Need the real truth. Are all EDs like this?

[JR81]

I'm coming up on my one year anniversary as an RN, and I've spent this first year in a very busy community (no trauma by EMS) hospital ED. The way we ED nurses have to work at this hospital has left me disillusioned, deeply sad, and looking for a way out. But before I head for another position, I need to know if the problems I'm facing are universal ED problems or just at select hospitals.

First though, I want to say that difficult, rude, and even violent patients are not driving me from the ED. One reason I chose nursing was to work with people of all kinds, and I LOVE that part of it. I thought I'd make a list of things that bother me and make me think that I cannot give proper, safe care. Then I'm looking to find out if these are normal practices.

- The 1:4 ration for all patients except intubated, STEMI, arrests, strokes, or walk-in traumas. All other patients, even those going to step-down with sepsis, DKA, cardiac drips are in the 1:4 category.

- 1:3 ratio for critical and walk-in trauma patients (except TPA for stroke, the charge nurse monitors them) does not seem safe.

- ED nurses transport their own patients to CT, Xray, MRI, inpatient units (at night), and tele units when techs aren't available (see below). Also, nobody covers my rooms when I transport a patient. Management states another nurse can watch 8 patients during that time. We do not have a float nurse unless staffing is exceptionally good.

- Techs. Most days it's one tech in triage, and express care gets priority for the 2nd tech. Rarely do we have a tech for the other 37 rooms. Therefor nurses hook patients up, do EKGs, collect urine samples, and do all the "cleaning up" that has to be done with every patient. Even with EMS patients, the nurse is usually on his or her own to do all the work.

- The rush to fill rooms. If wait times top 90 minutes, as soon as one patient shows discharged on the tracking board, the charge nurse does a quick discharge with the patient (that he or she doesn't know) and has a new patient waiting in the hall while the room is still being cleaned.

- Supplies. Nurses are responsible for stocking their assigned rooms and IV carts sometime before clocking out. Usually after giving report.

I worry myself sick because I can't give proper and safe care. It's wearing me down. So, there it is. Do I need to seek another hospital or seek another specialty?

[chivon101]

Unfortunately, this sounds typical unless the hospital is unionized. Ive worked several places.. As staff and as a traveler. Ive worked in California, New York and Texas.....some have more resources in one area but may be lacking in another. I always tell people same s***, different state.

[SquishyRN, BSN, RN]

I've only worked in one ER but it still certainly sounds like mine.

EDIT: AND Union BTW.

[sleepingquietly]

I have recently moved to Utah, but have worked in several EDs in southern CA, from large to small. What you describe is a typical shift, except some don't have techs at all. I do miss the ratios in Cali.

Here in Utah is not much different except staffing is definitely not what Im used to. Currently working in a 20 bed community hospital ED, and it is staffed with only 2 RNs on days, 2 RNs on nights, with a swing shift tech and swing shift RN.

[RunnerRN2015, ASN, RN]

I worked as a new grad in a level 1 trauma center. Our ratios, depending on which area of the ED we were in, could be as high as 1:5 -- including ESI 1 and 2s. Our wait times could easily be 6-8 HOURS at peak times. If I had a couple of discharges pop up at the same time, another nurse would swoop in, d/c them, clean the room, and place another patient in the room before I even knew it. We had to take our own patients to ICU to give report, which could take 30 minutes. Meanwhile, my rooms weren't being watched. We didn't always have enough techs so I would take my patients to XRay and CT.

So yea, your ED sounds typical!

[gonzo1, ASN, RN]

Yep, I've worked in about 30 EDs as staff, agency and traveler. This is the way it is. I usually worked nights cause it was a little slower after midnight.

[Lunah, MSN, RN]

Not unusual. If you find one with good staffing, support, and reasonable ratios, climb in and hang on for dear life! :)

[MedicFireRN]

It's very typical. Our hospital is 1:4 but our sister hospitals are 1:5 in the ED. I worked at one hospital where the ratio was 1:3 for all patients except ESI 1's-2's which were 1:1 or 1:2, but the nurses there complain about the pay because it's less, but that's the only way they can support that staffing ratio. You either nurse 1:4 or 1:5 or you have less patients but also get less pay because there's more nurses.

[rearviewmirror, BSN, RN]

Go to free standing ERs or urgent care. Or just leave bedside like I did. I love a nursing job first time in my life.

[emmy27]

Not every ER is like this but many are, and nearly all have at least some of these aspects. Some are worse.

The crucial difference is not in the policies (unless perhaps you can find one that truly adheres to lower patient ratios) but in the typical staffing (this kind of bare-bones staffing really becomes problematic when you have multiple call-outs), retention, and morale/teamwork.

4:1 patient ratios are pretty standard in many EDs even though I agree they are not ideal. Some are much higher. Whether that's merely inconvenient or genuinely unsafe is down to the common acuity and the degree to which your coworkers and charge nurse have your back when those four patients are sick sick.

I regret to tell you that most other inpatient/acute care specialties are similar in terms of responsibilities, but with even higher patient ratios. In med-surg we had all these responsibilities (stocking, transport on nights and weekends, no float and usually no tech) but with 6-8 patients. In theory these patients are nice and prepped and lower acuity than fresh ED patients, but think about the patients you send to the floor and you'll probably realize they aren't always all that low of acuity or tied up with a bow upon arrival. Although ER is in my experience more mentally and emotionally taxing due to the chaos and potential level of acuity, med-surg was much more physically exhausting to me.

Welcome to nursing in 2016, I'm afraid.

[Lev, MSN, RN, NP]

Hmmm...sounds fairly familiar. We too are a 1:4 ratio. However, I started off with a patient in septic shock today - had that patient from 11am to 3pm and did not get another patient until about 2:15ish. The patient I was sent at 215 had labs drawn in triage and was an ESI 3. However, if I had 3 full rooms and got that ICU patient, I would still be responsible for my other 3 patients; nobody would take over my assignment. Staffing is poor and float nurses are rare. Nurses transport all patients going to ICU and step-down units as well as any patients going to telemetry on a drip or even a med-surg patient on heparin. Techs are sitting on psych or dementia patients very often or busy doing other things or just plain lazy and unapproachable - so there are days where I line and lab all my patients, do their EKGs, take them to the bathroom, clean commodes for them, do their belongings sheets, get them food etc. We do not have lunch relief or any relief at all. We leave 1 nurse with 12 patients sometimes when someone transports a patient upstairs and someone else takes a patient to CT. It really isn't safe. Rooms are filled very quickly. Many times someone will clean my room and dump a patient in there before housekeeping even gets around to it. When it gets really bad they will put patients in the hallway (those waiting on beds) and send a new one into the room. Or patients will be seen in the hallway. We don't officially have to stock the rooms. The techs are supposed to stock the linen. Respiratory stocks the suction supplies. There is someone who stocks the carts, but they got rid of the night shift stocking person so we are constantly stocking our own supplies. My ED sounds similar to yours. Community ED. 46 beds in the main ER. Not supposed to get any trauma (but we do PRN).

[Nienna Celebrindal]

I work in a Level 1 Trauma Center, we are not union, and we are nothing like that. We are usually 3:1 sometimes 4:1 when we get slammed but one of those 4 is on the more minor side, doesn't need a lot of attention. But we always have float nurses around, in addition to a charge nurse plus team leads for the different areas. We have transport nurses for critical patients or floats will help. Techs, or dispatch can also take patients places depending on how sick they are. Drips are not usually 3:1 but if they are like I said you always have back up. But normally they are 2:1. And again, lots of floats. In my ED you are never alone. I also don't stock. I mean I do if I see it and have time, but it's not my job, we have volunteers and techs who do. I'm sorry you are experiences.

This site has made me realize I'm completely spoiled and I'm probably never going to be able to leave my hospital. I'm a float nurse and our staffing is awesome everywhere.