2 weeks ago, my 60 year old mother, for only the 4th time in her life, went to an ER in a moderately sized hospital, part of a large statewide hospital system. Her symptoms/age and recent medical history, were suspicious of stroke activity. Not blatant, but with a bit of critical thinking it would be considered. Although my mother walked in, she gave the "right words", let alone her general presentation, that should have had her whisked to a room immediately, if not a stroke alert called, she was placed in a waiting room, by an RN, due to a "full unit." No triage, No VS, no assessement but immediately dismissed to the waiting room out of view of the registration nurse. After sitting in the waiting room for 30 minutes, she was taken to a room, initial VS done (high blood pressure present) triaged and continued with possible stroke symptoms. Again, not blatant, but many factors that should have been alarming. My mother was in the ER for 8 hours. And not a single nurse or doctor physically examined her. The only physical touch by another person was when the LPN took her BP and an IV was started. No neuro checks, no circ checks. Nothing. No continuous monitoring, not even a cardiac monitor. I was shocked and embarrassed to be part of the profession. If my mother, the mother of a seasoned nurse in the same hospital, could be so poorly treated, what about all the other mothers out there. My father, an LPN, sat at her bedside. He told me he did not intervene because he "assumed" that at any time, she would be examined. He was also interested to see if it would be done after her testing was completed. Had he not pushed for a CT, it would not have been done, after all, her 10/10 head pain was likely a "migraine" It was only at her transfer that he pointed out that no ER staff member had done a physical assessment. And my mother left the hospital for the same pain she arrived in. The "migraine" cocktail did not work and the dr. lectured my father of the pitfalls of opoids when he requested more treatment for her pain.
It's led me to a great deal of thinking and sadness over the last few weeks. I've tried to dive deep and figure out what in the world is happening to our profession. Are we so reliant on machines that we no longer need to touch and assess? In the ER, are we so reliant on protocols that we no longer critically think? Are we so hung up on patient satisfaction that we miss key factors? Are we no longer teaching the importance of physical assessment? Are we too management top heavy and working too short as the front line nurses? Are we more worried about presenting a KPI board to 4 administrators then doing a pupil check on a possible stroke patient? Are we too worried about "real time" charting and meeting parameters that we can't get off the keyboard and look a patient in the eye? Are our up and coming physicians no longer taught to examine a pt? Do they rely on protocols, machines, results and e-med so they no longer need to think either?
I know without a doubt that this is in no way an isolated event. I have seen nurses chart lung sounds, when they haven't had a stethoscope on hand for 8 hours. I've watched nurses chart a complete neuro check, when all they've done is hand grasps. I could go on and on and on. I, for one, will call out a nurse when I see this. I remind a nurse that it's falsification of records, in the least, to chart what we haven't done. I have also reported it to management.
I would greatly appreciate thoughts, opinions and experiences with our new trends in nursing. For me, it's terrifying. To the point that I vow to leave a profession that I have been in for 19 years because I know there are wrongs I can no longer right. I have loved being a nurse and used to be so proud. As time goes on, I find myself feeling more concern, more fear and more disappointment.
In regards to the medical professions relying on machines too much for assessments and diagnostics - if a pulse ox is 98%, do we then assume the cap refill is prompt? If the pulse ox shows a pulse of 88, do we not need to physically check a radial pulse? If the monitor shows NSR, do we not need to listen to heart sounds? if parameters per a machine are "WDL", is this all we need? Unfortunately, I've seen many nurses electronically chart a "WDL" based solely on a machine reading, even though that "WDL" also includes many other things that can only be assessed with touching or listening. In addition, in my 10+ years of ER experience, I've seen physicians not even enter a room if "protocol orders" were initiated by the primary nurse, until every report was back. The physician used no clinical assessment skills to aid in his diagnosis. It was based purely on the read out of a machine. While they may have an ESI of 4, is it fair for them to only be seen by a physican 2 hours after arrival, only after an xray reading or lab report. And I see this as common practice in every single ER I work in. And I work in several as a float. One physician in particular never carries a stethoscope and this is well known in our unit. In 5 years, I've seen him auscultate a chest one time. On a dying CHF patient.
While the situation with my mother is not only disappointing, but beyond aggravating, the bottom line is my mother is not alone. And again I pose the question, what has changed? How do we get our profession and the culture back to what is important. How do we make sure bare bones basic nursing care is done and how do we get our managers to focus on what is truly important, our human being patients.
Incidentally, my mother is a retired paramedic. She explained her lack of advocating for herself, "I was too sick. I just wanted someone to keep me alive because i felt like I was dying." Thank you to the well wishers. She was admitted for observation, her BP was managed and her pain was treated and she was disch home in stable condition. And my father not only stayed by her side, but made certain that her OBS nurses knew his observations of the lack of care in the ER.
Triage by definition does not include a full assessment, same goes for the role of ER which is only to rule out an immediately life threatening condition.
As to your examples such as " if a pulse ox is 98%, do we then assume the cap refill is prompt?", the theoretical purpose of capillary refill is not to measure oxygen saturation, it's to measure perfusion, although even that isn't relevant because cap refill is not a valid indicator of perfusion (or anything else).
I realize when it comes to a family member it's easy to think every possible resource should be immediately directed towards them, but what you describe was handled appropriately and after ruling out acute pathologies, the most appropriate action is to defer your mom to her primary care MD for further assessment and treatment.
Okay, I apparently am not making my point so let me try this. When I have an ER patient, as the triage nurse, I do a primary assessment - mentation, resp, disability and skin color. In addition to VS. As the primary nurse, I do a secondary and/or focused assessment. None of these, other than a set of VS 30 min into the visit, were done. The care in this ER absolutely in no way was appropriate. And your response is very concerning. I'm glad my mother was referred to her primary care doc, as he was the only one besides her floor nurse that did an actual physical, hands on, touch assessment.
You've missed the point. I wasn't expecting anything extraordinary. I was expecting appropriate care.
Triage by definition does not include a full assessment, same goes for the role of ER which is only to rule out an immediately life threatening condition.
As to your examples such as " if a pulse ox is 98%, do we then assume the cap refill is prompt?", the theoretical purpose of capillary refill is not to measure oxygen saturation, it's to measure perfusion, although even that isn't relevant because cap refill is not a valid indicator of perfusion (or anything else).
I will agree with Muno, since that seemed to have shocked you.
The second thing is regarding your comment about ESI 4s. An apparently oft-forgotten fact is that the ED exists to prioritize emergencies. Patients having emergencies do not have any other option for appropriate care, at all, period. You should consider that some of the wise ideas about how we can see low-risk patients as fast as humanly possible have led to ridiculous changes that make your other concerns impossible to avoid.
There is a breaking point and we are past it. We cannot take good care of every patient STAT despite what anyone says.
PS - in really "smart" places they construct those WDLs very carefully so that you can check them off honestly while doing minimal hands-on. Fact. I'm not defending it.
Specializes in Psych (25 years), Medical (15 years).
I, too, want to convey my empathy for your situation, butterball.
Yours was a good opening post and well worth the read. This part stood out to me and hit home:
It's led me to a great deal of thinking and sadness over the last few weeks. I've tried to dive deep and figure out what in the world is happening to our profession. Are we so reliant on machines that we no longer need to touch and assess? In the ER, are we so reliant on protocols that we no longer critically think? Are we so hung up on patient satisfaction that we miss key factors? Are we no longer teaching the importance of physical assessment? Are we too management top heavy and working too short as the front line nurses? Are we more worried about presenting a KPI board to 4 administrators then doing a pupil check on a possible stroke patient? Are we too worried about "real time" charting and meeting parameters that we can't get off the keyboard and look a patient in the eye? Are our up and coming physicians no longer taught to examine a pt? Do they rely on protocols, machines, results and e-med so they no longer need to think either?
Having had merely a handful of years in the totally medical arena of nursing, I wasn't really ever a crackerjack medical nurse, strong in some areas, others merely adequate.
I took your questions to heart, and you know what? I believe I've fallen under the reliance of machines and readily-available medical consults and allowed my skills at assessing to wane. Meeting guidelines imposed by the pencil-necked bureaucrats weighs heavily on my focus, mind and time.
I have worked predominately in geriatric psych for the past 15 years which has its mild to moderate share of medical interventions. I am regularly praised by peers and higher ups for my nursing assessments, interventions, and documentation.
But it's more paint-by-numbers these days. Since I have my quick fix monitoring machines and medical consults, I've taken the easy way out.
I'm rambling a bit, but wanted to let you know your post has given me a perspective and caused me to consider things.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
Hi Butterball. I'm sorry you and your mother had such a difficult time on your visit to the ER and glad that it didn't turn out to be anything serious.
Based on a number of anecdotal experiences over the last 5 years or so, it isn't really unusual to have an exam and diagnosis without someone ever doing all the hands-on we normally associate with a healthcare provider, including the stethoscope.
Just wanted to put that out there, because that particular aspect shouldn't be assumed to be unsafe or negligent based on the facts you described.
Since I don't work in the Emergency Department, I can't comment on the other factors related to standard protocols in the emergency department.
Hopefully you'll get some resolution as a result of your talk with hospital management.
Specializes in ED, Cardiac-step down, tele, med surg.
The Face tingling and left arm tingling along with HTN and headache warrant an esi 2 in a patient with risk factors (like diabetes or prior stroke or MI). It might be a TIA or CVA or migraine and perhaps the development of neuropathy in a diabetic. I would have made it an esi 2 and put the patient in a room for a quick MSE and on to the CT scanner. If there was no room, perhaps an MSE in the triage area (we have a room where that can be done) then the patient can get their CT and blood work and all the necessary work up to r/o CVA. I work in a primary stroke center, so we tend to get a lot of strokes.
Are you complaining that your mom didn't get their CT scan soon enough? I wouldn't do a full neuro exam in the triage area. I might do a full NIHSS if we were thinking this was a real stroke, but not before. The symptoms warrant a quick MSE and CT scan. Glad your mom was okay. I guess that's something to be thankful for right?
So much of the assessment can be gathered from just looking at a patient and speaking with them, that I don't do a full head to toe on every patient. If I were the MD that would be a different matter.
I'm so sorry for your frustration and the long wait time as well as lack of "hands on" assessment that your Mom experienced. While we can't comment directly on her care, its hard not to personalize it when its a loved one who has this experience.
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MunoRN, RN
8,058 Posts
Triage by definition does not include a full assessment, same goes for the role of ER which is only to rule out an immediately life threatening condition.
As to your examples such as " if a pulse ox is 98%, do we then assume the cap refill is prompt?", the theoretical purpose of capillary refill is not to measure oxygen saturation, it's to measure perfusion, although even that isn't relevant because cap refill is not a valid indicator of perfusion (or anything else).