New to ER - tips, tricks, recommendations & prioritization?

Specialties Emergency

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So, after 6.5 yrs as RN/shift charge on a step down unit, I moved to the ED! Very excited to work with the excellent team!

Though I know how to be a nurse, being an ER nurse is a whole new world to me... different processes, different resources, and different expectations. These things are stressing me a little bit... I hope that I eventually adjust to the process... like what is expected and when...

Last night in the last 30 mins of my shift, I had a stable NSTEMI admitted (needed to transport her to floor), and back to back ambulances (relatively stable COPD resp distress/tachy & a pneumonia with god knows what drugs in her system).... I decided to try my hand and triaging the COPDer... I was halfway through getting my quick history and trying to enter it in T system when the pneumonia came in. I hadn't gotten labs or checked orders on COPD by the time the next pt was in her room, needing triage/assessment. Went to pneumonia patient's room, let my preceptor triage her as I collected blood/hooked her up to monitor, etc. Got that done and tried to call report on admitted pt so I could take her up since the next shift was already there and I didn't want to dump a transport on them... meanwhile COPD lady is climbing all over the stretcher bc she has to pee! (not to mention, I still haven't collected labs on her... by then I think I had forgotten!)... oncoming RN got her off the bedpan and I kind of mentally checked out... a little bit of shell shock? maybe. I had a sudden and overwhelming feeling of incompetence! I do realize some situations are just overwhelming, no matter how experienced you are...

So I'm wondering... how do you guys prioritize these things? Triage has to go into the computer right away... but I'm inclined to line/lab/problem solve before getting to the computer. I get that this will come with time, especially as I get better at charting in Tsystem... but.... woah. I guess that's what orientation is for...

How long did it take you to get used to the flow/process/your resources?

Any words of wisdom? I know I am an ED nurse at heart and I look forward to getting the hang of it... I just hope it doesn't take me too long... :-P

Specializes in ER, progressive care.

I'm assuming you have computer charting, OP? Whenever I get an ambulance and have to triage, I always bring the computer with me so I can type the triage note as the EMS personnel give it to me, then as I get the initial set of vital signs I can just plug away at the computer, ask my other questions, assign the ESI level and bam! I'm done. I think a lot of times the triage note dictates who will be seen first by the providers and not necessarily the ESI level. ESI levels can change, however.

As for the rest of the charting, it all can wait, in my opinion. I write all sorts of little notes on pieces of paper and then chart when I can, which isn't always right away.

Where I work, we are very teamwork-oriented. A person would never get back-to-back ambulances unless of course you were assigned to the cardiac/trauma rooms and those patients coming in needed those rooms. Even so, we always help each other out and do team nursing. One nurse will do the triage, another nurse (or tech) will do the EKG, line/labs, assessment, etc.

A lot of good advice in this thread. I was floated a lot to the ER since January but officially made the switch in April, and I couldn't be happier. I was shift charge and came from a step down unit just like you. I think that previous experience is invaluable to working in the ER!

Specializes in ER, Addictions, Geriatrics.
Ok I had someone tell me this tip that was So Simple and SO BRILLIANT that I felt dumber just hearing it....

MD orders 1000ml NS bolus stat then 200/hour continuous when that finishes...

A 27 year veteran of emerg nursing told me: "Run the bolus as a secondary IV then the primary 200/hour will take over automatically when it's done."

What an awesome tip!! Thanks!

Specializes in Emergency.

What an awesome tip!! Thanks!

What pumps do you guys use? Seriously, I want them if they run fast enough on the secondary line to give a healthy adult a bolus (

ours max at 999 ml/h). I do use this trick for bolusing CHF pts and Peds though

Specializes in ER, Addictions, Geriatrics.

What pumps do you guys use? Seriously, I want them if they run fast enough on the secondary line to give a healthy adult a bolus (

ours max at 999 ml/h). I do use this trick for bolusing CHF pts and Peds though

Ours max at 999 as well, so I usually end up hanging by gravity if a bolus is required, then attaching them to the pump afterwards

Specializes in Med-Surg, Emergency, CEN.

I run it at 999.

Specializes in Emergency.
I run it at 999.

Oh, ok, I was all excited!

I'm a pressure bag kinda gal, to be honest. I rarely use a pump for saline.

Specializes in Emergency, Med/Surg, Vascular Access.

We're required to run everything on a pump, so a simple L bolus takes an hour :-/

Specializes in Med-Surg, Emergency, CEN.

I only use pressure bags if someone's coding badly. If I need a pressure bag, there won't be an order to follow it up with 200/hour. It'll be followed up with another pressure bolus order.

Specializes in Emergency.
We're required to run everything on a pump so a simple L bolus takes an hour :-/[/quote']

Yikes! We don't have enough pumps for that. If you aren't fluid restricted or getting a med that requires close control it's gravity or a pressure bag (which we do use pretty frequently).

I can just picture one of our physicians barking "a liter in an hour isn't a bolus"

LOL.

Specializes in Emergency, Med/Surg, Vascular Access.

I couldn't agree more...but policy is policy, unfortunately!

Specializes in Cardiology, ED/Trauma, Med-Surg, Telemetry.

Thank goodness for this post! I swear I am in the same position right now. I just recently got hired and I'm on my first month, almost, of working in the ED. I'm experienced, about 3 years in, and I feel so incompetent.

Everyone's comments were very helpful. Thanks!

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