tweety55

In our 25 bed ED, we use paramedics, at least one per shift. They work along side and are responsible for 4 pts. They do it all, IV's, Blood, intubation, EJ's, splints, casts, and all other things just as we do. The only thing, the charge nurse has to review their charts, assessments and sign off on them. I trust my paramedics as much as if not more than some of my RN's. They give report, do critical care one on one and are always around to help us. Thank God for ours, we are 10 FTE's down and without them, we would not survive!!!

In our facility, our budget and scheduling is all tied to the Press Gainey's. We have a busy 35,000 visits per year rural ED and some of the expectations that pts have are completely over the top. How do I make sure that the guy that called and asked us to see his iguana doesn't get mad when we won't? And then there's the angry older woman who parks in the ambulance bay and expects valet parking while she waltzes into the backdoor of the Ed! We can no longer have bottled water at the nurse's station, but the pts expect and get whatever they desire--it has become total anarchy!!

Believe it or not, our former director did try the "secret shopper" bit. But her trick was to call on the phone. Our policies do not allow for ANY telephone advice. She would have someone call to make sure that we were doing exactly that. Everytime I come to work, I have a stack of press gainey's in my box. I am expected to address them with the staff that worked with that particular pt and to reply back to our assistant director with our "Plan of Action" for that particular press gainey. This, all the while I am expected to manage the flow and control of 25 beds and triage!! Yeah, I'll get right on it!

At a recent staff meeting, we were asked what ideas we had to make it up to the patients when they had a complaint. TPTB suggested that we give them a 10 dollar gas gift card. How many of our regulars are now going to really start to complain---------let's give them a reason to make our lives more difficult!!!!

We see 100-110 pts per day in our 25 bed ED. We started using ESI about one year ago. It has helped with more accurate triage, but that is about all. Two years ago, we had one triage nurse with a triage room right in the admission/registration area. The triage nurse would triage each pt, then assign rooms. When we were busy, the triage nurse could initiate protocols, get labs and we also have a 4 bed holding area that we could use for those that had to wait, but needed a bed. Now, our triage nurses are to go to registration immediatly, bring the pt straight back, assign an ESI level, turn the pt over to the primary nurse. The emphasis is on filling the beds and having no one in the waiting room. If there are pts in the waiting room, our director will come out and find out why. We closed our Fast Track and now use that FNP and nurse in the ED. The expectation is that our triage nurse has to eyeball the pt in less than 10 minutes. If she is in the middle of doing another triage or assisting in a trauma, or with a cp that she just brought straight back, she is expected to drop everything and get that pt triaged. I have come on shift to find a frequent flyer migraine in one of our major trauma rooms because we have to fill the rooms! This goes back to pt satisfaction and also the the beloved Press Gainey"s

Not only are we also being scripted and being sent to class, we are now being taught on how to greet docs who come into our ED to do procedures. We are to greet them, make them as comfortable as possible and be at their beck and call. Harken back to an earlier era, anyone? We are also being told to introduce ourselves, give our educational background, years in nursing, etc. Then, when there is a switch in nursing, such as "triage" nurse bringing them back, we are to talk up our colleague and to rave on about how great the docs are. At the end of the "visit", we are to say " We are glad that you chose (name of the facility) and we hope that you will return again." I did not realize that the ED and WalMart had so much in common!

Our process now is that as soon as they hit the door, registration clerks are on our radios to let us know that there is a pt. The triage nurse, who also is a float nurse, is expected to stop what they are doing, go directly to the front, get the pt, bring them back. Initial registration is done at the bedside and then full registration is completed when the pt has seen a physician, or FNP. Several times, our triage/float person has brought someone back and because the primary nurse was unavailabe, started CP or stroke protocols on that pt. Now, they have to drop everything to "eyeball the pt" and initiate the triage time on the computers. We are expected to have triage times under 10 minutes at all times, no matter what the circumstances. Many times, our primary nurses will get hit with up to 3 new pts at once.

One of the problems that we have seen in multiple MVC's plus routine ambulance calls all comming in at once and then the triage/float nurse is filling all the beds at the same time. We see 30,000+ visits. We are only a level 3, but we see many MVC's, we are in a rural area at the crossroads of 3 major highways plus railway transit. My greatest fear is using one of our two trauma rooms for a migraine and then needing them in a hurry. In addition, we are adding an interventional cardiologist to staff and that will change the type of pts that we will be able to see, it's getting interesing:confused:

I am a "Shift Manager" on the weekends in a 30 bed ED. Our process flow is to bring all patients back to the ED if we have open beds with no triage done in our triage area. The only time we are to use the triage area is when we run out of beds. Anyone else doing this and if so, how is it working for you? As both primary nurse and shift manager, I have a problem with the patients being brought straight back with nothing but an eyeball assessment. I have had patients brought to me that came in by POV, with subdurals because of a head injury that had not been triaged.