chip193

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

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

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!

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!

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!

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.

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.

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

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

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

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!

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

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

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.

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.

Whether you get an immediate bed or not is based on your complaint and what other patients are there waiting. It has nothing to do with mode of arrival. The detox patient, so long as he's cooperative and not urinating all over himself, can go to Triage. He's a wildcard, if you will, as you need to see how much of a problem he's going to cause in the waiting room. The last thing that you need is to rile up the whole place! The ankle guy can go to the waiting room and get his XR. Chip

I've done this twice in 18 years - both times in an ambulance. Both times it made a huge mess. You did fine with what you did. Crazy things like this happen!

You're welcome. I'm actually at a conference right now discussing solutions to handle employees just like the one that you've mentioned. And good luck growing into the RN role.

Was it the amoxicillin or the time that did it?

Disclaimer: I am a 2004 graduate of the ASN program at Excelsior College. California has a time limit in place - I'm not sure when it was - that states that if you are not enrolled in the EC program before "x" date, you cannot obtain licensure in CA. I know that I can be licensed in CA, so I started (2003) before the cut-off date. Some other states require an extended period of clinical. Most will take your license on reciprocity, just like any other program. If you have advanced your degree from ASN to BSN, you may be able to be licensed in CA. I believe that they look at these on a case-by-case basis. And remember, you can still work at federal facilities in CA (the VA, etc.) without a CA license. Good luck!

There are two kinds of people who are trying to climb the ladder. There are those who excel and do whatever it takes to make themselves better (like attend CME, conference, read journals, become a resource for others, etc.) and those who make themselves look better by making everyone else look worse. I think that you know what you have just run into. You did really well standing up to her. We have several of these folks at work and we have simply isolated them. They no longer know what to do as no one is listening to them. As someone in a leadership role, I can tell you that I know who is in what category. Ms. Catastrophe is well known to the leadership and her opinion is generally not valued. Keep up the good fight and remember to take care of yourself. And, take care of those who come after you by letting them know that they may need to grab this bull by her horns!

Ear infections – well, most of them are caused by a virus. Using antibiotics immediately out of vogue per AAP and most of our ER docs are sending parents home with a prescription to be filled in two days if no better. Decongestants are sometimes given immediately as are pain medication and eardrops. As for visiting the ER for a child screaming in pain on a Friday night – well, we always see them. As a Dad of a two year old, I understand why parents are there. So do most of the staff – as they’re Moms or Dads. What causes great amounts of stress in the ER is the patient who has multiple visits for the same or similar complaints. Ignoring the discharge instructions that say “see your doctor in two days” or something similar causes a problems. Multiple visits for vague complaints of pain (dental, back, headache, etc.) cause concern in the ER.

I've read this thread with great interest. To give my background before I get onto my soapbox, I'm in a leadership role, at night, in a busy emergency department. In my past life, I served in all sorts of leadership roles in the ems world. So, for the past 19 years, I've been leading people. You may have noticed that I choose the word leadership over the word manage. People hate being managed. People like being led. Part of being a good leader is knowing the difference between the two and allowing people to develop. Managing is focus on what the person is doing wrong and how to punish for what has been done wrong. Leading is having the employee make the right choices based on the framework that you have provided for them. The folks that work with me do the right thing because it is the right thing to do. They take exceptional care of the patients, they make sure the families are informed, they explain delays, and they are always looking to go the extra step to make sure that everything is taken care of. Why? It is the culture that the leadership team has created. Our leadership is never too busy to talk to a staff member. If we cannot answer the staff member's question on the spot, we make sure that we get the right answer and let the staff member know what the answer is. As for doing clinical work - we do lots of it. When an rn went home sick last week, who picked up her assignment? Who watches over patients when the primary nurse gets a real sick patient? If a staff member has a question about a procedure or an assessment finding, who do they call on? Yup, it's our leadership team. I'll admit, it's fun to watch the department director transfer patients to the floor in a talbot's suit and heals, but it's what we do. It is how we lead. Part of leading is developing staff. Our charge nurses are probably the most empowered group of charge nurses that I have ever run into. When they come to me with a question about how to deal with a situation, the answer is usually "What do you want to do about it?" rather than a concrete "Do this". Why? It continues their empowerment and makes them able to replace me one day. It seems that capecodmermaid is managing. It seems that rather than lead, she is looking to motivate through negative reinforcement. This was typical of the "Head nurse" type of management that is still epidemic throughout healthcare. I've never heard "I used to do that and more" or "I don't see why you can't do that" at my job. We focus on what can be done and fixing what needs to be fixed. Does your staff have the equipment that they need to do their jobs? As silly as it may sound, our folks had problems finding thermometers. How did we handle it? We got more. There were reliability problems with our transport monitors. How did we handle it? Biomed now replaces the batteries quarterly. Yeah, you may have taken 50 patients every night, with one hand tied behind your back, and had to do multiple dressing changes, tube feeds, and even answer the phone. Your staff doesn't want to hear that. You can't start motivation and leading with the big things. You have to start with looking deep inside yourself and realizing that you may not have been doing things the best way. I've heard many of my peers from other departments laments on the current state of the nurses. Many of them sound like capecodmermaid. They blame the lack of respect, lack of caring, lack of work ethic on the newest employees. We don't have the same problems. It is our culture - the staff members hold each other to standards - and their standards are much tougher than the hospital's! They come to our department and watch the staff and how they interact with each other. Usually, the comment is something to the effect of "My staff isn't like that". Then I will generally say something like "Do you lead them to be this way? We do." But, what do I know. I've only been a leader for 19 years.

I have firmly believed for a long time that there needs to be an ativan lick in the waiting area. And, the best way to get your Press Ganey scores up is to hand out crack at Triage!

Nah, just late enough that the bars are already closed and a Saturday morning so there's no "I can't possibly work today with my..." crowd.