ICU holds

  1. I would like input as to what others are doing with ICU holds in the ED.

    The ED I work in is holding patients nearly everyday. I can handle the M/S folks but the ICU holds leave me nervous. I do not have ICU experience and am not familiar with the paperwork. When we are holding, we are assigned a hold room and 4 other ER rooms to equal 5 rooms per nurse. At that level I can not provide the same standard of care that they do in the ICU where the nurse to patient ratio is 2:1. I have discussed this with my manager but am told that if I can work ER I can handle an ICU hold. What to do?
    Thanks for your feedback!
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    About samie

    Joined: Jan '05; Posts: 6; Likes: 2

    16 Comments

  3. by   austin heart
    I agree that if you work in the ER that you should be able to take care of an ICU patient as they are both critical care areas. But, I don't agee that you should have to take care of 4 other ER patients at the same time. As you said, it is impossable to offer the amount of care required. You could possabley be placing yourself in a bad situation depending on the patient.
  4. by   Love-A-Nurse

    when one of our icu patients is held in the ed, one of our nurses is sent to the er to care for them.

    i can respect the concern about having an icu patient alone with 4 more patients. i believe when one of the er nurses comes to the icu, it is just as a concern to have 1-2 patients for 12 hours as in most cases, this is not the "nature" of the er nurse.
  5. by   Rena RN 2003
    when we hold ICUs, it's usually because they have no staff instead of not actually having the room. sending down a nurse isn't an option for us.

    we are told that we have to care for our ICU patients as if they were actually on the unit and also carry our ER loads. i refuse. i will take 2 ICU patients and that's it OR i will be an ER nurse. i'm good but i'm not good enough to be both at the same time.
  6. by   needsmore$
    I wish I could take a stand like Rena- I too believe that when you are doing too much-everything begins to suffer and serious mistakes could happen---it's hard to say "sorry I can't take another I have 2 ICU ones already" when EMS or triage is bringing them to you though--(job security concerns)

    We're holding a lot too- 17 bed acute care-4 bed FT community hospital--very high geriatric population (lots of nursing homes). Then after you do the best you can and finally get a HOLD upstairs- you get notes sent to your mgr because you didn't fill out a unit based form correctly! What a day

    As Scarlett said- "tomorrow IS another day"...

    Anne
  7. by   RN92
    I do not have ICU experience and am not familiar with the paperwork
    Well, you have ICU experience now. I worked ER for 2yrs and we were always holding ICU pts. Now, Im trying ICU. What I find irritating, is that I have to go through "orientation" (which is understandable), but the ICU nurses act like I should take one ICU pt for a while and get used to that - then maybe take two. Excuse me, but it was ok for me to take care of two icu pts AND 3 ER pts downstairs - and NO, I didnt kill anybody.
  8. by   rwall
    Quote from samie
    I would like input as to what others are doing with ICU holds in the ED.

    The ED I work in is holding patients nearly everyday. I can handle the M/S folks but the ICU holds leave me nervous. I do not have ICU experience and am not familiar with the paperwork. When we are holding, we are assigned a hold room and 4 other ER rooms to equal 5 rooms per nurse. At that level I can not provide the same standard of care that they do in the ICU where the nurse to patient ratio is 2:1. I have discussed this with my manager but am told that if I can work ER I can handle an ICU hold. What to do?
    Thanks for your feedback!
    In a way, you do have ICU experience just by working in ER and knowing what needs to be done in an urgent/critical situation. In California, Title 22 states that in CCU or ICU, staffing is 2:1 or better. If there are 2 ICU patients in ER holding, the Management should get staff in (or Registry), especially if this will go on to the next shift.
  9. by   RN92
    In California, Title 22 states that in CCU or ICU, staffing is 2:1 or better. If there are 2 ICU patients in ER holding, the Management should get staff in (or Registry), especially if this will go on to the next shift.
    Ive had that conversation with my manager. Their response is, they cant make people come in to work when they're supposed to be off. Truth is, they couldnt make me come in on my day off, either. We have CRISIS nurses, but they only want to work 9-5! M-F.!
  10. by   rwall
    Quote from ERslave
    Ive had that conversation with my manager. Their response is, they cant make people come in to work when they're supposed to be off. Truth is, they couldnt make me come in on my day off, either. We have CRISIS nurses, but they only want to work 9-5! M-F.!
    No, they can't. But do they use Registry? I know it's "expensive", but sometimes they will come in. Plus, nothing beats a helpful working manager!
  11. by   erjulie
    We have the same issue in ourED. Our staff relly tries to help relieve me (and others) when we get an unstable ICU pt., however sometimes there just isn't enough staff. I worked at a hospital previious to this where we were encouraged by our union stewards to make out an "unsafe staffing" report. This is not an official report, but it is a little note that you write when you tell a)your charge nurse b)your manager that the situation is unsafe. When I was charge, I would notify the supervisor that the situation in the ED was unsafe. Or, if I have too many patients, and I think it's unsafe, I tell the charge nurse. Then, you write it down, and forward it to the manager/director and keep a copy. We were told that if/when it goes to court, you have done your best to inform the chain of command that the situation is unsafe, and the burden is off of you (as far as communication is concerned). Now it's the manager's job to fix the situation. The burden will rest on them to fix it if they can. Often, there's not a thing they can do (can't use agency, no registry available, no ICU nurse available). At lest the liability is shared, though.

    I have had horrendous days when we're holding ICU pts, vented, on many drips, and the doors can't close cuz we can't go on by-pass. I feel extremely lucky that nothing terrible has happened (yet). Any ICU nurse who complains about the paperwork being done badly will come back in the next life in an ER as a vented unstable patient where the nurses only care about the paperwork and let them lie in their sopiled sheets, and worse...
  12. by   wayover20
    ER has been HECK lately and last night just as I came in to start my 7-7 night shift, a full arreast was coming into my assigned room. The patient "made it" but remained on the vent, drips all over the place and no ICU bed. Well actually there were TWO empty ICU beds but no nurse to cover them because the day shift super had told a night nurse to stay home because "the census was low". They tried calling her to go ahead and come in, but no answer....we don't blame her either...they pull this c**p all the time. In the meantime arrives a code III acute cva pt in my other assigned room at which time I shouted out to my teamleader (as I was knee deep in care for the first pt) "ok, you'll have to handle that one until I can come out!" So that took the teamleader off of circulating in the ER managing/helping others. The other nurses had their own medsurg holdovers to deal with. OH YEA.....not to mention the "regular" er pts. getting p'od cuz there was no where to put them.
    Ends up the night super was awesome as he got on the phone to drs of ICU pts that were stable enough to transfer out, got their ok and my pts (both ICU) finally ended up getting there.
    The problem is even though I was tied up with 2 critical patients, everytime I would come out of the room to get something, the er drs. would ask for my help or a patient would ask for help. It makes it difficult to play ICU nurse in an ER setting when you see your co-workers "drowning" and you can't leave your pt long enough to get involved in other care.
    I've been nursing for 30yrs and this is absolutely the WORST I have ever seen. They staff the floors/ICU by what the CURRENT census is. So the day shift super calls nurses at 5-6pm to say stay home, the census is low. They say they put them "on call" but 9/10 of those told to stay home don't answer their phone because either they took another assignment somewhere else or just playing hardball like the hospital is. Personally, if I was hired full time and no mention of having to be on call was made, I wouldn't play that game either. Alot of the ICU nurses are registered with agencies so if they're deleted for that day, they go elsewhere to make the money. Who wouldn't?? I don't blame the supervisors (however I couldn't do that job) as they're doing what upper mgmt. tells them to due to budget issues and the "we can't have nurses here with not enough work for them" mentality. The whole thing stinks.
  13. by   veetach
    Quote from love-a-nurse
    when one of our icu patients is held in the ed, one of our nurses is sent to the er to care for them.

    i can respect the concern about having an icu patient alone with 4 more patients. i believe when one of the er nurses comes to the icu, it is just as a concern to have 1-2 patients for 12 hours as in most cases, this is not the "nature" of the er nurse.

    this is what i am begging to have happen in our ed. we get no help.i believe that nurses from the perspective departments should come in and take care of these patients. the problem is not lack of staff, it is lack of space... we hold patients every day, sometimes we have 12 or more holds and we have had situations where 10 of those were ccu/icu patients. after 1:00am our staffing goes down to 3 rn's. this does not equal 2 patients to 1 nurse. it is becoming a problem that management is very aware of, but are not doing anything about.

    i dont know what the answer is, but i do know that if i have 3 critical care holds and 6-7 er patients, then i am gravely endangering my patients. i used to work critical care, so i do have an advantage on a lot of my coworkers who are either new grads or just have 1 yr or less of med surg experience under their belt. it is a sad and scary situation.
  14. by   samie
    Thanks guys for your response.
    wayover... your situation sounds live one I've been in more than once. It used to be a rare thing now it's almost weekly. I've been in some situations that I felt were unsafe and I went up the food chain..... chrg nurse, manager etc.. but, I did not document it. I will in the future.
    I love the ER but I've found myself wondering lately if it's worth it.
    I keep a smile on my face and focus on what's right in front of me. :spin:

    sam

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