Skills in the We

2ndCareerRN · Apr 9, 2004

How are they to demonstrate competency in emergency situations if they have never been in that environment before. I think a better solution is to develop a comprehensive education program to ensure your Nurses become competent within a set time frame.

Rural ER is a little different, they need to have ACLS cold, RSI skills, Bagging for hours at a time (the one vent may not be working and the helicopter may be grounded), mixing and administering emergency drugs/drips, chest tube insertion, with no CT the lost art of peritoneal lavage may need to be taught.

bob

tknrn · Apr 9, 2004

Thanks for your response. We are fortunate to have CT available to us. Since the nursing staff that work in the ER also work the MEd-Surg area of the hospital, I want them to feel comfortable with the skills needed for the ER. I will add your input to the growing list I have to discuss with the Medical Director of the ER and the DON.

Thanks:)

2ndCareerRN · Apr 9, 2004

I wish we had a CT, the closest one is 60 minutes away by ground. If we think it is bad we will call the helicopter. One is 40 min away, but often can't get over the montains, the other is 1 hour away and is often grounded for weather. We can get a fixed wing, but the airport is 30 min away by ground. Those minutes sure do get long sometimes.

You need to look at the most life threatening things that can happen (ABC's) and multi system trauma and tailor a training program to fit them.

Good luck

bob

jonas42 · Apr 9, 2004

As a nurse you really think that RSI, Chest tube insertion and peritoneal lavage are within your scope of practice.

A poorly equiped rural hospital shouldnt be doing a peritoneal lavage anyway. if they cant do anything with the information that it provides. if there is that much question of injury that pt should be transfered as soon as possible. too much risk in the procedure to be done outside a hospital that has the capability to handle possible complications such as perforated bowel.

as far as the original question I feel that ACLS alone isnt enough to be able to handle alot of what comes into a ER. I have my CCRN, CEN, TNCC, ATCN, ACLS, PALS. I work in a high volume level 1 trauma center, and still learn things from nearly every pt I see. they never stop amazing me.

tknrn · Apr 9, 2004

Thanks for your input. The skills that you mentioned are physician only skills at our facility. The nearest level 1 trauma center is an hour away by air evac.

My concern is that the nurses working in the ER should have competency skills that address both medical and trauma emergencies. I agree that ACLS is not sufficient for the ER. We have been sending our nurses to TNCC courses.

Rural medicine is a challenge in itself, I'm just looking for ways to help the nursing staff become more competent with the skills expected of them in the ER setting.

OC_An Khe · Apr 9, 2004

Certification programs like CEN TNCC for continuing education should be highly encouraged. Entry level competencies a good but its the continuing competencies that are really important.

2ndCareerRN · Apr 9, 2004

Those things are phsician skills, but the ER nurse needs to know how they are performed so the they don't just stand there while they are being performed. Part of teamwork is being able to anticipate what other team members may need.

Ideally, every patient that needs to be sent out gets to go. But there is always the possibility that may not be feasable. As far as peritoneal lavage, we may not have a CT, but we do have the surgeons living about 5 minutes away. Just because a hospital does not have all the latest whiz-bang toys does not mean we do not intervene as necessary.

As far as a level 1 nearby, not even. We are in northern Montana. The closest Level 1's are Salt Lake City or Seattle. Even the closest level 2 is 40-50 minuts away by air, if they can get over the mountains.

I too have a bunch of initials behind my name, and have worked in several Level 1/2 trauma centers. Rural nursing is a whole different ballgame. At night it is typically 1 MD, 1RN, a CNA and possibly a couple of EMT-B's. Teamwork is always important, but becomes even more important in that type of setting.

bob

RNin92 · Apr 9, 2004

I think the more training your nurses can get their hands on the more comfortable they will be with whatever rolls thru your doors.

I would agree that healthcare is a team sport...the more you know the better team player you are.

We are a Level II Trauma Center with a helicopter based at our ED. But with Northern Illinois winters being what they are...we have gotten our share of Level I's anyway. You have to be as ready as you can be. It isn't about the initials after your name, it's about being as prepared as you can be so you don't freeze-up on your patient.

In our ED everyone has to obtain their ACLS, PALS, TNS (Illinois thing in place of TNCC), and ECRN within their first year. But like I said, it's about trying to prepare for anything that may show up.

jonas42 · Apr 10, 2004

OK i thought you were saying that the nurse had to be competent in preforming those skills. My bad, i agree with you that you should be at least be able to handle management of a CT or know how to set up a lavage, oops this tubing is only one way usually doesn't play well with the surgeon on a lavage after all the fluid goes in. management of these is vital. with a proper mentor i think any go getting nurse with a good attitude and a willingness to learn can go to the ER, as far as being the only one there some lonely night that may need a few more certs, and a few more years of experience.

sorry puncuation and spelling are my enemy

mcmike55 · Apr 10, 2004

Speaking as a rural Ohio nurse myself I feel your pain, as far as long response times go. The golden hour is often almost gone before the squad can get to the scene. But I tip my hat to you, 2ndcareer, you guys must really feel cut off at times. You have my respect!!

Our hospital is a level III, no neuro or open heart (thank god!! :chuckle )

We are about an hour by ground to a level I. In normal weather, a chopper is normally 15-30 mins away, and about 1/2 hour from us to a level I.

First a disclaimer. I am a surgical nurse, with previous emergency room and EMS experience. I currently float to ER to help when needed and sometimes traumas.

My thought on competencies. People in the ER need basic training, such as ACLS, PALS, TNCC and so on with the alphabet soup.

The competency part comes after the basics. That could be with periodic self and peer (supervisor) evaluations.

Some of the smartest "book" nurses I knew, couldn't function out in the real world. Evaluate them both.

veetach · Apr 10, 2004

I think you have received some good suggestions. I like the idea of developing competencies that will be unique to your ER and then require all of the RN's to comply and be certified in them.

For instance, I used to work in a rural ER in southeast Kansas. We were 100 mi away from our nearest level 1 trauma center, the weather was not always condusive to helicopter transport, so we ended up seeing and working with lots of traumas of various levels. We saw numerous farming accidents along with MVA's, and believe you me, those MVA's in a rural area are pretty horrible. We were also the regional medical center who carried the Anti-venin for snake bites.

All of our RN's were required to have at the very least, ACLS, PALS and TNCC. Anything over and above that was up to the RN. We also had competencies that we had to be credentialed in every year.

I then moved to a much larger, level II trauma center and found that the nurses there were not at all as qualified as we were out in the "podunk farm community". LOL

Good luck!