ER vs ICU, how did we get there?

Hey Marcie - several of our nurses are in the CRNA course at Bradley University, so they work in the ICU to get their critical time in and that has helped us tremendously! Nice talking with you too.

Right back to you Judi!!

We have been talking about "trading spaces" but so far it hasn't gone anywhere. Has it worked other places I wonder?

Thanks!

Marcie

I love the battles we have with ICU, I really do. Ever since they got mad at me last year. We resuscitated a lil ole lady what little was left on dopamine and isuprel, I even went out of my way to keep her in the ER for 3 extra hours to see if she would go to heaven so they wouldnt have to admit her and do all their work there. Of course wouldnt you know it I finally take her up and 10 minutes after I leave the unit she finally expires.

The ICU charge nurse wrote me up for dumping a terminally ill pt on them, and a very unstable one. My nurse manager stood up for me and I didnt get in trouble. But the lines have been drawn by them.

Let the rumble begin!!!!!!!!!!

Now Tom,

I am sure that you knew the exact minute that lady was going to code and timed it just perfect to make sure that you had her in ICU just at the right minute. LOL

We work very well with ICU, and frequently ICU and ER nurses float back and forth depending on the busy. We all have the same nm.

Our unit nurses hate the ER nurses. they think we are not nearly as knowledgable as they are and they cannot figure out why we cut peoples clothes off and why we dont bother to put their clothing in the special little bags while we are running them to the CCU after resuscitating them

Their new demand is for us to complete their patient assessment form (8 pages) while we are holding the patient in the ED (where our RN's have 4-5 or more hold patients along with the ER patients to take care of!) NOT GONNA HAPPEN! It is a huge fight right now and the ER nurses have finally put their foot down. It never ends......

Our unit nurses hate the ER nurses. they think we are not nearly as knowledgable as they are and they cannot figure out why we cut peoples clothes off and why we dont bother to put their clothing in the special little bags while we are running them to the CCU after resuscitating them

Their new demand is for us to complete their patient assessment form (8 pages) while we are holding the patient in the ED (where our RN's have 4-5 or more hold patients along with the ER patients to take care of!) NOT GONNA HAPPEN! It is a huge fight right now and the ER nurses have finally put their foot down. It never ends......

Oh MY God...You MUST work in my ED!!!! :rotfl:

Why is it that THEY get to "put their foot down" ?

I am not making them come and do my job.

Hey...I'ld be ecstatic if they would just do their own!!!!!

I agree, Rnin92. We have a problem in that our administrative director is also the administrative director for the ICU and CCU. She is a former CCU nurse, so we know where her loyalites lie.

ICU and ER at my hospital gets along fairly well, but there is bad blood related to a few things. Awhile back, several nurses offered to cross-train to ER to float there when our census was low.

Almost all of those nurses now refuse to go to ER because some nurses there are so rude and unpleasant to work with. They keep trying to give our floats pedi patients, etc... when we don't routinely ever work with kids and aren't familiar with dosages, etc. (for example)

ER is chronically understaffed (probably influencing their attitude) and seem very unappreciative when we help them out. Furthermore, they never help us out and you know how that whole one-sided float thing goes.

But as for transferring patients... there's rarely any problems at all. We overall have great communication and they certainly pull their weight and get a lot done before sending the patient over.

I am not anti-ER at all. I completely respect and believe that ER nurses are knowledgable as well as good, caring nurses. Most of my encounters with them have been positive. However, this weekend I had a not so positive experience that I will share..

I had one patient who was busy as can be on CVVHD very unstable, titrating mulitple pressors, swan readings every hour, multiple blood products overnight and hgb still 6... etc...also on contact precautions which just takes up more time... he was truly a one to one however, we were understaffed and so I was paired with an empty bed, with the plans of me getting an "easy admission". At 1 am I find out I am getting a stable rule in MI... so I get all the ICU admission stuff ready, labs, history, etc. No word from ER... 4 am roles around still no report, 430 am I call down asking for report... the nurse said she was too busy to give it then and she would call back...5 am no report.... 530 am no report still and so I call again... nurse again refuses... that is fine... 645 am the nurse calls up to give report... I am at the time managing a BP of 40, decrease flow on CVVH, as well as trying to hang PRBC on my sick as can be patient... I ask charge nurse to either take report for me or to ask if I can call back in 5 minutes... my charge nurse is busy (our charges have to take a full assignment) and so another nurse explains what is going on and the ER nurse says "typical CCU excuse" and hangs up... two minutes later the same nurse calls back demanding to give report at the time... I am still stuck in MRSA room trying to keep my patient from coding and the charge nurse was in the middle of another emergency... so the ER nurse starts screaming at the nurse taking the call saying she is going to write up the unit for refusing report... ahhhhhh...... anyhow, five minutes later i am able to get out of my room w/ my patient somewhat stablized and call this lovely nurse back who continues to reem me out for not being able to take her call when she called me....... :angryfire Nevermind the fact that I tried calling down there twice for report and the patient had a bed since 1am.........why at 645 am did it become so emergent to rush the patient out...............

Sigh,

We're fighting a turf war battle with the ICU at our facility too. Seems that our ICU department head and division officer decided to impliment an admission protocol for our ICU...in effect making the ICU a closed ward where all admissions were to be approved by the attending pulmonologist.

Ok, fine. However, they neglected to tell anyone that they were going to do this....and one day, they started refusing to take report or accept ICU admissions. Down in the ER, frantic to move our admissions.... we were like "what the heck is this?"

A huge shouting match erupted, supervisors got called, and things heated up almost to the point of hair-pulling and fist-fights. Serious. So we had a big meeting, where the ICU department head came down and attempted to explain her position. Needless to say, she heard an earful about what the ICU could go do with it's admission protocols. We were aggrievated, to say the least.

Now the chief problem here was not that they decided to have a formal admissions protocol...but that they neglected to tell anyone about it....including the residents and the attendings. Had they put out the word, none of this would have happened. It all boils down to communication. Which I suspect is the chief problem in most ICU/ER disputes.

To the new ICU nurse who had the MRSA patient, I sympathize with you....it sucks to get a patient dumped on you just before shift change...and ER nurses who've never worked a ward or unit don't realize how much work is involved in admitting a patient. As a rule, if I can't get them upstairs by 0615 or 1815, I hold 'em for the next shift. But keep in mind, that while your patient may have had a bed at 0100.....the ER nurse may not have orders or the time to call report upstairs due whatever chaos was going on down in the ER that night......maybe the attending wouldn't answer his pager, maybe she'd spend the whole time with a trauma patient or something. Nights like those can really make you cranky.....cause you don't even get to eat.

So how to get the ICU and the ER to communicate better? Any ideas?

My suggestion would be to hold a critical care nursing round once a month....have the nurses from the ER and ICU present a case together from it's start in the ER to it's finish in the ICU. this is what we did, this is what we shoulda done, this is how to make it go better next time. Cause the ER and the ICU would have to work together.

Sigh,

We're fighting a turf war battle with the ICU at our facility too. Seems that our ICU department head and division officer decided to impliment an admission protocol for our ICU...in effect making the ICU a closed ward where all admissions were to be approved by the attending pulmonologist.

Ok, fine. However, they neglected to tell anyone that they were going to do this....and one day, they started refusing to take report or accept ICU admissions. Down in the ER, frantic to move our admissions.... we were like "what the heck is this?"

A huge shouting match erupted, supervisors got called, and things heated up almost to the point of hair-pulling and fist-fights. Serious. So we had a big meeting, where the ICU department head came down and attempted to explain her position. Needless to say, she heard an earful about what the ICU could go do with it's admission protocols. We were aggrievated, to say the least.

Now the chief problem here was not that they decided to have a formal admissions protocol...but that they neglected to tell anyone about it....including the residents and the attendings. Had they put out the word, none of this would have happened. It all boils down to communication. Which I suspect is the chief problem in most ICU/ER disputes.

To the new ICU nurse who had the MRSA patient, I sympathize with you....it sucks to get a patient dumped on you just before shift change...and ER nurses who've never worked a ward or unit don't realize how much work is involved in admitting a patient. As a rule, if I can't get them upstairs by 0615 or 1815, I hold 'em for the next shift. But keep in mind, that while your patient may have had a bed at 0100.....the ER nurse may not have orders or the time to call report upstairs due whatever chaos was going on down in the ER that night......maybe the attending wouldn't answer his pager, maybe she'd spend the whole time with a trauma patient or something. Nights like those can really make you cranky.....cause you don't even get to eat.

So how to get the ICU and the ER to communicate better? Any ideas?

My suggestion would be to hold a critical care nursing round once a month....have the nurses from the ER and ICU present a case together from it's start in the ER to it's finish in the ICU. this is what we did, this is what we shoulda done, this is how to make it go better next time. Cause the ER and the ICU would have to work together.

I guess my name is decieving, but I'm not so much a brand new nurse and I do realize that the ER is quite busy and there are nights when there is no chance to eat.... that happens in the ICUs too though!!!! At my facility the patient will not be called out to get a bed in the unit w/o the attending having the order for the admit and our resident (at night time only has accepted the patient which pretty much means does whatever the ER attending wants) so that isn't the case... I would like to give excuses, however, we all have bad days and it doesn't justify screaming at another unit..... and as far as there being a trauma...well that is quite possible, however, it kinda irks me when that is used as an excuse because where do you think the traumas go after their initial stabilization... to the ICU....... and just because they leave the ER doesn't mean they magically become stable and a cake walk..... and if a trauma is an excuse for not calling report for almost 6 hours... fine, but then understand that a hypotensive, multiple pressors, multiple blood products, swan numbers every hour, CVVH, hgb 6 patient is also quite time consuming. Nevermind the other CHAOS that occurs on the unit...sometimes it means that the instant you decide to call report, the unit may be tied up and unable to take it...asking for five minutes shouldn't be a big deal....sorry.....are you forgetting the fact that I called down twice to get report?? I mean no disrespect, but the excuse that "maybe she didn't get to eat that night" kinda hit a chord because she wasn't the only one..........

Now Tom,

I am sure that you knew the exact minute that lady was going to code and timed it just perfect to make sure that you had her in ICU just at the right minute.

Us ER Nurses are crafty little devils!

The other day i get this pt who comes in being bagged by EMS. Doc tubes him, goes on a vent etc. Now I have tried to learn to what the ICU likes in their patients and get it all done for them. So I get the Doc to put in a triple lumen subclavian central line, the pt get's a foley, all labs and cultures done, he's on three drips the doc wants another, and puts in a femoral line for rapid fluids,pt's blood glucose was above 1200, he was also septic. We get his BP up to 66/40 which was great since had no bp earlier. I'm told there is a "ready bed" for him in ICU. I call up and give the report. ICU nurse tells me "Oh you have to get that BP up to 100 before we can take him." Naively I ask why that matters. "Oh it's dangerous for him to have the low bp up here." I reply, "No more dangerous than it is for him down here." And I think and maybe less dangerous because his primary nurse will have only one other pt in the ICU instread of three others down in the ED. And since I do both Critical Care Transport and EMS, I'm of the philosphy that some BP is better than none and 66/40 is respectable when you're in shock.

So I explain to her that we are flowing fluids and have a norepi drip running and the doctor has offered to accompany the patient to the floor to ensure his safety. She replies "He's too unstable." So I say. " Where do you think unstable people go? If he was stable he could go to PCU or med/surg."

She finally accepted the patient, but I really get a pain from these people. They look down on us in the ED because we don't grasp all the nuances of critical care (supposedly), but when we punt to them for help we get a thousand reasons why the pt is too unhealthy to come up. I mean if they are the "best care" in the hospital, isn't that where the pt is going to have the best rate of survival? I just don't get it. If you're so proud to be a critical care nurse, shouldn't you want to take care of a critical patient? Or is it all about low pt to nurse ratios?