High acuity patients in Minor Care and low ER staffing

[FNPveteran]

I work in a moderately busy emergency department in DC. I have worked in the ER for 13 years, and have worked at busy city hospitals, and as an agency nurse, and now a staff nurse. The hospital where I currently work has had a high staff turnover with 2 new managements in the past 2 years. We are constantly understaffed, and the charge nurse is often expected to take a full patient load, in addition to charge nurse duties.

I work in all areas of the ER...charge, triage, main ED, and our express care area. Our patient ratios for the Emergency Department are 4:1, and Express care are 8:1.

Because our management is focusing so much on patient satisfaction surveys, the goal is to get patients seen in 5 minutes from walking through the door. Which means that they are wanting patients triaged at the bedside, even if triage has no patients. Meaning, the nurse in Express care with 8 patients is also expected to triage patients in addition to treating patients.

They also don't want anyone waiting in the waiting room, so they are bringing level 3 patients to express care if rooms are open. Today I had a guy with a ROMI, and another patient in CHF, tripoding at the bedside that ended up being an ICU admission. I understand getting patients seen in a timely manner, but expecting one nurse to take 8 patients including level 3's seems unsafe to me. When I approached my manager about my concerns, and the possibility of allocating extra staffing if there were higher acuity patients in express care only brought the condescending response that "any competent nurse can handle the acuity and numbers of patients in Express Care".

I am looking for a new job, but wanted feedback on other Urgent or minor care areas attached to an ER. What are your ratios, and do you have age cutoffs for patients sent to Minor care?

[PostOpPrincess, BSN, RN]

A R/O MI and someone in acute CHF does NOT belong in express care.

Show her national standards of care.

[SummerGarden, BSN, MSN, RN]

i work all areas too, which includes trauma. guess what? when i work the rapid/express area and am given a patient that is high acuity, i literally move that patient to another room. if there is no other room available (this has happened) i close beds in the express area! yes, i have been yelled at... and yes i yell back!

so… using your scenario... as soon as i realize the patient is high acuity (usually when they walk in and the doctor is notified to assess) i take care of that patient first. others have waited... seriously i have had nurses and physicians come to me complaining that “patient so-and-so wants to go and is discharged.” i told them, “well patient so-and-so is stable, this patient is not. if you want to discharge patient so-and-so go right ahead otherwise, so-and-so can wait.”

i worked med surg prior to the er. i learned very quickly that managers do not listen to you after an incident so i do not waste my time complaining later. i deal with the situation when it arises. gl!

[Rickbos]

The Press Ganey pacifying "immediate bedding" management idea violates the original concept of triage.... "treatment as per acuity". If you want "first come first serve" go to the deli counter or McDonald's. If you want sound, efficient emergency care, utilize an accepted ESI system. "Immediate bedding" should not be done in ERs. The only thing it may accomplish is to give the false sense of being seen faster. It actually can delay treatment of high acuity patients that come in after you fill all your rooms because now you have to throw someone out, who didn't need to be there originally, to get the sick patient in. So Dr Press & Dr Ganey, how is that therapeutic for that high acuity patient? "Immediate bedding" is nothing but a PR gimmick and is detrimental to the delivery of efficient emergency care.

[Altra, BSN, RN]

The Press Ganey pacifying "immediate bedding" management idea violates the original concept of triage.... "treatment as per acuity". If you want "first come first serve" go to the deli counter or McDonald's. If you want sound, efficient emergency care, utilize an accepted ESI system. "Immediate bedding" should not be done in ERs. The only thing it may accomplish is to give the false sense of being seen faster. It actually can delay treatment of high acuity patients that come in after you fill all your rooms because now you have to throw someone out, who didn't need to be there originally, to get the sick patient in. So Dr Press & Dr Ganey, how is that therapeutic for that high acuity patient? "Immediate bedding" is nothing but a PR gimmick and is detrimental to the delivery of efficient emergency care.

Absolutely true!

[Lunah, MSN, RN]

I think we're all doing that bedside triage thing. Gah. I've had days in which I'm assigned to fast track and I had a couple of ICU admissions from there ... good times! Not. LOL.

[DC Collins, ASN]

I work in a moderately busy ED. Triage is the quickest portion of the process, so we have usually 1 RN, and 2 when busy, staffing triage. Our Fast Track (your express) has a ratio of 4-1, and even that can be a lot at times.

The rest of the ED has a team of two RNs, one Tech, and one Float RN per 7 patients (most of the time - nothing is completly perfect of course). The two RNs on a team each have firm responsibility for 3 pts, and switch back and forth on the 7th room, depending on who is busiest. The team float just does procedures / handles whatever is necessary as needed, and provides breaks.

I am glad to hear you are looking somewhere else. What you are experiencing, imho, is NUTS. Wishing you good fortune on your job hunt!

DC :)

[PACNWNURSING]

It feels good to read these posts and realize I am not alone. I am good nurse and try real hard to be safe and efficient. Since taking this ER job, I have been very stressed. My previous ED was properly staffed and the nurses had plenty of support. Here we are short staffed on a daily basis. I am working at a brand new ER with 79 beds with a large health care provider. We doing everything minus mopping the floor, tech support might as well be zero they have 16 patients. I assumed that the proper staffing and support would be here. I assumed wrong. Many of the nurses that worked in the old ER have quit since moving to this new ER, because of the staffing levels and no triage. Common sense would tell you if you have 40 beds and nearly double your beds but keep the same staffing levels, this will not work. With no proper triaging and improper patient assignments due to their acuity level, I am have been overstretched and placed in unsafe positions. Needless to say I am done with ER nursing and will go to urgent care and will be part of the endless supply chain that sends patients to the ED. How I envy the medics and EMT's who drop patients off and smile and laugh heading back to their Rigs

[Hagabel]

It feels good to read these posts and realize I am not alone. I am good nurse and try real hard to be safe and efficient. Since taking this ER job, I have been very stressed. My previous ED was properly staffed and the nurses had plenty of support. Here we are short staffed on a daily basis. I am working at a brand new ER with 79 beds with a large health care provider. We doing everything minus mopping the floor, tech support might as well be zero they have 16 patients. I assumed that the proper staffing and support would be here. I assumed wrong. Many of the nurses that worked in the old ER have quit since moving to this new ER, because of the staffing levels and no triage. Common sense would tell you if you have 40 beds and nearly double your beds but keep the same staffing levels, this will not work. With no proper triaging and improper patient assignments due to their acuity level, I am have been overstretched and placed in unsafe positions. Needless to say I am done with ER nursing and will go to urgent care and will be part of the endless supply chain that sends patients to the ED. How I envy the medics and EMT's who drop patients off and smile and laugh heading back to their Rigs

I Know exactly where you work, I worked there when campuses were separate...just toured round your new er last month..heard a lot of complaints..i would move too..:)