Frustrating... ED is Not Critical Care

[bgxyrnf]

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?

[MadruGada]

... tiny, rural, critical-access hospital (as I call it, Level None) ...

I realize this is OT but I expect to be employed soon in a CAH and so have been reading up everything I can on them. By and large the comments seem to be positive. Could the OP (or anybody) please elaborate on the above excerpted quote? Thanks!

[~Mi Vida Loca~RN, ASN, RN]

I realize this is OT but I expect to be employed soon in a CAH and so have been reading up everything I can on them. By and large the comments seem to be positive. Could the OP (or anybody) please elaborate on the above excerpted quote? Thanks!

What is it you're wanting to know exactly? They can definitely be a good starting base to get good at your skills. Some places refer to them as stabilize and ship hospitals. If someone walks or drives into the ER with a trauma, you will care for them and stabilize and ship them to the appropriate hospital. You will do so with far less resources then a designated trauma center. You have to get good at your skills and you will have the opportunity. It's just most situations you won't have EMS bringing you traumas. They will be taking them to the closest designated trauma center unless there is a specific reason they have to bring them to you.

So you might not see near as much as working at a level 2 of 1 trauma center but you'll still see some stuff and you will find you have a far more active role in things that come in then in one of the bigger hospitals. You'll get to know your docs good and if you form good relationships they will teach you a ton and depend on you. You will have the ability to have a lot of autonomy. (if it's within your scope)

Mind you, every ER will be a little different. But IMO it's definitely a good starting point if your goal is to get into a bigger center.

[guest940422]

ED nursing isn't considered Critical Care? You have got to be kidding me! As a Critical Care nurse that is embarrassing. Aside from the traumas or transfers who come directly to the floor, ED nurses do the hardest part of the job before I ever know the patient exists! I hate it when they have to hold ICU patients because that's a bed someone in the waiting room needs. Even if you never had to hold a patient and there was magically a bed for every admit as soon as you were ready, you still sure as hell do Critical Care work. My best friend is an ER nurse and she can run circles around me.... crazy.

[renardeau, BSN, RN]

My ICU was a trauma I 800+ bed hospital and we precepted many different types of nurses from new grads to seasoned ICU nurses. For us, ED nurses (both ours and from other hospitals) always had the hardest time adjusting to ICU (sometimes more so than the new grads). Typically they were great in codes, but had more difficulty thinking longterm and really 'advancing' care or working with the doctors to actively suggest interventions, etc. They kept the patients alive, but often they didn't wean pressers as aggressively, didn't bother to work with RT/intensivist to optimize vent settings or try to wean, and forget about getting a patient out of bed or pushing to take out unnecessary lines or Foleys. We worked on a floor where the nurse is given a lot of freedom and the doctors, especially residents, really listened to our suggestions re: meds, labs, should we SBT, do they look ready for extubation, do you think they'll tolerate pulling more fluid off CRRT, etc. Often when I tried to express to one of them that perhaps they could have tried X or Y at some point in their 12-hour shift, I'm often met with 'well, they were stable so I didn't'. Perhaps this is just a bad sample of 4-5 non-critically thinking nurses that just happened to be ED nurses and results in an availability bias for me, but it definitely made me wonder if our differences in mentality were due to personality or ICU vs. ED training. To be sure, a critically-ill patient will stay alive in their hands, I have no doubt of that. They definitely knew their ACLS and emergency procedures. To me though, that's not all a critical care nurse is.

[bgxyrnf, MSN, RN]

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.

Having worked across the spectrum, I do too.

My present position in a Level 2 does not provide the breadth and depth of experience.

[~Mi Vida Loca~RN, ASN, RN]

I wouldn't expect an ER nurse to think like an ICU nurse. Two completely different areas. That however doesn't mean ICU is the only unit to carry the Critical Care title.

I mean to simplify it, I am pretty sure that most patients aren't coming into the ER stable and admitted to the ICU just in case and then turn critical. They are coming into the ER unstable, in critical condition where they are stabilized (as much as they can be) and moved to the ICU. so unless the ICU nurses are standing by in the ER like the Surgical Residents on Greys anatomy do, waiting for a critical patient to come in, I am pretty confident it is the ER nurse that will be providing the care needed for that patient, whether it be for an hour or multiple hours.

We aren't thinking about weaning off of drips, D/C Foley's, preparing to extubate. Why would we be thinking like that? Our focus of care is much different. But it doesn't make us any less of a critical care nurse. I know sometimes I get annoyed giving report when some questions I feel are absurd are asked. I have to remember we have two totally different roles going on and my priorities are much different. As they should be.

Doesn't make ICU nurses or ED nurses any better or smarter than their colleagues. Just a different focus. I never understood why their always seems to be such discord between the two units no matter where I have worked.

[FolksBtrippin, BSN, RN]

Ed nurses also get a lot of psych patients, but I wouldn't call them psych nurses either.

Relax. Everyone knows you're cool. Carry on with your saving lives and whatnot.

[~Mi Vida Loca~RN, ASN, RN]

Ed nurses also get a lot of psych patients, but I wouldn't call them psych nurses either.

Relax. Everyone knows you're cool. Carry on with your saving lives and whatnot.

I wouldn't consider us psych nurses either, psych encompasses a full circle of things. However, I have had many psych nurses come to the ED and be shocked and thankful that we get them in their acute psychotic phase before sending them inpatient. (yes I am aware they can have acute outbursts once admitted sometimes, it tends to be a much more controlled environment though)

IF you have a patient in an acute psychotic episode, especially with drugs on board. You're gonna want that ER nurse there over the psych nurse. Again, not because we are better than, just completely different focus.

Of course this isn't the case for everyone. We always have those cowboys that like to puff up their chests and provoke the psych patients or combative patient. But you get those everywhere. I'll never forget the big "gym rat" that came was from ICU and was in the ER to take a patient when another patient coded and he wanted to show us all how amazing he was at compressions. How he could do like 200 compressions a minute, until the doc kicked him off and our tech pushed me forward *I was a very new nurse but I can rock out some compressions* because although Fabio was pretty and had huge biceps and had speed. He had no depth on his compressions and it was pointless.

[All_night]

Last I checked, Midwestern in AZ does. Keep looking!

[AZQuik]

Honestly I don't think of an "er nurse" as a "critical care nurse". Not to say a nurse can't be good at both, and there is a lot of overlap in drugs/blood tests/skills/charting. But really they are different in mindset, and obviously pt load/demographics.

In my opinion, if a critical pt comes in, the ER specializes in stabilizing. The ICU is where the healing begins.

The real difference IMO is that The ED nurse needs to be able to have two septic pts tubed and on pressors while having one to three other whatevers. Facing that the mind set will always be," well, did they die"?

The icu nurse is trying to get their pt to the floor, so they can decompress the ED.

Two totally different mindsets and priorities.

Who cares which one the CRNA school accepts? Want to get into X school? Meet X requirements. The two points are apples and oranges to the parent of the child you are coding, no matter if you are in the ICU,or the ED

[renardeau, BSN, RN]

We aren't thinking about weaning off of drips, D/C Foley's, preparing to extubate. Why would we be thinking like that? Our focus of care is much different. But it doesn't make us any less of a critical care nurse. I know sometimes I get annoyed giving report when some questions I feel are absurd are asked. I have to remember we have two totally different roles going on and my priorities are much different. As they should be.

Doesn't make ICU nurses or ED nurses any better or smarter than their colleagues. Just a different focus. I never understood why their always seems to be such discord between the two units no matter where I have worked.

This is super delayed and but I tend to the visit this site in spurts and then leave in spurts... I was re-reading old threads that I got alerts from and just wanted to clarify.

I truly don't believe that ED nurses are better or worse, but we do focus on different things---there we seem to agree.

If we are talking specifically about the realm of critical care nursing, perhaps this is merely a difference of opinion, but to me, things like down-titrating pressors, DCing unnecessary things, knowing vent settings well enough to move care forward, advanced therapies, etc. are absolutely a part of critical care nursing and, as you said yourself, are just not done/prioritized in the ED. Do they get critical patients? Yes. Does the ED consequently handle some aspects of critical care? Again, yes. But my main point---or perhaps, just opinion---is that critical care is not just stabilizing a sick patient.

[Guest374845]

As an ED nurse, I can assure you we aren't critical care nurses. The majority of ED nurses couldn't tell the difference between SIMV and assist control, much less understand auto-PEEP, whether to shorten or lengthen I:E, t-piece weaning etc. I know a lot who can barely zero an art line, and I know none (except former ICU) who can look at PAS/PAD from a swan and make an informed decision about drips. Will you ever have to worry about a swan in your ER? No, but a critical care nurse knows those numbers like they know SBP/DBP.

I recently had a pt with a catastrophic ICH discovered subsequent to RSI with roc. When it was time to re-examine her, maybe put in an EVD, it was like looking at a school of fish when I suggested to my colleagues we get a ToF to see if she was still paralyzed.

Heck, we don't even pay attention to Is and Os on people we're admitting for major hemodynamic compromise.

But none of that matters. The ED is its own special entity with crossover into various lands. No other nurse from any other unit can practice with the breadth and flexibility we have, but with that comes the limitation on how deep you really get to go with that practice. We're not specialists in all these essential areas, we're generalists with emphasis on rescus and life supportive care.