ER Prioritizing/communication help please!

**canoehead, BSN, RN** · Oct 9, 2010

1) I write "Received pt in room 3 at 1045," and then my 1st assessment when I think they've been there for some time.

2)There must be a way people find out which patient have rooms assigned. Ask the charge nurses how that happens. Or after you have orders keep checking with the charge hourly. As far as getting paperwork done, once you have orders you know it needs to be done, so start it right away.

3) If you are new you need to slog through about a year of always being behind. That said, there is nothing wrong with going up to someone who is sitting and chatting and asking them if they'll take off your orders, or give a med. You have to let people know what they can do to help... the onus is on you to ask. If they refuse and go back to their conversation then they are rotten team players. Make sure you are equally ready to help them sometimes too.

This is just me, but I've found that if a CNA or aide isn't ready and willing to work it's just easier to do things myself instead of asking twice, and checking behind them. If you see them sitting down and someone needs the commode, definitely make the request that they help, but something like getting vitals I just do on my own.

tepbsmith · Oct 9, 2010

1. pts placed in rooms. they should be telling you when they do, esp if its obvious you're in the middle of something and they should be writing atleast a note, if nothing else. also, as for your note i would suggest something like "initial contact w/pt at..." vs what you mentioned.

2. admissions. where i work, we call admissions and transfer after the bed mgr assigns a room and the accepting doc has written the orders. i'm honestly unclear as to how a pt could be admitted w/o the nurse knowing because of the consults, labs etc. a lot of ER nursing is being proactive and i think that getting used to staying on top of where a pt is in the admissions process is something you have to learn along the way.

3. teamwork is a problem everywhere, so i can't really address that. again, as you get used to ER nursing you will be able to better anticipate orders for your pts. as for the CNAs, i would imagine that if you need them to do an EKG or something else you would have to ask them. are they busy? hiding?

4. you know, ER nursing is very very different (imo) than floor nursing and one of the biggest challenges is getting used to the fact that you have to anticipate what kind of workup/interventions your pt needs and initiate that as soon as possible. then you have to stay on top of your labs, studies, etc to keep everything moving along.

for example, you mentioned a CP protocol. so in my facility, our CP protocol is EKG & aspirin within 10 minutes and a chest xray. and these things are done in triage and of course, you always have to make sure they got the asa. from there they are either going to a room or back to the waiting area.

in the room, if this is a garden variety chest pain (vs a STEMI or someone that looks like crap) and especially if they came to me from the waiting room, they are getting an IV, labs drawn and at the bedside -we dont have standing orders for lab- put on monitors, and re-assessing pain. if they are pain free, they get a repeat EKG. i may or may not put them on O2. they may or may not get nitro depending on the situation.

that whole thing takes me less than 10 minutes- but it didn't always.

point being, organization and time mgmt don't develop overnight in any setting that is new. and given the questions you're asking i'm really wondering how your orientation went. as you learn the workups, your time mgmt will improve.

also, the book "Fast Facts for ER Nurses" is a great resource for nurses new to the ED.

good luck to you!

cmarn · Oct 9, 2010

Thanks for the responses so far. Helpful. I've always thought of myself as very resourceful and efficient, but this has been a challenge. Our triage is a bit different. Not a lot is initiated there. If we have beds, especially CP patients, they are brought back and we start the protocol. It takes a bit longer that way and we are often trying to talk over registration to get our initial info...

Regarding admissions, I am hoping to get a better handle on this. Even some of the nurses who have been there a while seem perplexed. I think what happens is that we complete every order on the chart...the doctor pulls all of his charts that he has been waiting on labs, studies, etc and decides whether or not to admit several patients at once. He then sticks it in the secretary's rack to order the bed...the secretary puts the chart in the done rack....Sometimes a bed is assigned within a few minutes...all without me knowing.

I'm going to work with the assumption...everyone's an admission today and see how it goes :)

Larry77, RN · Oct 9, 2010

Some of the issues you mentioned are present in many ED's. I agree that the communication needs to be there but I am a charge nurse and sometimes the communication to me is lacking so I may not know that one nurse is slammed. Sometimes a patient can be very time consuming even if they aren't that sick and I can't tell that from the computer. I encourage teamwork with my crew and lecture on it at least weakly. If you see someone on your team stuck in a room, help with their other patients etc.

If you haven't seen a patient and they were placed in one of your rooms by a tech or nurse I would chart something like "First contact with patient" like others have mentioned. In my department I usually am told when this happens so I can speak with who ever roomed the pt to remind them they have to at least make a quick note on how the patient got there and a quick assessment.

My suggestion is to find a charge nurse that you can approach easily (I know that some are not very approachable) and speak to them about some of the pitfalls you have noticed and find out what you can do to improve. I would be very receptive to this and would be very happy to give you pointers on what works for the department and other RN's...

meyerbj81 · Oct 9, 2010

I recently moved to the ED from the floor a few months ago as well. What I found was important was to pretty much draw a rainbow on everyone, within reason of course, this has saved me a lot of time being proactive. Also, they should have been triaged and had an initial triage assessment done, that being said don't stress and hope someone would have told you if they put a mysterious critical pt in your room. As far as people being admitted without your knowledge I have nothing to add about that as we have to call report personally so where I work I don't see how thats a problem. Now onto IV's...I understand that there is an issue of pride sometimes involved in getting an IV in but if it costs you time and you've gone 0-2 go ask someone else. There is no need to spend 20 mins trying to start an IV when there are others who could give it a look i.e. charge nurse, tech, another nurse etc etc. I guess the biggest message of my post is to speak up and ask for help, its not a sign of weakness or incompetence but an ideal of teamwork to make it easier on everyone.

nrstdwalden · Oct 9, 2010

When I first read your post, I felt like you were talking about the ER that I work it. Its the same BS all the time. I am fortunate enough to work with a shift that is very helpful to one another, however from time to time I get scheduled with one of the other shifts and it is a complete nightmare and horror show from the get go. We have to do our initial assessment within 10 minutes of the patient arriving to the room, therefore when a patient is brought back and their chart goes to the physician, the room time is written on the triage papers. Also with our chest pains, they go straight to the back and an EKG is to be performed before we are allowed to triage them in. Unfortunately working the the ER can be highly stressful somedays and you don't always have anyone to rely on but yourself. I have only been working in the ER for 6 months myself and there are days that I hate it. Just figure out a system that works for you but most importantly make your opinions and concerns known.

cmarn · Oct 10, 2010

Today was more of the same but I am just learning to have thick skin and stay ahead of the game. I had 4 rooms and a hallway assignment. Was taking out an IV to discharge a patient and got a phone call that I had a new rescue. Explained I would be just a minute. DC'd my patient quickly and went to the rescue. Now, that wouldn't be a problem but one of the aids I work with went up front and saw 3 to 4 nurses munching on goodies and told them my rooms were slammed. No one lifted a finger. I mentioned this to the charge nurse.

Honestly, if there is a chart in the rack, I always help if I'm available so I just don't get complacency?

Things that made today better...

I communicated with the docs on a regular basis to anticipate what was around the bend. Focused on my critical patients and didn't spend us much time checking on patients who were just waiting for results. Had admission paperwork ready ahead of time. It helped me. The bottom line is I have to stop looking for what others "should" do and just keep truckin'

tepbsmith · Oct 10, 2010

its great that you are communicating with the docs so you'll know what to anticipate. i'm sorry about your coworkers that are unhelpful. i'm glad you mentioned it to the charge... since you are new there i'm not sure how you being direct about it with those coworkers would go for you.

it will get easier to manage your time and it won't be so stressful.

mmutk, BSN, RN, EMT-I · Oct 10, 2010

Yeah it is tough having to NOT treat a patient because another is more ill or you have a task at hand. Be sure when you see a patient is put in an empty room, see what thier triage level is and what their complaint is. That way if it's a chest pain level 2 you can go to them next, but if it is a finger laceration you can finish your tasks you have planned out first. I agree with the charting, "arrived to room to assess patient" in your notes.

After you see the patient it's more your responsibilty but if you haven't seen the patient yet it's a shared responsibility between the charge nurse, triage, you, and the physician in the ER.

mcknis · Oct 11, 2010

To the OP, I completely understand what you are talking about. I have been in the ER for just over 10 months and came from the floor after working there 3 years. I do agree that the ER is much different than the floor, no matter what unit you worked on. Most of the time you had 12 hours or so to complete your tasks, not like the ER. I do agree with the idea of proper time management and dealing with the sick one's first. Like another poster stated, you are obviously going to see a c/p over a finger lac. If I can not lay hands on the pt in a timely manner, I at least try to make a brief visual observation from across the way just to get a feel for how sick they really are. I try to stress the importance to the techs on what "sick" means. Little Sally who has had a fever of 101 and "not holding down fluids" as told by mom is not truly sick if they are eating a popsicle without any problem, but the 40yr old who is c/o a dull ache in the abd and back is more concerning. I found that after I emphasized "sick" to them, my days eased slightly. Also letting the charge nurse know when you need more help or are getting a real critical pt is of importance. Good luck and keep up the work! It sounds as though you are doing a great job already!

murphyle, BSN, RN · Oct 11, 2010

Your mileage may vary based on how orders, admissions and other "paper" tasks are handled in your department, but here's a brief rundown on how we make it work. (Note that we use Epic oneChart as our EMR. We've been doing entirely computerized provider order entry for almost a year in the Emergency Center; the hospital just went live on CPOE a month ago.)

1) Accepting new patients: We've implemented face-to-face handoff to avoid the "I didn't know I had a new patient" syndrome. All patients are brought back from Triage by a tech or a RN, who gives report to the accepting RN, puts the chart in the "waiting for ECP" rack and assigns the patient to their room in Epic. Most of us are also in the habit of monitoring the triage queue in the system to see how many are out waiting, and if they've had a tentative assignment placed (the triage coordinator will place a "sticky note" with the room he/she plans to assign each patient).

2) Admissions: Epic pops up a little telephone icon next to a patient's name when a room is assigned, indicating that you need to call report to the accepting unit. It also starts a timer letting you know how long that patient has had their bed assignment. (As a general rule, it's useless to call report before 15 minutes have elapsed on the admission clock - it takes the floor that long to become aware of the new admit, assign a nurse and prep the room.)

3) Anticipating orders: We do a lot of advance workup in our unit, at least as far as lab orders are concerned. (On imaging, we can advance chest films and C-spines, but that's about it.) As others have said, pretty much everyone is going to need four things as soon as they hit the door: an IV to saline lock, a purple top for a CBC, a tiger top or gold top for metabolic panels and/or enzymes, and urine for a UA and/or HCG. (Do not ever let a patient go to the bathroom without a sample cup and instructions! There are very few things more annoying than having female patients sit and wait to get imaging or meds, because they either went to the bathroom before they left the house or while they were waiting at Triage, and it takes an hour-plus for a serum preg as opposed to fifteen minutes for urine.)

After that, you can anticipate based on presentation and past medical history. For example, any patient on anticoagulants is going to need a blue top - someone, somewhere is guaranteed to order a PT/INR and PTT. Likewise anyone with chest pain or extremity pain suspicious for DVT, either for coags or D-dimer. If you suspect someone of pneumonia or sepsis, use CHG or Betadine to prep your IV site, and consider drawing your first set of blood cultures at that point if your unit policy allows. Our policy is not to keep blood at the bedside, so when we advance draw labs, we'll send it all down labeled "Extra" with the patient's name, MRN and B-number, and if the ECP orders additional testing, we can call the lab and have them use the existing samples. Anticipating is a skill you'll learn with time and knowledge base expansion.

4) Teamwork: Unfortunately I don't have an easy answer for you there. We're very fortunate to have a good team concept going in our department; we assign three RNs and a tech per "team" of 10-11 rooms (each RN covers three or four rooms and up to two hallway pulls), and everyone on that team keeps an eye on the entire team, not just their assignment. If one team is burning down, we'll all pitch in to clear the mess. We've found that it benefits no one to leave someone flailing with a heavy assignment.

Hopefully you've found at least some of this helpful. Hang in there! :)

*ECP = Emergency Center Provider. Could be a MD/DO, NP or PA depending on where the patient winds up - acute care, peds or minor care respectively. If the patient is seen by a resident or a midlevel provider, the supervising attending is the ECP for purposes of documentation.