How do you protect yourself in unsafe situations in the ER?

**canoehead, BSN, RN** · Jan 25, 2004

I can only speak for my own hospital, and we usually manage pretty well. The RN's in the ER call the supervisor, and she becomes an extra nurse. If that's not enough the supervisor will call down the code team to help do tasks and clear things out. If there is a gridlock because the floor is full we transfer patients out. The med/surg unit has been very good about timely transfers upstairs, because the ER has been good about delaying when M/S is busy. If both are busy we have admitted M/S patients in the past to ICU or OB and transferred out once we have discharges.

We've never ended up with people in the hall using this scenario although that is another possibility- if someone is just waiting for labs and we have an emergent patient they can wait in the waiting room or on a stretcher in the hall. At night we could also open the day care OR area and put non urgent patients in there with the PA. On call docs are called to provide extra coverage if we get an influx of very critical patients.

I think the reason our system works so well is that we don't have to do it every day though, or even every month. If it is a recurring problem obviously you need more beds and more staff, and TPTB need to respond.

NickeyJ · Jan 25, 2004

I am new to the ER, but not new to nursing. In the 6 months I have worked in the ER I have seen pts wait 6+ hrs after being traiged, even after xrays. Our Hospital is small, with one Doc and a PA, 10, 12 if u add hall beds, 2 code rooms and a fast track area,total of 17 beds for one Dr. Staffing 5 nurses a secretary and a triage nurse....and security when we need them to monitor psych, or uncontrollable pts. We r not a trama center, tho if we are the closest to an accident or code 3, we get it. We are in the process of a major expansion, with no new staff being added, or so the story goes, because we have adequate staffing. Personally, I find this highly dangerous, boardering on the insane. Knowing that my years as a nurse are down to single digits....I wonder what life or what kind of death will be mine, should I someday need to be in an ER. I am seriously considering leaving the profession all together. However, in my heart I can't, because, each day, no matter how tired I am, or what I have seen, or cried behind a door for someone who died when we did all we could...I hear "thank you for being here". I was born to be a nurse and I will be one until I can't anymore....It is not for the faint hearted or the hard hearted. I don't have answers, but serious concerns about under educated and poorly trained entry level nurses. We need to hold a hand and help them, not condem them or rip their hearts out and have them with chips!!!! I remember my new nurse days...it was horrible...reach out for the new, inexperienced nurses and teach them...someday your life, my life may be in their hands.

RNin92 · Jan 25, 2004

In our hospital we are holding patients every day.

We are a 200 bed level 2 trauma center.

We have a total of 20 beds-14 ER beds and 6 fast track beds.

We are staffed every day with a charge RNs, 4 RNs, an RN in fast track, and a triage RN. Also, 3 techs and a secretary.

We see about 35, 000 pts. yearly.

It has become routine to hold 4-7 pts daily.

When our ER numbers are down we can absorb the holds fairly well. But when we start hitting the fan...it is VERY dangerous.

Our manager lets us bypass when we need to but that doesn't stop the front doors.

So we have tried transfering from our ER rather than holding...especially the ICUs. Our attendings are fighting it HARD. Of course they loose the bucks...the heck with the patient.

I just worry about being in a courtroom after a bad outcome and the judge saying...where's your documentation that you notified your supervisor? Why didn't you follow your hospitals' staffing policy? Why didn't you transfer the pt to another facility?

It's a scary nightmare to think about.

RN92 · Jan 25, 2004

I WORK IN A LEVEL 3 TRAUMA CENTER. WE HAVE 5 EMERGENCY ROOMS: (OB/PSYCHE/TRAUMA/MEDICINE/BURN). I WORK IN THE MEDICINE ER. WE MAY HOLD ICU PTS 2DAYS OR MORE. OUR NURSE/PT RATIO IS SUPPOSED TO BE 1:3-4. HOWEVER,WHEN TWO OR MORE OF THOSE PTS ARE ICU AND PCU PTS - IT BECOMES DIFFICULT TO PROVIDE THE KIND OF CARE THEY REQUIRE WHEN YOU ARE STILL TAKING IN NEW PTS. AND YOUR JUST SETTING YOURSELF UP FOR MISTAKES.

ITS HARD, AS A NURSE, TO ADMIT WHEN YOU HAVE MORE THAN YOU CAN HANDLE - BUT I HAVE LEARNED OVER THE LAST FEW YEARS THAT I NOT ONLY HAVE A RIGHT TO REFUSE NEW PTS, (IF IM ALREADY OVERWHELMED), BUT I HAVE A LEGAL AND MORAL OBLIGATION NOT TO DO SO. IT IS THE HOSPITALS RESPONSIBILITY TO PROVIDE QUALITY MEDICAL CARE - AS SOON AS YOU TAKE REPORT AND ACCEPT THAT PT - IT BECOMES YOUR RESPONSIBILITY ALSO. THE HOSPITAL IS NOT GOING TO RECONGIZE THAT WE NEED MORE STAFF UNLESS AMBULANCE STRETCHERS START LINING UP DOWN THE HALL - AND GOOD LUCK ON GETTING THE NSG SUPERVISOR OR CRISIS NURSE TO COME HELP. THIS IS AN EVERY DAY ISSUE WHERE I WORK. . IF YOU DO EVER FIND YOURSELF IN COURT - YOU BETTER BELIEVE THE HOSPITAL IS GOING TO DISTANCE THEIRSELF FROM YOU AS MUCH AS POSSIBLE. THE JURY AND OR STATE NSG BOARD IS NOT GOING TO ACCEPT THE EXCUSE THAT YOU WERE "TOO BUSY" OR OVERWORKED. JUST A WARNING FOR ALL OF THE NEW NURSES COMING INTO THE HOSPITAL ATMOSPHERE - KNOW WHEN TO SAY "I CANT ACCEPT ANOTHER PT RIGHT NOW " BECAUSE ULTIMATELY, ITS YOUR NSG LICENSE THAT WILL BE ON THE LINE. :nono: :nono:

zenman · Jan 25, 2004

Erslave, please use lowercaps, otherwise we think you are SCREAMING AT US! :chuckle

tymomrn · Jan 26, 2004

We have a total of 33 beds in our ER. We have a peds ER, fast track, even a seperate second trige room with 3 beds that never gets used because it's too far for the docs to walk. We hold more often than not, sometimes we even get hold nurses! Other than that we deal with 1 charge RN(no pts),1 triage RN, and 4 staff RNs after 11p. We lose 2 RNs at 3a. It's not bad, when it's actually staffed like it's supposed to be. But we ususally work short. Oh, and 1 doc after 1a. Winter is the worst, of course. But they try to get hold staff if they can. When it's unsafe, we fill out a specific grievance form with the union. I had one night when we got up to 27 holds(ICU in the hallway!), 2 hold nurses, 3 ER nurses. Of course, they ALL had holds, too. I was in charge, covering triage(we didn't have a seperate triage RN yet), and hadling base calls for the medics in our county. And it was 3rd time in charge! I called my manager, she ASKED if she should come in. I actually said no, because I knew she never worked ER, wouldn't do pt care, only breathe down my neck. Then 2 L&D RNs came down for blood exposure ( not wearing gloves, THEN found out pt was HIV+) and had the nerve to complain the next day about their wait. BTW, that is our record so far for holds.

Trauma Columnist · Jan 26, 2004

The OP wanted opinions to avoid lawsuits in the ER. Well - I caved in and got out after almost 8 years in a level one trauma cente where we hold (routinely) 3-8 pts every night. It got to be ridiculous! And seriously scary. I still work in the ER, but now I'm a case manager. Good luck...

MAGIK GIRL · Jan 26, 2004

DOCUMENT,DOCUMENT,DOCUMENT!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

did i mention document? stuff rolls down hill so i document who i told, when i told them and what they said. i also document that i told the pts. i even go as far as to document "report to so and so for lunch relief". sounds paranoid but i worked for a lawyer once for a brief time and my job was to go over an er chart. lets face it, our documentation sucks but it is the nature of the beast!

have a great day, mg:cool:

RNin92 · Jan 27, 2004

Originally posted by MAGIK GIRL
DOCUMENT,DOCUMENT,DOCUMENT!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

did i mention document? stuff rolls down hill so i document who i told, when i told them and what they said. i also document that i told the pts. i even go as far as to document "report to so and so for lunch relief". sounds paranoid but i worked for a lawyer once for a brief time and my job was to go over an er chart. lets face it, our documentation sucks but it is the nature of the beast!

have a great day, mg:cool:

I have a friend that says the same thing. Plus, one of the nurses I used to work with on Tele has a friend who is a legal nurse consultant...documentation is the key. But here is the dilemna...

Document where?

We are not union...so no grievance forms.

It doesn't seem right in the patient charts.

Do we need to create yet another form?!!?

It is so paranoid but also so needed, I think. Just to CYA...

:eek: :eek: :eek:

veetach · Jan 29, 2004

Ok here is our story:

We have a 25 bed ER, no fast track beds. We see $50,000+ pts per year and in the winter we see about 150-180 pts per day...

We hold patients CONSTANTLY. Out of our 11 monitored beds and 3 portable monitors it is not uncommon for 3/4 of them to be occupied with "hold" patients.

On night shift we have 4 RN's until 3am and then we go down to 3 RNs (not including the charge RN and the triage RN) our ratio can be up to as many as 3 Critical Care holds per RN and 2 or more Med Surg holds for the same RN. We NEVER get help. Havent you heard? the hospital closes at7pm. :rolleyes:

I do not know what the answer is, we stack people anywhere there is an available space to put a stretcher. We are beginning a remodel of our ED which will give us 35 beds, everyone is wondering if this will just give us more beds to hold patients in.

It is a problem, and no one seems to know the answer. If you guys figure it out, PLEASE let me know.

MAGIK GIRL · Jan 29, 2004

Originally posted by RNin92
I have a friend that says the same thing. Plus, one of the nurses I used to work with on Tele has a friend who is a legal nurse consultant...documentation is the key. But here is the dilemna...

Document where?
We are not union...so no grievance forms.
It doesn't seem right in the patient charts.
Do we need to create yet another form?!!?
It is so paranoid but also so needed, I think. Just to CYA...

:eek:

you can document anywhere! the er nurses notes with addendums are good places to start. as long as you are not sounding accusitory (sorry, i really can't spell) it is ok, ie; "pt complaining of pain. attending and er md's made aware and no further interventions ordered at this time." interperatation, this is the 5th such documentation and the er md doesn't want to get ivolved and the attending doesnt' either.

you just have to learn to document the facts only with out emotions (and i know how hard that can be!:chuckle! cause some people warrent lots of emotion.) have you ever written an incident report? try charting like you are writing one of those, just facts and what the involved parties say.

i know is sounds cynical but unfortunatly, we live in a law suit happy world! good luck, magik girl:cool: