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?

[Lunah, MSN, RN]

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.

This is the way it should be! My hospital's ED is making a huge push to increase nursing staff in the ED; just the fact that the positions have been approved is huge. I have never seen staffing like it will have once the hiring gets going.

[AntiplatitudeRN]

The short and skinny of it; yes, it is like that everywhere there is are no ratios set in place.

What you're more mad it is seems is the wrenching of productivity from the worker *you* rather than a focus on providing you with the resources to be able to render safe care. That is the business aspect of running an ER; one that no one readies you for in nursing school. I have worked in the ED coming on 15 years. You're expected to do more with less and even forego merit-based pay increases.

To address the other concerns you're not voicing and everyone of your replies does:

You're going to have to deal with this in your own way. Perhaps by streamlining your delivery process and delegating as much as safely possible. Perhaps by readying yourself for compassion burnout which will hit you eventually. As other's have pointed out: this is not going to change. It is one reason why it is so hard for a neophyte nurse to secure a position in ED as a new grad, but if you do, you will have to learn to compensate for all of the depressing, violent, and sad cases you're going to see. You rely on your team, which changes on a daily basis, and you learn to work with these people as much as you can to get the job done.

Remember from nursing school when they told us that our profession originated in the religious orders of nuns and was militarized in its evolution to the present day? You're going to have to deal with that history and adapt your practice in the future. If you don't, and I have seen this happen over and over, you age in this profession with bad habits and sloppy work ethic to the point where you cut corners and compromise effective nursing in favor dubiously labeled "efficiency" (i.e. playing Houdini with magically appearing patients when the last one was "green" to be D/C'd - no time for a proper bed wipe down and we wonder why MRSA and others spread so easily in hospitals). Decide for yourself where you want to be in this profession, don't let others stick you in something you resent.

If you are not happy in your current position, you should check out other venues and knowing what you know now, ask these difficult questions of the managers whose job it is to wring as much work out of you, like a washing machine on rinse does a tee-shirt.

Good luck, it does get better,

A.

[LadyFree28, BSN, LPN, RN]

My ratio is 1:2 to 1:3 and can be up to 1:4 in the critical zone and the emergency zone; 1:7 in the fast track zone; the critical zone has the Resus Room and usually one nurse is assigned to the room, unless the charge nurse assigns a nurse from the emergency zone (happened recently to me).

For a while it ended up being critically low staffed where nurse assumed total care and only three ED techs, so even on the busy days we had no tech and had to do EVERYTHING; most were fast tracking to burnout because management was a key issue in driving people away and for those who wanted to be per diem was blocking them from returning, thus leaving the experienced staff at 30 percent, newbies 40 percent and fresh experienced staff at 30 percent; sometimes the charge nurse was the ONLY experienced nurse with 5 plus years of experience.

We got a union, management changed, and we have a director that scrutinizes thorough put and flow and how it affects the nurses; with having an input on the workflow, especially for new to practice ED nurses, we have been working together as a unit to make changes; increase of experienced nurse hires and ED techs have helped as well.

One shift we had a Level II Trauma and one of the kids needed to under go a procedure; I ended up clearing my assignment out and helped assume care for the procedure while the barge nurse assumed care for my new pts they just put in (old habits die hard, but we're truly working on it) and closed rooms to get the pts remaining in the ED stable and dispo'ed, then if needed we would open rooms again.

If properly staffed, we split the bay in the critical zone, have at least one float nurse, some items two to help out in the critical zones and the fast-track, and then by 11p, the staffing goes down and everyone has and assignment; it is also dependent on the provider ratio and staffing as well, and we are working together to make it run smoothly as possible to prepare for the winter; some days when we are constantly getting the trauma specials, it can get VERY busy, but if staff med well and the th river from a Level I gets stable or admitted to the PICU within 15-20 minutes it's not so bad.

Since it's getting better and the unified nurses have been working together, we have been able to get changes while negotiating a contract; so I'll keep working at the table and in the unit for assist with improvements.

It has been such a 180 that I have no plans to leave my position.

[DanidelionRN, BSN, RN]

Where are you all at, geographically? I am curious about how location affects staffing practices.

[Roy Fokker, BSN, RN]

You have ratios in the ER??!!!

My old ER - I've had 12 hour shifts where I've had 2 patients on ventilators, a non-STEMI on a Nitro drip and 2 Tele patients and that was considered a "normal assignment."

My current ER gig is pretty good - we are a level II ED with 2 trauma bays. When you're assigned a trauma bay, the expectation is that you'll have 3 patients (4-5 if you don't have critical patients). But what's really important is management - heck, just last shift I was literally 1:1 with a critical patient - for almost a good 7 hours until transfer. Charge nurse called it, management approved it - float nurses took over the rest of my assignment (which included another critical/septic patient!) We had 1 tech for 16 bed assignments.

I could've been a disaster - but I work with an awesome crew! And ultimately, I think THAT is what makes or breaks a department - the folks you work with!

cheers,

[turnforthenurse, MSN, NP]

I will say that some EDs are like this and others are not; some have a mix of these issues that you are describing.

The ratios where I have worked have always been 1:4 except for where I currently work; we have one side that is supposed to be 1:3 (more critical patients, larger rooms) and the other side is 1:4. If we're short staffed, we're expected to up our ratio to 1:4 on the acute side which is stupid, in my opinion. Work smarter, not harder.

In other places that I have worked, we had to transport all of our own patients. Where I currently work, we only have to transport ICU patients. CT/MRI will come get the patient and unless the patient is sedated/intubated/on a drip or something, we don't have to be there with the patiet. If they are, CT/MRI/whoever will still come get the patient but we need to go with them. When I worked the floor, I ALWAYS had to bring my patients down to radiology.

For the most part our techs are great at helping get the patients into a gown and hooked up to the monitors. We have designated EKG techs and phlebotomists.

There is ALWAYS a rush to fill rooms. If you have an empty bed, don't expect it to stay empty for very long unless your census is low. A lot of times there is a rush to get the patients out - if there is someone critical that needs a room, I understand that, but otherwise there's no need to rush. One day I was working and this happened to me. I was behind and needed to update my vitals which I could print from our central monitoring station and then type them all in. Someone discharged my patient so that room could be made for another one and they cleared the monitor, therefore I lost all of my vital signs and it looks like I did no monitoring what so ever.

Techs stock our supplies for us but if we're short on techs then of course we need to help with that.

[Graduatenurse14]

I'm not an ER nurse but work in a urban Level I Trauma, Academic hospital with a union.

I don't think the nurses have ratios in the ER and didn't realize that they could since they can't turn anyone away.

How does that work?? I am very curious. If it works in some hospitals maybe it could work here.

[RunnerRN2015, ASN, RN]

I'm not an ER nurse but work in a urban Level I Trauma, Academic hospital with a union.

I don't think the nurses have ratios in the ER and didn't realize that they could since they can't turn anyone away.

How does that work?? I am very curious. If it works in some hospitals maybe it could work here.

We never turned anybody away but they may wait 6-8 hours to be seen unless they had a true emergency.

[emmy27]

We have to triage and (eventually) see everyone, but enforced ratios mean that administrators will *do something* when patient ratios exceed a certain point, like call in additional staff, float nurses from other departments, work to move admits upstairs and free up beds, potentially go on EMS bypass or diversion, and recognize that long wait times are a systemic issue, not the fault of staff.

In hospitals without enforced ratios, they just keep piling the patients on to the existing staff, and/or blame the staff when inevitable problems occur or wait times/procedure times creep ever upward.

[MassED, BSN, RN]

seems to always be the same, no matter which ER you work. Sorry. Though every day is different and a teaching hospital has some more resources, but otherwise same-o, same-o