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ICU to ER transition issues

Emergency   (11,132 Views 8 Comments)
by RoyalNurse RoyalNurse (New Member) New Member

RoyalNurse specializes in CVICU, ER.

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Hi everyone, I worked in a CVICU for 2 years, then moved to the ER 3 weeks ago. As I expected, I'm having problems switching gears to the ER world. Everything's so fast and flexible, things are changing too fast for me to realize, and I'm having a hard time keeping everything together. Basically, I can't just purge everything that happened 30 minutes ago, and stuff all the new things into my brain with 3 new patients. I can look at the computer screen and check off tasks, but can't think fast enough about what's going on with the patients. I have no critical thinking.

One example: a guy kept complaining of dizziness, headache and "asthma symptoms": I remembered someone saying an EKG needs to be done for syncope/dizziness, so I did an EKG, not thinking that his dizziness was probably due to lack of oxygen from asthma, and got chewed out by the ED doc for doing it.

I just don't know what I can do to change my thinking faster.

Anyone else move from ICU to ER? Any help/advice appreciated.

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interleukin has 14 years experience and specializes in Mixed Level-1 ICU.

6 Articles; 9,445 Visitors; 382 Posts

Problem is, 2 years in ICU are not enough to provide you the broad understanding and comfort when dealing with a wide range of emergency symptoms and presentations.

And this "critical thinking" thing is not something that can be learned, contrary to what many nursing teachers believe.

Critical thinking is simply experience and dedication to task.

After five years or so, many things become easier because you've seen "it" before.

What you once had to think hard about comes naturally. Nursing loves to use the "critical thinking" phrase, it makes us sound very special.

Well, we are special, but it has nothing to do with our thought processes. That's just experience and focus.

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16,880 Visitors; 1,553 Posts

2 pt's x 12 hrs vs 12 pt's x 12 hrs. Not exact, but you get the idea. Ist thing, is to give up some of the control you are used to. You are dealing with their chief complaint. Doing less with each pt seems to be difficult for ICU nurses. ( I have 2 yrs ICU experience)

Another thing that was hard for me to get used to was that the docs are right there. Make good use of them.

As far as getting "chewed out" for doing an EKG on someboddy who is dizzy. That's silly. An EKG is a good idea on somebody who is dizzy, depending on age, etc. this is assuming, of course, you have dealt with ABC's. If you were diong an EKG on somebody who was hypoxic and wheezing rather than dealing with (B)reathing, than you weren't making good use of your time.

BTW- "chewing out" is unprofessional. Giving guidance to a professional in a new environment is appropriate. Chewing out isn't.

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djaychris specializes in lots.....

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In my opinion, ICU to ED is one of the toughest transitions a nurse can make. I speak as a nurse who worked Med-Surg, then ED, then ICU, then ED. I have worked full time in the ED while working casual in the ICU, and vice versa. Before I knew ICU, I knew ED. ICU nurses are trained to be creatures of routine (forgive me for generalizing). Most give their patients their bath at the same time every day. They start their mornings the same way every day. There is a time to review labs, a time to document on care plans, a time to meet with the CCM for rounds, etc.etc.etc. ICU nurses must do a TON of charting, they have to be extremely thorough. They are also strong critical thinkers, and often diagnose and treat the patient themselves based on pre-determined protocols. Most of this goes out the window in the ED. There is no routine. Every day is different. You cannot spend hours diagnosing and attempting to treat all the patient's problems. You deal with the most pressing issue, then get them out of there. You chart just enough to get by, and no more than that. You must deal with emergencies with no warning, and often with aging/broken/missing equipment. That is the problem I see with alot of ICU nurses. They wish they had more time to spend with the patient. They cannot get all the charting done. They are shocked by monitoring a critically ill patient with only a bp cuff and pulse ox (no swan, no art line, etc.) They feel like they really didn't get to "fix" the patient. In my experience, I find that most ICU nurses feel that their job is way tougher than an ED nurse. Most ED nurses feel that their job is way tougher than an ICU nurse. After doing both extensively, I think that neither one if tougher. Each one presents their own challenges and required skill sets. Transitioning from a controlled (but extremely difficult) environment like the the ICU to the madness of a busy ED can be extremely traumatic (no pun intended).

-Just my humble opinion, I'm not trying to offend anybody.

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MassED has 15 years experience as a BSN and specializes in ER.

1 Article; 20,156 Visitors; 2,636 Posts

In my opinion, ICU to ED is one of the toughest transitions a nurse can make. I speak as a nurse who worked Med-Surg, then ED, then ICU, then ED. I have worked full time in the ED while working casual in the ICU, and vice versa. Before I knew ICU, I knew ED. ICU nurses are trained to be creatures of routine (forgive me for generalizing). Most give their patients their bath at the same time every day. They start their mornings the same way every day. There is a time to review labs, a time to document on care plans, a time to meet with the CCM for rounds, etc.etc.etc. ICU nurses must do a TON of charting, they have to be extremely thorough. They are also strong critical thinkers, and often diagnose and treat the patient themselves based on pre-determined protocols. Most of this goes out the window in the ED. There is no routine. Every day is different. You cannot spend hours diagnosing and attempting to treat all the patient's problems. You deal with the most pressing issue, then get them out of there. You chart just enough to get by, and no more than that. You must deal with emergencies with no warning, and often with aging/broken/missing equipment. That is the problem I see with alot of ICU nurses. They wish they had more time to spend with the patient. They cannot get all the charting done. They are shocked by monitoring a critically ill patient with only a bp cuff and pulse ox (no swan, no art line, etc.) They feel like they really didn't get to "fix" the patient. In my experience, I find that most ICU nurses feel that their job is way tougher than an ED nurse. Most ED nurses feel that their job is way tougher than an ICU nurse. After doing both extensively, I think that neither one if tougher. Each one presents their own challenges and required skill sets. Transitioning from a controlled (but extremely difficult) environment like the the ICU to the madness of a busy ED can be extremely traumatic (no pun intended).

-Just my humble opinion, I'm not trying to offend anybody.

well put, djaychris. I haven't worked in an ICU, and don't think I'll ever leave an ER, but I can appreciate your take on working in both worlds. I think it takes a special person to work in each area.

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Altra is a BSN, RN and specializes in Emergency & Trauma/Adult ICU.

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Just out of curiousity ... anyone care to share any observations on making the opposite transition - from ED to ICU?

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djaychris specializes in lots.....

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That was a transition I made. I went from full time at a busy community ED, to full time in the biggest and toughest CT-ICU in my region. What it showed me, was that I did not know nearly as much as I thought I knew. I had no idea how to handle the ICU patients. There was tons of equipment I'd never seen (IABPs, VADs, Primsa, multiple kinds of swans, tons of drips, EVD's, ECMO, etc.etc.etc.) I had to learn hemodynamics. Not BP and pulse ox, but SVR, PA pressures, Cardiac Index, etc.etc.etc. It was a great experience, and one of the best decisions I ever made. I left that ICU a different nurse, and it has only enhanced my ED abilities ever since. The thing to keep in mind if you transition from ED to ICU, is be prepared to find out how much you don't know. In ED you know a little bit about everything. In a focused ICU, you know everything about one or two systems of the body.

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LilgirlRN is a ADN, RN and specializes in ED staff.

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I went from CCU to ER 20 years ago. CCU, everyone was monitored. ER that just doesn't happen. CCU, I knew that the people I was taking care of were legit, they weren't drug seekers (generally). CCu our main focus was either keeping the patient alive till they could have their surgery or taking care of a sick post-op. Q2 0r 4 hour everything and I had the same patients throughout my 12 hour shift. ER is treat and street as quickly as possible in most cases. If they're gonna be admitted then we get that handled as quickly as possible. The good thing about ER is that most patients with the same complaint get the same treatment. ie 35 to 45 year old female with abdominal pain will both get the same workup. ER is kinda like having a conversation....... triage says the problem to the er nurse, er nurse talks to doc, doc talks back by giving orders. er nurse talks to lab and xray via orders, they talk back with results. er nurse gives doc all the info so he can talk to the pts doc to find out what needs to be done, stay or go? etcetc

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