Skin assessment in the ED

[amarilla, RN]

Hi all,

I am a surgical floor nurse visiting you all with a question about how skin assessments are done in the ED. The hospital where I work has initiated a protocol that a head to toe skin assessment should be done on all admits at point of entry (the ED) before being admitted to their respective unit. Here is the kicker: we are to report any patient who arrives without an assessment done and also if skin alterations are found to exist but were not noted or measured. We were ignoring this and doing our own regular admission assessment until they began to do chart audits of why we're failing to report 'missing documentation'.

Can anyone give me some insight about how your assessment/charting works in the ED? I imagine that it depends on the patient's complaint, the happenings at the time, and what took priority, but are skin assessments even routinely done? Not that it matters, but our ED admits are nearly entirely GI complaints, (obstructions, appys, gallstones; no active bleeders.)

Pardon my ignorance, but I work the floor and really don't know! I appreciate anything you all can tell me about what's it's like for you. Relations already tend to be poor between the ED and the floor and this is only making things worse.

[PAERRN20]

Sorry, but that is ridiculous. Skin assessments are about the last thing I am worried about in the ED. Who has the time to do a skin assessment when the patient next door is seizing and needs intubated? Or that level 1 trauma that just rolled through the door. Or the psych patient who is running through the hallway naked?

The ED nurses are being lazy by not completing the skin assessments. And really, the ED is not the place for it to happen.

[classicdame, MSN, EdD]

Skin assessments are done on the floor on admit. The ED in our facility does focal assessments only.

[ckh23, BSN, RN]

One facility I worked at, we had to not only document the skin assessment but we also had to measure and photograph them as well. In my opinion it was very overboard. However with Medicare not reimbursing for decubs acquired in the hospitals, I think more and more facility's are going to extreme measures to document patients coming in with them so the hospital can be reimbursed.

[Flo., BSN, RN]

Admission assesments are done on the floor at my hosopital.

[Altra, BSN, RN]

Skin assessments have been done on admission at all 3 of the hospitals where I have worked.

This is the only practical solution, unless someone can figure out how I am to do a complete skin assessment on my hallway patient who is never in an exam room during the hours he/she is in the ED prior to getting upstairs to a bed.

If I had to quantify it, I would say that only half of ED patients who get admitted get completely undressed while in the ED.

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

ER life revolves around the chief complaint and getting the patient out ASAP to make room for those in the waiting area, or inbound by EMS. There are times we could probably do the whole admit assesment for the floors, 'cause lord knows I wouldn't want to do what you have to do, but then I have to report a whole assesment to the floor nurse making it kinda wasteful time wise.

[emtb2rn, BSN, RN, EMT-B]

Whlie in theory all pts will have their skin inspected, we use common sense. If the pt is from a nursing home/snf or has a history that raises the probability of a pressure sore, then yeah, we're looking. Very big deal in my ER/hospital as we're trying to forestall the medicare no pay for hospital acquired decubes.

Our charting system carries over pressure sore assesments from each er visit, so you can double check that you actually found each one.

[amarilla, RN]

One facility I worked at, we had to not only document the skin assessment but we also had to measure and photograph them as well. In my opinion it was very overboard. However with Medicare not reimbursing for decubs acquired in the hospitals, I think more and more facility's are going to extreme measures to document patients coming in with them so the hospital can be reimbursed.

This is exactly what they are citing - reimbursement issues for undocumented pressure ulcers - but I think they are going about this the wrong way by pitting departments against one another. Personally, I don't feel it's appropriate for me to be auditing the ED's charting and be required to tattle on them, (or be reprimanded myself.) I want to bring this to our shared governance committee but wanted to solicit some opinions from ED nurses before doing so.

I appreciate all the answers guys!! Thank you for your responses!

[PAERRN20]

My post above should say that the ED nurses AREN'T being lazy

[amarilla, RN]

If I had to quantify it, I would say that only half of ED patients who get admitted get completely undressed while in the ED.

See, now *this* is what gets missed even though it seems like common sense. I had another nurse pass on in report that newly admitted patient 'had two small, closed sores - one in-between third and fourth toe and one on the bottom of second toe that the ED didn't catch." I remember thinking, 'who's looking at a AOx3, walky talky 38 year old appy's feet in the EMERGENCY department?!'

UG!! This is exactly why I'm here to gather some info, because there are some who seem to be under the impression that you guys strip everyone naked and know and see all.

Thank you again for all of your responses. Even for a few hours, I wish they'd let us come down and see how things operate. I'm sure it would eye opening and most helpful with things like this.

[mama_d, BSN, RN]

I'm not an ED nurse, so I really have little idea of what goes on there.

But the very name implies it deals with stabilizing urgent issues, which as far as I'm concerned does not include a head to toe skin assessment.

If I get sent a SNF pt with a stage 4 on their coccyx, I'll be a little irritated that I didn't get a heads up so I could have camera and supplies ready for when the pt rolled up. If it's a small open area that the walkie talkie 20-something got breaking in her new heels on the dance floor that night, I can totally understand it being missed.

Our ED is supposed to do the pics and documentation if they find something. Honestly though I'd rather do it myself b/c they never get it right. Not their fault...barely any training, and we do WAY more wound photography and documentation on the floor, so we've had a lot more practice at it and all the little quirks in our charting system.