Emergency Room Nursing Vs. TELECOMMUTING

[Jerry 75]

i had worked er an rn for around 14 years and was thinking about my past years as ed nurse and comparisons of ed with present job of telephone triage remote working out of my house. i wonder how many other er nurses made similar transitions to home triage nursing

triage without seeing or touching

you can't see the rash/skin color, can't visualize the size of the lump/bump. leave it up to the pt. to determine if their is any angulation or out of place joint or if it is just swollen. you can't touch nor feel over the phone. if phone quality is poor you may not be able to hear barley audible wheezing nor stridor.

you can't put a stethoscope to a child's chest and they tend to breath hold or push the phone away when you try and listen to them breath, can't observe gait or pupil size.

you may be dealing with a deaf patient and have no verbal from him and openly be talking to the interpreter who is signing or typing back and for to the patient. with this pt. you can't really sense how much distress he is in by his voice nor hear any breath sounds! but then again not being very close to a cough can be a good thing in this age of swine flu. also on the positive side of telephone triage nursing is never having to come in contact with body fluids! and no restraining nor take downs!!!!!

and what about arrythmia all we get is my heart is beating fast or irregular. we have no idea what the hell rhythm the guy is in??

ed rn maybe to close, to often to rashes and coughs and other bodily fluids. ed has telemetry to know wht the heck is going on!

identity/confidentiality issues/misrepresentation issues

you never really know who you talk to because people lie allot. i mean you have confidentiality issues/hippa laws and when you ask am i talking with joe the plumber they answer yes! if you ask with whom am i speaking to they will give the patients name. they don't even have the courtesy/honesty to tell you they are not the patient! till after a few triage questions you hear them asking your questions to someone else (the real patient) and confront them about it and get the real pt. on the phone. imagine if you went into a bank and try to cash someone elses check and identify yourself as that person!

at least in the ed you see someone face to face and are able to identify the patient.

and quite often you are talking to a caregiver who identify their selves as a nurse! they are not nurses! they are impersonating a nurse. try pulling that working in the ed and pt. asks what you are and tell them you are a doctor! see what happens!

pt's have the speaker phone on so all their friends and buddies can hear your private examination of the pt. plus you have the patients looser friends and relatives telling them what is wrong with them (like the pt. can't talk for their selves).

i suppose that is the equivalent to having to deal with meddlesome visitors in the er

control freaks

then you have the other control freak husband or wife of patient who refuses to give up control of the question answering and wont put the pt. on the phone "well i can answer your questions" "he can't talk", "he doesn't want to talk", "he is to weak to talk" "he is sleeping" "he is eating" "he is in the shower".

i insist on getting the pt. on the phone i don't need any third party info till after i speak with the pt.

half the time the audio quality is crap, quite often the phone disconnects.

not willing to wake the patient/non compliant parents

you always have to be ready to give a rationale for any question you ask the patient or parent. one of the major 911 questions "is the pt. arousable" and you have to give rationales so they will wake the patient because they don't want to wake up their kid. have the patient stand and walk "he doesn't want to" "he was walking 10 hrs ago fine". pt. feels feverish "what is his temperature"? they either feel his head and make up a number or never took it or don't feel it's necessary to check it until you insist on it. or dealing with a patient who weights 20 lbs "take his temperature please" "he wont let me" "he doesn't want me to" if this kid is in control of his parents at 1 year old and 20lbs weight how will they ever control him as a teen?

in ed it was much easier you didn't have to ask the person on the other end of the phone to wake the kid you just do it yourself.

phone control, redirection, diffusing

you are stuck with these terrible time constraints to complete your call in, have quotas so many calls per hour (some times i feel like a cop handing out as many tickets as he can at the end of the month to meet his quota). so you have to keep your pt. focused by redirecting him when he talks to much or goes off topic. you also have to deal with allot of angry patients and be able to diffuse and redirect them. "why didn't that **&^% doctor give me an anti biotic" "you people *&(()^$%$$%" "i waited 2 hrs for you to call me back and now uc is closed and i can't seen and have to go to the ed" you have patients that are experiencing both physical as well as emotional pain.

advice, recommendation's, disposition

as a nurse we don't diagnose, based on your symptoms and history i recommend that you........

as far as advice/recommendations/disposition very tight parameters/policies and protocols to adhere to. very little room for deviation from the protocols.

when you downgrade the "recommended disposition" ie your computer program advises you "recommended disposition" to hang up and call 911 and you instead elect to send him pov to ed you better be very sure of why you are doing it and sure he can last the car ride to the ed with out crapping out. your clinical judgement and years of experience better be sound or you will hang in court if he or she goes south on the way via car to the ed

every thing in telephone triage is recorded on real time tape with playback that shows your typing as well as your paperwork and verbal so if you screw up you are really hung!

everything in telephone triage is based on very rigid protocols and they even give you automatic computer generated dispositions now!!!

resources

when you have questions you have a lead nurse and a supervisor. things are improving i remember back in the day 3 years ago when you were on a call and asked the supervisor a question they were useless "look it up in your notes" "but i already did and couldn't find the answer" and they were very rude in their useless response instead of answering your question and help expedite the completion of the call, they are oppositional and rude and belittling you like you should know that and not have to answer that.

but after numerous complaints from me and others to administration about this issue and also that all the supervisors used to do was sit on their lazy butts and listen to your calls as you do them, and not contribute to reducing call volume by talking calls- now they are helpful and allot more pleasant!

we are getting better internet med link sites but internet is not as fast as it could be with our system

ed supervisors in contrast were helpful but they were always very busy mostly occupied with finding beds or expediting getting new admits up stairs. but when you asked them a question re pt. care they would be helpful and give you a direct answer not bs around

physical effort

no lifting, carrying

ed having to deal with obese unbelievable overweight patients. having to turn them, lift them, position them, transfer them

feedback

i am pretty good at diffusing angry/volatile patients so i can usually turn a fighter around and get an apology from them at the end of a call for being so difficult with me. but aside from that it is nice to get a thank you at the end of the call!!

if someone wanted to complain about the triage nurse every breath you take was recorded for your supervisor to her and review on your call!

ed inner city hospital patients with a gripe would attack you in white collar hospitals where everyone spoke english and the worst od you got was tylenol they were very articulate and instead of attacking you they wrote eloquent letters with very specific complaints about you! but in the end it was your word against theirs!

so all in all would i go back to ed? no way! the thrill is gone! it was fun but after a while time to move on!

i mean like how can you beat doing a few laps in my pool or get on my rowing machine on my break or have a nice home cooked meal and tv in your kitchen instead of the break room? when i was at the call center there were so many unhealthy very obese nurses and yet management brought in soda and candy machines and there would always be some celebration at work with cakes and sweets and other junk food to further fatten the nurses up. nothing like promoting health!

[emtb2rn, BSN, RN, EMT-B]

Mike, take a deep breath. Based on your recent posts, I'm sensing some anger towards ER staff. Not sure what your point is....

[allennp]

WOW! Lengthy post that my eyes blurred reading! Did you type all of that!!! I am replying to your first paragraph about telemedicine. Yes I like it. I was a level 1 ED RN, Manager, airlift, na na na na . Took a Consulting Nurse position with a progressive, forward looking, dynamic health care company, took my extra energy from spending it doing what ED RN's do and went back to school to be a NP (another story there!).

Did I miss face to face? Yes I did, that's why I went back to be a NP in ED's. Did I like the telephone bit, I loved it. The outfit I work for has many RN's working remote from home, as well as in our office. I think working remote is a little socially isolating, but there are many benefits, some of which you mentioned. It really works your other senses, hearing noises on the phone, breathing cadences, as well as the tonal inflection of voice. One learns about using your own voice as a real tool of communication. There are a lot of systems using telemedicine in different ways. The RN's intergrate care for our patients, am able to order test, antibotics, follow up with results based on protocols and consultation with MD's or ARNP's. Its pretty cool with the possibilities in trying to structure cost management, improve patient outcomes and provide patients with more interaction with their health care team.