Patient flow in the ER

[Sailnaway]

I am a nurse returning to the ER after 4 yrs as a manager. I have been appalled at the process for moving patients through the ER. I have worked in several ERs during my career and I am a CEN but, I have never worked in a more disorganized ER. It's really scary! I was expected to function on my own my second day there! Over a 1/3 of the staff are agency nurses who have had little to NO orientation. They have had a 50% staff turnover in the last 6 months and I can definitely see why. There is no rhyme or reason to how pts are brought back. The object is to get them in a bed which means emergent pts may sit in the waiting room for hours. Since I have been there (3 wks) 2 pts have had siezures in the waiting room. I was told after giving Cardizem IV push to leave the pt and tell the family to come and get me if anything went wrong !!! The issue I understand is that the reason things are done the way they are is "because that's the way we've always done them". The ER is not divided into emergent, urgent, and non urgent . . . anything can go in any bed as long as they are "brought straight back". I have never worked with a more disgruntled bunch of nurses and I can certainly see why. Fortunately more than half of the staff is new and the hospital has a new VP of nursing who wants to form task forces to make changes, so I would like advice and web pages or anything to do research and prepare a presentation that will convince them that there are safer and SANER ways to run an ER!

The chart is divided into two charts becasue the medical director wants it that way. You never know your pts lab results or if you have orders. When we made suggestions for change we were told that in the "future" they are going to computerized charting which will eliminate these problems but they can't say when that will happen. Several of us want to make presentations of several ways to move pts through the ER that are tried and true and hopefully they will choose one of them. Any advice will be appreciated !

[KHERNSE]

unfortunately, i know how you feel. however i have been practicing in the er for 8 years and the changes being made are to improve the budget, not the patient care. our er has pods for patient care. 1 nurse is assigned a pod with 4 cardiac beds. the nurse is responsible for transporting, drawing labs, doing ekgs, entering orders, taking orders from adm doc, etc. the problem with this is that if the nurse leaves her/his pod to transport a patient, there is no one caring for the other patient. i once wondered at what point would this change, then a few weeks ago i found out, that even the death of a patient whose alarms could not be heard due to no central monitor did not make a difference.

[LisaPRN]

Wow!! I thought my ER was disorganized with our large volumes of patients every day. We see between 350 and 400 every day.

I would be surprised if you weren't violating EMTLA guidelines for triage or JCAHO. hmmm....food for thought. I wonder if it would change things if these groups knew anything about their practice. I'm not telling you to blow the whistle, but if the subject was brought up to administration or current management to review these guidelines....

[NurseyK]

In our ER, the MEDICAL Director keeps getting a wild hair up his..ahem...and demands that all patients be "brought straight back to a bed", "no lines no waiting", "we don't want those pt complaints now." OK great...I'll pack the beds in with crap that could conceivably wait to be seen; then when the MI/CHFer/etc walks in gasping his last..well then, I'll just put 'em in the hall....never mind those ambulances coming in....

Triage is an ER's most valuable asset. This is where your most experienced nurse can weed thru the non-urgent, emergent, and just plain can-wait-in-the-WR-until-tomorrow people. (JCAHO and EMTALA demand this of us) I would start first with Triage by parking your most experienced RN out there. You might need a meeting with the staff to get everyone "on board" with the idea of cleaning the place up. Also, it sounds like you need to recruit your OWN nurses (not agency).

JMHO

Kat

[deltapen]

I've done E.R, for 6 years now and only see it getting worse before it gets better due to the nursing shortage. We have LOTTS of agency and now the main goal is to hire more nurses. Never mind they have no experience and as a PAST preceptor with many concerns about the skills of some of the nurses I've precepted they've gone unanswered and put into the schedule so us more experienced nurses get the critical ones all the time with an enormous amount of burnout. I just couldn't precept anymore...what's the use? I'm so discouraged.

Our triage system at least focuses on acuity but with only one triage nurse, who is expected to bring back the patient, get them into a gown and do the initial assessment, goes back to the triage area to find 6 or 7 more patients waiting, you get the picture.

We are staffed for 75 patients(supposedly) but see and average of 100-120 a day. And we are the trauma center!! We cannot pee and many times work our 12 hour shifts without a break or even lunch. Needless to say our marriages and families suffer.Our critical care area has one nurse for 4 patients who are ICU patients. We run our asses off doing the best we can hanging drips and giving RPA, getting ready for cath lab, etc. The "less acute" area, which includes overflow from the acute area, is staffed for 1 nurse for 11 beds until 11:00 when another nurse comes on. Gee thanks! Our trauma area has 5 beds for 1 nurse. Oh boy.

If our patients had any clue what we go through for $16 and hour I think they would do less complaining and start writing letters of support to our office princesses to get more competent staff. Maybe they could get off their asses and at least do some transporting or something to help. We draw all the blood for labs too since our lab is short of phlebotomists. We have one tech who works harder than any of us to get pts to their rooms and CT, stocking rooms, etc. I feel more sorry for them!

[map]

we,re installing tv,s, magazine racks, serving box meals and bringing warm blankets for "Patient satisfaction" lack adequate nurses and techs to provide quality patient care. Am I the olny one a bit overwhelmed and frightened to be caring for a pediatric code, new vent patient and an acute MI at the same time? Is the only answer giving up?

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[ALISHAJO]

Sailnaway: It sounds like you have your work cut out for you. Organization has to start somewhere. Why not a unit meeting and present possible triage rules and agree together on what is the policy? Then post the triage rules in your triage areas. Not everything falls into clearly into these rules....I am a firm believer in intuition and that is why you need someone with experience to do the triage/teach others....I have worked in the ER at a small hospital for 17 of my 18 years. I love ER but hate the improvements that keep happening!!! I'm not talking about medical advancements.....I mean administrations ideas of advancement/cost savings or improvement... we average 20-25 patients per day plus outpatients. We have 1 RN per shift (12 hour shifts) and 1 MD. The Rn is responsible for all the ambulance calls, triaging, answering the phones( which we are the operator also after 11 pm), caring for the patients plus advise phone calls. Most days the phones ring endlessly!!!!! :mad: My family doen not understand why I hate the phone so much when I am at home. On night shift, we are responsible for registering patients and being the operator after 11 pm and security since the only unlocked door is the one that leads to the ER.....When we need help, we have to beep someone like the house supervisor or maintance.....Sorry so long but it is so frustrating!!!

I work hard to give my patients the best care possible and when my needed help arrives, I have to end up doing their job too!!!! Even the Doc's can tell because they will by pass the person who is their to assist and give the orders or ask the question of the ER RN......You need to take a stand about getting things organized there or things will not improve...Why work harder when you can work smarted for everyone!!!! Good Luck!!:)

[Irish Lass]

Write down your thoughts and objectives.

If there are enough willing souls, form a task force group to work out the "rules" and logistics.

In your presentation acknowledge who "wins" and why if your process is approved.

Don't expect immediate success. The only one who likes change is a wet baby.

GOOD LUCK