ER nursing: adjusting to ratios

[Snorkelgirl4, BSN, RN]

Hello,

I have relocated from Tennessee to Florida for my husband's company. I have a couple of years of ER experience, most of which was in TN...I used to have 3 patients (4 max). I did not have techs or medics to help. I would triage, assess, obtain IV, etc, for all of my patients. When I moved to Florida, it was not lost on me that the ratios would be different. I have 5 patients (6 if slammed)...I have found that I have been unable to fully establish a flow, as I am still learning the rest of the team members (techs, etc) and how each of them work. Are there any ER nurses out there who have worked both with and without techs/medics? If so, how did you adjust your flow to keep up with the pace, specifically if you moved to a higher ratio? I hope this all makes sense..... I am quite grateful for all team members, but at times I feel that I slow down the flow because I am constantly trying to determine what has and has not already been done (labs, etc). I try to communicate well, but of course, we are all busy so it can be hard..... Thanks in advance.

PS: I would also appreciate any advice for your routine (I say that loosely, as things can change in an instant in the ER) for moving toward higher ratios. :)

[MassED, BSN, RN]

I think you just have to give yourself time. There is a learning curve in any new ER and everyone knows this. Hope everyone is patient with you in that learning curve. You'll soon figure out who is doing what and come to expect or anticipate that. Even with all of that, some days are just more awful than the other and even knowing what to expect, some people are just not good communicators . Good luck!

I would add for your ratios, remember your sickest ones go first. A young woman with belly pain can wait a bit (if you're not thinking ectopic), get that urine and move along. I'd pay most attention to the highest acuities and move on from there. Assume you are alone and when you are in each room, if you can, put your sick ones on the monitor so at least you know vital signs will be taken care of if there's not anyone else to do it later. When you are in a room with a chest pain, for example, get that IV while you listen to their story. Do their EKG, put them on the monitor, get their history, meds, etc. Send off the blood and move on to your next one. With many patients, doing all you can while you're in the room the first time is usually easiest and then you can move on to the next sickest and so on.

Routine is different for each place. You'll find your groove.

[Anna Flaxis, BSN, RN]

Not all EDs use ratios to determine staffing needs. There are different models in use for this purpose. Of course, you know this.

I've worked both with and without techs, and both have their pros and cons. I can't say which I prefer, because there are so many variables.

at times I feel that I slow down the flow because I am constantly trying to determine what has and has not already been done (labs, etc). I try to communicate well, but of course, we are all busy so it can be hard.....

Is your documentation system electronic or paper? Do you have electronic reader boards to alert you when there are new orders, or to the status of labs/imaging/etc.?

It can be hard going from an environment where you do most everything, so you know where in the process things are, to an environment with lots of ancillary staff who do things that you are accustomed to being responsible for.

Face to face communication is good, but you can also round on charts to see what has and hasn't been documented. When I worked in a bigger, busier ED, one survival strategy I employed was to put everyone on the monitor, and set the NIBP for every hour at the top of the hour. Then at the top of the hour, I would just go down the line and round on everyone- eyeball them and document my observation and their current VS. Inbetween that, I'd be tasking and keeping up on new orders, lab and diagnostic results, admits, discharges, etc. By imposing a loose structure on a chaotic environment, I could answer my own questions about what had and hadn't been done, and save the face to face communications for things I couldn't figure out just by tracking documentation and eyeballing the patients.

Now that I work in a smaller, less busy ED, I can afford to be less structured, but when the poop hits the fan and we are slammed, I go back to my old ways and find it really helps.

[applesxoranges, BSN, RN]

We do what we can with 5 patients and no tech or a tech able to do the tasks they supposed to do (thanks tech that thinks the transport is more important than the EKG on the 65 year-old woman with chest pain and not to mention I need to go start cardizem on my other lady along with 3 other patients I haven't seen yet). Our techs cannot even do much. They are allowed to do EKGs, transport, and assist with repositioning or toileting.

To be honest, I am thinking of quitting my ER and going over to the one where I work per diem. They said they would love to have me. I have been picking up there and I have a few months to think about it.

In all, the one with the ratio of 5, we are stressed and there isn't as good group cohesion. We are tense and I honestly hate it there. I withdrew my day shift applications as I am more willing to work nights part-time or afternoons than to work day shift in a place I hate. 5 seems like it is too much without adequate staffing support. I know ERs make it work but my last place I quit because I was sick of the ratio (and patients hanging themselves because we had no sitters but that's a different topic).

I do what I have to do and I keep in mind that I am one person. There is a reason why we lost a lot of nurses recently and it is because of the 1:5 ratio. Granted there is a 1:2 or 1:3 in the critical care side but the med-surg area is too high for a department where the techs cannot or do not do much. There are some departments where they swear by the 1:5 ratio but they either have to have a lot of ancillary staff or they are not providing potentially safe or adequate care. With 5 patients, you have approx 12 minutes to see patients each hour. If you have a critical patient, those tasks take time. Hooking up an ekg machine, starting an IV, giving medication, assessing the patient, etc. If I can have lab or a paramedic start my IV, have them do an EKG, hook them up to the vitals, have my triage done before they get to the room and meds reconciled, transport to CT or Xray, etc then I would have plenty of time with 1:5 usually.