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.

Specializes in Emergency, Telemetry, Transplant.
Hey ER nurses:

Please quit suggesting people come down and see what we actually do. Last thing I need is somebody looking over my shoulder while I surf the web as my patients deteriorate. I am mostly sitting around eating bon bons until the floor takes report. Once word gets out, there is going to be one heck of a lot more competition for ER jobs.

As far as nurses from other departments being critical of lazy incompetent ER nurses:

Where else are we supposed to work? We aren't smart enough for the ICU, not hard working enough for the floor, and not compassionate enough for long term care.

Be happy we are down in the ER and not mucking things up in your unit.

^^best post ever

Specializes in Med Surg/ICU/Psych/Emergency/CEN/retired.

Hey ER nurses:

Please quit suggesting people come down and see what we actually do. Last thing I need is somebody looking over my shoulder while I surf the web as my patients deteriorate. I am mostly sitting around eating bon bons until the floor takes report. Once word gets out, there is going to be one heck of a lot more competition for ER jobs.

As far as nurses from other departments being critical of lazy incompetent ER nurses:

Where else are we supposed to work? We aren't smart enough for the ICU, not hard working enough for the floor, and not compassionate enough for long term care.

Be happy we are down in the ER and not mucking things up in your unit.

Another post that made me smile, which I needed with all the sad news his weekend. I loved this post. (Wish I were as clever.)

True, in our ICU they give tPA on a 4:1 assignment...

Yikes! When tPA is started in my ER that patient is 1:1.

Specializes in Trauma Surgical ICU.
True, in our ICU they give tPA on a 4:1 assignment...

ICU with a 4:1 ratio!! Yikes, give me the name so I avoid it at all costs. The most I will take is 3:1 but that's rare!!

Specializes in Med Surg/ICU/Psych/Emergency/CEN/retired.
ICU with a 4:1 ratio!! Yikes, give me the name so I avoid it at all costs. The most I will take is 3:1 but that's rare!!

Ratio is 2:1 where I am and sometimes 1:1, depending on the situation. Maybe that is only true for CA, where we have ratio laws. Not that they are always adhered to!

Specializes in Trauma Surgical ICU.
Ratio is 2:1 where I am and sometimes 1:1, depending on the situation. Maybe that is only true for CA, where we have ratio laws. Not that they are always adhered to!

Same at my hospital. I'm not in CA though. However we rarely and I mean rarely have more than 2 pts per nurse but the post I was quoting stated they had a 4:1 ratio for their ICU!! That's just scary and unsafe

Specializes in Med Surg/ICU/Psych/Emergency/CEN/retired.
Same at my hospital. I'm not in CA though. However we rarely and I mean rarely have more than 2 pts per nurse but the post I was quoting stated they had a 4:1 ratio for their ICU!! That's just scary and unsafe

Not an ICU nurse for a long time, but I would have to agree it is unsafe.

The problem between ER and floor nurses/ICU is they do not understand what we have to go through in the ER. Personally speaking, I work in a very busy ER (to put into perspective we saw 239 pt's in a 12 hr shift the other day). EVERYTHING in the ER is STAT (EKG's, labs, urine, xrays, ultrasounds, c/t's, mri's). There's no routine meds, no routine assessments, no routine charting...everything is on the fly. What the other departments do not understand is in the ER we get these things called rescues where ambulances bring 911 calls (sometimes stable, sometime unstable, strokes, stemi's, actively seizing, unresponsive, cardiac arrests, respiratory arrest, drug overdose, suicidal attempts, etc.) and we have to make room for them. When a patient comes into the ER, we do not have a diagnosis like the floors/ICU get, they know what they're working with. All we get in the ER are symptoms and we do the work up for the dx while stabilizing the pt.

Specializes in ER.

Hm, to be honest, some of the worse cases are when there are ED holds in the ER. This is the most dangerous situation in the world in my book. I remember someone online was trying to get rough staffing ideas for a unit that was going to have some ICU hold rooms. I remember commenting that if you have ICU hold rooms, then those rooms need to have ICU staffing which in most places is 2 patients. If you hold ICU patients in the ER, they need ICU level care and not ER level of care which can be 4-7 patients which 2 are ICU.

Specializes in Med Surg/ICU/Psych/Emergency/CEN/retired.
The problem between ER and floor nurses/ICU is they do not understand what we have to go through in the ER. Personally speaking, I work in a very busy ER (to put into perspective we saw 239 pt's in a 12 hr shift the other day). EVERYTHING in the ER is STAT (EKG's, labs, urine, xrays, ultrasounds, c/t's, mri's). There's no routine meds, no routine assessments, no routine charting...everything is on the fly. What the other departments do not understand is in the ER we get these things called rescues where ambulances bring 911 calls (sometimes stable, sometime unstable, strokes, stemi's, actively seizing, unresponsive, cardiac arrests, respiratory arrest, drug overdose, suicidal attempts, etc.) and we have to make room for them. When a patient comes into the ER, we do not have a diagnosis like the floors/ICU get so they know what they're working with, the ER does not. ER DOES THE WORK UP. All we get in the ER is symptoms.

I have to agree with this too. The floor and ICUs have a diagnosis and orders, more often than not anyway. I don't want to feed any feud between departments. I've worked in the other departments during my career so am empathetic. But the situations were often fluid with stress oozing from every pore. It's just hard with so much being expected from nurses. Pointing fingers at each other is unproductive.

The problem between ER and floor nurses/ICU is they do not understand what we have to go through in the ER. Personally speaking, I work in a very busy ER (to put into perspective we saw 239 pt's in a 12 hr shift the other day). EVERYTHING in the ER is STAT (EKG's, labs, urine, xrays, ultrasounds, c/t's, mri's). There's no routine meds, no routine assessments, no routine charting...everything is on the fly. What the other departments do not understand is in the ER we get these things called rescues where ambulances bring 911 calls (sometimes stable, sometime unstable, strokes, stemi's, actively seizing, unresponsive, cardiac arrests, respiratory arrest, drug overdose, suicidal attempts, etc.) and we have to make room for them. When a patient comes into the ER, we do not have a diagnosis like the floors/ICU get, they know what they're working with. All we get in the ER are symptoms and we do the work up for the dx while stabilizing the pt.

I have spent time on the floor and ICU as a float pool nurse so I understand what goes on there, but most of my experience is in the ER and that's where I have spent the past 5 years full-time. I agree entirely with this post, but I have to be honest and qualify one of your statements just a bit. 239 patients can make for a busy ER, but how that translates for an individual nurse depends on how many beds an ER has and how well staffed that ER is for those patients. So while that number may be overwhelming for one ER, causing high and unsafe ratios, it could very well be a slow night for others that are used to seeing way more than 239.

I also want to expound on a previous post where I advised that someone change their attitude, and finally to stop complaining and do their job. Noting I said in this post was plucked from thin air. I have lived and done exactly what I have advised. A good deal of the frustration I was dealing with (and still do) was being caused by my fellow ER nurses. I start work at 7P so when I take over a team it's chaotic in the ER on most nights. It's not unusual for me to find that some or all (our ratio is 1:4 with a 5th, hopefully less acute hallway patient during our busiest times) of my patients not properly cared for, with many of the same complaints that floor nurses have been citing.

For instance, I received report on an elderly gentleman recently who I was informed was incontinent, and the reporting nurse told me that he had cleaned and changed this man twice. I don't remember his admitting diagnosis but I do remember that he was to be a tele admit. His chart was in re-eval and with the doctor at that point but we knew he was being admitted. So I went to see this patient and the first thing I noticed was that he was not on the monitor and he still had his clothing on. Then a family member in the room informed me that he was wet again and needed to be changed. So when I lifted his covers to take care of the situation, I saw that this patient not only still had his shirt on, but he was naked from the waist down with only a pad underneath to catch any urine, but of course he had peed in such a way as to get his entire bedding wet. Why this known incontinent patient, who had already been changed at least twice, was at least not in a brief was beyond me and very annoying.

This same patient also did not have his home medications updated, which is a VERY frequent occurrence when I take over patients. And it never fails that the excuse is that the nurse was too busy and didn't have time, as if I'm not going to be just as busy, but I had to somehow find time to update his medications because this patient could have had a room assigned at any time, and it needed to be done before he went to his room. This lack of attention to something so important by the reporting nurse often results in delayed times getting patients to the floor because it is just impossible most times to sit right down and address home medication lists when I first get there. Not to mention that the reporting nurse probably didn't even attempt to get an updated list from the patient, so I have to spend extra time with patients trying to figure out what their medications are because they may not have a list, can't quickly find their list, or when they do find it, it isn't complete or accurate.

I also take over patients where rooms often look like a tornado hit them with all kinds of trash everywhere, as if the concept of putting the paper from some tubing or an IV in the waste basket is a foreign concept. Our patients already don't feel good and families may already be frustrated by the long ER stay, so having to also sit in a room filled with trash where their family member has not been properly cared for just adds to the frustration and sense of ill feeling.

I also find sometimes that not all medications have been given. Or a patient with a nitro drip doesn't have a second PIV, BP may not have been cycling q 15 minutes (until stable), and sometimes not even on a monitor, all of which are policy at my hospital for a patient on nitro. I could go on and on here, but I think you all get what I'm saying, and I'd be surprised to find any ER nurse who could honestly say that he or she has not experienced some of the same at some point.

So I get it. AND I've taken my own advice. When possible and appropriate, I calmly discuss any issues with the nurse in question, and I write up the worst offenses, primarily the unsafe ones. I also will make suggestions for improvements when I have them. But admittedly, it isn't always possible to address another nurse, and it certainly doesn't mean that it's not still frustrating. HOWEVER, I don't jump to conclusions about why certain things weren't done and automatically blame the other nurse because I wasn't there and I don't have all of the facts. I do try to ask questions to try and ascertain how things got to be such a mess, but I don't name call and I DON'T complain constantly about how I was done wrong, because I know that I don't want to listen to that kind of negativity from someone else, so it only stands to reason that no one wants to hear it from me. Doing that, dwelling on those negative issues, just sets the tone for making a bad night all the way around and does NOTHING to improve anything.

So, like I advised another post-er, I suck it up and set about doing my job to set things as right as I can make them. Because as frustrated and annoyed as I might be, the world doesn't revolve around me and my sometimes petty problems. No matter how bad I may feel that I have it, my patients don't need that negativity and they don't deserve it. I do my best at making sure that anyone taking over for me in the ER, or the nurse getting my patient on the floor, doesn't have any of these same complaints about me, regardless of the way things may have been left for me. IF, on some rare occasion, I haven't been able to address something that should have been done, I am up front with the receiving RN that it wasn't done, state why, and apologize for my transgression. Floor nurses tend to be quite understanding when this approach is used rather than having them surprised when they find out on their own that something wasn't done, and helps avoid an otherwise potentially contentious situation.

So many of these problems would be prevented if only the hospitals would properly staff their ERs and their units.

And a 4:1 ICU ratio should be illegal. What part of "intensive" care is alluding these administrations?

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