ER Organization

[Praetorian581]

*BACKGROUND*

I'm a fairly new ER nurse (about a year's experience) and currently work in a smaller level 3 community hospital. The hospital itself is only about 3 years old (but we had moved from a previous location so the staff itself is experienced). We currently have 25 beds in the ER (24 monitored, and 1 seclusion room) with 2 of the 24 monitored beds designed as trauma bays. We do not have specific areas (such as fast track, critical, etc.) due to the rooms being designed universally so that any patient could be placed into any room.

Our hospital system consists of 5 facilities - 1 small facility w/ an urgent care ER and long term acute care unit, another mid-sized community hospital similar to ours with an ER, an large outpatient surgery facility, and a large level 1 trauma center.

While I currently work at the level 3 community hospital, I actually completed by practicum in the ER at our level 1 facility. This is a rather large ER with a Peds unit, Critical Care (which includes trauma bays), Intermediate, Fast Track, Observation unit (CHF/Stroke), and a small Psych area (ISA - Intermediate Stabilization Area).

The ER nurse ratio at all hospitals in the system is typically 6:1 (even in the critical area at the level 1 since each nurse assignment consists of 4 rooms and then 2 hallway patients).

*QUESTION*

We are currently looking into our ER's structure and organization (such as nurse ratio, assigning specific designated areas such as fast track, etc.) and I was wondering if anyone could offer suggestions as to what they have found to work best - especially in the area of patient flow.

Currently our process has a nursing tech at the front desk to check people in (aka, quick-registration) and then these patients are brought directly back to rooms (as long as we have rooms available). If at any time someone has a complaint such as "chest pain," "shortness of breath," "alerted mental status," etc. the tech is instructed to notify the rest of the team via our communications system (Vocera) and we bring the patient back to start protocols whether the registration is completed or not. This means while rooms are available, Triage takes place in the back with the triage nurse going to each room to triage the patients. Once the rooms fill up the triage nurse goes out front to triage (and is instructed to stay there as long as there are patient in the lobby - in fact the triage nurse signs up for these patients as if he/she is the primary nurse).

Where this process often breaks down is when we get a flood of patients, leaving several untrained in the back and the triage nurse out front triaging the patients out there - this then leaves the primary nurses to triage the patients in there areas (with a 6:1 ratio). I should say that we do have 2 ER techs and a floating charge nurse in addition to the triage nurse and the primary nurses (we have 2 docs and 1 midlevel during peak times).

We are apparently budgeted for a 5:1 ratio (but not staffed d/t turnover) and our NM is working on getting budget approval for a 4:1 (though most of us doubt this will ever practically happen).

SO - what systems, methods, patient flows, etc. have you found to work best in your experience???

*SUGGESTIONS*

Typically all our rooms are open with the exception of 1 trauma bay which is held for codes/emergencies/etc. HOWEVER, I had the thought that perhaps (especially if we are budgeted for 5:1) that one of the 6 nurses rooms should always be reserved for emergencies (chest pains, SOBs, stroke, etc.). This room could then be opened if needed and the RN would then have 6 patients (but as soon as another could be discharged, that room would again be held and the RN would be back to 5).

One thing I particularly liked about working in the critical care area of our level 1 was that everyone tended to jump on patients as a team and just knock everything out all at once rather than just the primary RN trying to tackle one thing at a time as time allowed. I was wondering if the same approach could be applied to our ER - i.e. a ER Rapid Response Team of sorts - when a chest pain, SOB, stroke, etc. is called we could have a specific team (possibly the Charge RN, a Tech, and the Triage RN - or the primary if Triage is out front) respond and try to get everything done on the patient so that the primary RN is free to continue with routine patient care.

I think this is one area where our team particularly breaks down - COMMUNICATION - this is difficult since typically when our night team gets there we replace the charge nurse and several of the primaries but other mid-shift nurses are still on the floor and not in on the briefing (i.e. the 11p, 3p). I think someone really needs to go to these nurses at shift change and say "okay, here's the plan for tonight."

ANYWAY - please, if you have any suggestions I would look forward to hearing your thoughts on this.

Thanks!!!

[EmergencyNrse]

There is no easy way to go about it. Many times it's hit 'n miss with different ways of organizing. Try something this month... try another the next.

Always evaluating & reevaluating until you find your way.

With patient flow the doctors have to be on board with certain standards that need met. Admission, discharge, reevaluations. Doc's just get into a comfort zone and only want to see 4 pts./hr. They drag their feet until shift change then dispo everyone at once.

Do you have a physician group that staff your facility or are they home grown(work for the hospital)? Do they "eat what they kill" or are they salaried?

The nurses are sure to do their parts. Assignments always are about FTE's available and the number of call-in's each shift. How many bodies can you put on the floor? I hope your management is supportive with staffing which is a whole other issue.

You have a mufti-faceted question that cannot be answered here without direct knowledge of how your ER operates....

Hey, but good luck.

[Esme12, ASN, BSN, RN]

I agree whole heartedly with Emergency nurse. There are soooo many factors that influence flow. Having MD's on board and a medical director that makes them behave is HUGE. Check with the ENA for ratios as well as the JC and AHRQ. I also belive separating acute and urgent key. The ENA used to have it on their web site but has been removed for purchase...

http://www.nursezone.com/Nursing-News-Events/more-news/ENA-Creates-Tool-to-Aid-Emergency-Department-Staffing_27082.aspx

http://www.innovations.ahrq.gov/content.aspx?id=1754