Organizing yourself in the ER?

hiddencatRN, BSN, RN · Aug 7, 2012

I tried to keep a "brain sheet" in the ER but it ended up being more of a hindrance than a help so I gave it up pretty quickly. We do more frequent vital signs based on acuity so I use vitals to organize my shift. When I enter vital signs, I am also checking the chart to see new orders and lab/diagnostic results as they are ordered. Unlike on another floor where tasks are schedules in advance and you have to remember to do them at a specific point in your shift, all your orders in the ER are STAT orders so you do them as you get them. When you have multiple orders go in at once, you prioritize and do the most important ones first. And you're constantly reassessing the patient's response to the orders you're carrying out, so that becomes your organizational framework: new patient, assess, carry out interventions, reassess.

chansen · Aug 8, 2012

Similar to what was said before, the ED is so much more task oriented than other places, and the biggest thing you need to do to provide the safest care to your patients is continuously reassess what tasks need to be done and place them into three basic categories.

1) Life saving interventions that cannot wait.

2) Important things that must be done soon.

3) Tasks that can wait, be easily delegated, or are not time sensitive.

Experience will help you place tasks into these categories, and from there things begin to feel more organized. It's easy to start working in the ED thinking you need to make every patient the most important person because you want to excel and you want to be a good nurse. Some times there are going to be people that no matter what you do, they are not going to appreciate what you are doing for them, the time you are spending on them, and the customer service you are attempting to provide. The sooner you understand that, the better. While customer service is an important facet in today's world of healthcare, your number one priority still needs to be focused on providing the best outcomes for all your patients.

So, as time goes on, you start to develop your gut list for where each task belongs in those categories. You aren't always going to have a number 1 at any given point in the day. In fact, you may go an entire shift or more without having a number 1 task. So how do you sort the giant stack of number 2s you have? I personally like to do it by who I haven't seen in the longest amount of time. This way I can cluster care and try to keep seeing my entire patient load as often as possible. Reassess pain medication or past interventions, provide interventions required for new diagnostic testing or medications, get any charting caught up (the ED isn't a friendly place to catch up on charting at the end of the shift - staying on top of your charting will come easier over time but is pretty crucial), vitals, etc.

Barring all those things, you can never go wrong seeing the person with the highest acuity first in the scheme of things. Look at your patient load and mentally assess which one is "the sickest" and make sure they get just a bit more of your attention (at the least).

Lastly, communicate with your fellow ED nurses. This is a team sport, and an ED team that works together is a much better work environment. You may not feel like you're organized enough early on to help the other nurses in your area, but when you do have some down time, make sure you're asking if they need help with anything, try to make yourself available to help assess and check in patients arriving by medic, and don't be afraid to ask for help. Sometimes one or two basic tasks (even number 3-type tasks) being done are enough to get you over a hump where you feel like you're falling behind.

Christy1019, ASN, RN · Aug 8, 2012

Just curious, does your facility use an electronic medical record system? And if so, is it one that prints off orders on assigned treatment areas? My facility uses Emstat (planning to switch to epic this year), and as an order is entered on a patient, a little receipt pops up on the printer assigned to the nurse caring for that patient.

I have ADHD and literally have to write everything down to remember it but this system saves me so much more time b/c I can carry the order slips with me and by prioritizing them based on each patient's acuity, whether the order is urgent, and my handwritten patient assignment/info/needs etc.

My personal patient organization sheet is pretty simple & consists of what info is important for me to know. At shift report we print out a list of the patients assigned to each nurse's area (also a function of emstat EMR), that lists each pt's name, MRN/DOB, room, chief complaint, assigned physician, length of time in ER aka TID, and dispo if one has been made.

Under each pt's name I write a slightly more descriptive list of complaints (if the chief c/o is abd pain & the pt says it's epigastric/pelvic etc plus any associated symptoms i.e. N/V/D), most current VS, blood glucose etc, what IV access I have/IV fluid rate, pertinent meds given by previous shift RN (BP meds/insulin etc so I know when I need to check the pt's response to them), a brief medical history if relevant (hx: CHF,COPD,MI,CVA), and lastly, only the abnormal lab results or those pertinent to treatment plan.

I know it seems like an awful lot to write for each patient, but I have all sorts of abbreviations & symbols that I use considering that I may have 5-10 acute care patients & my sheet only gives me 1.5in x 3in of space to write this all in. I can try to write an example but it won't be exactly the same b/c of typing, but here goes..

Rm:236

Smith, John 65/M C/O: DIB MRN:543513135 Dr. A. Davis TID:3hrs

c/o CP SOB w/Pr cough(grn),fvr x3d VS:166/90 108 22 38.2 90%RA

hx:COPD,asthma CXR: RLL pneumonia

20g RAC NS@200/hr WBC 22k CO2 55 trop 0.07 lact 4

|_| draw bld cxrs x 2, alb/atr neb tx x 3, 1g tylenol, IV ABX

^ thats supposed to be a lil checkbox i make myself so i know what still needs to be done, then I check it off as i do it.

Keep in mind that not every pt will have such extensive work up, so it doesn't take me that long to write out my sheet at the start of my shift, and as pts come and go I continuously update my list so that regardless of where in the ED I am or whatever situation may occur (pt coding/seizing etc), I will have my pt's info without having to access a computer/chart.

Hopefully this will give you some sort of direction for creating your own system :idea:

brainkandy87 · Aug 8, 2012

Paper towels. They're an ER nurse's best friend. :)

NurseOnAMotorcycle, ASN, RN · Aug 8, 2012

Lol yes! paper towels for quickie notes! I keep a quickie list of immediate things to do that I don't want to forget and do them according to priority or delegate and then check them off... For example

Rm1 EKG

Rm2 needs blanket

Rm5 labs

Rm 12 ready bed 216

hiddencatRN, BSN, RN · Aug 8, 2012

I know it seems like an awful lot to write for each patient

You're right, it does seem like a lot! This is what I tried to do initially and it ended up being way more time consuming than glancing at the chart every so often to check recent vitals, recap the visit ("are we ready to dispo? why or why not, what still needs doing?"). I have pretty bad attention and memory issues too but keeping a brain sheet slowed me down in a major way.

sserrn, BSN · Aug 9, 2012

^I agree. When I get report I do have a piece of paper that I put a pt. label on for each room; I write the room number, their chief complaint, and sometimes I write when they arrived. When they leave, I write "dcg" or "admit" or "transfer" across the sticker. Honestly, I have a hard time keeping up with that little bit of a 'brain sheet.' I often look at my paper at about 5A and realize I haven't updated it in hours. I use the chart and the tracker board as my reminders; otherwise I'd be writing so much I'd never get anything done.

Robublind · Aug 10, 2012

Yes I also have a notepad in every room right next to the sink I use one to dry my hands and one to write a note (VS, med list). A "paper brain" doesn't work in the ED. I use the tracking board as reminders ie trop at 0400 etc. Spend you time getting task done and done quickly, not filling out a brain. If you are wondering if it is time to get new VS or reassess, just go do it. It will take longer to look it up then to get it done.