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?

[Lunah, MSN, RN]

Having done critical care while deployed and now rounding on trauma patients in the ICU, I am grateful for my experiences in both the civilian world and the military setting that have given me a broad foundation in critical care topics. I guess I always assume that all ER nurses are knowledge junkies like me, but I know that's not realistic.

I think some ER nurses are definitely critical care based on knowledge, skills, and experience, and others not so much. Kind of the way that some ER nurses are really more "urgent care" than "ER" when it comes to their skills and abilities. It's a spectrum.

[bgxyrnf, MSN, RN]

Having done critical care while deployed and now rounding on trauma patients in the ICU, I am grateful for my experiences in both the civilian world and the military setting that have given me a broad foundation in critical care topics. I guess I always assume that all ER nurses are knowledge junkies like me, but I know that's not realistic.

I think some ER nurses are definitely critical care based on knowledge, skills, and experience, and others not so much. Kind of the way that some ER nurses are really more "urgent care" than "ER" when it comes to their skills and abilities. It's a spectrum.

Yeah, perspective is a great thing.

Just as not all ED nurses nor EDs in general practice critical care, some of the ICUs that I've seen hold patients who are only slightly more acute than floor patients. Some of the critical patients that we boarded in my primary ED gig were much more 'critical care' than the sickest patients in two of the community ICUs in whose orbits I flew.

[ILUVERNSG, MSN, RN]

Yeah, when I help stabilize a post code pt and initiate therapeutic hypothermia, I think I might be a critical care nurse. When I defibrillate the little old lady returning from CT scan whose eyes roll back in her head as she goes in and out of VT and start amiodarone, I think I might be a critical care nurse. When I start titrating the pressors on my septic shock pt who is going down the tubes and there's no unit bed, I think I might be a critical care nurse.

But even better than that, I'M AN ER NURSE!

[ILUVERNSG, MSN, RN]

Great post!

[Kaybee1983]

National University accepts trauma ED experience on a case by case basis. It is the mech vent experience they are looking for.

[2mint]

I've been an ED nurse for 7 years....

We are not Critical Care nurses.

OP, take your typical sepsis alert patients for example: you draw labs and blood culture and start Abx infusions, then admit the patient. Same with your RSI patients: after intubation and starting drips, you admit the patient. Same with copd/chf exacerbation, Stroke, etc.

As ER nurses, we stabilize/start initial TX, then dispo.

This is how my ED works:

Level 1 Trauma center: a main ER, a fastrack, and a Trauma bay

I will speak for the main ER

1. Pts come in, we put them on the monitor, draw labs, send them to diagnostics.

2. Run IVF and/or medicate for pain, give appropriate meds in the meantime, as warranted.

3. Labs/diagnostic results will dictate further interventions and appropriate dispo (d/c, admit, or transfer to observation)

Steps 1-3 happen in an avg of 90 minutes.

As ER nurses, we receive 'Emergency Nursing' training, which entails BLS/ACLS stuffs: Primary survey (ABCDE) and Secondary survey (H&P). After a year or so, ER nurses will receive additional training in Trauma to work in Trauma bay.

I'm an ER nurse, I don't do Q2H repositioning or strict I&O (or even I&O for that matter), therefore I'm not a critical care nurse....I kid, I kid...but lots of truth to it, though.

[Wuzzie]

We are not Critical Care nurses.

OP, take your typical sepsis alert patients for example: you draw labs and blood culture and start Abx infusions, then admit the patient. Same with your RSI patients: after intubation and starting drips, you admit the patient. Same with copd/chf exacerbation, Stroke, etc.

As ER nurses, we stabilize/start initial TX, then dispo.

This is how my ED works:

Level 1 Trauma center: a main ER, a fastrack, and a Trauma bay

I will speak for the main ER

1. Pts come in, we put them on the monitor, draw labs, send them to diagnostics.

2. Run IVF and/or medicate for pain, give appropriate meds in the meantime, as warranted.

3. Labs/diagnostic results will dictate further interventions and appropriate dispo (d/c, admit, or transfer to observation)

Steps 1-3 happen in an avg of 90 minutes.

As ER nurses, we receive 'Emergency Nursing' training, which entails BLS/ACLS stuffs: Primary survey (ABCDE) and Secondary survey (H&P). After a year or so, ER nurses will receive additional training in Trauma to work in Trauma bay.

I'm an ER nurse, I don't do Q2H repositioning or strict I&O (or even I&O for that matter), therefore I'm not a critical care nurse....I kid, I kid...but lots of truth to it, though.

Salient points 2mint but what about those ICU patients that are boarded in the ED until a room is available? Sometimes for days. This happens very frequently in institutions large and small all over the country. No CC nurses get floated to care for the patient so it's on the ED nurses. Now granted they won't be running CVVHD but not all CC nurses do it either. Multiple drips-check. Ventilated patients-check. Invasive monitoring-check. Multiple meds-check. Q2 hour turns-check. I'm not sure we can say absolutely but it seems to me that ED nursing moves along a continuum that does indeed include critical care. But the bigger question is why does it matter?

I wanted to add I've been a CC nurse, an ED nurse and a flight nurse. They're all awesome!! Just rock at what you are and don't worry about critics (they're everywhere). If someone puts you down throw them some shade and relax in your own supreme coolness!

[canoehead, BSN, RN]

As an ER nurse I only feel competent in titrating drips up, not weaning down. I have seen a Swan, and could run the various numbers, but I don't have much of a clue what they mean. That gentle persistent encouragement over months to push patients just a little more, get a little better, and stay optimistic, that's frigging amazing, ICU nurses are the bomb. I always feel like I don't know how much I'm missing in patient care, like a new grad, when I have an ICU patient. There's a difference between being competent to deal with a vent or art line, and being an expert. I'm just competent.

[2mint]

....why does it matter?

...I've been a CC nurse, an ED nurse and a flight nurse.

My level 1 trauma training hospital pays CC bonus, we ER nurses did not get CC bonus pay, so we know that we are not CC nurses. But we argued for and finally got ER bonus pay just a few years ago.

My ED comprises Psych ED nurses, Observation nurses, Clinic nurses, Flight nurses, ER nurses, Trauma nurses, and MICN's.

The last three are 'ER' nurses; all seven are 'ED' nurses.

[JKL33]

We are not Critical Care nurses.

OP, take your typical sepsis alert patients for example: you draw labs and blood culture and start Abx infusions, then admit the patient. Same with your RSI patients: after intubation and starting drips, you admit the patient. Same with copd/chf exacerbation, Stroke, etc.

As ER nurses, we stabilize/start initial TX, then dispo.

This is how my ED works:

Level 1 Trauma center: a main ER, a fastrack, and a Trauma bay

I will speak for the main ER

1. Pts come in, we put them on the monitor, draw labs, send them to diagnostics.

2. Run IVF and/or medicate for pain, give appropriate meds in the meantime, as warranted.

3. Labs/diagnostic results will dictate further interventions and appropriate dispo (d/c, admit, or transfer to observation)

Steps 1-3 happen in an avg of 90 minutes.

As ER nurses, we receive 'Emergency Nursing' training, which entails BLS/ACLS stuffs: Primary survey (ABCDE) and Secondary survey (H&P). After a year or so, ER nurses will receive additional training in Trauma to work in Trauma bay.

I'm an ER nurse, I don't do Q2H repositioning or strict I&O (or even I&O for that matter), therefore I'm not a critical care nurse....I kid, I kid...but lots of truth to it, though.

I won't argue whether or not we are "critical care" nurses, since I personally don't care.

And I can't disagree with these written words ^.

However, I do think words don't convey it; simply listing the scope of our "tasks" doesn't convey what we are really doing. For example, "giving appropriate medications" isn't just that. If it were, anyone who can fog a mirror could step up to an ED gurney and twist this one thing into that other thing and push a plunger full of whatever "appropriate" med the provider ordered. No matter if it is vasoactive or a paralytic or antiarrhythmic or x, y, z ED med.

Generally-speaking, there's a reason or two that our medication policies, for example, are not the same as the policies on general units. And there is a reason or two (beyond just staffing ratios) that a number of the patients we care for in the ED are not appropriate for general floor admission.

Listing our tasks tends to severely underestimate the assessment and re-assessment and critical-thinking portions of the ED RN role. In my years of observations, THAT part is what makes the difference between an excellent and mediocre (or even scary) ED nurse. It is where subtleties are recognized and differences are made. I can pick out people who are mostly-task-oriented fairly quickly.

We do provide care to critically-ill and injured patients. It is different than CC Nursing. Each have their own place and thus their own merit.

[2mint]

W

2. Run IVF and/or medicate for pain, give appropriate meds in the meantime, as warranted.

...For example, "giving appropriate medications" isn't just that.

We're ER nurses; we know what we do.

These three steps are just a down&dirty snapshot of what goes on in the ER for non-ER nurses.

Based on your selective quotation of me, I agree with your objection.

Based on my full quotation of me, I disagree with your objection.

Here's why: your objection is that I am omitting the critical thinking aspects of our job.

Look again at the full quotation, those subtle and somewhat sexy two words "as warranted" encode said critical thinking skills.

E.g. This Pt is very tachycardic, let's give some meds to control the HR.

Appropriate? Yes. Warranted? Let's see: the Pt is also very hypotensive. So, no, it's not warranted.

[JKL33]

Edit/nevermind. I didn't mean to offend. I don't understand what point you are making in the post that I inadvertently incorrectly referred to, and don't want to cause any further offense.