ER dropping the ball?

Dranger · Jan 13, 2016

From an ICU perspective, the ED drops the ball A LOT.

But then again you have to realize how hectic the ED can be, some things get overlooked because of the nature of the environment.

ProgressiveActivist, BSN, RN · Jan 13, 2016

What kind of unit do you work?

They lied to get this critically ill person out of their ER. I would call a rapid response for the altered mental status on a septic person.

I would inform the right people about this inappropriate admission, missed orders, and information witheld on a critically ill patient.

Lev, MSN, RN, NP · Jan 14, 2016

From an ICU perspective, the ED drops the ball A LOT.
But then again you have to realize how hectic the ED can be, some things get overlooked because of the nature of the environment.

Really, I feel bad when I sometimes have to send a patient up to the unit with a dirty gown and sheets. I wish I knew all his/her history. I wish I could give you an ICU level report. But I just didn't have the time.

I was busy putting in every line and tube that you document intake and output from.

I was titrating up his sedation so you can have a sleeping patient instead of a bucking one.

I was busy stabilizing the patient's vitals signs

Dealing with truly sick patients in the ER (people that belong to be hospitalized) is like having a rapid response again and again and again. That is the amount of work and interventions and meds and IVs and labs and tests. Imagine having to put in multiple lines on your patients each shift, everyone has labs ordered, give meds every hour, do vitals every two hours (or more often and sometimes less) and discharge half of your group of patients and get 4 new ones each shift, sometimes two new patients at a time. Not to mention having an unstable patient thrown in here and there. And these people are all hungry, tired, and thirsty and you can't get them food and half of your patients are in severe pain. In addition to all that hands down one of your patient is either psych, drunk, critical, or demented and trying to to climb out of bed. Then your tech is pulled to sit on the psych, drunk, or demented patient and you have to do all the valuables sheets and take all your patients to the bathroom (and there are no bathrooms in the room).

Perspective.

Lev, MSN, RN, NP · Jan 14, 2016

Well, once again I've been sent a patient that is just a complete mess and I have no idea what is going on with him. This seems to happen more than a lot lately.
This patient came in because his wife found him on the floor and when he came to he was confused and weak. He had chest pain in the ambulance that was relieved by nitro.
When he got to the ER they did a lumbar puncture, EKG, CT of chest, abd, and head that were all negative except the LP. They were unable to get that because of bone spurs apparently. His vitals were stable, but white count was 23.9 and he had some respiratory acidosis. The man wears oxygen at home due to copd and smoking 3 ppd. He has sleep apnea but will not wear a cpap, so they sent him up on 2L. I ended up having to get him a mask due to him breathing through his mouth and being knocked out cold from morphine he got in the ER.
So anyways, I talk to the wife and she says he has been throwing up every morning and sometimes through out the day for 9 months, also having malaise, fevers, urinary retention, and just not feeling well. Apparently he had been confused more over the last three days. Turns out he had a pretty significant cardiac history with stents and was a recovered alcoholic. There was no mention of this by the ER nurse.
I soike to the MD and she said he was over sedated from meds he takes at home and possibly had gastroenteritis. She said she was going to order a repeat LP for the am.
First of all, I was only told that he came in confused for 3 days and had an elevated white count and unsuccessful LP. The nurse said he had no other tests done, did not mention any of his history other than HTN and COPD, and didn't say anything about fevers or vomiting. Second, he had been in the ED for 12 hours and didn't even have his EMS stick replaced, had no temperatures recorded except right before coming to the floor, and hadn't been given any fluids, just 1 dose of vanc and ceftin.
Im very confused as to how they can get away with not recording vitals. I figured she had only given me his last set because he just got there. She could've given me a range if he'd been there an entire shift already!
I had to call that nurse back when I got the patient to ask why there were orders for fluid boluses and to get the results of tests that she said he had never had. She denied he ever had a fever or that there were orders for a bolus when she had him. She was very rude and acted as if I was overreacting, but the Dr told me the patient needed to be in ICU. There were just no beds. Then the nurse finally said she thought he had meningitis and to just wear a mask. Ugh!
Also, in the doctors h/p it said nothing about any of his symptoms except for chest pain and elevated white count. I'm so confused and probably too exhausted to be thinking about this right now. All I know is this patient is sick and would be better off going somewhere else if the ER doesn't even have a clue what's wrong with him after he's been there for that long.

Lactate level? Blood cultures? If his vital signs are stable and lactate isn't super elevated he can go to tele or stepdown.

If the patient was there for 12+ hours I understand how this nurse didn't know that much about him. She may have been the 4th nurse taking care of him, 4 quickie reports down the line.

Still vital signs. Nursing 101.

In our ED we are not required to document a repeat temp other than the triage temp unless febrile at triage. Of course we do temps if they appear febrile. We do a lot of rectal temps too especially on those elderly patients. But for routine vital signs...don't do temps.

mvm00 · Jan 14, 2016

Change the medic stick? Your er does this? He had a working line didn't he? You mention vitals not being done but don't say what they were.. If they were stable then the ER did their job, it might take 2 days to find the source of the infection.. Should he have waiting that long in the ER till cultures are back? There are plenty of times the ER drops the ball but there's also many times the floors expect too much..

Wile E Coyote, ASN, RN · Jan 14, 2016

ED has little to no control over what the admitting physician chooses to record in their h&p.

Changing out a field stick while still in the ED is not a good use of ED staff's time.

Routinely taking temps when they don't present out of range or with noted clinical changes is also not a good use of ED time.

Fluid bolus(es) and other orders may have been given by the admitting doc vs ED docs, which CAN be more easily overlooked.

Vitals should have been recorded per a protocol for pts waiting for admission.

Pangea Reunited, ASN, RN · Jan 14, 2016

...but the Dr told me the patient needed to be in ICU. There were just no beds.

And that's the BIG problem, as far as I see it... This was not a med/surg patient and should never have been sent to the unit.

pasdequoi · Jan 14, 2016

The ED's role is to stabilize patients, get an educated idea of what is going on and initiate appropriate treatment, call in the appropriate service, and get that patient somewhere safe ASAP. You do not say what type of unit you are on. Regular floor? Step Down? ICU? Believe it or not, that does matter in terms of what kind of report you will get and what interventions will have been done before the patient leaves the ED.

Also, just a pet peeve of mine - ED nurses do not have time to fluff and puff patients or change field IVs unless they are blown or otherwise useless. Or read charts. There very often is no H&P to read because things are happening on the fly, even if they have been there for, as you put it, a long time. By the way, I am saying this to you as someone who has worked med-surg, ICU, and ED. I realize that it can be very frustrating to not have a complete picture on your admission, but realize that the ED is probably not dumping on you - more likely they are despatate to make room for one of the 12 ambos lined up, even though they are on diversion.....

ED Nurse, RN · Jan 14, 2016

I suggest you spend a little time in the ED to get some perspective about a critical vs non critical pt. You are obviously a new nurse and need to get a little more experience and understanding of the different depts in the hospital.

This pt does not sound like an ICU player- if he had been then arrangements would have been made for a bed if you have a good placement staff. You said his vitals were stable, what's the problem. He also reviewed abx. What was his lactate? An elevated WBC count is not a reason for a pt to go to the ICU.

Many elderly pts Bevin confused with infection- he had a full work up in the ED minus the LP. The job of the ED is to identify things that may kill you in the very near future and correct it- anything further they are admitted and the hospital MD needs to continue a more extensive work up.

Why in the world would I change out a working line from EMS?! That's just dumb.

That pt was in the ED for 12 hours and STABLE- that pt changed hands multiple times. You also have no clue how many other CRITICAL pts those nurses had- pts that required the nurse to do what an ED nurse does- save their life or keep them alive. Have you ever had a critically ill pt, intubated, and titrating multiple gtts to keep them alive? I HAVE! Sometimes I'm doing all that on 2-3 pts at the same time- so yes, that stable floor pt is going to not see me.

As far as fluids- I can't put orders in- and I don't have time to continuously chase down a resident to fix orders. Also, if the lactate is not elevated and the pt does not appear dry on labs, they may only get a liter. Fluid resuscitation in the elderly is a tricky balance.

I suggest you get some perspective before making comments like this- spend an hour in the ED and then perhaps you'll understand the dynamics of emergency medicine. Until then, don't crucify your fellow nurses. I can assure you I'm not sitting on my rump browsing Facebook or allnurses; hell, I typically go 12 hours without eating or peeing! Just the simple perks of seeing 100,000 pts a year!

ED Nurse, RN · Jan 14, 2016

Just to add- it's also not important for me to get an entire history- I'm trained to get pertinent information in a very small window. A lot of the time we have no info and literally fly by the seat of our pants- that takes a lot of skill and training believe it or not. It takes advanced assessment skills that ED nurses possess to treat pts.

Finally- maybe the wife didn't tell the nurse, or the three nurses prior, about the other health info she told you. When a pt changes hands multiple times, it's like playing telephone, not all the info gets passed the same. Sometimes, the family will tell me one thing, and tell the MD something completely different.

Again, my point is perspective and not throwing others under the bus when they truly did nothing wrong. You'll understand, hopefully, the longer you are a nurse and the further experienced you'll get.

Nonyvole, BSN, RN · Jan 14, 2016

Even in the ED, pts and their families tell everybody different things. They see the nurse first - they're anxious. ED doctor - less anxious. Etc.

When a rapid response is called on the floor, how many people respond? In the ED, I am my own rapid response team. I have to be.

Not sure what all the hate is about the field PIV. It isn't like they're licking the patient...they have the same exact training in placing IVs and the same - or equivalent - supplies that are in the hospital.

I'm also having to answer many, many questions by the floor that I don't know. I'm sorry that I don't strip my patients down, I'm sorry that I don't listen to bowel sounds or ask about last BM when somebody comes in with severe respiratory distress.