prioritizing in the ER


so this is my last week of orientation and I'm off on my own next week. I still don't feel ready, and was denied more request for training. To keep up I know something has to give. I'm ok w.maintaining speed when new pts come through the door. work them up, pass out meds, keep an eye out on the more acute ones but when i start out the shift with a pt load of 8 that includes 5-6 admitted pts who are waiting for beds in other depts that have have a never ending list of meds due in 2 hrs, getting their meds, requesting it from pharmacy, and passing them out takes forever to the point where I have trouble documenting, and taking on new pts. (and there's ALWAYS new ones. sometimes it gets to a pt load of 12-17 all at once) i have the worse urge to forget the relatively stable admits and hold off on the admitted meds which means they either get their daily meds at the very end or not at all. if they crapped out due to not being able to get their daily cardiac meds or seizure meds or me being inattentive i would feel awful but I need to keep up with my workload.....


227 Posts

Specializes in Home Health/PD.

Wow! That seems like a lot of work! I work on the floor and the ED nurses rarely, if ever, start giving medications on admitted Pts. Our Pts med recs aren't even scanned until the pt is on the floor. I don't know how you all do it, but kudos to you and good luck!

Altra, BSN, RN

6,255 Posts

Specializes in Emergency & Trauma/Adult ICU.

Am I understanding you correctly that you have 12+ patients per nurse?


234 Posts

Specializes in ER. Has 5 years experience.

8-17 patients? Geez...what kind of ER is this? That seems unsafe to me.


33 Posts

That workload just does not seem safe. If I'm being honest and if it were me, I'd run for the hills! I'm sorry but that's just how I feel. I usually get 3-4 patients max! And if I have a one to one patient, my team is usually good with picking up the slack for my other not so critical patients.

As far as prioritization, I suggest that you stick to the basics and deal with airway first, breathing next, and circulation last. That's my mindset when I am at work. Regarding the other patients who are supposed to be admitted but being held in the ED because there are no beds available on the floors, shouldn't there be one dedicated staff for those patients especially if they are critical? That's how we do it in our ED. Maybe you can ask your nursing colleagues how they have handled this issue in the past? Just a suggestion. Good luck!


27 Posts

yea 12+ doesn't seem safe to me either :/ were expected to be competent enough to care for 9-10 which I'm not at this point unless half are relatively stable. The 12+ number is due to the recent shut down of hospitals in my area in 2010 & hurricane sandy. we're also a 24 hr stroke center & trauma 1. We do have a trauma room that can hold 5 so they *try not to load the main ED nurses with trauma pts if possible. We have admit nurses on the floor but not enough. Most will take only 8-9 pts. I think I might have to talk to the night manager if at 11-10 I'm max out. So far my preceptors been helping me. Being new they should be ok with reassigning. And I probably have to cut my breaks shorter to catch up on documentation.

Specializes in Emergency. Has 21 years experience.

If those ratios are the norm and they're not all esi 4/5, which doesn't seem to be the case, head for the door NOW. Incredibly unsafe.

amarilla, RN

318 Posts

Specializes in MS, ED. Has 2 years experience.

I've only been in the ED a few months myself but agree with others that your ratios are outrageous! I'm not sure how much better you can be at 'prioritizing' if you're babysitting a handful of admits as well as *ten* or more new patients - there is only one of you and only so much can be done.

If it were me, I'd start applying elsewhere and see what you can come up with. IMO, the experience isn't worth being stretched so thin. Good luck.


2 Posts

I don't think I carried that heavy of a load when I worked the floor. For ED, that isn't acceptable. It depends on the acuity level but still not safe. I don't know about you but I worked too hard for my license...I don't want to lose it to something like this. Plus we love in such a sue-happy society, I wouldn't want to lose my personal possessions either. At the very least invest in some professional ! (and keep that fact to yourself) Good luck!


27 Posts

thanks bubblzrn, i have my on personal insurance as well as what the hospital offers.

The pt load is overwhelming but i see everyone else being able to handle it. even if I learn to deal with this pace, i'd like to

find another position elsewhere. for now im going to stay and apply stimultaneously to other openings at least till i'm off orientation. which is soon. what is the normal pt load for you guys? and how does everyone prioritize their load with the handful of admits and their laundry list of meds.


2 Posts

Our patient load is anywhere from 1-6...again depending on the patient's acuity. And I think that with time you do learn how to handle a larger patient load, but the patient load you are talking about is too big for anybody. Mistakes will and probably occur multiple times. Burn-out would be a huge issue I would think. Glad to hear you have personal professional insurance. Most hospitals say they will protect you (the nurse), but if it comes down to losing millions of dollars vs losing a nurse...most hospitals will hang a nurse out to dry and let them take the brunt of the responsibility. I have heard hospital administrators call nurses "a dime a dozen". Protect yourself and your patients above all. If you are having to talk yourself into need to move to a different unit/company.


18 Posts

Specializes in ER.

In my ER we never have more than 4 patients per nurse (except on breaks:). {actually, the minor nurse may have 10 - 12 but those are usually fingers lacs, earache = walkie talkies}. Sometimes, it is 4 admitted pts with tons of meds, or a mix of new ER and admits. Something I've learned since I've started: one thing at a time. (yes, you might be doing more than one thing at any given time, but if you can prioritize and assess/give meds to the most critical pt.first, then go on to the next task). I can't even imagine trying to take care of 10-12 admitted patients all at once - that sounds like unsafe practice to me. If you go into a pts. room for any reason, do vitals, ask if they need anything else while you're in there (may cut down on call bellitis...)

Good luck:)