As an ER nurse, how do you determine which tasks you leave for the floor nurse? Yesterday I was ABSOLUTELY swamped. I am a new nurse in the ER (1 year of experience). Lately, as I have posted in another thread, the floor nurses seem to be less-than-satisfied with my efforts.
Would you leave a heparin drip for the floor nurse, or make sure it was started in the ER?
The other day, I got a lot of flack from a nurse for not starting Vanco. I had gotten the patient her Zosyn and Tobramycin, but the Vanco had not yet been administered. The floor nurse gave me MAJOR flack for that.
Based on that, I was concerned about sending my patient to the floor with the heparin drip not started. HOWEVER, I had 3 other admissions I was working on as well, and didn't really have the time or bandwidth to get the heparin drip going. Because I chose to work on the heparin drip (out of sheer terror of the dreaded floor nurses!), care for my other patients was delayed.
I am still learning task prioritization. I also had another patient whom I was watching closely due to unstable blood pressure patterns. We had weened her off levophed, but she was walking that line (SBP just barely about 90 and MAP between 61 and 65) where I might need to start up the levophed again.
I think I am so concerned about sending the patient to the floor nurse without Vanco ... or heparin ... or whatever being started. I am trying to be a good nurse, but getting mixed signals from floor nurses vs. ER nurses, so learning to prioritize has been a problem. Getting a patient admitted is time consuming. Should I have just left the heparin drip for the floor to do?
I very rarely leave an ER order to be completed on the floor (other than the occasional UA because the patient was unable to void while in the ED). I also do my best to get the important floor orders started if I can (especially if the admission is taking a while to complete). This typically includes IV Antibiotics, Drips and Blood Product Admin. I very rarely get any grief about this issue from the nurses on the floors and I make sure to apologize if for some reason I have to pass something on to them.
I would never ship a pt to the floor with a heparin drip ordered but not started. I would start it, also most if not all now orders. Having said that, if I couldn't do all now orders (like in the case with multiple antibiotics), I would start one based on my judgement and report what has/hasn't been done in my sbar. On our particular sbar, there isn't a place where this is obvious so I use the margins for big notes "VANCO hung 1743, still running, other antibiotics ordered but not hung ...." I usually underline this and make a big deal about it because it is really the most important piece of information that the floor nurse needs to reconcile from the orders during the handoff.
If the now order takes a long time, I might start it but not finish it. Again I hung the vanco, but didn't wait till it was all in to ship the pt to the floor.
So in short: Now orders, started before taking pt to the floor, rest of floor orders are theirs....
Our ED does not weigh pts and will start a heparin gtt based on stated weight. So, when we get them with the drip started and we weigh them, the rate is incorrect. Needless to say this is a much bigger headache than starting from scratch.
So, if you have an accurate weight and start the drip, you are awesome. Otherwise it's easier to start from scratch.
When I'm in the ER I narrow it down to just what the patient really needs right now, which in your examples would have included the Vanco and the heparin. In sepsis for instance, the goal, based on evidence that it does make a difference, is to give the first "appropriate" antibiotic within an hour. If vanco is ordered, then by definition it is the "appropriate" antibiotic and the other's actually don't count towards this when we do outcomes reporting since the Vanco was given based on a suspicion that other antibiotics won't be effective.
I'm not trying to pick on you. I think your point is well made. However, in this instance, the OP's ED does not stock Vanco. The ED RN would have had to fax the order to pharmacy and get the med mixed and sent to the ED and then start the gtt, while the patient already had a bed on the floor. This would have created an unnecessary delay in transport to the floor. What the ED nurse *could have done*, and I have done this many times, is put the order for Vanco in to pharmacy and tell the pharmacy to tube it to the patient's destination (also be sure to alert the receiving nurse that you did this so that there is not a duplicate order and confusion on the floor).
As a floor nurse I have no issue completing orders put in while in the ED. All I ask is that you tell me in report. 'I did this but haven't had time for this.'. Because I might not have time to go through everything you sent me, check what was done or not, and complete, all while trying to stay on task with my other patients. Basically, it all comes down to communication. We are all on the same team, and at the end of the day our goal is the same. Get our patients healthy or at baseline and discharged home.
I'm not trying to pick on you. I think your point is well made. However, in this instance, the OP's ED does not stock Vanco. The ED RN would have had to fax the order to pharmacy and get the med mixed and sent to the ED and then start the gtt, while the patient already had a bed on the floor. This would have created an unnecessary delay in transport to the floor. What the ED nurse *could have done*, and I have done this many times, is put the order for Vanco in to pharmacy and tell the pharmacy to tube it to the patient's destination (also be sure to alert the receiving nurse that you did this so that there is not a duplicate order and confusion on the floor).
Last night I held the patient for 5 hours. I gave Zosyn and Tobramycin, but had not yet given the Vanco. The nurse asked me THREE TIMES why I hadn't given the Vanco yet. I told her I had only gotten the meds from the pharmacy a few hours prior and had worked as quickly as I could. She kept insisting Vanco was in my pyxis - why did I have to wait for it from the pharmacy? VANCO IS NOT IN MY PYXIS!!!
She had the patient for 5 hours, the goal for the appropriate antibiotic is 1 hour.
Something that many ED Nurses don't realize, is that when a patient comes to the floor all previous orders must be cancelled, that means a further delay in giving the vanco because it now has to be re-ordered, re-entered, and re-reviewed. There's evidence that mortality increases significantly if antibiotics are delayed, the same can't be said for delays in moving to a floor bed.
She had the patient for 5 hours, the goal for the appropriate antibiotic is 1 hour.
Something that many ED Nurses don't realize, is that when a patient comes to the floor all previous orders must be cancelled, that means a further delay in giving the vanco because it now has to be re-ordered, re-entered, and re-reviewed. There's evidence that mortality increases significantly if antibiotics are delayed, the same can't be said for delays in moving to a floor bed.
These are things that vary with facility policy. As I noted earlier at my facility Vanco is *always* given last, if they order 4 antibiotics you need to infuse all of the others first. Also your point about the orders needing to be discontinued and reordered is no longer true at my facility, the computer systems have been reconciled, and even when we did need to re-enter orders it was only a technicality and took about five minutes by the charge nurse.
I agree, it would have been better to get the antibiotics on board faster, but something many inpatient nurses don't realize is that the patient they are receiving may be the least sick of 5 or 6 that the ER nurse is responsible for and prioritization is thus at a different level, sometimes the best you can do is not ideal, and at the point that the patient has a bed and the Vanco has not indeed be hung it is unproductive to be perseverating on why it wasn't. Time for that nurse to accept the facts and move on with life. I'm sure the facility has a procedure for incident reports if it is felt to be necessary.
As an ER nurse, how do you determine which tasks you leave for the floor nurse?
I prioritize all of my tasks among all of my patients and try to do those things which directly affect the primary problem.
I use a mental picture of a quadrant with urgency along one axis and importance along the other.
Would you leave a heparin drip for the floor nurse, or make sure it was started in the ER?
I would start the heparin for sure.
The other day, I got a lot of flack from a nurse for not starting Vanco. I had gotten the patient her Zosyn and Tobramycin, but the Vanco had not yet been administered. The floor nurse gave me MAJOR flack for that.
In general, antibiotics are a pretty high priority but it would still have to compare against all the other things going on with my patients.
Based on that, I was concerned about sending my patient to the floor with the heparin drip not started. HOWEVER, I had 3 other admissions I was working on as well, and didn't really have the time or bandwidth to get the heparin drip going. Because I chose to work on the heparin drip (out of sheer terror of the dreaded floor nurses!), care for my other patients was delayed.
Well, think of it this way: The floor nurses might be just as busy... or busier... and the heparin might be delayed there, as well... getting a thrombosed patient on the heparin's a pretty big deal. I really don't care what the floor nurses think or say but I do care about providing my patients excellent care and delaying heparin isn't excellent care.
I am still learning task prioritization. I also had another patient whom I was watching closely due to unstable blood pressure patterns. We had weened her off levophed, but she was walking that line (SBP just barely about 90 and MAP between 61 and 65) where I might need to start up the levophed again.
Yeah, but what's the big deal... have the monitor grabbing q15 minute pressures (or q5... or get an art line...) and keep an eye on them... that doesn't take any time away from your other tasks...
Should I have just left the heparin drip for the floor to do?
No, you shouldn't. I would try to be kind about it but I would criticize your decision if I worked with you... and especially if I were the patient or a family member.
She had the patient for 5 hours, the goal for the appropriate antibiotic is 1 hour.
Something that many ED Nurses don't realize, is that when a patient comes to the floor all previous orders must be cancelled, that means a further delay in giving the vanco because it now has to be re-ordered, re-entered, and re-reviewed. There's evidence that mortality increases significantly if antibiotics are delayed, the same can't be said for delays in moving to a floor bed.
Antimicrobial prescribing practices can vary widely, as I assume you are aware. I'm not quite sure where you're coming from with your rationale that if Vanco is ordered it is *the* appropriate antibiotic, as I rarely see it ordered singly -- usually in conjuction with other abx. I completely agree that timely initiation of antimicrobial therapy is important, and this initiation occurred in both the OP's scenario and the other post in this thread to which you responded.
I'm sorry to hear that your hospital's EHR/order reconciliation system cancels all orders not completed in the ED. That is a significant impediment to patient care, and I hope that it gets rectified by your IT department promptly. Fortunately, that particular systems issue is not universal.
And if you have some time for some reading and you're interested, you can do a literature search for "boarding patients in the ED and increased mortality".
She had the patient for 5 hours, the goal for the appropriate antibiotic is 1 hour.
I strongly suspect that this was empiric combination therapy, in which case getting all of the antimicrobial agents in within one hour is not a realistic goal. We don't know that the intiation of antimicrobial therapy was delayed; the OP gave the Tobra and the Zosyn, presumably in a timely fashion because they are kept in the ED Pyxis and so are readily available.
Something that many ED Nurses don't realize, is that when a patient comes to the floor all previous orders must be cancelled, that means a further delay in giving the vanco because it now has to be re-ordered, re-entered, and re-reviewed.
Having worked the floor at my hospital prior to transferring to the ED, I can say that this is not the case at my facility.
There's evidence that mortality increases significantly if antibiotics are delayed, the same can't be said for delays in moving to a floor bed.
Perhaps not to a medical floor bed, but *absolutely* there is evidence that delays in admission to the ICU are associated with increased mortality and worse outcomes. And the patient you're referencing with severe sepsis certainly needs an ICU bed.
When possible, I ask the admitting doc what he/she sees as priorities before transfer.
In your case, given your case load, the Vanco might have been further holding the admitted pt. Because you are in the ER, that Vanco may legitimately be your lowest priority. If you are titrating levo, you have an unstable pt. Even on the floor they prioritise ABC problems over routine abx.
The degree to which somebody else expresses frustration should not affect your prioritization. In other words, just because the floor nurse complains, does not mean you should be doing things differently.
cjcsoon2bnp, MSN, RN, NP
7 Articles; 1,156 Posts
I very rarely leave an ER order to be completed on the floor (other than the occasional UA because the patient was unable to void while in the ED). I also do my best to get the important floor orders started if I can (especially if the admission is taking a while to complete). This typically includes IV Antibiotics, Drips and Blood Product Admin. I very rarely get any grief about this issue from the nurses on the floors and I make sure to apologize if for some reason I have to pass something on to them.
!Chris
By the way this is post number 1000!