ER dropping the ball?

[Birdy2]

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.

[ED Nurse, RN]

This is where these ED/inpatient arguments get ridiculous. The specific assessment you're saying is never done was if the patient was "following commands or withdrawing from pain", in other words a GCS. As a trauma nurse it's a bit embarrassing to hear another nurse claiming to represent trauma nursing to claim it's ridiculous for us to know a GCS on a patient, it's something you are aware of if you're within 5 feet of the patient at any time if you're a competent trauma nurse. So to try and support the argument that the "other side" is ignorant of what you do, you're willing to support that by admitting you're an incompetent trauma nurse, which I doubt is actually true.

The discussion was about a neuro assessment, to include gag reflex, pupils, etc., nothing about GCS. Of course the GCS is the first thing assessed- it's called out by the MD at the head of the bed while assessing the airway. I, as the trauma nurse, do not assess the GCS- why would I when it is the responsibility of the MD at the head of bed?! I have numerous other responsibilities as the primary RN. Be embarrassed all you want, but I can assure you I'm way more competent at trauma resuscitations than you- I have 20,000+ traumas in Afghanistan to thank for that, with a 99% survival rate at the only level 1 in country. Put the claws away and calm down.

[ThePrincessBride, MSN, RN, NP]

My only gripes with ED are not getting report (we used to but now they are no longer required), dropping the patient off in an empty room without notifying staff (and showing up without giving us a reasonable notice) and ignoring orders (especially the CT/diagnostic scans as that would mean that I would have to leave my other patients unattended to take them down to CT...which is right beside the ED!).

I realize it gets busy, but can a girl at least get a heads-up that a patient is on the way up?

[Horseshoe, BSN, RN]

I realize it gets busy, but can a girl at least get a heads-up that a patient is on the way up?

Yeah, that would be frustrating. Not an unreasonable request at all.

[PrincessDarkCloud]

AMEN!!!

[banterings]

Calling someone out for giving inaccurate information is not being a troll or unprofessional. The issue is speaking about nursing priorities in other departments when you have first hand knowledge. I, at no time in this post or any other, have presented information, or ideals, about a unit I have not worked in- - correcting someone again, is not unprofessional.

The original premise of this post is that OP has no firsthand knowledge about the primary responsibilities of the ED nurse and therefore, placed blame and anger where it did not belong. Understanding the primary responsibility of nurses in differing units is key to cut down on "turf wars." A nurse(s), sharing inaccuracies based on opinions, is not professional and further leads to division of nursing departments. Just bc YOU think ED nurse should do A,B, and C does not mean that A,B, and C are ACTUALLY what is expected of that nurse or part of their primary duties.

The term troll” is derogatory in and of itself. It is paramount to gomer,” noncompliant, or the other n word. While technically correct, the term also dehumanizes the person that it refers to.

The use of derogatory terms is not professional and further leads to division.

As to the OP "firsthand knowledge about the primary responsibilities of the ED nurse,” do you work in her facility? Then how do you know exactly the ED nurses are required to do in her facility?

There are ways to have discourse and be respectful.

[Susie2310]

It is also a shame that patients view healthcare just as they view cable TV and cell phones, it is NOT who is the best, it is who sucks the least. Patients enter the system with the expectation of incompetence and mistakes occurring. It seems that everyone accepts that it does not have to be good, only good enough.”

Again, I ask why?

In my experience, patients and family members very often don't have enough medical/nursing knowledge to recognize problems/errors in care, or to recognize if the patient is receiving poor, dangerous, care. And even if they do recognize these things, they may find it very difficult (for a number of reasons; not least that they are often very sick and lying in bed) to address these problems with the doctors/nurses, and remedy them.

[ED Nurse, RN]

The term troll” is derogatory in and of itself. It is paramount to gomer,” noncompliant, or the other n word. While technically correct, the term also dehumanizes the person that it refers to.

The use of derogatory terms is not professional and further leads to division.

As to the OP "firsthand knowledge about the primary responsibilities of the ED nurse,” do you work in her facility? Then how do you know exactly the ED nurses are required to do in her facility?

There are ways to have discourse and be respectful.

Did you really just equate the word troll to being equal to the n word?! You can't be serious and just lost complete credibility as far as I'm concerned. Also, you do know what gomer stands for from the ED perspective right? It's a phrase, not a deragatory name.

Primary responsibility of ED nurses does not change from ED to ED- policies do differ, like calling report vs not calling report. Did you read the original and subsequent posts by OP- the majority of issues are not the responsibility of the nurse. Nurses do not order meds, nurses do not write admit orders, nurses do not order labs/studies.

[dianah, ASN]

Note:

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[banterings]

...Did you read the original and subsequent posts by OP- the majority of issues are not the responsibility of the nurse. Nurses do not order meds, nurses do not write admit orders, nurses do not order labs/studies.

Yes I did, and as I stated previously, the OP places blame on the entire department (hence the title of the post).

[Lev, MSN, RN, NP]

Honestly, the only thing that really gets me that the ED does is not take people for stat scans. In the middle of the night, the only open CT scanners are in the ED.

My ICU is all the way on the other side of the hospital. Once the ED brings me the patient, and I get the patient on the ICU bed which is way bigger, heavier, and harder to steer than the ED stretchers, I have to take the patient right back down to the ED for a head CT that takes less than five minutes. I wish they would just tell me up front they weren't willing to do that - I'd have someone watch my other patient and I would go down, roll the stretcher into CT myself, bring the patient to ICU, and I'd even return their stretcher to them when I was done. It would be so much easier than rolling our old dinosaur beds, half of which have broken/malfunctioning steering mechanisms and take at least two of us to manhandle the bed in the right direction.

ED people - what do you think about this? Coming from the ED, the CT scanners are right before you get into the rest of the hospital. Am I being unreasonable when I ask the ED nurses calling me report why they can't do the stat head CT that's literally on the route between where they are and where I am? I don't mind when the patient is filthy and covered in poop. I don't mind starting new lines. I don't mind intubating a patient. I don't even care if you don't know what the patient's name is. I just mind having to take the patient back down to the ED myself when the patient was already in the ED to begin with.

I hear you and I generally will stop at CT on the way up to ICU. (It gives me a little break and I can log onto a computer there and chart a little). I cant always do this though. (3 other peeps to worry about that I have just ignored for 4 hours).

[Breanna09, BSN]

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.

I work ER and ICU and the ER does not the ICU is filled with princesses. The ER nurse has 4-5 patients and at times 3 or 4 are ICU yes I have in the ER been assigned 3 ICU patients and still expected to take care of a 4th patient cause we have 4 room assignments. You want every tube placed before they come up and every order done by the admitting doctor that's not our responsibility. Also once a room is assigned we have 30 mins to get them to that room or we are dinged. The ER does not remove/replace field sticks if they work. As far as orders the ER nurse is only responsible for administering all ER orders if it's an admission order we don't start them. I find my ICU shifts cushy only 2 patients for an entire shift how nice in the ER I see and average of 8-12 patients, that all need line, labs and tests we are expected to turn our rooms over in under 4 hours. Also in the main post stating patient should be in the ICU that's not up to the nurse if the patient needed ICU the admitting doc should have wrote for that. I'm tried of ICU nurses giving **** to the ER who do you think saved them so they could make it to the ICU. When I do my ICU shifts and I get a new patient all I ask is are they stable and what still needs to be done state otherwise I just read the chart and my orders and go from there. Also remember ER is focused assessment only we don't do full head to toe assessments so if someone is there for CP we are not looking at their skin and lots of times while they are with us they are in bed the whole time so we don't know if they can ambulate. Imagine you continually get a new patient every 4 hours and within the first 30mins you have ever to assess, get an IV started get labs, medicate and get them ready for all their tests for they can be admitted or discharged within 4 hours to get them out and start all over and doing this to 4-5 patients at a time, and that's the simple ones. What if one of the 4 is a stroke protocol I'm doing Q15 min neuro checks while still responsible for 3 other patients and taking them monitored to CT. Or STEMI protocol we have to have 2 lines in, EKG and naked to go to catch lab in under 10 mins again. With 3 other patients needing us. Heaven forbid ones coding again we still have 3 other patients pressing call lights, having orders to be done and wanting their meds. So please remember the ER is a hectic situation we we never get a report every single patient is an unknown, no H&P and lots of times patients don't know their history, their meds and neither does the family. Can't tell you how many times I try to get a med list and they say well I take a yellow pill, 2 small ones, and you ask what they are for and they don't know and say they have no medical problems. It's not easy getting any info and most don't even tell us the full story of why they are there. C/of right flank pain but don't tell you the day before they got thrown off an atv. So you think kidney stone work up instead of trauma work up. Or c/of fall but don't tell you they felt dizzy just before and passed out prior to the fall. I think for the most part we all are doing the best we can for our patients.

[OhioCCRN, MSN, NP]

Don't dare compare ICU to ED because you will NEVER get a cardiac arrest admission whereas rescue will bring us a cardiac arrest in the middle of giving report and the nurses upstairs are so concerned if the MRSA screening was done. Then when we transport the pt upstairs, the receiving nurse is sitting at the station drinking their coffee and watching videos on their cellphone.

Umm... I feel the need to point out that as ICU nurses we get coding patients as admissions ALL THE TIME...

What the heck are you talking about?