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Is the future of ER Nursing I-stats?

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On 12/23/2019 at 9:48 PM, dream'n said:

If the lab is taking too long to run STATs, then that is an issue that the lab needs to solve.  It should not be pushed on nursing like everything else is.  Sometimes it seems that any issue another department encounters, the answer is "we'll have the nurses do it" instead of fixing the problem in the responsible department.

Rooms not being turned over quickly enough by housekeeping, "we'll have the nurses pick up the slack." Not enough pharm techs to bring up the urgent medication, "we'll have the nurse run down for it."  Not enough transport personnel, "we'll have the nurses transport."

Again, you are missing the point of what an ISTAT is for.  Not all STAT labs go on the ISTAT.  It’s when you need immediate results.  The lab is not immediate.  I’m sure for many situations in the ED, they need immediate results to decide how to proceed.  

I do not view the ISTAT as an added thing I need to do.  It’s part of patient care.  Some of my patients are on q2 lactates, or q2 abgs, some are getting q2 sodium levels.  I can’t wait an hour for those results to titrate meds or change vent settings.  

This helps with pt outcomes.  How can anyone be against that?

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On 12/23/2019 at 9:48 PM, dream'n said:

If the lab is taking too long to run STATs, then that is an issue that the lab needs to solve.  It should not be pushed on nursing like everything else is.  Sometimes it seems that any issue another department encounters, the answer is "we'll have the nurses do it" instead of fixing the problem in the responsible department.

Rooms not being turned over quickly enough by housekeeping, "we'll have the nurses pick up the slack." Not enough pharm techs to bring up the urgent medication, "we'll have the nurse run down for it."  Not enough transport personnel, "we'll have the nurses transport."

Thank You!!! and the reason why everything is pushed on the nurses is because we do not stick together and we are highly efficient.  

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On 12/25/2019 at 2:31 PM, LovingLife123 said:

Again, you are missing the point of what an ISTAT is for.  Not all STAT labs go on the ISTAT.  It’s when you need immediate results.  The lab is not immediate.  I’m sure for many situations in the ED, they need immediate results to decide how to proceed.  

I do not view the ISTAT as an added thing I need to do.  It’s part of patient care.  Some of my patients are on q2 lactates, or q2 abgs, some are getting q2 sodium levels.  I can’t wait an hour for those results to titrate meds or change vent settings.  

This helps with pt outcomes.  How can anyone be against that?

How can anyone be against better patient outcomes?

Please add on additional sentences in a cohesive manner with sources to back it up and submit a paper to the appropriate authorities/management/law makers so that we can finally have nation wide mandated ratios in the nursing profession as a whole. 

It's not that anyone is against it. It's about providing excellent care with the resources you have... 

i-stat machines have a place in healthcare but should the sole responsibility rely on the one nurse to obtain it along with all the other critical life saving interventions that are deemed appropriate at the same time. 

For the facilities that do not have i-stats, I wonder how any of the patients make it out alive.  I wonder how did we ever save lives before i-stat machines became available for the ER nurses to use? 

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27 minutes ago, gcupid said:

For the facilities that do not have i-stats, I wonder how any of the patients make it out alive.  I wonder how did we ever save lives before i-stat machines became available for the ER nurses to use? 

Patients had poorer outcomes. Sepsis deaths were higher, we had more cardiac cripples, worse trauma outcomes, and the list goes on.

As a regional leader in sepsis, severe sepsis, and septic shock outcomes (30 day mortality with initial presentation or transfer through the ED of 0%, 0%, and 2% respectively YTD) I will tell you that our istats are a big part of why we have such good outcomes. We are a major outreach center for sepsis management, and delay of diagnosis and delay of treatment are two massive factors in poor performing centers.

Before the 90s patients in the ED rarely were placed on a pulseox and we didn't have remote monitoring in the ED.

Times change. Care evolves.

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1 hour ago, PeakRN said:

Patients had poorer outcomes. Sepsis deaths were higher, we had more cardiac cripples, worse trauma outcomes, and the list goes on.

As a regional leader in sepsis, severe sepsis, and septic shock outcomes (30 day mortality with initial presentation or transfer through the ED of 0%, 0%, and 2% respectively YTD) I will tell you that our istats are a big part of why we have such good outcomes. We are a major outreach center for sepsis management, and delay of diagnosis and delay of treatment are two massive factors in poor performing centers.

Before the 90s patients in the ED rarely were placed on a pulseox and we didn't have remote monitoring in the ED.

Times change. Care evolves.

Congratulations! It's great that you all have the "resources" as well as the reinforced & proactive education to improve patient outcomes in regards to sepsis management.

As you know, the ability to recognize possible sepsis goes past having an i-stat machine available.  Thank God there are additional indicators at times.

Times change & Care evolves. But can we evolve away from the nurse being the sole responsible party for EVERYTHING? 

I wonder if these saturated workloads that contribute to nurse burnout & high ratios are linked to poor patient outcomes.  Does it have to be the nurse who does them? Will the lactic acid results magically be different should another disciplinary team member perform them? If the nurse now has this added simple task to do, will another simple task be taken away from the nurses responsibility? 

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6 minutes ago, gcupid said:

Congratulations! It's great that you all have the "resources" as well as the reinforced & proactive education to improve patient outcomes in regards to sepsis management.

As you know, the ability to recognize possible sepsis goes past having an i-stat machine available.  Thank God there are additional indicators at times.

Times change & Care evolves. But can we evolve away from the nurse being the sole responsible party for EVERYTHING? 

I wonder if these saturated workloads that contribute to nurse burnout & high ratios are linked to poor patient outcomes.  Does it have to be the nurse who does them? Will the lactic acid results magically be different should another disciplinary team member perform them? If the nurse now has this added simple task to do, will another simple task be taken away from the nurses responsibility? 

We are just as accountable for cost management as the next hospital. We just happen to see a lot of very sick, very high risk sepsis patients and have become well practiced in their management.

The number one reason why we have good outcome though isn't resources. It's that our nurses own their care. They own rapidly assessing and identifying sepsis, they own initiating the sepsis protocol and sepsis alert (or fever in neutropenia alert) with the attending, they own getting their cultures and labs (including lactate on the istat), giving early antibiotics, starting fluids early, and completing the one hour, three hour, and six hour bundles on time and before the patient leaves the ED (our average level 3 ESI patient stays under two ours before admission, ESI 2 under three hours). Our nurses work hard to give that rapid care, and I wouldn't have it any other way.

We also discuss our sepsis concerns in committee, and have ran quite a few QI/QA projects as a result. We have played with the nicom, flotrack, clearsight, and other modalities including ultrasound assessment. We ran our own data on NS vs LR vs Plasmalyte after the vandy study came out. We discuss our choices in pressors, antibiotics, and other interventions regularly when new literature comes out or we start to see a new trend.

I would ask what you are using as your perfusion indicators that you feel works better and quicker than a lactate on an istat. ESR, CRP, Procal, LDH, WBCs, et cetera don't change quickly enough to judge the effectiveness of rapid fluid intervention. Sending a tube to lab to run a lactate will take most good labs 20-30 minutes, average labs much longer. Flotrack requires the placement of an A-Line, clear sight is very limited by patients that don't hold still. We found the NICOM to not be robust enough to stay in place during ED care, and the accuracy we just didn't find as good as the flotrack or clearsight. On that note a CG4 cartridge is a couple bucks, non-invasive cardiac output monitors are hundreds. Ultrasound is great, but typically only preformed by our docs and are heavily reliant on good technique. Capillary refill may indicate poor capillary perfusion but doesn't really show the level of anaerobic metabolism in the body. CVP requires central line placement.

Certainly POC labs are not the only way to assess sepsis, but are a critical tool in patient management.

Our nurses are not responsible for everything. They are not responsible for the medical decision making. They are not responsible for mixing non-vial dose antibiotics. Our bedside nurses are not responsible for the decisions that are made in committee. They are responsible to make sure that the bedside care is performed, but we work as a team to ensure good care.

Who do you think should be running the lactate? If the lab runs it you will have delayed care. If you have an additional lab tech or ED tech in the ED you will still have a delay, albeit much shorter. However also consider that if you are up-staffing a lab or ED tech that the FTE has to come from somewhere, and will probably result in fewer nurses for the workload. Would you rather have one more lab tech and ED tech but as a result have one fewer nurse (and therefore take on another patient in your load)?  Do you want that tech to be calling you while you are seeing that additional patient to let you know of the result, or do you want to delay care to only see it when you get back in the patient's chart?

If your system doesn't provide adequate supplies or staffing then that is a different problem, but that doesn't make nurses performing POC tests less valid.

As far as burnout. I doubt the reason many nurses leave the bedside is due to running POC tests. Most employees leave because of poor management, not because their work is hard.

Back in the day docs were doing all the blood pressures, nurses were just feeding the patients, perhaps changing a dressing, and putting oil in the lamps; is that the nursing you would prefer? Or is there a different list of skills you want to keep or get rid of?

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On 12/26/2019 at 2:36 AM, PeakRN said:

As far as burnout. I doubt the reason many nurses leave the bedside is due to running POC tests. Most employees leave because of poor management, not because their work is hard.

This sounds very credible. Very interesting. Sounds like you did a lot of "Research" on the subject matter.

And I never stated that running POC tests is the reason for many nurses leaving the bedside.

On 12/26/2019 at 2:36 AM, PeakRN said:

Back in the day docs were doing all the blood pressures, nurses were just feeding the patients, perhaps changing a dressing, and putting oil in the lamps; is that the nursing you would prefer? Or is there a different list of skills you want to keep or get rid of?

An avg iq could comprehend that I'm not advocating for nursing to go back to an era in which all we do is basic ADLs, simple wound care, and rely on the dim light of a lamp during night shift to perform rounds. 

On 12/26/2019 at 2:36 AM, PeakRN said:

If your system doesn't provide adequate supplies or staffing then that is a different problem, but that doesn't make nurses performing POC tests less valid

I'm glad that you are now starting to somewhat understand. There's nothing wrong with adding shock factor to a title or the start of a thread. And guess what magical word comes back up when discussing adequate supplies or staffing? Resources. 

On 12/26/2019 at 2:36 AM, PeakRN said:

The number one reason why we have good outcome though isn't resources.

I beg to differ.

Happy Holidays! You can sleep with an i-stat machine on your nightstand for all I care. 

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On 12/26/2019 at 11:46 AM, gcupid said:

There's nothing wrong with adding shock factor to a title or the start of a thread. And guess what magical word comes back up when discussing adequate supplies or staffing? Resources.

Sensationalism is not professional, and has no place in evidence based practice.

Since you don't seem to like my thoughts and experience on sepsis management tell me yours. What is your facilities sepsis, severe sepsis, and septic shock outcomes? What are you currently using to judge the effectiveness of volume resuscitation? What is your facility doing to improve outcomes? What do you think improves patient outcomes better than lactate on an istat, and is it a practical solution?

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23 hours ago, gcupid said:

How can anyone be against better patient outcomes?

Please add on additional sentences in a cohesive manner with sources to back it up and submit a paper to the appropriate authorities/management/law makers so that we can finally have nation wide mandated ratios in the nursing profession as a whole. 

It's not that anyone is against it. It's about providing excellent care with the resources you have... 

i-stat machines have a place in healthcare but should the sole responsibility rely on the one nurse to obtain it along with all the other critical life saving interventions that are deemed appropriate at the same time. 

For the facilities that do not have i-stats, I wonder how any of the patients make it out alive.  I wonder how did we ever save lives before i-stat machines became available for the ER nurses to use? 

I’m not understanding.  You would like me to explain how an ISTAT gives better patient outcomes?

Do you work at a hospital that has a phlebotomy team who comes in and draws labs?  Is that what your issue is?  Phlebotomists draw your regular labs and you think they should do ISTATs as well because it’s too much for you?

I do all my own labs.  Yes it better for my pt if I know how they are oxygenating in 2 minutes over 60.  When I have a trauma pt it’s often better if I know their hemoglobin quickly.  
 

I still have to draw it myself.  I’ve always had to do it.  Good for you guys if your hospital employees phlebotomists for your unit.  Most places these days don’t have them unless it’s in an outpatient area.  I stand by the fact that ISTATs benefit the patient and take 2 minutes.  Whether it’s an ABG or Chem 8, it’s 2 minutes.

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