RNinED

OK, I CAN NOT FIND ANYTHING FROM CA. BRN THAT SAYS OK FOR RN TO PERFORM MSE AT TRIAGE. I DID FIND AND PRINTED OUT OREGON'S STATMENT AND IT REQUIRES THAT THE HOSPITAL PROVIDE A GREAT FRAMEWORK FROM ALGORYTHMS TO SPECIFIC TRAINING FOR EACH RN REQUIRED TO DO THE MSE. DO ANY CALIFORNIA RNs CURRENTLY PERFORM THE MSE IN THE ED TRIAGE????? IF SO WHERE DO YOU GET THE INFO ON YOUR LIABILITY ETC. THANKS

Thankyou, I will look up california's BRN for their rules. I don't think we would be doing anything more than we already are but the charges for the tests..labs, xrays and the visit could be applied to the pt even if they AMA. as it is now, if the MD doesn't actually lay eyes on them the pt can not be charged after these tests if they AMA before the MSE. Big loss of revenue, and wasted resources. (medical/medicare will not reimburse for tests without the MSE). Again thankyou for the information. I will feel better about it if the Ca. Board of nurses says it is within my scope.

The facility is mandated by law to pay a large amount of money for missed lunches as well as a fine to state or federal agencies for each incident. My facility choses not to pay that fine and does every thing in it's power to get us our 30 minute lunches on days. That usually means the House Supervisor with a min. of ACLS will come down and relieve each of us. It is on us to be ready if possible for that relief. The smaller breaks are grab 'em as you can and usually you can't. Follow the money. If it costs too much they will fix it. Of course for that to work....we can't lie and sign out for lunch when we don't take it. I do often go back earlier than my 30 minutes as a courtesy but am in no way required to. Oh...that goes back to ratios of 4:1 and that we can not be required to cover other's pts if the ratio/acuity is met. I forget that Ca. may be different than other places. best of luck and take your breaks as it reduces burnout and improves pt care/outcomes.

Do you do the official EMTALA required MSE at your triage. We are getting ready to change from normal triage then MD medical screening exams to MSE done by the triage RN. That is, if our manager gets his way. I think there must be some formal training required but manager doesnt seem to think so. I know that we do a heck of a job at triage assessing med emergencies vs non-emerg. We already order many tests from triage to facilitate flow without the MSE having been done by MD yet. It still feels like we are taking on too much without further training to say now "triage is the MSE". The ENA seems not to recommend that triage be the MSE. your thought and experiences would be helpful.

Whoa, after reading your post all I can think is...I LOVE MY JOB, I LOVE WORKING IN CA. WITH 4:1 ratios and I love working in a rural hospital where the nurses are, overall, treated with utmost respect by the admin. I think it must make a difference that the law requires certain standards of care. I used to have my beds filled without my knowledge, but now if the charge/triage nurse puts someone on a bed they give me report and/or make the first notes and assure the ball is rolling and the pt is hooked up to monitors, orders, ekg etc. and tell me if the pt can wait for further attention. If immediate attention is required we all jump in or they call the house supervisor. That was one of my big changes at this ED with a certain Triage nurse. She would not listen when I said I was getting too many critical pts or that 1:1 was needed for intubation so I started telling her she had to call the house supervisor because I was tied up in the room with whatever and that pts at risk of injury. If she didn't I would. My license says I am capable and responsible to assess my abilities and reporting unsafe conditions to protect pts. If the BON won't get involved I bet the state would. I would rather be fired for protecting pts than be negligent and hurt someone. bottom line the triage nurse didn't want her behavior to come to light so she adjusted without much noise. good luck with traveling and think about states with reasonable ratios by law.

Thankyou for writing, I know I sounded off a bit. Did you go through a "new grad" program when you started or just orientation to the unit and facility with check off lists etc.? I wonder how often it occurs that new grads are hired without a program in place. The face of nursing is changing and somewhat for the better but we are losing those that are very experienced and have not replaced the knowledge resource yet.

Hello, I Have Read Several Threads From New Grads In The Ed And I Am Very Excited To Be Getting Fresh New Blood In The Specialty. Having Said That, I Worry About My Ed Hiring A New Grad Since We Have No New Grad Progam Designed To Move Them Through Their First Ever Nursing Experiences Or Even Sufficient Training For Experienced Nurses Looking To Change To Ed. Every Thing I Know I Researched And Obtained Through Classes And Otj Training With A Strong Crew And I Started Out With 3 Years Experience In Micu And Home Health. (and I Still Anfter 3 Years Continually Learn) Even Though We Have No Program In Place And Have Never Before Had A New Grad In Our Ed The New Manager Has Hired One Without Informing Staff Of The Formal Change In Policy. The General Feelings Are Not That She Should Not Be There But That The Manager Should Have Set Something Up Better For Her To Help Her Succeed. We Are Doing Our Best To Support Her And She Will Be On Orientation For As Long As Needed But...we Often Have Docs From Out Of The Area And The Nurses Have To Be Strong Pt Advocates And Know What We Can And Can't Do At Our Critical Access Hospital As Well As Services Avail. In Our Community. It's More Than Doing The Tasks Of Nursing. One Of The Scariest Things Is That This New Rn 2 Mos Into The Orientation Thinks She's Got It And "just Needs To See A Couple Codes." I Love My Community And The People I Serve. I Want More For Them Than For Their Nurse To Think "wow That Subcutaneous Emphasema Feels So Cool" That Pt Did Not Feel Cool And In Fact Was Flown Out With Complications Of Esophageal Rupture. The Boss Won't Listen And The New Rn Thinks She's Got It So The Rest Of Us Feel Unsafe And Unsupported In Her Orientation Process. We Need New Nurses, Period, But First We Need A New Grad Program In Place To Protect Them, The Pts And The Staff. Please Give Me Your Constructive Advice, Info. And Know That We Are Already Supportive And Appropriate With Our New Hire.(not Eatin' Our Young)

Thankyou for the list and no ofense taken for anything I already knew. This would have been so helpful 3 yrs ago when I started in my little ED. I had never needed to give flouroscein until then, though I had several yrs on monitored care/ ICU and believed I was well prepared for the high acuity of the ED. I had no idea of the broad spectrum of nursing care it would require. Any thing that is positive that will help others (no matter how new or experienced ) is appreciated.

WOW! I hope you are just venting. With the changes in health care laws/regulations, there is less tolerance for the above attitudes. I am not a bleeding heart and certainly do not like the state our healthcare is in but the fact remains many poor working adults do not have PMD or coverage. There is a whole generation that grew up without them and therefore the ED is their only acccess to care. If we don't like the nonurgent in the ED then we must vote in elections that support changes. But please don't become less humane....the cost is too great. I try to see the questions about waiting as if it were me asking it. I simply EMPATHISE and say "waiting is the worst thing, other than not breathing that is. I know you are here and will get you back as soon as possible. If any thing changes let the clerk know and I will check you out again." Then I order anything that I believe the doc will need and explain to the pt that this will help make the whole visit quicker for them. Pts thank me for helping them and understanding. All of this in less than 10 minutes per triage. Of course, sometimes I vent too.

However the more experienced opinion was that the packets were useless and unwelcome. The very experienced nurses have not all realized the changes to the ED numbers and clientel with higher acuities requires streamlined processes so new resources can be utilized (like floor nurses to prepare records for tranfer, admit, etc.). Fortunately you have inexperience on your side and can simply put it that the change was the only way you could manage at this stage of your carreer while she is free to manage it her way when she is there. Good changes usually carry themselves and you may not ever be appreciated fully by the few who hate change... the new nurses comming on and especially the pts. will benefit from your efforts and suffering. Use numbers when you tell the boss, supervisor etc. "using this packet decreased the time for tranfer by about===minutes putting the helping nurse back to her own area sooner."

A little education goes a long way. The patients I explain it all to (possible wait, recheck vs, more serious c/o first...) seem to deal with the ED process much better. Can't a ED tech (CNA or EMT-1) do repeat vs and report abnormals to the triage RN so pt can then be reassessed? I work in Ca. in a 7 bed ED that is often stretched to overflowing 10 bed/chairs. On the busiest days we see 60 pts in 24hrs. Average is 35-45. I think we are well staffed with 3 bedside nurses,a triage nurse and a tech. but We still haven't developed a plan for rechecking VS if pt is out in WR >2 hrs. What we have accomplished is an average ED visit of less than 4 hours from arrival.

I have seen our ER docs clean house about the same time daily because they don't want to pass those cases on to the next DR. And yes they are usually the soft calls and those we tried to treat in ED with wahtever that didn't work. OUr next big thing will be I-STAT bedside lab testing so dispositions can be decided sooner----Hopefully

I work in a small 7 bed ER where we see about 50-60 pts /day and we are also struggling with covering the busiest times by adjusting two 10hr shifts. one will come in at 10am and the next at 1300. We do not have a charge nurse and who ever does triage is supposed to help with pt flow. Would you describe POD nursing.

I am glad that concious sedation and propofol came up here. Today my ED Dr wanted me to push propofol for a closed reduction of hip dislocation that had occured less than 30 min prior to arrival. I related to the MD that we did not use propofol in the ED for cons. sedation. I was, thankfully, workng with two very experienced RNs that helped me get the policy and procedures to show him we were not covered for that drug in our ED for this type of sedation. The patient had to wait until the MD had exhausted all his resources including calling the anest. who was not avail. before he would agree to versed. (1.5 hours) The whole procedure took less tha 5 min. for sedation and reduction and 30 min. for pt to recover nearly completely. he was dcd home within 1 hour after sedation. The pt suffered too long even with fentanyl 200mcg. DOES ANY ONE HAVE A CLEAR POLICY PROCEDURE FOR PROPOFOL FOR CONSIOUS SEDATION IN ED? I had a precepting sn with me and he got to experience the ability of nurses to keep pt safe and stand up to MD who really wanted it his way. I was very dissappointed that the pt had to wait though.

What is it with nurses who think it is ok to take report with their back turned to you or while they walk back and forth "keep talking. I'm listening". It is rude not to mention unsafe for pts. since pertinent info may be missed. If I can give short, clear concise report they can stand(or sit) for three minutes and receive it. Any insight would be helpful.