Things you'd like the ER to Know

JJRBuckeyeRN · Nov 12, 2008

I should probably shadow a RN in the ED where I work before I start to judge their practice. However...it just seems that whenever they bring a pt up to the MICU they are a MESS!

The other day it took 5 nurses in the MICU a good solid hour to untangle all of the lines and get a pt organized that had come up from the ED. For the first 20 mins after the pt got on our unit if she would have coded we would have been in big trouble. And it was very likely that the pt could have coded on us...she had come in for cardiac arrest.

2bnursenikki82 · Nov 13, 2008

give me more than 5 minutes!!! When our ER calls report and says they're on their way...Darnit, they're on their way!!!

nrsang97, BSN, RN · Nov 13, 2008

I know they are busy down there, but do a decent assessment of the pt. Send them up clean and dry. Do not send the pt up in soiled linens.

CHECK PUPILS, this is a basic nursing assessment for a pt with neuro problems. Learn the neuro terms. Really I need something to compare to. I need to know about subtle changes, so I can notify the neurosurg resident on call.

Give a decent report. I shouldn't have to drag out of you if the pt follows commands, or not. This is basic again.

Really I know things are insane in our ER. I have gone down to assist with inseritng a EVD and can see that you are busy, but do NOT try to give me report and have me take over the pt when I am assisting in a sterile procedure. I will not do it. I am here as a courtsey to you. I have other pt to take care of upstairs. I am not even taking this pt, and even if I was you still need to wait to give me report. I will gladly take report after the sterile procedure is done and I know the room is clean and ready. Heck I will even help you take the pt to CT and then to the floor if we aren't waiting for the room to be cleaned.

Dinith88 · Nov 14, 2008

I'm working on an education program on Critical Care Education for ER Nurses. My question is;
What things the you as ICU nurses know that you'd like the ER nurses to know?
for starters I"m working hemodymic monitoring and how to use MAP.

ER nurses take alot of crap from unit nurses...many times unjustified...but,

Anyway, i think ER nurses being inserviced on hemodynamics is a waste of time (outside of simple CVPs and MAPs). ER nurses dont (speaking vast majority) ever see SWANs...so it's a waste of your time/resources in my opinion.

I think a solid understanding of ABG interpretation and Vent-settings would be infinitely more useful...as well as intensive 12-ECG interpretation. This has been my personal experience. Of course, the no-brainer idea that they shouldn't bring their patients over in a mess is at the top of the list...

ER nurses come in all sorts and flavors (just like ICU nurses), so i'm not making blanket statements...just some things that can facilitate patient report/transfer.

meandragonbrett · Nov 16, 2008

1) A good review of labs and their implications

2) A good pharmacology review. I think a solid understanding of how these drugs work is something that's lacking for many RNs. A review that is based on receptor agonism and antagonism and teaches expected physiological changes would be good (Not just that epi increases the BP...but how does it do that?). Not a touchy feely "Administer over 10minutes" review. Recently had a ED RN tell me that the patient had been given a "paralytic". I asked what it was and was told "Etomidate" :yeah:

3) Goal directed therapy for sepsis

4) ABG and vent settings

LittleLindz · Nov 26, 2008

Okay, maybe I can be of some assistance on this question. I worked in the ICU of a Trauma Center for 3 years after I graduated from nursing school. Due to life circumstances, I'm now working in a small ER. So, I've kind of been on both sides of this equation. I have never quite understood the animosity between ICU and ER nurses to be honest. I guess the differences I've noted between ER and ICU is that when I was in the ICU I had TIME to know my patient better. In the ICU, i generally carried 2 patients (sometimes 1 if they were REALLY sick)...so i spent 12 hours with those 2 patients. In the ER, we usually have a 4 to 5 room assignment. With constant rotating patients, you barely have time to learn their names let alone a full report! In the ICU, our reports took a half hour...we went through EVERY SINGLE body system. In the ER, it doesn't seem to go the same way since most of the patients leave anyway. I've found that some of my fellow nurses don't know some of the assessment skills you pick up in the ICU. This is probably due to, as i said before, the lack of time to know your patient in between the time they hit the door, the doctor sees them, placing a line, drawing labs, running to XRAY, then CT scan, then back to the room, then suddenly you have a bed available upstairs and the doctor is telling you to hurry up because there's a waiting room full of people! YIKES! hahaha :nuke: So you don't get a TON of time to really KNOW this patient of yours (even though it seems like you should!) I try to apply the assessment skills i learned in the ICU (and, like i said, it was a Level 1 Trauma Center so we really saw a lot of stuff), but i can really only have time to do a quick overview before i'm running the patient to the next test.

I think a good thing to teach ER nurses is how to do a quick, but THOROUGH assessment. If they come in with a head injury - pupilary response, GCS score, motor response, any posturing? those sorts of things. So, try to think a little less detailed, a little more of "what can i teach these nurses to assess in the 3 minutes they actually have with this patient".

I can certainly attest to the fact that the ICU and the ER are two very different places to work. Much different sets of nursing skills involved in the two places! (I for one am reading the books the residents received in the ICU so i don't lose all my skills!)

Hope that helped!

~Lindsey

pH7.40, LPN · Dec 7, 2008

For septic patients, get that antibiotic in immediately and make sure you report that to us when you give us the patient.

If you put in a central line please be sure to put the biodisc on correctly, blue side up, and a proper dressing after the doctor inserts it or else I am just going to half to change it again when they come to us and this really irritates the patient.

Thanks.

stressgal, RN · Dec 7, 2008

I agree that patients should not be brought to a unit a "mess". Many times I have received patients lying in dried feces. This is just not acceptable. I also have a problem in my facility with medications ordered in the ED not administered. Last week a patient had a K+ 8.2, kayexalate ordered but not administered in the ED, levaphed ordered but not started in the ED. This patient arrived to my unit with the POCT riding the cart perfoming compression, we ran a code the next 90 minutes on the man. I know they cannot stablize all patients prior to transfer but come on. I also struggle with ED nurses who cannot tell me vent settings during report. Most truly do not understand the different settings. We will hopefully turn a corner as our Acute Care Director has just stepped in as ED director until a replacement is found. She is comsidering a shadow program where newer ED nurses will follow an ICU RN.

pH7.40, LPN · Dec 8, 2008

I agree that patients should not be brought to a unit a "mess". Many times I have received patients lying in dried feces. This is just not acceptable. I also have a problem in my facility with medications ordered in the ED not administered. Last week a patient had a K+ 8.2, kayexalate ordered but not administered in the ED, levaphed ordered but not started in the ED. This patient arrived to my unit with the POCT riding the cart perfoming compression, we ran a code the next 90 minutes on the man. I know they cannot stablize all patients prior to transfer but come on. I also struggle with ED nurses who cannot tell me vent settings during report. Most truly do not understand the different settings. We will hopefully turn a corner as our Acute Care Director has just stepped in as ED director until a replacement is found. She is comsidering a shadow program where newer ED nurses will follow an ICU RN.

exactly.

matt2401, MSN, RN · Dec 16, 2008

I know they are busy down there, but do a decent assessment of the pt. Send them up clean and dry. Do not send the pt up in soiled linens.
....
Give a decent report. I shouldn't have to drag out of you if the pt follows commands, or not. This is basic again.
....
.

Wow, you get report? Lol, our hospital went to just faxing a report then the patient comes 15 mins later! Thats always awesome when a patient rolls in just as your other patient (or patients) are crashing.

If it were me I would focus on what treatments NEED to be started in the ER, which ones can be turfed to ICU. For example I had a patient sit down in the ER with an INR of 7, actively bleeding GI for two hours. Do you think the STAT vitamin K or STAT packed RBC (4 units for HGB of 4) was given? If you answered no, you win the cookie! Yes, they were on the admission orders but c'mon. A subQ injection has to wait? :banghead:

After that I would focus on the core measures type stuff...antibiotics given quickly but cultures drawn before. Heavy on 12-lead ECG interp, NIH scoring, pharmacology of ACLS/critical care meds.

joeyzstj, LPN · Dec 16, 2008

That there are other pressors besides dopamine. And furthermore, dont give dopamine to a tachycardic patient. I swear, our ER doesnt know what Neo is.