but if a patient has been fired by multiple dialysis center due to their abusive nature towards their care team then this patient failed themselves. This is what I mean by refusing to take accountability. No amount of education will make a difference. Also, there is no need for a patient/family to exit their designated ED room to enter into another ED patient's room to demand I feed them or to request results. That's what the call light is for. The ED is dynamic and someone is always around to assist if the nurse is unavailable. These are the types of patients that have exhausted me.

But I hear you.

These are some thoughts: Severe kidney failure can lead to mood and personality changes, irritability, altered mental processes including delirium, amongst numerous other serious symptoms. Patients can have hemorrhagic strokes and cardiac tamponade. Missing dialysis can cause serious problems, and serious problems can also arise during or after treatment. It's not any fun to deal with people who are aggressive or hostile, I agree with you. For myself, I find it helps to keep in mind that processes such as uremia and electrolyte/fluid imbalances are greatly affecting the patient's mental status and can significantly change the behavior of even people who have normally, during their lives, been even tempered, fair, and reasonable. I find it helps both me and the situation to try to understand what the person is experiencing and to try to put myself in their place.

I agree that even when very sick people need to be able to manage their behavior to the point that they don't physically harm other people or make it virtually impossible to provide care for them. Kidney failure and dialysis treatment puts huge limitations and restrictions on a person's life and can result in the person experiencing great frustration and grief. I believe it helps not to take the behavior personally even when it appears to be directed at one. To be clear, I'm not suggesting that I think you should be expected to tolerate behavior that is demeaning or insulting or that exposes you to the threat of physical harm. I think (or at least I hope) nurses wouldn't get angry with a patient who had an acute stroke behaving unreasonably because they know that those types of behaviors are a symptom of acute stroke.

I hear your concern about family members leaving the patient's room to find you in another patient's room to demand they are fed, or to request labs. Patients and family members don't usually live in a world of patient confidentiality/HIPAA, and are encouraged in health care settings to speak up if they need something, or to contact their nurse if they have any concerns about the patient or any other questions, including requests for food.

You made the point that family members should use the call bell; I would suggest that, if you don't make a point of routinely telling patients/family where the call bell is and how to use it, that you do this, and hopefully family members will remember to contact you this way.

I hope that you might find something useful in the above.

Dre2416, BSN, RN · Oct 13, 2022

I'll give your my input as I just transitioned to a busy level 2 SICU/TICU from 9 years (on and off) in the ED. I am 7 weeks into my journey in the ICU. Overwhelmed is an understatement. I go home every shift thinking I forgot something. Since the ED mindset is treat and street it or send them to the floor and move onto the next, the ICU has been a 180 for me. The amount of detail in little things (dressing changes, line changes, the literally 3-4 hours of charting I do a night is exhausting) you don't know what you don't know and I would get feedback saying I haven't changed my propofol tubing and I almost missed my art line dressing change... as someone who has NEVER worked the floor who the F cares about those things cause I was busy keeping my patient alive... but the ICU cares! Most of my patients have been intubated but once they start circling the drain you're on the phone paging the doctor multiple times, hoping they'll come to the bedside and just ASSESS their patient. I was spoiled having the ED doctor a yell away if things started going bad. It's also not as a collaborative environment as the ER. There is a lot more critical thinking in the ICU as you have multiple drips, pressers, playing a dance with stabilizing your patient.. yes, you do that some in the ER but its not all shift everyday with paralytics, pressers, sedation, plus knowing your vent settings, what they mean, having the freedom to stop to start a med based on your own judgment. I will say, I am happy that my unit is acute enough to have mostly intubated patients who can't talk back to you. NO MORE PSYCH HOLDS! No one is going to throw their urinal at you on the daily. I'll post an update once I'm on my own for a bit but take the leap! If you hate it there's 1000 ER's that will take you back.

Lipoma, BSN, RN · Oct 16, 2022

On 10/13/2022 at 8:02 AM, fsuandrea said:

I'll give your my input as I just transitioned to a busy level 2 SICU/TICU from 9 years (on and off) in the ED. I am 7 weeks into my journey in the ICU. Overwhelmed is an understatement. I go home every shift thinking I forgot something. Since the ED mindset is treat and street it or send them to the floor and move onto the next, the ICU has been a 180 for me. The amount of detail in little things (dressing changes, line changes, the literally 3-4 hours of charting I do a night is exhausting) you don't know what you don't know and I would get feedback saying I haven't changed my propofol tubing and I almost missed my art line dressing change... as someone who has NEVER worked the floor who the F cares about those things cause I was busy keeping my patient alive... but the ICU cares! Most of my patients have been intubated but once they start circling the drain you're on the phone paging the doctor multiple times, hoping they'll come to the bedside and just ASSESS their patient. I was spoiled having the ED doctor a yell away if things started going bad. It's also not as a collaborative environment as the ER. There is a lot more critical thinking in the ICU as you have multiple drips, pressers, playing a dance with stabilizing your patient.. yes, you do that some in the ER but its not all shift everyday with paralytics, pressers, sedation, plus knowing your vent settings, what they mean, having the freedom to stop to start a med based on your own judgment. I will say, I am happy that my unit is acute enough to have mostly intubated patients who can't talk back to you. NO MORE PSYCH HOLDS! No one is going to throw their urinal at you on the daily. I'll post an update once I'm on my own for a bit but take the leap! If you hate it there's 1000 ER's that will take you back.

Awesome! Thanks for your input. That's what I'm hesitant about, the massive learning curve going from treat-em-and-street em mentality to "this is the highest level of care" in the hospital setting. I love the ED because the physician/PA is right there in arms reach. I'm a very collaborative individual who like to talk things out with another clinician and see what the best approach is.

I'm most likely going to take the leap and test out the waters. I love the heart and always volunteered for these kind of patients because you see immediate change with whatever intervention is being done.

I look forward to your update!