Impossible standards

[canoehead]

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.

[Guest219794]

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?

,

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.

Where does the ENA say this?

[turnforthenurse, MSN, NP]

Where I work, our vitals flow over from the monitors in the computers. The only way to obtain Q15min vitals would be to set the BP to go off Q15min and then chart everything else accordingly. For our ESI level 3's, we do vitals Q1-2h depending on the patient.

I can see Q15min or more frequently for ESI level 2's (and especially ESI level 1's) but again, it depends on the patient. I had a patient triaged as an ESI level 2 but they really should have been at minimum a 3, possible a level 4. Therefore, I charted their vitals hourly as opposed to Q15min.

[Esme12, ASN, BSN, RN]

I agree where does the ENA state level 3 requires vitals every 15 mins. Here is an example of making things up as they go along.

I have used for policy.....pedi trauma.

ESI 1: q5 min vitals x3 then q10 x3 then q15 x3 then q30x3

ESI 2: q10 x3, q15 x5, q30 x3 etc by 30 min increments.

ESI 3: q15 x3 then q30 x2 then hourly

ESI 4: vitals every 2 hours while in the ER

ESI 5: vitals every 4 hours while in the ER.

The ENA actually recommends

ESI Level 1: Every 5-15 minutes as needed and no less frequently than every hour for the first four hours, then every 2 hours if clinically stable.

ESI Level 2: Vital signs no less frequently than every hour for the first four hours, then every 2 hours if clinically stable.

ESI Level 3: Vital signs no less frequently than every two hours for the first four hours, then every four hours if clinically stable.

ESI Level 4: Vital signs per acuity and clinical assessment, but no less than every four hours.

ESI Level 5: Vital signs per acuity and clinical assessment, but no less than every four hours.

Believe it or not.... I know one of the authors personally, worked with her she was the department educator and that is not the recommendation.

ENA guidelines.....

ESI Triage - Emergency Nurses Association

[That Guy, BSN, RN, EMT-B]

Qhour for most pts per our facility. Its easy though for us. Set spacelabs to q15 checks and then import at your convenience.

[sydnies]

Yeah, in our ED the computer puts a bell by any patient if you don't have vitals for them at least every 2 hours. I just hook them up, set the monitor to go every 30 minutes and then i am able to pull them up from the computer and validate them as often as I would like. (Our vitals machine readouts can be pulled up on the computer). I only do q15 minutes with esi 1 patients and they are 1-to-1 anyway.

[Altra, BSN, RN]

Level 3 patients can be a finger lac that needs an xray and a tetorifice shot. (2 resources)

I can see no justification for q 15 min. vitals.

[psu_213, BSN, RN]

Level 3 patients can be a finger lac that needs an xray and a tetorifice shot. (2 resources)

I can see no justification for q 15 min. vitals.

Having done a presentation at work on the ESI, it seems a bit contradictory that "IM medication" counts as a resource, while the algorithm states that tetorifice immunization is not a resource. Oh well. Either way, q15 min VS for the majority of ESI 3 pts. is not necessary.

[turnforthenurse, MSN, NP]

IM and IV meds are considered resources whereas PO meds and tetorifice immunizations are not considered resources.

Resources:

* Labs (blood, urine)

* EKG, XR, CT, MRI, US, angiography

* IV fluids

* IV, IM or nebulized medications

* Specialty consultation

* Simple procedure = 1 (lac repair, foley)

* Complex procedure = 2 (cons sedation)

Not resources:

* H&P (including pelvic)

* Point-of-care testing

* Saline or heplock

* PO medications, tetorifice immunization, Rx refills

* Phone call to PCP

* Simple wound care (dressings, recheck)

* Crutches, splints, slings

http://www.ena.org/membership/document_share/triage/Documents/ESIReview.ppt

[canoehead, BSN, RN]

I'm in Canada, even for major surgery the docs don't get a paper consent signed, but they document in their charting that they talked to the patient and obtained consent. In the ER docs may leave their charting until the patient contact is completed. So the consent has been obtained, and usually I have witnessed the conversation while getting ready for the procedure, but they forget to formally chart that they did it. Of course, now I can chart myself that the doc got a verbal consent, but I'm a little miffed that my boss dinged me for something he neglected to chart. In the policy, it doesn't say "the nurse shall ensure that the doctor got consent." But stuff just seems to fall on nursing anyway.

[Anna Flaxis, BSN, RN]

Level 3 patients can be a finger lac that needs an xray and a tetorifice shot. (2 resources)

What??? Noooo... a finger lac is a 4 unless they need IV access and a plastics/hand surgeon.

Anyway, I agree with most here, level 3s are Q2, unless they are in the lobby. In the lobby, they are Q1, in case their condition has changed while waiting for MD eval.

[NotReady4PrimeTime, RN]

I'm in Canada, even for major surgery the docs don't get a paper consent signed, but they document in their charting that they talked to the patient and obtained consent. In the ER docs may leave their charting until the patient contact is completed. So the consent has been obtained, and usually I have witnessed the conversation while getting ready for the procedure, but they forget to formally chart that they did it. Of course, now I can chart myself that the doc got a verbal consent, but I'm a little miffed that my boss dinged me for something he neglected to chart. In the policy, it doesn't say "the nurse shall ensure that the doctor got consent." But stuff just seems to fall on nursing anyway.

In my part of Canada we have very detailed written consents for procedures. The onus is on the person who will perform the procedure to obtain it although we nurses are expected to ensure the document is with the chart and that the chart is with the patient. We have an elaborate telephone consent protocol and in emergencies we'll go to a 2-physician consent, but it still has to be spelled out in writing.

[canoehead, BSN, RN]

Hi Jan!

We have consent forms, but I have yet to see one used. It seems like bad practice, especially with major surgeries, but I am not the boss. The docs dictate or write that verbal consent was obtained. On rare occasions I've gone into the room after that conversation to do a preop checklist, and the patient has no idea that they're going to the OR. Everything stops, and the doc goes in to chat again, but still no paperwork was signed.