First NP hired into my old ER

[Mica RN]

Hello everyone. I landed a great job at the ER I used to work at as an RN. I am the first NP the physician group has hired. Traditionally they've used PAs, but the leadership seemed very eager to bring me in and made me an offer which I could not refuse- great pay/benefits/schedule and I've built great rapport with most of the providers (some will forever remain "difficult to deal with"). I currently work in a retail clinic and find the job very useful in preparation for my transition in terms of managing minor illness/injury.

I have some questions for those who have experience practicing as an NP in ER.

1. Would 28 training shifts paired with a MD for 8 hours (1 hour charting) be adequate? Its a self designated level 3 ER and I would be seeing acuity 3-5 (the threes will be light work ups if triaged appropriately!)

2. What supplemental training or resources would you recommend using for reference/preparation?

3. What are the areas you found needed to improve and what were your strong points when you started in the ER? I'll have a great Doc who will be my go to clinician. He asked what areas of emphasis would he like me to focus on if any. I'm weak with Derm and I could always use more practice with procedures. But I'm sure I could use help in a lot more areas.

4. Did you go from being an RN in the ER to a NP in the ER? If so what were the challenges and what was particularly useful for you having that experience?

Pretty broad questions and I sincerely appreciate you taking the time to respond. I'm super excited and at the same time nervous because I want to set a good example that NPs belong in the ER contrary to what other clinicians may think. Thank you!

[MissDoodaw]

Hi Mica,

That's a pretty big jump from retail to er. My guess is it will be a lot of learning the first two years. I was an ER RN, as an NP back in the same ER after a year or so in clinic. Epocrates and uptodate will be your friends. Check out your hospital's antibiograms to decrease your bounce backs and increase effectiveness. Someday lots of procedures, other days not so many so you will become good at them and fast with practice.

Most ER providers are not great with derm in my experience and most of the derm stuff is not truly emergent anyways. What is more important are your EKG interpretations as an ER RN I assume you're good with these.

I was the first midlevel in one of our ER's and working with RN's I had no previous relationship with I had to blow off the sandbagging and prepare a lot of my own procedures for the first couple months until they realized I knew what I was doing and I was good at it and all of a sudden my orders were being done promptly, procedure set-ups were done, pts were being discharged promptly, but I had to be patient and give people time to adjust to the change.

My advice to newbies in the ER.....

Know your belly pains and workups for these.

Know your geri pharm and ADE's in the Geri population.

Make sure you have good outpatient settings to refer people too.

Know your 4$ drug list/5$ drug list.

Know what community resources there are for the underprivileged.

Supplemental training: the ER bootcamps are a good refresher if you can find one, Im sure you have TNCC and ATLS, Foundation for critical care course I found helpful for some of the higher level acuity pts.

Listen to your gut.

Good history and good exam always.

Chart really well -yes, take the time to do this every pt every chart- it will pay off in many ways. I was surprised when a MD would come back and comment about one of my cases that he had read my chart as part of this or that oversight committee or ER director position. It gave me a good reputation besides covering my backside.

Ask for help when you need it.

Good home and look stuff up when you aren't familiar with things or the depth of knowledge isn't there.

Good Luck and have fun!

[Mica RN]

Thank you so much! Exactly what I was looking for.

[DizzyJ DHSc PA-C]

1. Would 28 training shifts paired with a MD for 8 hours (1 hour charting) be adequate? Its a self designated level 3 ER and I would be seeing acuity 3-5 (the threes will be light work ups if triaged appropriately!)

2. What supplemental training or resources would you recommend using for reference/preparation?

3. What are the areas you found needed to improve and what were your strong points when you started in the ER? I'll have a great Doc who will be my go to clinician. He asked what areas of emphasis would he like me to focus on if any. I'm weak with Derm and I could always use more practice with procedures. But I'm sure I could use help in a lot more areas.

4. Did you go from being an RN in the ER to a NP in the ER? If so what were the challenges and what was particularly useful for you having that experience?

I think 28 training shifts is great. You will likely see all the common ER complaints over 28 shifts. Then, you still have the doc there to consult with.

UpToDate is by far your best friend and as mentioned the antibiograms.

Study up on knowing when a urine culture, wound culture, back up throat culture, packing, etc is actually needed and when it is not needed. Newbies often over order these tests that will not make any difference in treatment/outcomes and are not medically necessary.

Splinting various injuries

A good xray resource....especially with peds. Like knowing the elbow ossifications ages.

Going from RN to NP in the same ED can be tough sometimes as MissDoodaw stated. I've seen RNs being rather disrespectful to new NPs that used to be an RN colleague. Needs to be handled with grace and respect while also being stern and confident. It's a tough spot because you want to have a good relationship while also letting it be known that you will not tolerate your orders being overlooked or treated any differently then any other provider in the ED.