ER New Grad- ICU holds in ER - Is this a normal situation in the ER?

[rlunay21]

Hello Everyone,

My employer plans on cross training me to be in ER, ICU, and Telemetry Units. My first stop is the ER. I finished 2 months of RN orientation and am currently on my own in the ER. This one particular busy day in the ER--we were short in resources. our Charge Nurse functioned both as a Charge Nurse AND Triage Nurse. Our only ED tech was unable to help any nurse because they had to watch 51/50s the whole shift. WE had no ICU nurses or beds available and so if we had an ICU pt- we would have to hold them in ER--amongst other things. (We do not have Unit Secretaries in my facility)

So I basically received an ICU patient who we ended up diagnosing and admitting the pt for- renal failure, pneumonia, dehydration, abd pain --and of course when labs came back - septic protocol was initiated- and so came a whole stream of antibiotics, blood work, exams, etc, etc. (Pt was relatively stable).

In addition, The Admitting physician had written orders for this patient and had ordered to get consults from 3 different specialties (Cardiology, Nephrology, and Pulmonology). So, I had to call and get a hold of all these 3 different MDs and Look (and decipher) through all four MD's orders and try to carry out ALL their orders! A few of these orders included - Antibiotics, fluids, regular meds, labs (which the MD states to CALL THEM for the result), v/q scans, doppler studies, CT w/ contrast, and the list goes on and on. Sometimes you get orders that cancel each other out. One MD states they want NS while another MD states they want D5W as maintenance fluid. So the rule of thumb is to take the orders from the most recent MD who wrote the orders most recently...

I had all these orders from different doctors and so I tell my Clinical Director (who was nice enough to come down and help us out) " I need help, i got all these antibiotics ordered from 3 different Physicians..and shes in renal failure already!..and i have all these other orders..can you help me determine what I need to do and how I should go about doing this?" She tells me to basically do not worry about any other orders except the "STAT orders"..She reviewed the MD notes very briefly and saw that I did quite a few of these orders (even the non stat orders- i wanted to be nice to the ICU nurses!) and emphasized again to just do the STAT orders and ICU will have other orders dealt with. I also keep in my mind that this pt is ICU-which means as much as possible --be treated as an ICU pt--v/s and check up on them every hour- ekg strips every hour--thorough charting---pressure ulcer checks--i tried my hardest -- i didn't take a lunch break AND i stayed 2Hours OT! [Pt eventually got transferred to a proper ICU holding place]

Keep in mind that I am constantly getting patients in my other rooms--SOB, lethargic, weakness, helping with intubations, Chest pains, overdoses...who are also getting discharged or admitted or transferred out - so that means a whole new set of calling MDs for consults, calling ambulances, dealing with insurance people, case managers, and talking to accepting hospitals etc. etc.

@ the same time --the ERmd is throwing order after order..and sometimes they verbalize orders to nurses who are NOT the primary RN for a certain pt and sometimes the memo doesnt get passed to the proper RN.

Anyway, I went home 2H after I was supposed to actually go home--then I get a phone call from the night shift nurse who i gave report to for that ICU pt...she tells me that the Admitting MD for the ICU pt got super mad at me for not putting in certain labs in the system and not getting a hold of the cardiology MD, and told the night shift nurse to specifically tell me "an ICU hold in the ER means that they be treated as an ICU patient.......just think about how your loved one would want to be treated..don't let this happen again or else I am going to have a fit"..

Then the night shift nurses tells me that they will have to file a incident report and that my charge nurse and the clinical director is informed of this incident.

OMG,after i hung up..i couldn't help but cry mainly because Im a New Grad and I know I am on probation just because i am new to this company!...I didnt know what to think and I do not know what is going to happen to me! Will i get fired? My boyfriend (who also works in ER) tells me he gets to be 1:1 when he gets a critical pt. I almost never see that happen in my ER...How are things supposed to be run when someone gets this kind of patient load?

IF the Admitting MD really wants me to treat this pt as an ICU pt ..doesn't that mean I should be 1:1 or even 1:2?

Can any shed some insight? Any advice would be greatly appreciated!

[LalaJJB]

What is your facility policy. I have also had the horrible experience of holding an ICU patient in my ER for longer than i should have. I basically told the charge nurse, "hey, this patient is 1:1, i cannot take on any other pts unless they are and acuity 3 or higher." Each hospital should have a policy in place where the acuity of the patient and nurse/pt ratio whether its 2:1 or 1:1 where you can file an assignment despite objection form. Basically you are signing a document that says i do not feel safe caring for more than this critically ill patient, and it's there to save your license.

Also, the ICU patient that you have, as long as theyre stable in regards to the ABC's, the inpatient orders can wait... antibiotics should be hung in the ED if the IV access is available...also, if they're tubed, you HAVE to make sure they are properly sedated...but home meds, maintenance fluids, even skin care (unless they have a disgusting draining wound that needs attention now), that can all wait.

What you did sounds just fine to me. You are NOT an ICU nurse. My charge nurse told me once when we were completely full one night, "ICU nurses have a 1:1 or 1:2 policy. you should never have to manage more than 1-2 ICU patients in the ER. and if you do, the inpatient orders can wait."

the docs who got upset with you and said "what would you do if this was your family member..?" They should also think the same way. what if it was their family member?...im sure they would coordinate a little better with the other specialists.. thats not your job so dont feel bad

[Orange Tree]

Ridiculous! I can understand the MD being upset about orders being held, but you shouldn't be the target. I would have agreed with the admitting MD and encouraged him or her to complain to someone who actually has the power to change things. Either that, or put on a magic cape next time you go to work so you can answer the phones and enter orders while doing CPR and telekinetically priming IV tubing.

[rlunay21]

Thanks for getting back to me LalaJJB! I really appreciate your insight. At our facility, I have not heard of that form that you are describing. I don't think that exists in our department.

In addition, It is very rare that i see one of my co-workers go totally 1:1 or 1:2 when they get a critically ill patient..we just do not have those extra resources to do that...Our charge nurses also operates as a triage nurse. and on that particular day I am writing about--the charge nurse had so many things to do and was triaging left and right ...if we have a full house, its hard to delegate assignments to other staff RNs because they got a full case too..and if i do get help, its not like they take the patient entirely off my hands--they help by putting orders in and maybe starting an IV and fluids--i still have to follow through with the patient and make sure the orders are being put through.

I was always told that when i know I am holding a patient- i have to start doing the inpatient orders--and so..i did..that is, I tried to do most of them. but its so hard sometimes !especially when u have 3 other patients waiting for your care.

I am just upset that I am getting written up for an "incident report" . I have yet to received any further news @ the moment.

[rlunay21]

Hi Orange Tree! Thanks for your insight! :) it kind of made me laugh. sometimes i feel that the MDs don't understand all the things we have to juggle..they give orders left and right--sometimes you dont get the memo--you get the erMD marching up to you saying "WHY ARENT MY LABS IN!? CALL LAB!" or "Where is my urine for bed ___!? I wanna close my charts so i can go home!" --ughhh-- sometimes i think--why cant the erMD call thee consulting MDs or call the labs to check up on a result?! They DO have a phone in their area!

[LalaJJB]

One more thing. Dont worry about getting written up. When i was new, I was written up like 3 times in the first 6 months for things that were out of my control. At first i got all offended and was worried they'd can me... but they never did and never would because we were so short staffed anyway. New grads should never be expected to be perfect at their job and know everything.

Being worried about this situation just shows that you care about your job. You're going to be just fine :-) Every new grad, no matter if they admit it or not, feel this way. It gets better, i promise.

[meandragonbrett]

The person who writes the order for a consult is the one who needs to be calling that service and discussing and requesting the consult. You are NOT the physician's secretary or personal nurse. That is ridiculous.

[LalaJJB]

^ exactly what @meandragonbrett said

[NurseOnAMotorcycle, ASN, RN]

LaLaJJB is completely right as far as I'm concerned. Take a lot of deep breaths and try not to think about it too much.

Unfortunately, this does happen. Especially in critically understaffed emergency rooms. Normally the team would step up and help you take care of the more stable patients while you care for the ICU patient while juggling all the others.

Don't be afraid to say "My hands are completely full with this patient, can you please do XYZ for the other room?" And make sure you return the favor when they are having the same problems by asking them what you can do to help.

[JBudd, MSN]

You did the right thing in notifying the Clinical Director. The night nurses are doing a CYA with the incident report because of Dr. Pompous; and since the CLinical Director will be receiving the report, she should deep six it right there. After all, she is the one who told you what to prioritize, which orders to fill, and reviewed the charts/orders with you. One of the few times the chain of command was involved first hand!

We are sometimes stuck with holding several ICU pts, and if the charge can't help, well, we do the best we can with the extra pts. Frankly, mine sit there until I have time for them; they aren't the ones trying to die. MOst of the time, the rest of your team will take care of the rest.

Sounds to me like you did a magnificent job for a new grad in a tough spot. Nobody died, nobody got worse, and the doc is worried about a set of labs. Not the worst thing that could have happened or been missed. Remind yourself of that! Ya did good!

[sapphire18]

Either that or put on a magic cape next time you go to work so you can answer the phones and enter orders while doing CPR and telekinetically priming IV tubing.[/quote']

Omg, I wish I had that power!!! Lol!

OP, you did good, I understand why the MD was upset, but you are NOT the person to take it out on. We are unfortunately the easiest target.

[Sassy5d]

Omg, I wish I had that power!!! Lol!

OP, you did good, I understand why the MD was upset, but you are NOT the person to take it out on. We are unfortunately the easiest target.

Ya I would have been crying at work, before the phone call.

Something will always be next. Sounds like you did great.