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.

[dream'n, BSN, RN]

This is not an ED vs Inpatient unit problem. The problem is STAFFING and that is due to administration/money. Most nurses in the hospital are working the hardest they can, ED and inpatient, but there is only so much a nurse can do at once. Everyone is running around doing everything they can, and if there was an appropriate nurse staffing cushion, this would not be an issue. Hell, there are nurses out there praying for jobs, but they're not hired. Put the blame where it lies; not the ED, not the inpatient units, but on the money-saving staffing initiatives by administration due to the American healthcare system. Nurses need to stop blaming other nurses and look at the root of the problem.

[Nurse Leigh]

This is not an ED vs Inpatient unit problem. The problem is STAFFING and that is due to administration/money. Most nurses in the hospital are working the hardest they can ED and inpatient, but there is only so much a nurse can do at once. Everyone is running around doing everything they can, and if there was an appropriate nurse staffing cushion, this would not be an issue. Hell, there are nurses out there praying for jobs, but they're not hired. Put the blame where it lies; not the ED, not the inpatient units, but on the money-saving staffing initiatives by administration due to the American healthcare system. Nurses need to stop blaming other nurses and look at the root of the problem.[/quote']

This X infinity

And you know TPTB love the interdepartment fighting because then the focus is not where it should be - fighting for nurse-patient ratios and the like.

[Dranger]

I am not dogging on the ED nor am I making extreme generalizations.

All departments drop the ball and in my opinion day vs night ICU RNs are the hardest on each other. ED gets off light in that regard.

I am just surprised at the defensiveness. You can't tell me none of your ED companions have said, " That sounds like a floor/inpatient problem".

[ednurse17, BSN, MSN, RN, NP]

Amen!

[Lev, MSN, RN, NP]

I haven't said anything about any other departments not doing a good job. All I did was give an example of how a typical shift runs in the ER I work at. I'm sure it is twice as bad in level I centers and those with high nurse-patient ratios. Where I work in the main ER we frequently have nights with all 2s and 1s scattered around. The 3s wait in the waiting room for several hours on those nights. Our light 3s and 4s are seen in fast track. We only have a couple 5s (medication refill, wound check, suture removal) each shift.

We are run ragged. We can't divert and we can't stop the ambos and people from coming in. A typical shift is utter insanity.

I am not undermining your experience. Some of our ICU nurses float down to ED. We don't float up there. We don't all have the in-depth knowledge. Some ER nurses have never worked on the floor.

Understand us and accept the circumstances. Believe me - we would do much better if we could.

Next time anyone has an ER nurse snap at them - know that it's not personal, but it's just a reflection of what is going on the background.

[Lemmy8]

I bet you would care if one of those 8 ambulances waiting with the patients in the ED had your mom, dad, brother, sister, uncle or aunt stroking out, having MI or seizing and needed immediate intervention. Some of you nurses here need to float to the ED and shadow ER nurses instead of convicting them based on care they provide to patients in a fast pace environment.

[ScrappytheCoco]

I could generalize about med/surg nurses due to all the RRs I've gone to where lack of assessment skills or appropriate interventions to prevent deterioration were blatant. I had a med/surg nurse open my clamped Propofol before we had an airway (she said she was "trying to help" and "thought I had forgotten to open the clamp"), and then then call me dangerous because I had PRBCs wide open on a post op who was exsanguinating on the floor. Really? Does that mean all med/surg nurses are raging idiots who need their hands held? Absolutely not. Those are individuals who need education and it's never appropriate to generalize based on limited experience. As PP said, the real culprit here is staffing. If I wasn't forced to care for 5-6 ESI level 2s at a time with possibly 2-3 level 1s or ICU 2s in there...perhaps I could tell you when my patient last had a bowel movement. If you weren't forced to care for 7-8 high acuity on the floor, maybe you wouldn't be so stressed about tasks like restarting your field stick.

At the end of the day, anything we can do to help each other out and improve patient care and outcomes is the point of what we do. A little perspective goes a long way on either end of this debate. If you feel patient care was truly compromised or neglect involved then it should be reported to the patient's physician and the appropriate supervisors.

[edmst]

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.

You would call a rapid response for the pt being altered even though he came in altered to begin with yet vitals are stable? Just an elevated white count does not = sepsis. The problem with the regular floors and the unit is they don't realize the difference in workload. When a pt comes in by ambulance, sometimes its just one nurse getting report from the paramedics, undressing the pt/connecting to the monitor, triaging the pt in the computer, starting an IV line if one wasn't started, drawing blood...all while stabilizing the pt. And guess what? EVERY order in the ED is STAT. Now the pt is stabilized, our other 3 pt's have STAT orders to be carried out. And then giving report, the floor/icu nurse moan and groan if every little thing wasn't done. The nursing profession is a continuation of care, NOT for the ED to do everything. I've worked MS/Tele/ICU/ED. In the ED you only get symptoms, everywhere else you get a diagnosis from the ED's workup. So you're welcome...

[Altra, BSN, RN]

I stopped reading the comments after page 3. Same old, same old.

• ED diversion is often dictated by local or state law. In my state, there is no diversion unless the whole hospital goes "black" - closed to admissions. The doors never close.
  
• Med reconciliation is a CMS requirement of physicians/providers. If your hospital is allowing them to pawn this task off on nurses ... suggest that nursing management do something about it, rather than individual nurses snip at each other for not doing something unreasonable.
  
• You probably know what core measures apply to evaluation of care on your unit. Do you know what core measures are for emergency departments? Look them up and educate yourself. Hint: they're all time based.
  
• You don't care about the other patients coming in? Really. There is no response to that - I can't even go there.
  

[edmst]

There are nurses that work ER that will screw you though, same as there are unit nurses that do it. I know they were slammed that night, but there have been nights when I get an admit and I'm running around giving meds,keeping people in bed, dealing with family members who are mad because their loved one hasn't been changed, starting IVs because somebody ripped theirs out and needs units of blood, insulin drips that need to be started, somebody hollering for pain meds, somebody else who can't breathe, and so on. ER will call for report, they're told we will call as soon as we get a chance, they call back in 5 minutes, are told the same thing, then they say they will wait on hold until the floor nurse is available. Well if there's time to sit and wait on hold then obviously it ain't that busy. They wait on hold because they're desperate to send us another crazy patient whose gonna climb out of the bed all night lol that's annoying

Pleeeeease come and visit the ER. What you just described, guess what, ALSO happens in the ER. Except, we see about 25 pt's a day (per nurse) while you only deal with max of 8 I guess. The ER doesn't call rapid responses because we handle it, as well as dealing with the drug seeking pt's, attention-seeking pt's, critically ill pt's, the strokes, the cardiac arrests...We have to send pt's up because they are stabilized and ready for admission. What happens if the ambulance brings a cardiac arrest? Do we tell they to come back in 5 minutes? Keep that in mind...

[ednurse17, BSN, MSN, RN, NP]

Isn't it up to the admitting doctor what floor this patient should go to? Who lied? Our hospitalist usually come down to the ER to see the patient before orders are written. Our house supervisor assigns our inpatient beds after speaking to the charge nurse or unit coordinator about the admission. Yes, we've had patients that have crumped out after getting upstairs, but we ER nurses can't control that. Please come walk in our shoes before you judge.

[ednurse17, BSN, MSN, RN, NP]

I don't know what hospital you work at, but our ER nurses don't screw anyone. We have 30 minutes to get a patient upstairs after admit orders are written. We have held patients longer to allow the floor nurse to get there, but we have to account for that delay also. We have those same patients who need insulin drips, getting out of bed, family members pissed off, starting IVs. We all do the same thing! And between all those, we have the drug seekers, the mental healths, the strokes, cardiac arrests... At least the floor knows what they are getting!!