Being Rushed in the ED

speedynurse, ADN, BSN, RN, EMT-P · Jun 5, 2020

That sounds very much like the last ER I worked at. I think the pull til full philosophy can work but a charge nurse or triage or float nurse needs to be available to either triage these patients or assist with immediate orders or a tech needs to be available to assist. I have worked every shift and I always thought the midshift was sort of a disaster shift because everything got dumped into a block at once. Day shifts were SO much better.

Wuzzie · Jun 5, 2020

30 minutes ago, speedynurse said:
I think the pull til full philosophy can work but a charge nurse or triage or float nurse needs to be available to either triage these patients or assist with immediate orders or a tech needs to be available to assist.

We tried this. It lasted a week. All the rooms were full of BS stuff and no room for people who were actually sick.

JKL33 · Jun 5, 2020

4 hours ago, Wuzzie said:
We tried this. It lasted a week. All the rooms were full of BS stuff and no room for people who were actually sick.

Ha, your people weren't too hard core I guess. No earaches in your trauma rooms!

****

21 hours ago, vtachy said:
They refer to this method as "pull till full." It is freaking me out because when I come in at midshift they give me 4 patients (we are 4:1) all within the first hour of work and it is really stressfull to tend to all of them at once like that, especially when they havent been triaged (which adds to time youre in the room with the patient).

If there routinely is no assistance with rooming/vitals/triage and you're getting the 4 patients like this when you walk in the door, I would look for a different arrangement pronto, like a new job.

However, it's worth bringing up in staff meetings and/or with your manager. Pull til full isn't all absolutely terrible. What's terrible is the way hosptials handle things like this; they always, always want to both have their cake and eat it. They can take a good idea and ruin it like nothing else I have ever witnessed.

Midshift is notorious for getting the shaft in this and other ways. There are ways to ease the transition of the midshift's arrival. For example: A nurse with a pod very near the one that will be yours could just as well take their 4th patient in one of your rooms (before you get there). This places a patient in your pod (the one you will be assigned when you get there) but lets the patient get settled and started by someone else (the other nurse). They're either going to leave all of your rooms empty til you get there or leave one of the other nurse's empty so s/he can admit a patient in your pod. So they might as well put that patient in your room and let the other nurse work on it. Now you only have 3 rooms that will have brand new patients within your first 30 minutes of arrival, which is bad enough. This is just an example of work-arounds instead of everyone throwing their hands up and saying "we won't put any patients in pod G til so-and-so gets here," and then promptly filling the entire pod when you walk in the door because you're the one with the empty rooms. That's just stupid and completely unthinking (and rude).

As to the rest of your message, I don't want to discourage you--some people love this type of chaos. As for me I think it is over the top mainly because of the demand to accommodate low-level patients and do it as fast as possible while trying to care for sicker patients as well. I personally have come to believe it is unethical; it distracts and detracts from the care of patients who are sick.

This is **not** going to change based on any nurse's ethical concerns (please don't wreck your sense of well-being by thinking you can change it or talk sense into anyone--know that and understand what it means for you, your life, and your happiness. This is the way it is in the ED, and the way it's going to be unless some financial incentive changes things. The fragmented, assembly-line care and the constant half-assed nursing being rendered due to rushing around at break-neck speed has encouraged many a nurse to find more pleasant environments in which to work.

Sorry for my crappy viewpoint and best wishes to you ~

NurseBlaq · Jun 5, 2020

I think it's unsafe. If you're triaging patients as soon as you wank in the door, it will leave you open to unchecked traumas and liability issues. For example, you may be in a room where a patient has a cluster headache and that's it. Meanwhile, there may be another patient who is having TIAs and is soon to have a full CVA. You wouldn't know that though because you have no clue what's going on at all, so it's not like you're incompetent. It's a bad situation you walked into. So let's say the TIA patient has had a full stroke by the time you get to her, the family member in the room is going to be irate and management will throw you under the bus knowing there was no way you could have prevented it given the situation you're placed in. Long example, but I hope you get the gist of what I'm saying. Basically, this setup has the potential for dire consequences for you and the patients.

Closed Account 12345 · Jun 6, 2020

I think that once metrics on STEMI, CVA, and trauma responses start rolling in, your management will change this approach. It's hard to get an EKG within 10 minutes when you don't even realize there's a patient waiting in one of your rooms because you're doing triage, monitors, IV, labs, etc. on someone else who just got pulled back. As a previous poster mentioned, if there were float and triage nurses available to help with settling new patients, that would be a game changer and could make this much more practical. Based on your post, it sounds like your ER is dangerously understaffed; having available techs and paramedics would also be a game changer.

Another problem with a pull til full philosophy is what happens when you pull back 3 sprained ankles and fill up your rooms, and no one notices there's someone struggling to breathe who just walked in?

I'd address your concerns with the manager, and in the meantime, just do the best you can do! Somehow ED nurses have a way of pulling off that which seems unmanageable.

JKL33 · Jun 6, 2020

8 hours ago, FacultyRN said:
I think that once metrics on STEMI, CVA, and trauma responses start rolling in, your management will change this approach.

Oh...no. This isn't somebody's one-off idea; it's being done in tons of places because throughput has been a quality measure for us in the ED, along with expectations about the other quality measures you reference. The big picture is that all of this is a disastrous collision of quality metrics, customer service, and business.

Concerns about higher-ESI conditions are mitigated by having "codes" for all of these. Code stoke, Code sepsis, Code STEMI, obviously trauma codes, etc. The real problem is if the patient checks in with registration and is simply put in a room to wait for the RN assigned to that pod, with no one else (a float, a CN, a triage nurse) going to the room to immediately assess the complaint. If this is the OP's situation, s/he should just get out of there. But...some places get around the idea of needing the assigned RN to immediately assess for potentially high ESI by just having the CN invoke a "code" upon seeing the nature of the complaint on the board.

@FacultyRN, it's become so convoluted. There is no appropriate triage any more. Instead patients are put into rooms and whenever the RN assigned to that pod can get to the patient, they must complete the "triage" which consists of 10+ minutes worth of crap information collection that puts them even further behind: Since providers are also rushing to meet their "door-to-doc" metric, they interrupt "triage" - as they should since it is almost worthless at that point - and before the "triage" is done there have been orders pending that you haven't been working on. Even being a quick, concise and very competent RN, you will go through your entire day always having orders pending on patients who haven't even been "triaged" yet. It's really demoralizing. The whole thing is just a jumbled, unbelievable level of stupid I couldn't imagine until seeing it IRL.

8 hours ago, FacultyRN said:
Another problem with a pull til full philosophy is what happens when you pull back 3 sprained ankles and fill up your rooms, and no one notices there's someone struggling to breathe who just walked in?

?/? You sound like me before I realized I was on my way to imminently earning my "Not a Team Player" and "Troublemaker" badges if I talked like that. I am getting out instead. By the way, the answer to your question in the quote is that this is not an issue: You're exaggerating how many ankles there will be, worrying about something that isn't going to happen, and those ankles will be moved elsewhere if we need the room anyway. (So, yes...we will a lot of time shuffling patients and not concentrating on identifying sick patients. NBD!!) It's only an issue for troublemakers who are not team players.

Closed Account 12345 · Jun 6, 2020

@JKL33 It's been years since I worked in the ED. Some days, when someone in charge felt like it, we'd pull til full leaving open only one of the trauma rooms, but the float and triage nurses would help room people, and we had great techs. Sometimes someone would get the bright idea to throw a "quick" ear infection or something petty into the open trauma room. Naturally, that's when we'd find out an ambulance was en route with a sick puppy in DKA or some mess like that. So guess where that sick person who could've used a big space would go? A tiny fast track room, intended for urgent care problems, where the assigned ED nurse had a 6:1 ratio instead of 4:1 (while mid-levels repeatedly asked "Why haven't you discharged my other 2 patients yet?").

Do I miss it? Mostly no, but strangely yes at the same time... about 2 days a year haha. I miss the cases where I know I really made a difference in someone's outcome. I do not miss rashes that made me feel vicariously itchy or people coughing sputum into cups... gag. I do not miss 12 hour shifts and working holidays or hospital politics.

P.S. I have exaggerated plenty of things in my life, but never the number of "emergent" sprained ankles. LOL ?

What's your next step when you leave ED?

guest464345 · Jun 7, 2020

Augh! I left the ED two years ago - but still today, just reading the phrase "pull til full" shot my blood pressure up! I was a midshifter too ?

Although, strangely, I kinda liked opening up a new pod and getting four brand new patients at once to triage, line, and lab. Before ya know it, three hours have disappeared! Not saying it's a good way to manage workflow, but it did keep things interesting. I was lucky to have great coworkers and reasonable charge nurses, so at least no one was throwing a STEMI in the last room while I waded through a psychotic person, a nursing home disaster, and a family loudly demanding a 3-D ultrasound for the woman who did a home pregnancy test ten minutes ago and "wants to see the baby."

Anyway, what you're describing is pretty typical for both places I worked. I would just try to eyeball the new ones rolling in and ask whoever was pushing the cart to throw on the monitor if needed. If it was sepsis or something else that was going to be task-intensive up front, people were pretty good about helping, and I was careful to help the 7-7 nurses get sorted out at their shift change.

As JKL33 mentioned, the docs are dealing with their own metrics and will definitely be interrupting "triage" by the time you're getting to your third new patient...I would just listen at the same time while getting a line or whatever, and try to interject the other BS questions of triage as quickly as I could.

It's inefficient, not patient friendly, not as safe as it should be, and generally maddening...just like most of our health care system.

allnurses Guide · Jul 2, 2020

On 6/4/2020 at 8:21 PM, vtachy said:
This is my first time posting on here so go easy on me. I have been an ED nurse for 1 year and I find myself in a strange situation in which im not sure if its normal or just crappy management. So I wanted to ask your opinion!

Recently my ED implemented this new thing in which they are not triaging patients in the front, instead they just bring them to the room and leave them there for you to triage. They refer to this method as "pull till full." It is freaking me out because when I come in at midshift they give me 4 patients (we are 4:1) all within the first hour of work and it is really stressfull to tend to all of them at once like that, especially when they havent been triaged (which adds to time youre in the room with the patient). On top of this, they are not providing medics to help us. Unfortunately, all nurses are going through this and because they are so busy, it is difficult to help your teammates. I feel that this tactic is unsafe and it threatens my license. Getting slammed with so many patients at once is really difficult because you don't seem to catch up and have lack of help. It is to the point in which many of us are struggling to take our breaks. Often times if your patient gets a bed, they rush you by putting in for transport for the patient to go upstairs without you even getting a chance to give report (often I cancel the transport but they put it right back in). Other times, they rush you by assigning the room the patient is in to a new one coming in by EMS, so that EMS stands outside of that room waiting for the bed until the patient currently in the room is out so they can put the new patient in the half assed cleaned room. Is this how your emergency department operates? this is an super busy hospital by the way. Because I have never worked ED before I am having a hard time recognizing if this is normal or if I should transfer elsewhere. Rushing and exhaustion make you prone to errors!
Thank you all!

How on earth are they screening for Covid this way? Are you going into every room in full PPE just in case??

Chickenlady · Aug 3, 2020

And THAT is why I don't do midshaft anymore. Walked into my 5 rooms with new patients consisting of: a stroke, a non-stemi, a GI bleed needing blood transfusion, a belly pain.....and here comes the ambo with the violent Tweaker in 4 point restraints.

Kooky Korky, BSN, RN · Aug 6, 2020

Anyone upset by being forced to work this way needs to find their sense and their courage and SPEAK UP.

If managers or admin won't listen, get them to work a few hours with you so they can experience it. Some people learn only by experience.

UNIONIZE.

Oh, yawn, I think I just woke up after dreaming that nurses found their courage and stood up to their oppressors and the suits who give a damn about nothing but the prestige and the buckaroos.