ER to ICU orders

[amys4304]

Ok, so I'm hoping to get responses as soon as possible. Today my ICU manager sent out an email to all of the ICU RN's. Stating that the ER is now facing a core measure saying that they must have the patient out of the ER within two hours of walking in the door. This would allow patients to arrive to the ICU without orders. And to be prepared that the "days of having all diagnostic test (CT SCANS) complete before the patient hits the floor are gone" My own experince is as follows. Came in one morning. Got report at the same time the patient arrived on the floor. Night nurse called ER nurse and specifically asked if the CT scan was read by the doc. The nurse said yes. We then took a look at the scan and seen the patient had a huge brain bleed. I work in a small community hospital that is not equip to handle this. This was a 50 year old man. The entire process of calling transport, preparing patient,giving report, getting copies of scans, and finally getting patient to his destination took 2 hours. Second case! Patient was sent prior to getting a CT, I received him, looked horrible, needed to be intubated within mins of arriving, after that I had to take him to CT. Guess what?! another huge bleed. Here we go again, two hour process of getting him to his destination. This man died shortly upon arriving at receiving hospital. Let me add, CT is on the first floor, right next to the ER. ICU is located on the fourth floor. Please respond and tell me how you feel about this and what your facility's policy is. I personal can not believe how dangerous this will be

Thanks,

Amy

[nursemeanie]

That sounds crazy. My ER has a one hour turn around time for non-urgent patients. Admitted patients they want to the floors within an hour of the decision to admit, not an hour from walking in the door!

[icuRNmaggie, BSN, RN]

This is so wrong on so many levels. ICU patients must be seen by a physician in the ER or in the ICU upon arrival. It sounds like you work in a small hospital that is a primary stroke center. The ER must try to stabilize the patient and EMTALA requires disposition to the appropriate level of care. That means sending the head bleed to a comprehensive stroke center. There is no such thing as a JCAHO or CMS core measure for ER throughput. There are core measure for Stroke that you should read and that will be helpful to your cause.

Without admission orders or a physician present, you, the nurse, are left to your own devices to determine the care of that patient.

So if I understand the situation correctly, the ICU manager is asking the nurses to practice beyond the scope of a nursing license. Forward that email to your home email address.

When the obtunded pt with a brain bleed herniates and becomes an organ donor or even a coroner's case, the ER staff will say "that's all new, he was fine, that all happened upstairs." Do they do the NIHSS or any kind of stroke code protocol? Find that policy and hold them to it.

The two cases mentioned were sentinel events and should have been reported to risk management with a root cause analysis investigation for each one. Unless you have a neurosurgeon and it sounds like you don't.

Find the policy for ICU admissions and admission orders as well as any stroke protocols. That is what the ER must follow. I think that you should call your malpractice carrier for advice on this matter. Personally I would be looking for other employment rather than follow such an idiotic directive in a community hospital. You need to enlist support from the medical staff, specifically the intensivists and neurologists who can and should oppose this ludicrous directive.

[NPOaftermidnight, MSN, RN, NP]

We don't have any specific time frame that I'm aware of. We get all of our trauma patients right from the ER and they have always already been scanned and xrayed before they come up to us. Sometimes they need to go back for more, but the preliminary scans have been done to identify any major issues. It sounds like your hospital is really compromising patient care in order to meet their arbitrary time quota.

[Lev, MSN, RN, NP]

This does not happen in my ER. We routinely board patients. ICU patients do go up pretty quickly. And generally with pertinent imaging completed. That core measure would never work. Our ER is just too busy.

[traumaRUs, MSN, APRN]

threads merged.

[ausrnurse]

These targets are absolute nonsense. Patients get transferred before even being worked up or stabilised and you end up with a hot mess on your hands, by the way you only have one cannula for your critically ill patient and they haven't been through the scanner yet*. I could go on and on about my opinion of these ED transfer targets, but there would be too many expletives for AN. Patients should be moved from ED in a timely fashion - but not before they've done their job. It's totally overridden clinical judgement and all you get is a shrug and "it's been 2 hours."

*not to mention putting these people in an elevator and transferring beds is a disaster waiting to happen!!!

[VANurse2010]

This is so wrong on so many levels. ICU patients must be seen by a physician in the ER or in the ICU upon arrival. It sounds like you work in a small hospital that is a primary stroke center. The ER must try to stabilize the patient and EMTALA requires disposition to the appropriate level of care. That means sending the head bleed to a comprehensive stroke center. There is no such thing as a JCAHO or CMS core measure for ER throughput. There are core measure for Stroke that you should read and that will be helpful to your cause.

Without admission orders or a physician present, you, the nurse, are left to your own devices to determine the care of that patient.

So if I understand the situation correctly, the ICU manager is asking the nurses to practice beyond the scope of a nursing license. Forward that email to your home email address.

When the obtunded pt with a brain bleed herniates and becomes an organ donor or even a coroner's case, the ER staff will say "that's all new, he was fine, that all happened upstairs." Do they do the NIHSS or any kind of stroke code protocol? Find that policy and hold them to it.

The two cases mentioned were sentinel events and should have been reported to risk management with a root cause analysis investigation for each one. Unless you have a neurosurgeon and it sounds like you don't.

Find the policy for ICU admissions and admission orders as well as any stroke protocols. That is what the ER must follow. I think that you should call your malpractice carrier for advice on this matter. Personally I would be looking for other employment rather than follow such an idiotic directive in a community hospital. You need to enlist support from the medical staff, specifically the intensivists and neurologists who can and should oppose this ludicrous directive.

Can I give a thousand times thumbs up to this? The families should sue the **** out of her hospital - and they'd win, deservedly so.

[Here.I.Stand, BSN, RN]

They need to read this--National Institute of Neurological Disorders and Stroke critical time goals:

https://www.acls.net/acls-suspected-stroke-algorithm.htm

This policy sounds extremely dangerous. Research-based standards for stroke care include door-to-scanner-to-treatment decision-to-treatment standards.... NOT door-to-ICU-admission standards. Placing the priority on getting the pt out of the ED before the scan even happns?? Especially if you're not a comprehensive stroke center?? That is eating a HUGE amount of time for these brains!!

[Altra, BSN, RN]

There is no such thing as a JCAHO or CMS core measure for ER throughput. There are core measure for Stroke that you should read and that will be helpful to your cause.

This is not correct - there are 6 CMS/Joint Commission core measures that measure ER throughput.

A complete list of core measures currently in effect for federal FY 2015 can be viewed here, by downloading the specifications manual and then searching the table of contents:

Specifications Manual for National Hospital Inpatient Quality Measures | Joint Commission

[icuRNmaggie, BSN, RN]

I appreciate the link to CMS ED throughput for 2015 though I must admit I have not had the time to read that section of the manual.

From what I can gather, the CT of the head must be done within 45 minutes of arrival for suspected ischemic or hemmorrhagic stroke, according to the CMS.

[bebbercorn]

As an ER nurse, I'd be terrified of sending up a pt who I suspect had any type of serious injury/illness without basic labs and imaging. It's bad practice. Agreed, once they're stable, they need to get the heck upstairs, for everyone's benefit... but I can see a lot of patients being sent to an inappropriate level of care if an arbitrary 2 hour time stamp is placed on pt flow.