Let's compare ERs

MassED, BSN, RN · Mar 24, 2012

sounds like where I work. Most nights seem to be like this now, the lesser acuity days seem behind us, unfortunately. It's such an arduous job with few breaks, fewer help and more work. At what point will it end? When will it ever get even a bit better, when it seems this is becoming the norm??

VICEDRN, BSN, RN · Mar 25, 2012

In the southeast. Big level one trauma. Supposed to be 2:1 for traumas and criticals, 4:1 for most patients and 5:1 for lower acuity patients. Needless to say, we are never staffed to that level and have been dinged on it. The beds are always full and we rarely have a floater to cover breaks or whatever.

brainkandy87 · Mar 25, 2012

I work in Branson, MO, so we see a ton of tourists. I think it's a pretty interesting dynamic to work with. Our main ED has 21 beds (fast track area usually has 8 open). If we are slammed we can open up our hallway beds which bumps us up to 25 or 26 ED beds I believe. This isn't terribly uncommon in summer when Branson is packed with tourists. Our patient load is 4:1, but we do have 1-2 float nurses that don't have any assigned patients and simply help everyone else keep up with new orders, IV starts, transport, etc.

NO50FRANNY · Mar 25, 2012

Work in a level 1 trauma hospital in Australia, on average we see about 250 patients per day, 20 acute beds, 7 resus, two trauma rooms, a big waiting room and fast track / sub acute area with another 15 spots, short stay unit with 18 beds / 4 nurses. Staffing usually is 5 nurses for resus/trauma, all 7 bays two trauma rooms and the corridor (day and evening, drops to 3 overnight), 1 nurse to 4 acute patients and in the other areas usually 1 nurse for around 8 patients. We do a lot of "corridor" nursing too- so your 4 acute pts. may end up being 10 including those receiving treatment in chairs on a bad day (which is most days), same goes for resus. I guess like most departments, understaffed, under spaced, under resourced and overwhelmed. Not uncommon for ambulance crews to wait 2 hours to unload a cat 3 (30min) pt. Physically don't have the space for all that comes through the door- the thing is, no-one has to pay for their visit or the ambulance so nothing will change until this side of things is addressed, a primary care physician is usually cash upfront. Regardless of all this, we are constantly working on ways to improve flow and our standards, and I truly believe our patients receive excellent care, everyone pulls together in this environment so the teamwork and comraderie is fantastic. I am interested in hearing about other facilities, are they similar to what I describe? I should mention that not all days are that diabolical, but I could honestly say that 2 shifts a fortnight are what I would describe as manageable and pleasant.

BelgianRN · Mar 26, 2012

Ok I always feel bad when reading these. Keep in mind my city has 2.5 million people only and a hospital around every corner ^^. The hospital is located at the outskirts of the city so we mostly see emergent patients via ambulance or referred by their primary physician. People coming on their own (by law can't be turned away) hapens but not as often as the in hospital cities.

But my ER has 10 rooms for patients with medical problems, 2 boxes for sutures and small traumas. The patients rotate over a seperate waiting area to receive their assessment, diagnosis and treatment. 1 room for casting. 2 pediatric rooms (non acutely ill children rotate over another waiting area) and one of the pediatric rooms doubles as an OBGYN room as well. Then there are two trauma/resus rooms. One acute psych isolation room. Shower room for the occasional burn patient. There is an observation area (for overnight monitoring to admit/discharge) with 8 beds. A cardiac medium care unit with 10 beds (for pre and post CAG's and cardiac observation). And finally a hyperbaric chamber that can hold an ICU bed as well. We see around 100 patients a day (curse of sharing a few square miles with another level 1 trauma center and large lvl 2 trauma center). There is also an emergency radiology located at the ER but that is operated and staffed by the radiology department. Hopefully in the future a CT scan will be added somewhere close and not a few floors away.

We see the general population of ER patients. Not a lot of homeless people or drug addicts since they tend to stick to the city center. We see a lot of immigrants (creating a lot of language barriers). We are the referral center for tropical illness and children (we have the only PICU in the province). We on occasion get emergent transfers for placement of ECMO/ECLS if it's quicker for them to come to us as us to them.

Since prehospital care is organized from the hospitals in Belgium our staffing includes prehospital teams as well:

Hospital Team

1 nurse - Cardiac unit

1 nurse - Observation area

1 nurse - triage/coordinating/bed assignment

1 nurse - hyperbaric chamber - helps with the medical rooms mostly

Prehospital Team

1 nurse - MUG (team of doctor and ER nurse that leave for major events - cardiac arrest, massive trauma's etc) - helps out with the light trauma's and tries not to take critical patients when possible.

1 nurse - interhospital transports, ECMO/ECLS placement in other facilities, in house codes and resus rooms. Helps out primarily with the medical rooms.

1 nurse - ambulance (they get sent to cases where the ambulance personnel alone isn't enough, e.g. need for intravascular acces etc. They work based on protocols from the hospital). When not outside they help on the cardiac unit.

The patients in the rooms are taken care of by all. There is no single nurse responsible for one patient. We all do bits and pieces on our patients (exception children and resus room pt) so this requires very close documentation in case of problems. We report to the coordinating nurse and he/she keeps track of what else needs to be done.

As you can see our ER is sized well enough to prevent long waiting times in general. I can't imagine state allowing this to continue for much longer having three large hospitals close to each other all with ER facilities. In this time of budget cuts and economic crisis I think two of the three ERs could be closed and expand the facilities at the remaining ER.

MassED, BSN, RN · Mar 26, 2012

how can your ambulances spend time and not drop their patient? Don't they have other calls to go out on? Can they not just put them in a stretcher somewhere in a hall (corridor?) It's unheard of for a crew to wait long, but especially not 2 hours!

Below post is same, more or less... posted twice, oops.

MassED, BSN, RN · Mar 26, 2012

no50franny, how can your crews not drop a patient and move it along to pick up their next patient?? How can they get away with waiting for 2 hours?

NO50FRANNY · Mar 27, 2012

Hey there MassED, I hope this gives you an idea, I'd love to hear about how international departments run so chime in with how your department works, always need ideas!

We call it ramping when ambulance crews can't unload their patients which happens when every physical spot, including the corridor, chairs and all the stretchers in the hospital have been used and every bed in the hospital is occupied (called access block). The ambulances will be triaged and inside the department, but lining up. So we will have say 20 patients sitting in chairs having active treatment in the corridor, some in the waiting room, plus all the bays filled. Inpatients can't be moved from the department so the only way to free up spots is discharging people and we are only staffed for about 55 patients while the others just keep coming. In our city hospitals have the right to "redirect" or go on "bypass", if a hospital is on bypass the ambulance must go to a different facility. Even if they try to take an urgent patient they will be turned away. I had a crew try at 4 different hospitals the other night (1.5 hrs) gave up and came to us because they knew we would accept the pt. - vomiting and diahrroea in a 25 yr old for 4/24- out to the waiting room- staggering waste of resources. Unfortunately all of the hospitals can do this at the same time if they want to (and often do) but we incur financial penalties if we do this because we are the tertiary referral facility / trauma centre (there is one other trauma centre but they will always go on bypass before we do). We very rarely go on bypass and of course cannot if all the other hospitals are. When everyone else goes on bypass, we will receive every ambulance in the city (population just over 2 million).

So when we have 80-100 patients in the department with physical capacity for 50, the ambulances keep coming and they ramp. Until the ambulance crew unloads and hands over the pt. they are still the crews' responsibility but if possible the doctors will start investigations/treatment while they are waiting. They have other calls to go to but comms knows they are ramped- there is a significant percentage of "non-urgent" ambulance transports in my state as it is free for everybody to call an ambulance- for anything from a toothache to a stubbed toe, and our ambulance crews do not have the right to decline transportation. The ED visit is free too, so comms just triage and prioritise. Abuse of the ambulance service here is awful, as is abuse of the ED. I would say up to 80% of patients who come in via ambulance that I triage are not emergencies and a very hefty percentage of presentations (ambulance or not) are non-urgent and there is a tendency in our department to over triage. Not enough general practitioners (primary care physicians?)and an entitled / instant gratification population. I should mention that regardless of all of this, true emergencies don't wait, it's the semi-urgent that wait longer than they should, usually because of the of the 25 year old with gastro who could have walked across the road to her local hospital, who even though was on bypass, legally have to take walk in patients.

Altra, BSN, RN · Mar 27, 2012

Excessive delays for EMS crews unloading patients is not unheard of in the US either.

MassED, BSN, RN · Mar 27, 2012

no50franny, your description of your ED sounds like ours in the US. Many calling ambulances for non-emergencies, just like you there (in Australia?) and are triaged to the waiting room, where they are re-evaluated eventually when it's insane and there are no rooms/no wheelchairs, no stretchers in the hallway (and no nurse to assume care of them). We have a set number of providers (usually residents and attendings, sometimes med students) and we can't divert either, because we are the level 1 and have to accept all. Like there, we have many (mostly, I would say) who use ambulances and will never pay for it, because they have free care (state insurance). Most of our population fall into this category of those that receive state assistance, and eventually it will be freecare for all if Obama gets his way.

Editorial Team / Moderator · Mar 27, 2012

I work in an Army community hospital ER. Lately we're seeing 120+ patients daily, as high as 150 ... which doesn't sound bad until you realize we only have 11 beds in our core ER, and 4 in our Fast Track (and the Fast Track is open only 12 hours most days, but 15 hours on occasion). Our typical nursing assignment is 3 or 4 beds, depending on how many RNs we have. Our charge nurse usually takes an assignment for some or most of his/her shift, too. Some days there are only two nurses for the 11 beds in the core ER. Those aren't good days. On those days, I depend very heavily on my combat medics! They rock.

One thing I love about Army nursing is that patients don't have to choose to not have a necessary CT/other expensive procedure because it would cause financial ruin. I used to hate seeing patients without insurance who refused things because they couldn't afford it, when they probably really needed whatever it was we wanted to do.