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chip193 specializes in ER.

chip193's Latest Activity

  1. chip193

    Triage at the bedside

    Hi Maisy, It sounds like the problem isn't so much with changing the process, it seems to be the lack of input from the folks in the trenches. When we do something new (that we invent - remember, there are still directives that come from above!), we trial it for about two weeks on the original plan (unless it is a complete disaster) then have a meeting with everyone who has been affected by the change and iron out a new/better way to do it. Two recent examples were when we went to computer entry of home medications and when we changed the triage process. A couple of weeks after we started the home medications, we met and scrapped the whole process, and rebuilt it from the ground up, in the meeting. We noted a problem with "dump and run" from the triage meeting. We changed the process right there with the staff and have buy in. I also need to clarify what the Nurse First (my Director's little nickname for the greeter!) does. When the patient presents to the front desk of the waiting room, the patient will talk with the registration clerk to get entered onto the tracker. While this is going on, the Nurse First can ask a couple of questions if she needs to for bed assignment. She does not do vitals, allergies, meds, domestic violence screening, etc. That is done in the room by either the triage or primary nurse. Chip
  2. chip193

    Triage at the bedside

    We see 65,000 a year, three nurses in triage - one out front, two triaging either in their offices or in the rooms (depending on whether there are rooms available). Ratio is 1:3 in the trauma/cardiac area, 1:5 in the general area, and 1:7 in psych/Express (combined). And yes, the first nurse makes bed assignment based on a very short interview. I should have mentioned that all 23 beds in the main ER are monitored, so an acute/cardiac oops isn't a big deal. Chip
  3. chip193

    Triage at the bedside

    Let me tell you a little story... First a little background about me and the department. I've been doing ED nursing for about 5 years, the last 2 as a manager of the ED, and prior to that I held every EMS title that you can imagine, right up to COO. I continue to work for a nursing agency on the weekend, which give me access to 9 nearby hospitals to steal ideas that work! Our department is in an isolated community hospital, does trauma (level 2), has 23 beds in the main ER, 11 in Express, and 3 in the psych ER. Our clinical outcomes are excellent (in the top 5% of the country, per Healthgrades), patient satisfaction in the mid-80s percentile, and employee satisfaction is at about the 75th percentile. Anyway, about 3 weeks ago, we changed our entire triage process. Prior to the change, a patient would present to a desk in the waiting room where a registration clerk would enter the patient into the system and complete a search of the medical records system to find the right patient. We also had a "Liason" at that desk who, so long as she was not working with the family of a critically ill or injured patient, would keep an ear on what patients' complaints were and would advise one of the traige nurses (who each had their own "office") that a seriously ill patient had arrived. The problem with the system was that the Liason had no real training and would miss the "hidden" ill patients - the MI with the atypical presentation, the sepsis patient who was hypotensive but still talking, etc. So we changed things. A nurse now sits at that desk and does a really, really fast evaluation of the patient. She then decides where to put the patient - Critical Care, General Bed, or Express Care (Fast Track). One of the Triage Nurses will escort the patient back to the area and do triage in the room. Seriously ill or injured patients are picked off from the waiting room and sent back immediately - sometimes with a triage nurse, sometimes with the liason (who we are planning to teach EKGs, VS, and monitor leads next week) - just like an ambulance patient. We had some "dump and run" issues that were readdressed Thursday, which seems to have taken the pressure of the rest of the department. This process was based on one at one of the hospitals where I spent a couple of weekends. They had serious issues (including replacement of the entire ED leadership and most of the nursing staff and having state regulators in the ED to make sure that the behaviors that caused these problems did not repeat) and this was similar to their new system which worked wonders with their MI patients (and getting patients to the cath lab). So what do we have for outcomes so far? We reduced the average door to EKG time on patient from 22 minutes to 2 minutes. We have reduced the time of placement of the first order (usually labs or an xray) from almost 48 minutes to about 21 minutes. Our front end is more efficient - now its time for us to work on our back end - the admissions!
  4. chip193

    Foley Balloon Test

    We had a whole batch of catheters about 18 months ago that were bad. I always have tested the balloon (which is the institutional policy), and we quickly found out who did and who didn't!
  5. chip193

    New Grad ER jobs

    I am a big believer in going right to the ER when you graduate. Some of the best nurses that I work with graduated from school, took a position in our department, and were mentored well and have grown into great ED nurses, with many of them doing back-up charge. I believe that our collective success is because we have a long orientation with strong classroom and clinical experiences. All of our nurses, whether a new grad or someone who has been in nursing for 30 years, need to take dysrhythmia, respiratory, neurology, and "critical care" classes (or pass a test out of them), complete TNCC, ACLS, and either ENPC or PALS, and complete a week-long classroom orientation in the ED. Our new grads have 16-18 weeks of orientation, others are 12-14 weeks. Good luck with a job!
  6. Not in our trauma room! Seriously, make sure that all you have all the information that you need should a run to the OR be needed. Look at your paperwork while you look at mine - make sure all the "i"s are dotted and the "t"s are crossed. Remember that at night, there are fewer resources available to the whole hospital. A trauma in the ER will take resources away from other patients. If the trauma isn't headed to the OR, take a look around the ER for a second. If you even answer one call bell, give a patient a blanket, or something else that seems so silly, but is so often overlooked, the other patients will realize that they are still being taken care of. Just make sure that you stay within your own comfort level - taking primary responsibility for the STEMI that just came through the door would definately be a challenge! And, by the way, thanks for going to the ER and thanks for asking what we need from you.
  7. chip193

    Nurse manager says you can't refuse iv

    Patients can refuse and/all care at any time. So why would the access be any different? Seems to me that the manager is misinformed.
  8. chip193

    er visitors...a funny

    hey, hey, hey...watch those management comments...i resemble that remark :)
  9. chip193

    Excelsior...how long did it take you

    I did it in '03-'04 in 9 months...and would have been six if I didn't get married in the middle! Two exams every Wednesday...then about 5 mo wait for CPNE. Chip
  10. chip193

    er visitors...a funny

    Anyone want to take bets on how long it takes the "OMG, you're so uncaring, I can't believe that you're a nurse!" to show up here? I think the OP's work is wonderful...and will need to bring it to my next meeting! Chip
  11. chip193

    ETMC Athens

    Anyone have good or bad - especially the ER? Thanks!
  12. chip193

    So lets say....(Paramedic EC questions)

    If you don't want to be a Paramedic, don't go to Paramedic school! Your EC base will be your Paramedic training and, if you really have no desire to be a Paramedic, you will not have the interest in it that you really need to have. Then, when the time comes, after you have been through all of the EC program, you'll come across something that you should know about and will overlook, because you really had no interest in being in Paramedic school. Besides, there is a Paramedic shortage too...don't take a seat in a program if you're not going to actually use it!
  13. chip193

    Do you let ambulances drop off in triage?

    We start NS wells on patients in our waiting room, so this wouldn't really bother me!
  14. chip193

    Excelsior FL nursing grad endorsement dillema

    The clinicals are actually life-long. The competancy exam is three days.
  15. chip193

    Excelsior FL nursing grad endorsement dillema

    The reason for this is that the VA will employ you if you are licensed in any state, not necessarily the state where the particular hospital is located. The OP has an RN license somewhere - just not FL. So a VA hospital (or any federal hospital for that matter - so look at the military hospitals - some do use civies) in Miami can hire her, but a hospital licensed by FL cannot.
  16. chip193

    Can RN's work on ambulances?

    Having done both jobs, let me give you a little of my insight. RN and Paramedic are two completely different jobs. Some of the skills may overlap, but the whole thought process, autonomy level, and physical skills. A good RN does not necessarily make a good Paramedic. A good Paramedic does not necessarily make a good RN.