ER dropping the ball?

Nurses General Nursing

Published

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.

I want to say thank you to all of you who have had positive responses and tried to help me understand how they roll in the ED. I have a better understanding for some things now. As for those who have been quick to freaking bombard this post with negativity and insulting comments, no thanks. We all need to stick together, agreed!

Specializes in Emergency Medicine.
I want to say thank you to all of you who have had positive responses and tried to help me understand how they roll in the ED. I have a better understanding for some things now. As for those who have been quick to freaking bombard this post with negativity and insulting comments, no thanks. We all need to stick together, agreed!

I mean, to be fair, you are the one who started the whole thread with negativity and insulting comments towards the ED.

Specializes in Emergency/Cath Lab.
I mean, to be fair, you are the one who started the whole thread with negativity and insulting comments towards the ED.

Get out of here with your LOGIC!

Nope still not buying it. No guilt here for for exposing the dangerous and unethical practice of some ER nurses. Excuses excuses and more excuses.

Go on divert. Send them elsewhere if youre full. Stop enabling your incompetent

staff and blaming the rest of the hospital for calling out their negligence. Are you suggesting that we act like some of your staff and just not care? The we're always right mentality is dangerous.

Go work Med Surg then you can lecture the rest of the hospital

about how the ERs bed situation takes priority over patient safety.

im not saying that med-surg is harder than ER , but it is very true that when we get sent 6 admissions in one hour and they're just calling them and shipping them up in a matter of 5 minutes, that makes it very scary! I realize they're doing so because they have no choice, but that doesn't make it any less of a big deal that the patients being sent to the floor are unstable a lot of the time, dementia patients climbing out of bed, psycho people pitching a fit as soon as they get to the floor, all while we're trying to deal with our own set of emergencies with the other patients we have. We are short staffed and it's just impossible to take care of all these people and ensure their safety. A lady broke a hip the other night because the ER couldn't wait for us to move s patient that was more stable to another bed so that patient could be close to the nurses station. Then we get called the worst floor for falls, fined, and sued. When I've got 6 patients that all require attention at the same time it is kind of like being in the ER. And I don't work ER...that's kind of my point. I didn't sign up for all that lol I am a new nurse and need experience before I feel prepared for constant crisis. Plus, the patients and their families are not as accepting of their nurse being busy and having a hectic environment like the ER. Many of them believe they're going somewhere the nurse will be focused on them and provide them with the care they need. Often times it's just not possible because like I said, we also have s lot going on and can't help all these patients at once.

Just saying, I think it's a problem with staffing mostly. All of us would obviously do a better job if we had more breaks, got to eat, pee, and had enough people helping to do our job and not doing everybody's else's job. I can't tell you how many times I've been screwed and my patient at risk because lab didn't draw something when I ordered it timed and even called them. Or when I call respiratory and request stat abgs and get attitude or remarks insulting my intelligence because they just left the floor and the patient "just refused their breathing treatment and their 02 sat was 95%!" The guy literally strutted all the way down the hall giggling with his little RT buddy and said "we should do s stat abg after every breathing treatment". And my patient was blue and could not stop coughing, barely able to gasp for air. His abgs were whacked. It's like some people just don't take **** seriously. Obviously it isn't like this everywhere, but just FYI on some things some of us do have to deal with. It makes our job even harder.

Specializes in Trauma, Orthopedics.

I'm just sitting back waiting for everyone else to be as annoyed with this ridiculous thread as I am.

Specializes in Emergency Medicine.
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im not saying that med-surg is harder than ER , but it is very true that when we get sent 6 admissions in one hour and they're just calling them and shipping them up in a matter of 5 minutes, that makes it very scary! I realize they're doing so because they have no choice, but that doesn't make it any less of a big deal that the patients being sent to the floor are unstable a lot of the time, dementia patients climbing out of bed, psycho people pitching a fit as soon as they get to the floor, all while we're trying to deal with our own set of emergencies with the other patients we have. We are short staffed and it's just impossible to take care of all these people and ensure their safety. A lady broke a hip the other night because the ER couldn't wait for us to move s patient that was more stable to another bed so that patient could be close to the nurses station. Then we get called the worst floor for falls, fined, and sued. When I've got 6 patients that all require attention at the same time it is kind of like being in the ER. And I don't work ER...that's kind of my point. I didn't sign up for all that lol I am a new nurse and need experience before I feel prepared for constant crisis. Plus, the patients and their families are not as accepting of their nurse being busy and having a hectic environment like the ER. Many of them believe they're going somewhere the nurse will be focused on them and provide them with the care they need. Often times it's just not possible because like I said, we also have s lot going on and can't help all these patients at once.

Just saying, I think it's a problem with staffing mostly. All of us would obviously do a better job if we had more breaks, got to eat, pee, and had enough people helping to do our job and not doing everybody's else's job. I can't tell you how many times I've been screwed and my patient at risk because lab didn't draw something when I ordered it timed and even called them. Or when I call respiratory and request stat abgs and get attitude or remarks insulting my intelligence because they just left the floor and the patient "just refused their breathing treatment and their 02 sat was 95%!" The guy literally strutted all the way down the hall giggling with his little RT buddy and said "we should do s stat abg after every breathing treatment". And my patient was blue and could not stop coughing, barely able to gasp for air. His abgs were whacked. It's like some people just don't take **** seriously. Obviously it isn't like this everywhere, but just FYI on some things some of us do have to deal with. It makes our job even harder.

Your lack of perception completely boggles my mind- seriously.

If you are displaying the same attitude at work as you do here, thinking you are the only one dealing with difficult pts, then it's really no wonder that others don't take you seriously when you do actually have a sick pt- I'm sure you've heard of the boy who cried wolf, right?

You need to relax and stop making every situation into a) a pissing contest with the ED or b) some catastrophic event when it is not. I would find someone in your department, who is not a novice nurse, and have them mentor you. Maybe someone at your job outlining your lack of understanding and perception will help you more than strangers on an app.

Stop blaming others and trying to point the finger. You need to realize what you don't know and not walk around living in a bubble with blinders on- you will make nothing but enemies with others if you continue on this path.

Specializes in Education.

Birdy, in light of your last post:

Like ED Nurse said, if you're feeling overwhelmed, find a mentor. Use a mentor. Learn their tricks and see if you can make them into your own.

In the ED, patients and their families are also of the opinion that they are the only ones that matter; it's not just the inpatient units that get that. So it's up to us, the nursing staff, to make them feel like they are important, even if we can't respond immediately to them. Do you do hourly rounding? Just sticking your head into the room and asking how they're doing makes patients and families much, much happier, and it takes less than 30 seconds.

Communicating with patients and their families. "Sorry about the wait. I've paged the doctor and am waiting on him to call. As soon as I know something, I'll tell you." Boom. Patient feels empowered and involved in their care. They also feel like the hospital cares about them. I have to find the research, but I heard an anecdote. Patient satisfaction went through the roof when the only change made was people apologizing for extended wait times. Nothing else changed, people were still sitting around for much longer than they wanted to, but the staff started acknowledging the time and the patients felt like they were more than a number.

Warning patients about timing. "Let me go get that for you - it might take a few minutes, however. I'll be back as soon as I can." "The test results should be back in about two hours. In the meantime, here's the remote, here's the call bell. Nothing to eat or drink yet, but as soon as the doctor tells me you can I'll let you know."

Any time RT or lab refuses to do something or blows you off, tell your charge nurse. Passing it up the line means that they'll soon learn that their inactions have consequences. Will they be unhappy? Of course. But we've made enough noise at my current facility that people have been retrained, gotten enough warnings that they're one step away from being fired...Yeah, otherwise good people have left, but they had some amazingly bad attitudes and work ethics.

This may be anecdotal, but frankly, I've worked in some places that had things held together with duct tape. But the patients were happy and would return, because even though there wasn't enough staff, the few staff there were focused on their patients and their families. It's tough, yes, because you'll be starving, your feet will be sore because you haven't sat down in 6 hours, and you feel like your bladder is about to burst. I've worked in places that had the top-of-the-line equipment and way more staff than needed, but patients were miserable because they were being treated like a dummy in a simulation lab.

A lot of this is not taught in nursing school, and rarely during orientation. Mostly because it's hard to teach attitudes. But as my boss says..."If you're in this for the money, than you're in the WRONG field."

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.

Yes. I make sure all scans are done. If that is t the case it's either A. Ct is backed up and they said it would take and hour. In that case I tell you and offer to send someone to help push the bed (and it's usually refused) or B. It's a held order I haven't looked at. In which case I call the imaging Dept to see how long till they can get in, release the admit order, send them to imaging with everyone on the same page they will go to the floor/ICU with the appropriate monitoring when the imaging is done.

You are correct. None of the RN's where I work feel differently.

A lot of this is not taught in nursing school, and rarely during orientation. Mostly because it's hard to teach attitudes. But as my boss says..."If you're in this for the money, than you're in the WRONG field."

For sure. The money can be decent, it's not great, and it will not overcome burn out. Hate seeing RN's looking at Facebook while others around them are drowning.

Yeah some RN's in the Ed will dump on you. Write it up and move on ;)

I think the lesson learned is dig deeper in report. If it doesn't feel right , it probably isn't. This patient should never have been transferred to any floor that as not the ICU. Saying there are no beds and sending him somewhere else is dangerous for all involved , especially the patient . You should have created an occupancy report so ED mangers would be aware and have to respond ON PAPER.

Specializes in Critical Care.

It's ridiculous this blame game has gone on for 225 comments, and is the epitome of the reason why departments have trouble working together. I'm reading through the initial post and still having trouble picking out where the "ball was dropped."

He sounds septic. The WBC will be elevated. Hx COPD, I would've been surprised if his ABG was normal, he's acidotic on an everyday basis. Malaise, fever, vomiting... gastroenteritis, septic. Check, check. Vitals, our ED doesn't record them the way we do, either. A range of vitals? Lol, maybe in the TV shows. Same with the IV. If this pt is "ICU" like you stated, the last thing you're going to do is remove a perfectly good IV.

The only problem is the fluid bolus. If he's septic he likely needs it. But there's no mention of what time the order was placed, or by who. That's pretty standard here though, and part of the sepsis bundle. Should've been done.

Honestly the problem here is you. You sounds new and overwhelmed, but that's not the problem. The problem is bashing co-workers who likely work just as hard as you. The problem is bashing the ER because they don't "have a clue," despite you having a stable, breathing patient who had tests and ABX already done. Don't think you're immune. There will be plenty of nights where you leave the next shift a train wreck because that's the nature of 24-hour acute healthcare. If we can all pretend to work together and pretend like we don't all sit around doing nothing all night, it would make it that much easier for all of us. Welcome to nursing, Birdy.

Specializes in Emergency Nursing.
I have not read each post in this thread, but wanted to quote you because I really like what you've said. I am a med-surg nurse, and I cringed at your examples of the petty things you have been called about. Thank you for being calm and patient in how you responded. You have a great attitude.

Thank you for the kudos, I appreciate the kind words.

I think the point that we are getting away from on this post is that we are all working together for the best interests of the patients and that we are in different practice areas and thus have different priorities/work routines. On the inpatient units, there is a large number of orders that the nurse is responsible for ensuring get fully completed in a timely manner and many of the patients tend to require a lot of care because their illness/injury has left them less able to function independently. In the ED, the priority is urgent and emergent needs and so anything less than that tends to be deferred which is not the ideal but the nature of healthcare. That doesn't mean us ED nurses get a free pass not to properly monitor and document our patient's V/S (for example) but this is based on presenting condition and acuity. I will be the first to tell you that yes there are ED nurses who do not adequately document the patient's V/S or overall condition in their notes even when they are on a cardiac monitor and are being observed carefully.

I think one aspect of patient care in the ED that is difficult for nurses who have never worked in that setting to understand is that we cannot stop patients from entering the ED even if we are full. Putting an ED on diversion is a very difficult process and rare occurrence and definitely does not happen with the frequency in which we as staff may think is warranted. Just this evening in my ED for some time we had every room full with no available portable monitors and yet we still had patients sitting in the hallway who needed monitored beds for chest pain and other serious complaints. ED nurses we being pressured to call the med/surg units and repeatedly ask the nurses to take a report because we had no beds for the patients who continued to arrive in triage and the ambulance bay. When I transported an admitted patient to the floor the nurses asked how busy the ED was and when I explained this they appeared shocked. One nurse said "But you have no more monitors and these patients need tele. You can't safely take care of them. What did you do with them?" and I replied "We have no choice. They have to sit and wait without cardiac monitoring until we can get another patient admitted to the floor so we can have the available bed." We briefly discussed how it was better to have an admitted patient placed on a tele monitor on a med/surg inpatient bed even if it took a while for the inpatient nurse to finish admitting them rather then have this admitted patient sit in the ED on the monitored bed while another patient with chest pain or a similar complaint sits in the hallway with no monitoring because no bed are available. I was surprised to see how the inpatient nurses agreed and genuinely seemed motivated to expedite getting patients to the floor (especially in times when the ED is deemed oversaturated and without cardiac monitor beds).

With that being said, in my last post, I provided you with two examples of poor communication and mismatched priorities between units which is unfortunately very common. However, I recently had a really great example of good communication between the ED and an inpatient Med/Surg unit which I would like to share.

I was caring for a patient that needed a few units of PRBC to be transfused due to symptomatic anemia with a significantly low H&H. By the time that I got the orders for transfusion from the ED MD and the product prepared from the blood bank I already had an inpatient bed assigned and ready. So I faxed report to the floor, went to the blood bank to get my first bag of PRBC product and initiated the blood transfusion. After I had monitored the patient for (20) minutes I called the floor, asked the nurse if there were any additional questions and informed them that I would be transporting the patient at that time. I transported the patient to the floor and got him transferred into the bed myself with his call light. I found his nurse and asked if she would come into the room to verify that the blood was transfusing at the rate I reported and to show them that the was in no active distress and displayed no signs/symptoms of transfusion reaction. The receiving nurse was polite and receptive, I very briefly reviewed the report with her in person as well as the last set of V/S I took before leaving the ED. I told the patient that he was in good hands and would be well cared for on the unit by this nurse. I had not met her previously but I am a huge believer in talking up coworkers, it sets patients at ease and helps to set a positive expectation that people are more likely to live up to. Before I left the nurse complimented me and thanked me for getting the patient up to the floor in such good condition. I don't share this story to pat myself on the back or anything like that, I share it because it is a good example of positive, patient-focused communication that can exist between units when coworkers give each other the benefit of the doubt and assume that we all do our very best job most of the time.

!Chris :specs:

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