Impossible standards

[canoehead, BSN, RN]

The ENA says triage level 3 patients need vitals Q15min. So do my hospital standards. How do you get vitals done and documented that frequently? What is actually enforced at your hospital? How do you get actual care done between vitals?

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If you get a 1-1 patient, how do you pass off your other patients for coverage, and have it documented? Obviously there's no time to write a hand off on the chart.

If the doc takes a patient from one of your rooms, and adds another from the waiting room...how do you give/get report. Do you document every hand off for breaks, shift change, room change?

Currently our hospital has stellar standards on paper, but they are impossible in real life. So they get ignored, unless someone has an axe to grind.

[JBudd, MSN]

q15 mins? Level 1, life threatening situation maybe, but level 3's?? Ours is q2h, and even that doesn't always happen. I guess you could just set the monitor to go off q15, and chart them all at once.

Your charge should be helping out when you get a 1:1, nothing wrong with her charting "received verbal report, assumed care"

[Altra, BSN, RN]

I've taught a course on ESI triage, and have never encountered any documentation that recommends q 15 min. vitals for ESI 3 patients. Very few patients require q 15 min. vitals beyond an initial period of resuscitation/stabilization efforts, or during a procedure/intervention (such as cardioversion).

When a patient becomes unstable enough to require 1:1 care, or there is just something going on with the patient that the nurse will clearly not be leaving that room for a while ... we judge on a case by case basis whether other patients need to be formally handed off to a resource or other free nurse ... or if they are perhaps in a holding pattern (such as waiting for an inpatient bed) and can just "chill" for a while until the crisis with the other patient resolves.

In my department we do generally chart room changes, and handoffs.

[Larry77, RN]

Our standard is 1 hr rounding on all patients--this is a note, not always VS which are only required q2hrs if patient is stable and no interventions were given. I've never heard of a standard where you have to do VS q15min for any ESI. It doesn't make sense to give a standard in that way as some ESI level 2's require vitals q5 min (think IV Metoprolol for CP's) and some ESI level 3's only need VS every 2hrs. That being said any facility can create a policy to say anything they want and a manager can be held to that standard which of course requires holding the staff accountable. The answer is to question the policy or practice and give an evidence based argument against it.

Hmm...how about those SI pt's that are level 2, would you do their vitals q15min?

Larry

[sandyfeet]

Our ESI 3's have hourly vitals. Our SI patients get a note written that basically states "patient remains ESI 2 but vitals will be taken every 2 hours unless a medical change is seen". Also, back-charting. If I eventually wrote it, it happened.

[Esme12, ASN, BSN, RN]

ESI 3 is that they may require more interventions/resources.....not a vital sign driven level necessarily. if the vital signs are within certain ranges and the patients condition warrants then more frequent vitals...or an increase in their level.....Emergency Severity Index (ESI) Implementation Handbook, 2012 Edition | Agency for Healthcare Research & Quality (AHRQ)

But it is your facilities policy to do more frequent vitals...then you need to try....do your monitors have automatic B/P cuffs?

Our SI's are a level 3 for they require labs and multiple disciplines intervention as well as hourly checks.

If you get a 1:1...the receiving nurse can document hand-off by XOX RN assumed care.

[psu_213, BSN, RN]

In our ER, ESI 3s need q2h VS (although even that occasionally does not happen).

If a patient goes 1:1, report consists of "I have John Smith, 35 year old abdominal pain. He has been lined/labed, he is drinking for a CT, still waiting on urine." (Add any other pertinent info, such as relevant hx, abnormal VS/labs, etc.) Nothing too complicated, the rest is in the chart. Then a simple note in the chart--"report to Sally Jones, RN".

[canoehead, BSN, RN]

The written guidelines are one thing, and 98% of the time they are never followed, because it is impossible to do signs that often and get any actual care done. But if someone comes up for a pay raise, or if the patient goes bad, it's a quick tool to put the blame on nursing. I wanted to know if everyone is in that situation.

Also, if a policy states "the physician will document..." and they fail to do so, is that considered a nursing error? For example, the doc wants to put in a chest tube(nonemergent), I know they've talked to the patient, and we go ahead, but he never goes back and documents consent. Is that a nursing error?

[Larry77, RN]

Nursing definitely has a role in making sure a consent is done before ANY invasive procedure is done (ie LP, Chest tube, Conscious Sedation). I personally would not assist in any case like that until a consent is signed (if not emergent of course).

To Coneohead, I'm not sure if you realize how Management works but I've never heard of "Blaming nursing" to "get a pay raise"...that sounds like you have some issues with your view of leadership. In management we get pressure from our superiors just like you do. If it's noted that the ED staff is not revitaling their patients we have to act. We may have to come up with a mitigation plan for a resolution of the issue to our director or CNO. It certainly doesn't help us to have an issue called out and often times we are getting the brunt from our leadership as it is ultimately our responsibility to make sure the nurses are doing their jobs. I've seen plenty of Managers fired because they couldn't lead there direct reports to success.

I do not think hourly rounding (not always VS) is too much to ask from ED nurses and I also do not feel that VS q2hrs is too much to ask...if you are caught up with an acutely ill patient you should be calling your team to check on your other patients--this is basic ED nursing.

[morte, LPN, LVN]

I would have to wonder about that canoe. Selective enforcement would do the trick. Just write up those you want to penalize/get ride of. And Larry, that can come from the top down....

The written guidelines are one thing, and 98% of the time they are never followed, because it is impossible to do signs that often and get any actual care done. But if someone comes up for a pay raise, or if the patient goes bad, it's a quick tool to put the blame on nursing. I wanted to know if everyone is in that situation.

Also, if a policy states "the physician will document..." and they fail to do so, is that considered a nursing error? For example, the doc wants to put in a chest tube(nonemergent), I know they've talked to the patient, and we go ahead, but he never goes back and documents consent. Is that a nursing error?

[Lunah, MSN, RN]

We do hourly rounding, and our Level 3s require vitals q2hrs. Q15 for all 3s is crazy! That needs to change, because it's based on ... nothing.

[Sassy5d]

The written guidelines are one thing, and 98% of the time they are never followed, because it is impossible to do signs that often and get any actual care done. But if someone comes up for a pay raise, or if the patient goes bad, it's a quick tool to put the blame on nursing. I wanted to know if everyone is in that situation.

Also, if a policy states "the physician will document..." and they fail to do so, is that considered a nursing error? For example, the doc wants to put in a chest tube(nonemergent), I know they've talked to the patient, and we go ahead, but he never goes back and documents consent. Is that a nursing error?

It's my understanding that if the pt is alert and oriented to give consent, the nurse should be advocating for the pt. Make sure you have that informed consent paper with you while you're helping with the procedure. Make sure it's signed. PRIOR to procedure. Yes, it would be a nursing error as you're assisting with a procedure you know isn't following protocol.