ICU holds in the ER

ClaireMacl · Apr 26, 2006

At our hospital, the ITU SHO (junior doc) comes down to assess the pt, writes orders and generally the anaesthetics team will be there for any ITU patient for the whole time they are in the ED, so we have no problems with pain control etc.

Sounds like a nightmare for you tho!

mysticalwaters1 · Apr 26, 2006

I know that various problematic aspects of holding ICU pts. in the ER due to a lack of unit beds has been discussed here before, but here's where I'm struggling ...
At my hospital, orders for a pt. that goes to the unit are written by a resident when they get to the unit. So when a pt. is held for hours in the ER ... I really have no orders. Our ER docs have "washed their hands" of these pts., so to speak, and yet these pts. have continuing needs for pain control, control of HR/BP, etc.
Along the same line, any suggestions for nursing home residents who are seen in the ER, discharged back to their home facility, but end up waiting hours for transportation back ... these people are technically discharged, but they get hungry, need their glucose checked, have pain, etc. etc. ...
Any suggestions? I did search through other "ICU hold" threads ...

We have ER holds too and I am concerned over this as well for what happens with the pt. I'm on med surg and when the pt's would stay overnight in the ER medications the pt normally get on the med surg floor were missed. I just don't understand what is done in this situation. I'm going to have orientation in the ER soon so I'll find out.

chasing daylight · Apr 26, 2006

In my experience, ICU orders were written on the patient, and an ICU float nurse was sent down to take care of the patient. This was a problem at a hospital that I worked at last summer, where one day in particular there were 5 ICU overflow patients overnight in the ER. Add in the monitoring, A-lines. vents, etc, and it is impossible for an ER nurse to take care of one of these patients and all of the ER patients they would have also.

rjflyn, ASN, RN · Apr 26, 2006

Simple answer resident needs to get his butt down to the ER and write orders. If they are reluctant calls every 10-15 mins for this and that generally gets them down here. As far as the nursing home patients waiting we have that same issue and there is not much one can do about it. If for example the pt is being discharged with a RX for pain meds sometimes the doc will give a verbal order to give meds per that prescription. As far as routine meds at our hospital its not much of an issue as our transport issue occurs after midnight and most patients are not getting anything during that time.

RJ

I know that various problematic aspects of holding ICU pts. in the ER due to a lack of unit beds has been discussed here before, but here's where I'm struggling ...
At my hospital, orders for a pt. that goes to the unit are written by a resident when they get to the unit. So when a pt. is held for hours in the ER ... I really have no orders. Our ER docs have "washed their hands" of these pts., so to speak, and yet these pts. have continuing needs for pain control, control of HR/BP, etc.
Along the same line, any suggestions for nursing home residents who are seen in the ER, discharged back to their home facility, but end up waiting hours for transportation back ... these people are technically discharged, but they get hungry, need their glucose checked, have pain, etc. etc. ...
Any suggestions? I did search through other "ICU hold" threads ...

burn out · Apr 26, 2006

Ther have been times at my hospital when we have up to 5 overflow icu patients and they can be in ER , PACU, or makeshift mini ICU rooms on medsurg or tele- these are staffed by ICU nurses asap, but we are already working short staffed so sometimes the ER nurse has to care for these patients. My problem is that all of the patient have regular physician who have writtent orders but the ER nurses will not do them because they say they are admission orders and they do not do admission orders- they will not even put the admission assessment and meds in the computor. Our Pulmonologist is so frustrated with the ER nurses, he said that they couldn't even tell him what the vent settings were half the time on his patients. Why is it ER nurses can not function at this level?

rjflyn, ASN, RN · Apr 26, 2006

In this case it is the function of that particular ER. I have worked in a couple ED's where we "didnt do admit orders" the point being it forced the system to get those patients out of the ER and where they need to be. As far as vent settings most the time I couldnt tell the the doctor either. I do know where to look if I need to. Respiratory therapists more often than not manage vented patients in the ER. Now if it was up to me to manage the vent then of course I would. More time than not though I have enough to do with out having to worry about that. When it comes to giving report to the unit the ED RT typically reports to the ICU RT.

RJ

Ther have been times at my hospital when we have up to 5 overflow icu patients and they can be in ER , PACU, or makeshift mini ICU rooms on medsurg or tele- these are staffed by ICU nurses asap, but we are already working short staffed so sometimes the ER nurse has to care for these patients. My problem is that all of the patient have regular physician who have writtent orders but the ER nurses will not do them because they say they are admission orders and they do not do admission orders- they will not even put the admission assessment and meds in the computor. Our Pulmonologist is so frustrated with the ER nurses, he said that they couldn't even tell him what the vent settings were half the time on his patients. Why is it ER nurses can not function at this level?

mysticalwaters1 · Apr 26, 2006

Ther have been times at my hospital when we have up to 5 overflow icu patients and they can be in ER , PACU, or makeshift mini ICU rooms on medsurg or tele- these are staffed by ICU nurses asap, but we are already working short staffed so sometimes the ER nurse has to care for these patients. My problem is that all of the patient have regular physician who have writtent orders but the ER nurses will not do them because they say they are admission orders and they do not do admission orders- they will not even put the admission assessment and meds in the computor. Our Pulmonologist is so frustrated with the ER nurses, he said that they couldn't even tell him what the vent settings were half the time on his patients. Why is it ER nurses can not function at this level?

That's exactly what I'm concerned with! I feel like somethings missing. When I go through ER orientation I'm going to see what it is because I do here that a lot on med surg and can be frustrating. I know ER deals with emergencys but it gets tricky when there's no where to put the pt.

nursejennie76 · Apr 27, 2006

When a ICU patient must stay in the ER while waiting for a bed we are able to go by any orders that may have been written for that patient whether they are written by the ER doc or not. And off the subject i believe that emergency nursing should be listed under a critical care forum:madface: !!!! We ensure that they get to the ICU alive, and if they are to sick to stay at our hospital then we have to ship them put, so we actually care for patiets that are sicker then the ones that go to our ICU???? Ok I will get off my soap box!!!!:monkeydance:

allnurses Guide · May 2, 2006

We have a lot of patients who wait for a long time before getting to their room. We don't do the admit history, but we do the meds, glucose etc. according to the admit orders. On "here for the night" patient's, the float secretary will come do the paperwork.

Trauma Columnist · May 2, 2006

Hi there. I work in a level one trauma center and we do a lot (5-6/day) ICU holds, some vented others not. We in the ER are responsible for these folks. Our doctors handle the routine stuff and consult with the ICU team (we have closed ICUs) when necessary.

As to nursing home folks, we never discharge them until their transportation arrives. Yes, this can be hours but we must care for them, so we don't discharge them.

neneRN, BSN, RN · May 3, 2006

Some of our ICU docs routinely come down to see/write orders for our ICU holds, others don't until we page them because we need something. Its pretty rare that the intensivists don't respond to a page though. Worst case scenerio, can always grab an ER doc, who'll give some orders to hold us over. We always do the ICU orders though, if a pt's sick enough for the unit, then they're too sick for the ER nurse to say "we don't do admission orders," I'm surprised to hear that not everyone does the unit orders.....med-surg pts however, the most important/highest priority orders are done, the rest wait.