Frustrating... ED is Not Critical Care

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I've been an ED nurse for 7 years, working at four different hospitals from a tiny, rural, critical-access hospital (as I call it, Level None) through a regional academic medical center (peds and adult Level One). I've also worked in the critical-care float pool at the Level 1. Whether it be from CRNA programs or from ICU nurses in the smaller facilities, I get a bit tired of the offhand presumption that ED nurses are not critical care nurses.

While I will admit that that assessment does hold true in many circumstances, there are EDs where the nurses get substantial experience with some of the most critical patients.

Think about those times when the ICUs are full and you are boarding critical patients for hours. I've boarded critical burn patients, unstable trauma patients, critically ill medical patients on multiple drips, post-ROSC patients, as well as patients deemed too unstable for transport to one of the units or needing to hold in the ED for completion of various diagnostics or procedures.

How 'bout a shout out to and from the ED nurses who would absolutely raise their hands to self-identify as critical care nurses?

Specializes in Emergency Dept. Trauma. Pediatrics.

So question for my fellow ER nurses, how would you guys feel about an integrated ER. They are starting to pop up more and more. One of my best friends was doing his residency in EM/IM and then fellowed in Critical Care. At the time that was the only pathway they really had up and coming and now some places are starting to offer EM/CC.

Anyway I have learned a ton from him and it completely changed my way of thinking in my patient care even in the ER. As a lot of you know in the ER even when we have a critical patient come in, it often doesn't change our Ratios. The problem with this is when in the ICU the nurses typically have a ratio of 1-2 with these same patients, well a little more stable than when we get them regardless of what some might want to say.

So in the new integrated ER concepts the ER nurses would be cross trained in ICU and EM. There would be doctors staffed as well that specialize in both. If the nurse works the zone with these patient types their ratios would be reflected for that. The idea is not to hold patients longer in the ER. But more to provide safe and good care for those patients that will have to board in the ER while waiting for an ICU bed. Once a bed is available the intensivest and ICU RN would take over care. My friend was asked to come be a part of one of these ED's when he finished his fellowship and he was trying to convince me to do it as well.

For me personally, as long as the ratios reflected the higher acuity, I would be all for it. Not only is it safer and things aren't getting missed in the holdover, I have always wanted to cross train in the ICU for the knowledge aspect of it, however had no desire to leave the ER. Would still rather have my ICU patients for a handful of hours and move along to the next. Obviously the ICU nurses would not need to cross train in the ER unless they wanted to switch roles.

Anyway I was curious what others thought about this.

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From my perspective, ED isn't critical care.

I have done ICU, 2 years full time, took it seriously, got my CCRN. Didn't love it.

I am not as good at critical care as I was as an ICU nurse. Simply a matter of practice. I spend much more time at doing it. I spend a lot more time dealing with nonsense in the ER than I ever did in ICU. Of course I deal with critical patients, but it's just a question of mileage.

And, when an ICU nurse switches to ER, there is a steep learning curve because the two are so different.

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Specializes in Family Nurse Practitioner.
So question for my fellow ER nurses, how would you guys feel about an integrated ER. They are starting to pop up more and more. One of my best friends was doing his residency in EM/IM and then fellowed in Critical Care. At the time that was the only pathway they really had up and coming and now some places are starting to offer EM/CC.

Anyway I have learned a ton from him and it completely changed my way of thinking in my patient care even in the ER. As a lot of you know in the ER even when we have a critical patient come in, it often doesn't change our Ratios. The problem with this is when in the ICU the nurses typically have a ratio of 1-2 with these same patients, well a little more stable than when we get them regardless of what some might want to say.

So in the new integrated ER concepts the ER nurses would be cross trained in ICU and EM. There would be doctors staffed as well that specialize in both. If the nurse works the zone with these patient types their ratios would be reflected for that. The idea is not to hold patients longer in the ER. But more to provide safe and good care for those patients that will have to board in the ER while waiting for an ICU bed. Once a bed is available the intensivest and ICU RN would take over care. My friend was asked to come be a part of one of these ED's when he finished his fellowship and he was trying to convince me to do it as well.

For me personally, as long as the ratios reflected the higher acuity, I would be all for it. Not only is it safer and things aren't getting missed in the holdover, I have always wanted to cross train in the ICU for the knowledge aspect of it, however had no desire to leave the ER. Would still rather have my ICU patients for a handful of hours and move along to the next. Obviously the ICU nurses would not need to cross train in the ER unless they wanted to switch roles.

Anyway I was curious what others thought about this.

I see more cross training of ICU nurses to work in the ER, but not the other way around. I would welcome the challenge to cross train to the ICU.

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Specializes in Med-Tele; ED; ICU.
So question for my fellow ER nurses, how would you guys feel about an integrated ER. They are starting to pop up more and more. One of my best friends was doing his residency in EM/IM and then fellowed in Critical Care. At the time that was the only pathway they really had up and coming and now some places are starting to offer EM/CC.

Anyway I have learned a ton from him and it completely changed my way of thinking in my patient care even in the ER. As a lot of you know in the ER even when we have a critical patient come in, it often doesn't change our Ratios. The problem with this is when in the ICU the nurses typically have a ratio of 1-2 with these same patients, well a little more stable than when we get them regardless of what some might want to say.

So in the new integrated ER concepts the ER nurses would be cross trained in ICU and EM. There would be doctors staffed as well that specialize in both. If the nurse works the zone with these patient types their ratios would be reflected for that. The idea is not to hold patients longer in the ER. But more to provide safe and good care for those patients that will have to board in the ER while waiting for an ICU bed. Once a bed is available the intensivest and ICU RN would take over care. My friend was asked to come be a part of one of these ED's when he finished his fellowship and he was trying to convince me to do it as well.

For me personally, as long as the ratios reflected the higher acuity, I would be all for it. Not only is it safer and things aren't getting missed in the holdover, I have always wanted to cross train in the ICU for the knowledge aspect of it, however had no desire to leave the ER. Would still rather have my ICU patients for a handful of hours and move along to the next. Obviously the ICU nurses would not need to cross train in the ER unless they wanted to switch roles.

Anyway I was curious what others thought about this.

Once the patient becomes an ICU level of care, they should fall under ICU ratios (1:2 in CA). In the large hospital in which I work, this is the case; in the smaller facility, it depends on the nurse and his/her ability/willingness to lobby for same.
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Specializes in Critical Care.

"Critical Care" refers to a level of care that is usually required to be available in certain environments, including ICUs, ERs, ORs, Cath labs, sometimes PACUs. That doesn't mean that a nurse who works in any of these areas is automatically considered a critical care nurse, which is why CRNA programs will often specific ICU experience because that's the most likely area where anyone who works there will have the critical care experience they are looking for.

We do often hold ICU patients in the ED, sometimes for extended periods, but it's necessarily the same level of care they get in the ICU, one of the big arguments for getting patients out of the ED as soon as possible is that they supposedly don't receive the same care. That certainly doesn't mean that there aren't ED nurses who can provide care that is as good as or sometimes even better than what the patient would receive in the ICU, but for many it's a hard competency to develop or maintain when you don't get those type of patients day after day.

I have worked in an ED where critical patients were only taken by crosstrained ICU nurses, which worked extremely well. All experienced ICU nurses were crosstrained to the ED and regularly rotated through the ED, which was particularly handy since the nurse would often keep the patient when the moved to ICU, the nurse would move to the ICU with them.

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Specializes in Critical Care.
Once the patient becomes an ICU level of care, they should fall under ICU ratios (1:2 in CA). In the large hospital in which I work, this is the case; in the smaller facility, it depends on the nurse and his/her ability/willingness to lobby for same.

I've worked in 3 different ED's, and in all of them truly critical patients were 1:2 or even 1:1 depending on how much was going on with them. I keep hearing about EDs where they use basically the same ratios regardless of how sick a patient is, which sounds ridiculous.

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
I see more cross training of ICU nurses to work in the ER but not the other way around. I would welcome the challenge to cross train to the ICU.[/quote']

I cross-trained to the ICU while deployed, out of necessity. I was the ER/Trauma nurse for a Forward Surgical Team, and sometimes patients stayed with me for five minutes before we carried them 20 feet to the OR. When we had more patients than nurses, I worked in our ICU (20 feet the other way, haha). Definitely critical care either way! And when we held patients overnight and I was the night nurse, they were all mine.

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Specializes in Emergency Dept. Trauma. Pediatrics.
I've worked in 3 different ED's, and in all of them truly critical patients were 1:2 or even 1:1 depending on how much was going on with them. I keep hearing about EDs where they use basically the same ratios regardless of how sick a patient is, which sounds ridiculous.

It is ridiculous but I have seen it happen more times than not. Especially when staffing is poor. The end result is the nurses other 3-4 patients kinds get put on hold and don't receive care while the nurse is stuck in the room of the critical. One hospital that I finally had to walk away I literally saw the charge have EMS take a unstable critical patient to a nurses room KNOWING the nurse was actively doing CPR on the patient in the next room of hers that had just coded unexpectedly. EMS asked where the nurse was and then looked and saw her doing compressions;. There were other empty rooms. That's when I finally lost my sh** on the charge.

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Specializes in Emergency Dept. Trauma. Pediatrics.
Once the patient becomes an ICU level of care, they should fall under ICU ratios (1:2 in CA). In the large hospital in which I work, this is the case; in the smaller facility, it depends on the nurse and his/her ability/willingness to lobby for same.

It should but of course it doesn't always happen. I just really liked in these new concept ER's the the docs and the nurses were cross trained.

I am actually surprised to read some of the responses here that the ICU nurses were frequently cross trained in the ER. 5 Hospitals I have worked in and I have never seen this. The only ICU nurse I knew that worked down in the ER once in a while was in the ER first and also a Paramedic.

I wanted to cross train but was told to cross train in the ICU I would have to leave the ER and stay in the ICU for a year because they would want me on as a new nurse, not someone cross training.

In the ER's I was speaking of they cross train and you do 1-2 shifts of the ICU a week training and stay in the ER the other 1-2 a week. One of the ER docs on board would also be a ER/CC doc. The bottom line is we are always gonna be holding over in the ER. I have always seen it that way no matter what part of the country, it's gonna happen. Some patient types the "Floor orders" can wait until the patient gets a room. Others they can't and often the orders get ignored or things get missed. It sucks when it's regular inpatient cases because most of us didn't become ER nurses to play floor nurses. It's a different type of nursing and the priorities are different.

But in cases of the critical patients I can see the benefits to cross training.

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Specializes in ED, ICU, PSYCH, PP, CEN.

I worked ER for about 9 years, then went to ICU and am going on 5 years there. Both are considered "specialties" for good reason. The difference comes into play that in the ER everything is explore and stabilize, while in ICU you are tweaking and doing long term management. Both specialties require nurses to have great critical thinking skills and be able to multitask on a very high level.

In a way ICU is easier because you usually already know what the patients major malfunction is when you get them. In the ER you have to be a detective and try to figure out what the problem is.

Both ER and ICU nurses have to know how to code a patient, give lots of blood, titrate dopamine, fentanyl, and a bunch of other drugs. I do think it's easier to go from ER to ICU because as an ER nurse you learn to just deal with whatever comes through the door. I see a lot of ICU nurses who don't like the uncertainty, and will say, "I'm not ready to take another patient." In the ER we don't have that option. They just keep coming in no matter how busy we are.

Let's stop looking to see who is "better" or what ever, and start to appreciate the importance of each area of nursing. We are all highly trained individuals.

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Specializes in CRNA, Finally retired.

Only went as far as looking as the LSU section. Yes, they state that they do accept ED experience but only from a LEVEL 1 Trauma Center. I get that.

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