sumas8

We would put them on a 1:1 or safety sit and have an aide sit with them. Being drunk impairs your judgement to make medical judgements. After being given narcs (which we try to remember to ask prior to giving them how they are getting home if no one in rm with them) we either tell them they have to wait 4 hrs after the narc before driving self, or, if they say so-and-so will pick them up, the driver must come in and present themselves in the ED before we will discharge them. Otherwise we won't give them the drugs here, just a prescip at discharge. This is not to say that we NEVER have people leave after receiving narcs or with an IV in, we do. But we try - we have alot of 1:1s and safety sits, but it beats going to court as mentioned above...

I had posted about my NY hospital with 6-8 pts or whatever the traffic will bear. That more refers to our 'main' area, not critical care patients- our 'acute' higher level area is more like 3, maybe 4 pts on a really busy day. We have a separate fast track area where you may have more, but the RN had little to do for each pt. We had a nurse who moved to Calif and while the 4:1 ratio is nice, she can't believe the length of time patients have to wait to be seen. (6+ hours as a norm....) Ratios have 2 sides- the nurses' side and the waiting patients' side....

Has anyone else tackled this issue with any cute/clever/annoying or whatever tricks to help change the habits/culture?????

Hi from New York. I work at a level 1 trauma center/ univ. hosp/ teaching hospital. We are the only level 1 in our county, also have an interventional neurologist and the only cardiac cath lab/Cardiac surgery in the area. We get alot of transfers from other area hospitals for these and other specialty needs. We have no ratios-I can't imagine pts waiting for hours until I d/c a pt so I can take another one. We keep seeing as many pts as we can physically cram in. I'd say we avg 6-8 pts each, but can be more if we are packed. I love the variety, adrenaline, comaraderie and learning something new every day. We have great docs and a great culture of learning and never feeling stupid to ask questions like "what do you think that is" or 'can you explain that to me'. The jokes, humor, love and admiration for my coworkers is what gets me through the dark moments. I love the stupid patients, the sad stories, the success stories, the grateful patients- all of it good and bad. As I like to say, besides a paycheck the sheer entertainment value of coming to work every day is an added perk....

Help! We are a busy trauma/ER and have had horrendous compliance with handwashing before and after seeing patients by all staff, from MDs to aides. We have many different types of staff who audit us (secretly or not) and it is now almost a year and we are always the lowest unit in the hospital (avg. 20-30% compliance!) We've had people argue the problems w. the audits and the barriers to washing (phys. set up) but I think its more a habit/culture change issue. I always wash so it can be done. Patients are now on the lookout for this and stats are going to be published. We are immed informing staff who do not wash, sending them an email stating they did not wash, trying to encourage/remind everyone out loud to do it, thank those who do,etc. We have put the 'foams' mounted outside each room, etc. We now have a doc who wants to mount a can of foam on the foot of each stretcher ! I think we should just hang them from each doorway so the can hits you on the head on the way in...but I still can't make you rub your hands together. Another doc joked to attach them to each wrist so you can squirt it out like Spidey... Has anyone had any successful ideas for reinforcing the culture change? We are at our wits end. Thanks-love you guys -and Happy Almost Emergency Nurses Week !!

Hi- I'm an ER nurse and this looked like an interesting topic. I didn't read all 8 pages of comments so probably what I have to say may have already been covered. I always like to think of what is best for the patient. If a patient gets a bed assignment just before shift change, I think it is in the best interest for the nurse who has just cared for them for the last 8 hours or whatever to give report to the oncoming floor nurse. It doesn't make sense for the ED nurse to give report to an ED nurse who likely will not even lay eyes upon the patient but would have to report to the floor's next shift and not really be able to answer any questions that are not in the written report. I work nights and have asked floors to have their oncoming nurse take phone report from my offgoing nurse BEFORE they go into their full shift report, but that rarely happens. When space permits, we would prefer to have the offgoing nurse give report and then send the patient up in a half hour, but again, get a hard time from the floors. We often get beds assigned when pts go to OR or floors have not removed someone from census and the bed is not 'discovered' till start of business day. In my hosp. the admitting services sometimes come around and evaluate/admit pts in bunches so that is another problem. Bottom line is that our doors never close, we can't refuse incoming patients and are always looking to open more beds for the next people to come in the door. We traditionally do phone report, but often the floor nurse is busy and can't come to the phone, etc. etc. We recently initiated a written report sheet on all patients for which we collaborated with floor nurses to develop. We also call phone report. We are supposed to send a patient up with written report if the floor does not take report within 15 minutes but we rarely do. The floor staff finds that to be 'punitive' and goes crazy if we do. The actual policy is that the floor is supposed to call US within 15 minutes after a bed is assigned but that happens maybe 3 x a year! I know we need to change our behavior and either get people used to the written report and not feel its punitive which would also get patients upstairs sooner. Oops= digressing off the topic. In my ER, we don't have nurse:patient ratios, so if you purposely hold an admit patient (as mentioned in one of the first replies, so that the nurse would not get new patients) you will just have more patients, as you will continue to get patients assigned to you. It is in our best interest to get rid of whoever we can. And its not fair for the patients to be holed up in our hallway on a stretcher and not receiving optimal care, we are busier with the incoming people. It is not ideal for anyone to have change of shift admits, but it does happen and we need to work together to do what's best for the patients.

I found your posting to have alot of thoughts to process and digest. I think it is natural to have self-doubts when you are a new nurse, or even when thinking of changing to a different specialty. I also feel your post contains alot of misconceptions about Emergency nursing, as others have mentioned. You take care of a hundred patients or more in between 'saving someone's life'. There are very few or maybe no jobs in medicine where all you do is 'save lives'. Most you have to get satisfaction from yourself knowing that you helped a patient or family have a more positive experience with their illness or hospitalization or even their own death or death of a loved one, and not need to be on the front page of the news daily because you saved the baby dangling from the ledge.... If you need that type of reward you will never be satisfied. And while many of us like the challenge and satisfaction after a 'good trauma' or crisis patient, you need to have a large bank of experience/knowledge before you get to be a productive member of that team! I think you should make steps towards a goal or job you would find more satisfactory, and also look into why you are not getting satisfaction from helping patients in other ways and life's smaller satisfactions. As per your posts' title, you do seem interested in ED but don't sound like ED material at present, which you acknowledge. You sound like you want to go from point A to point Z without learning all the letters in between. I hope you can find something that gives you pride and satisfaction.

I agree- if you are handling 5-6 pts including ICU pts on drips you are doing very well. Does your ED have differently staffed areas for 'main' patients and acutely ill patients or are they combined and all staff cares for them? If your ER's system of assigning incoming patients is putting other patients at risk, it is a SYSTEM or MANAGEMENT problem, not an individual nurse problem. Over the past few years as my dept's pt volume has skyrocketed, we have developed a "lead" position (initially an RN but now due to staffing can also be a senior nurse's aide under the guidance of the triage RN). The lead nurse or NA keeps a written record of which 'team' and RN gets each patient (the staff develped their own 'flow sheet') with the triage times and we rotate through each RN in turn. Any ED with common sense does not want to give one nurse 'back to back' ambulance patients, especially higher acuity ones (of course when you get many ambulances in a row, you may end up getting one soon after another, but everyone else would have gotten one also). I would document incidences such as these, especially when patient safety is affected. I would bring my concerns through the proper channels (charge nurse, nurse manager,etc.) and have the concerns in writing. Every hospital now has quality assurance depts., risk management, etc. We have a 'patient safety network' where you can write up any problem that affects patient safety. It is on the hospital internet and then whatever dept is involved must reply and try to fix the problem. It is a non=punitive system intended to prevent/fix problems. Also, we like people who have a complaint to be part of the solution. Can you look at your system of how incoming patients are assigned and perhaps offer a solution if it is somewhat arbitrary? Base it on patient care and safety issues and you cant go wrong. Speak to management and/or unit educators to find out how you are doing. As a charge nurse, we discuss and know who the staff hates to get report from and who is not carrying their load. If your department and management is as small minded as it sounds, you may be better off working elsewhere. You sound like a good conscientious nurse who would be an asset to another place that would value your work. Sometimes you have to find the 'right fit'. There are better places out there!

Welcome to the wonderful world of Emergency Medicine! You sound like you have good life experience and a good attitude that should serve you well. I hope where you are working has a good internship/preceptorship for new grads. Starting in the ED is monumentally difficult as it encompasses all age groups and all illnesses/medical-surgical specialty areas. Don't be too hard on your self- you can never know everything in Emergency Medicine, every day is a learning experience no matter how many years you work here. Give your self 6 months or longer to really assess yourself, you'll be amazed at much you know and can handle. And as the other posts say, check and double check yourself, ask questions, look things up after your shift. PDA's are great for some, but where I work as we have internet access everywhere, we have approved pharmacy sites for references, and Google for every other usual and unusual syndrome, disease, etc. Find some good mentors and role models. KEY POINT= When you feel like you are drowning in your assignment, call your charge nurse or let someone know. Sometimes just talking to someone about the 6 or 7 things people are all telling you need to be done NOW will help you prioritize them, or someone pitching in and doing 1 or 2 of them for you can help you get back on track. As a night charge nurse, I often can help or find someone who can and would rather do that than find out after the fact that a pediatric septic work up waited 2 hours because you were too busy but didn't tell anyone. Remember, PATIENTS FIRST helps to whittle down what is really the most important thing to do next. I hope where you work has good support for new staff, it is so all important. Enjoy the humor/entertainment factor in the ED, it helps you get through your shift (see 'stupidest reasons to go to the ER' thread on this site). You can't make up the stuff you see here. Best of luck= you sound you will be a great asset to nursing and the ER where you work. A year from now you will be very proud of yourself!:welcome:

We are a large suburban trauma center. We actually have a system/forms for taxi vouchers. I'm not sure if it comes out of the ED or hosp. budget. But you are right about people asking for them, or their friend got one, etc. As the night charge nurse, I'm the one who approves them. If someone was brought in by ambulance for MVA or something and truly doesn't have a ride at 4 am, I don't mind. But for the majority of the 'rashes', etc. its a different story. First I speak to the pt. to ask about getting home, if they have money for cab, etc. Then often I tell them they can wait in the waiting room until 9 am when the social worker comes in= it's remarkable how many of them suddenly find a ride! Occasionally we have a person whose spouse doesn't drive at night, or cant get a ride till the am for childcare or other reasons- if they are a legit person, I'll let them sleep on an unused stretcher somewhere. And to answer your question, I don't think any hospital has an obligation to get people home, except obviously social work issues/pts. When you're 22 yo and got dropped off because you have a toothache, its not my problem how you get home. The sense of entitlement is truly amazing, we need to work hard to dispel that, esp w. pts who have been given a voucher in the past.

Those are all so true! - They come in wearing their hospital ID band from last time - We had a FF Alcoholic (now deceased- it's hard to believe these people actually do die eventually) who we dubbed the Mayor of our ED as once he sobered up he would chat with other patients, and even admonish others on the evils of drinking "Look what it did to me!". One of the nurses gave him a christmas gift one year- he was so touched by that, as we were kind of his family... We also had a FF young woman who would fake seizures on the floor in front of the triage desk or on the sidewalk just outside the ER entrance. People would look amazed that we all but stepped over her and weren't rushing over to help her. We finally found that she did not want anyone to take her backpack away from her, so we would just stroll over and say "S... we're taking your backpack and putting it over here..." after which she would miraculously regain consciousness. She literally had about 30 'allergies' so triaging her was very tedious.....

Thanks for your thoughts- (they really are worth more than 2 cents..) We do have some active committees w. staff on them, and this falls under our CQI, but you are right- we should get some staff specifically on this problem. The problems are multifaceted- sometimes the error report from the lab occurs after the staffer has gone home, by the time they hear of it it may be few days later and who can remember? I'm wondering if we can ask the lab to send us back up (we have a pneumatic tube system) the unlabelled tube, because we don't believe them sometimes- maybe they just lost it or something! But a few staffers have admitted being short one label and putting all tubes in a baggie, and sending them forgetting to get an extra label first. I appreciate everyone's input- I'm going to share at our CQI meeting next week and see if we can come up with a new/different approach. I am not without staff perspective, I've been in leadership a bit over 6 months, and worked here 6 years prior so I know how our specimen/label system operates and know how when it is crazy/hectic is all the more reason to take a few seconds out to verify everything is correct. Thanks all !

I am the one who posted this question. Thanks to all for replying. I agree it may be a 'systems' problem, but not sure. When a pt is registered in our ER within minutes 2 pages of labels w. attached arm bands are printed, so in almost all cases we can bring labels into the room. We often draw bloods (especially in acute/trauma) before labs are actually ordered or reqs are printed. In that case, the tubes are labelled at the bedside and placed in a ziplock bag awaiting the reqs. We have a computerized patient safety network, (PSN) so the lab enters one whenever there is an error. Many times the nurse swears they did not send an unlabelled specimen, but we have no way to prove it. The lab just calls and asks them to send another spec and req. We also have the lab calling at times and saying "you didn't send a red top" or whatever when we know we did, and then it mysteriously appears down there. If it is a case of the tube labels not matching the reqs, we can usually verify that, but not always. Also it is not so hectic here (although occasionally of course) that one cannot take a 15 second time out to verify correct labels, and it should never be. Our staffing is usually pretty good. And I agree (thanks) with pointing out being punitive to staff does not make it a hospitable environment to work in. Actually I think we are pretty management-friendly here, but we felt we needed to do something- we are having up to 10 per month, where we used to have 1-3/month. Its too serious a thing to not do anything. When we are discussing w. staff when they have their 1st event, we review the process- bringing labels in, etc. - if you don't have labels or not enough, leave tubes in pts room and go out and get them, and of course double check the reqs to tubes before sending. As I said, most staff has never had any, and also some of us question the lab techs reports. Thanks for everyone's input- these forums are great! I will keep looking into the system, but some of our nurses have 3 mislabellings- that's just careless work, and too dangerous to work in an ED....

We've been going from bad to worse with the number of mislabelled lab specimens in my ER lately. Does anyone have things they have done to stop this problem? We had been giving verbal warnings for 1st occurence, then if a 2nd, nurse had to give an inservice to 10 staff members and have specimen reqs cosigned for 1-3 months, and if a 3rd time, written counseling that goes in their file and possible reassignment. Well, over the past several months our numbers have increased! Most staff have never had any, but we don't know what to do. We have upped the ante by skipping verbal warning, and now have held back some RNs from advancing into our acute/trauma area. But its a big patient safety issue, we're tearing our hair out trying to stop it. We are a busy ED/trauma center undergoing construction and constantly closing rooms/ areas, etc. so a pretty stressful environment even physically. Our policy is to label specs in the room at the bedside, but we keep having problems anyway, often with unlabelled specs being sent. RN's draw all labs when IV is started, ( phlebotomy is only for AM labs for admit pts holding in the ED. ) Any suggestions? (Besides assigning the evil=doers the next dozen 'toxic sock' patients?) Thanks!!:monkeydance:

I've been in charge for a bit over 6 months now. Some great and true suggestions given here. The person who trained me got me into the giving out chocolates thing. I keep a bag of Hershey's kisses or something in the office and bring them around on a busy night. And absolutely pitch in= there is no task I don't do. I answer call bells, give bedpans, discharge patients, cover breaks if possible or needed. You have to show staff what you expect them to do. And when the spit hits the fan and staffing is bad, people appreciate to be covered if only for a smoke or fresh air break. And since you are visible around the dept, you can see things and give true compliments, such as "You handled that angry Mom really well" and such. I couldn't do this job without my sense of humor, so be sure to seek out and enjoy that too- only your ER co=workers can appreciate the things that go on at work!! I am on night shift for years by choice, because we have so much fun at work, although outsiders find that hard to believe. I periodically bake some brownies, or one of the docs sends someone out to get coffee and donuts or makings for an ice cream party. Just be the kind of nurse that you want your staff to be- compliment in public, and criticize/discuss in private. You know how you would want to be treated. I'm finding it tough to do all the paperwork (evaluations, chart audits, etc) but it's a challenge I'm enjoying. Good Luck------------