Things you'd like the ER to Know

RN82 · Dec 17, 2008

As the daughter and niece of ER nurses with 30+ years of experience, I heard both sides of the coin when I chose ICU as my specialty.

It is my understanding that in the ED, your attention must be on a focused assessment of the patient, rather than a full, head-to-toe assessment. This being the case, a rapid assessment of ALL physiologic systems is necessary for your focused assessment to be accurate. I understand if you didn't check your GIB's pupils, but please know if they are following commands, confused, etc. Please know how much O2 they are on, and WHY.

Secondly, if a patient has a wound, and you put a dressing on it, please complete the proper wound documentation. We will actually need to remove your dressing, clean, measure, and re-dress the wound properly otherwise. (In fact, this may happen, even if you DO document it. But please at least report what you see).

TURN YOUR PATIENTS. At least CHECK them to see if there are wounds or concerns on their posterior aspect. And please, please, please clean them up when they are incontinent. Not every patient becomes incontinent in the elevator ride up. And if they do, you can stay for 5 minutes and help me clean him up.

As far as hemodynamic monitoring, I have never received an ER admit with a Swan, and rarely do I see one with a CVP. When I have seen a CVP come up, I get report that says "CVP was 3..." Unfortunately, a CVP is not a one-time-read, and is impacted greatly by a number of factors, all of which are important for us to know through the initial phases of ICU care. Ie: How much IVF did the pt get down there? What was the trend of CVP or MAP w/ IVF? Is our hypotension a fluid volume concern? A sepsis concern?

Please know the names and mechanisms of action of the drugs administered in the ED. In receiving an intubated pt, I was told, "He got At...at...atropine for sedation." I would hope not.

Alot of what I see goes back to basic nursing skills. Focused assessment with a thorough understanding of what you are assessing, projected needs upon arrival to the unit, and clean, comfortable patients.

WalkieTalkie, RN · Dec 17, 2008

What things the you as ICU nurses know that you'd like the ER nurses to know?

LOL, how about how to clean up vomit, sputum, poop, urine, or any other obvious mess before transporting the patient to the ICU? Don't get me wrong, I used to work in the ER, and we don't exactly have time to bathe a patient, but I also didn't leave them sitting in a pile of poo, you know? Some nurses in the ER seem to think they are above cleaning up a patient. :jester:

Now, to be serious about this conversation, I agree with the hemodynamic monitoring. A lot of ER nurses don't know how to set up a transducer or the importance of inserting an SVO2 central line into a septic patient.

I think another important thing to teach them would be the importance of turning and repositioning. I work at a large academic facility. When I worked in the ER, we would often be physically full and several patients would have to be kept in the ER overnight. I recently read an article that showed skin breakdown could start as early as admission when patients are laying around on hard carts and not being turned as in this example. It would be very easy for ER nurses to at least turn their patients when they are doing vital signs (our ER has a policy that VS are to be done a minimum of every 2 hours unless otherwise written on admission orders).

WalkieTalkie, RN · Dec 17, 2008

Please know the names and mechanisms of action of the drugs administered in the ED. In receiving an intubated pt, I was told, "He got At...at...atropine for sedation." I would hope not.

LOL! Along with this example, I often struggle finding how much total IVF a patient got in the ER. One of the problems at our hospital is that the ER uses a different computer charting program than the floors. The I/O part doesn't cross over and I am constantly having to go back and look through the printed notes to find it. I also find that they aren't charting if the patient came in with 2 liters hanging, so it's frustrating when trying to figure out if they are at an increased risk for fluid overload when you don't know how much they've had.

The same goes for UOP. Often a Foley is inserted down there but you have no idea if the urine in the bag has been accounted for, has been emptied recently, or if the urometer has dumped over during the transport, etc. That's also frustrating when you go to call the MD and they ask you about the UOP.

I've also noticed that a lot of ER nurses don't know how to work our PCA pumps. I'm not sure if this is a problem at other hospitals or not. When I worked in the ER and we had to start a PCA, nurses would frantically look around trying to figure out what to do. I was a student at the time, and had worked with them in clincal and I would have to show them how to set them up!

I even got a patient upstairs the other day on a fentanyl drip for sedation (which was dumb to begin with, but that's another story). In any case, the nurse had just stuck the syringe on one of our regular Alaris syringe pumps (no locked door). I was alarmed. I asked her why it wasn't on a PCA pump and she said "We don't use those down there." I ended up writing her up for violating the hospital policy in regards to this. I probably wouldn't have because she is new and didn't know, but it's because she was so rude to me and would not listen to me when I stated that they could order PCA pumps in the ER like we do on the floors. It's more of a safety issue than anything else! *sighs*

WalkieTalkie, RN · Dec 17, 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.

I know! For some reason a lot of our older docs are scared or don't know about other pressors besides dopamine. When I worked in the ER, we would get patients who were already borederline/slightly tachycardic and hypotensive. Instead of starting a more alpha selective pressor, they would just hang dopamine. Of course, 5 minutes later the patient's HR was skyrocketing (duh)! I dislike using dopamine to increase BP most of the time. When I call about low BPs and a newer resident orders it, I will often suggest something else first.

I also noticed that when I worked in the ER, a lot of the nurses didn't know the starting or max rates for several kinds of drips. For example, I once encountered an experienced nurse cranking up the dopamine to 25 mcg. I asked her what she was doing and she said that the patient's BP wasn't getting any higher. I pointed out the error and she was embarrased.

Some of the drips I saw people having problems with where norepi, dopamine, phenylephrine, and nipride. This brings me to another concern: SEPSIS

There needs to be more education given to ER nurses and docs regarding the importance of starting a sepsis treatment protocol on patients who meet the criteria. Things such as cultures and lactic acid levels are being missed and then patients are having greater LOS and morbidity/mortality when they aren't being screened and treated early. Most of the sepsis education at my hospital is aimed at inpatient doctors and ICU staff. They need to educate ER nurses to screen for the sepsis criteria just as they would do a GCS score or a stroke scale. The ER doctor may elect not follow the protocol, but the nurse can at least state that they meet the criteria, which may influence, at bear minimum, the inpatient team's treatment plan.

So often I see patients admitted to the floor who meet the criteria and then we are called to an RRT in the middle of the night when they (surprise) aren't doing well.

WalkieTalkie, RN · Dec 17, 2008

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 agree with you about the Swans. I worked in the ER for 3.5 years and never once saw a Swan inserted down there. I did, however, see a lot of arterial and central lines inserted, and often times (especially with central lines), nurses did not know how to transduce them and most have no idea how to take a proper CVP.

pH7.40, LPN · Dec 17, 2008

I know! For some reason a lot of our older docs are scared or don't know about other pressors besides dopamine. When I worked in the ER, we would get patients who were already borederline/slightly tachycardic and hypotensive. Instead of starting a more alpha selective pressor, they would just hang dopamine. Of course, 5 minutes later the patient's HR was skyrocketing (duh)! I dislike using dopamine to increase BP most of the time. When I call about low BPs and a newer resident orders it, I will often suggest something else first.
I also noticed that when I worked in the ER, a lot of the nurses didn't know the starting or max rates for several kinds of drips. For example, I once encountered an experienced nurse cranking up the dopamine to 25 mcg. I asked her what she was doing and she said that the patient's BP wasn't getting any higher. I pointed out the error and she was embarrased.
Some of the drips I saw people having problems with where norepi, dopamine, phenylephrine, and nipride. This brings me to another concern: SEPSIS
There needs to be more education given to ER nurses and docs regarding the importance of starting a sepsis treatment protocol on patients who meet the criteria. Things such as cultures and lactic acid levels are being missed and then patients are having greater LOS and morbidity/mortality when they aren't being screened and treated early. Most of the sepsis education at my hospital is aimed at inpatient doctors and ICU staff. They need to educate ER nurses to screen for the sepsis criteria just as they would do a GCS score or a stroke scale. The ER doctor may elect not follow the protocol, but the nurse can at least state that they meet the criteria, which may influence, at bear minimum, the inpatient team's treatment plan.
So often I see patients admitted to the floor who meet the criteria and then we are called to an RRT in the middle of the night when they (surprise) aren't doing well.

We have the same concern with our ED regarding sepsis. We are trying to get the ED docs to insert central lines to better manage fluids in our septic patients, but they have really resisted.

This thread is amazing. I thought it was just our hospital that had these

issues! We really seem to have found something here.

cvicugirl, BSN, RN · Dec 17, 2008

1. Don't deliver a dead person to the ICU and then argue that they aren't dead. (This has happened to me. Twice.)

2. Please don't tell me that you didn't treat the 2.1 potassium level that was reported hours ago because you were "having trouble" with the pharmacy.

3. If you come into the unit complaining that you had to hold my ICU patient for three hours, don't be surprised if I write you up for not calling in the consults or initiating orders that were written in the ED.

4. If someone deemed it necessary to place a femoral arterial line in the ED, kindly transduce it.

stressgal, RN · Dec 18, 2008

1. Don't deliver a dead person to the ICU and then argue that they aren't dead. (This has happened to me. Twice.)
2. Please don't tell me that you didn't treat the 2.1 potassium level that was reported hours ago because you were "having trouble" with the pharmacy.
3. If you come into the unit complaining that you had to hold my ICU patient for three hours, don't be surprised if I write you up for not calling in the consults or initiating orders that were written in the ED.
4. If someone deemed it necessary to place a femoral arterial line in the ED, kindly transduce it.

LOL! Sounds as if it's the same as where I work. I love doing admission assessments on dead patients, seems as if I do them a couple of times a year. I am jelous that you all have Doc's who will place central lines in the ED. They never do in our ED. They will bring up bags of pressors not started because, "We didn't have access to start it" yet they have Vanc or a fluid bolus running in the one peripheral site available. This is often my first requests of the admitting physician and we just get a line in.

pH7.40, LPN · Dec 18, 2008

1. Don't deliver a dead person to the ICU and then argue that they aren't dead. (This has happened to me. Twice.)
2. Please don't tell me that you didn't treat the 2.1 potassium level that was reported hours ago because you were "having trouble" with the pharmacy.
3. If you come into the unit complaining that you had to hold my ICU patient for three hours, don't be surprised if I write you up for not calling in the consults or initiating orders that were written in the ED.
4. If someone deemed it necessary to place a femoral arterial line in the ED, kindly transduce it.

TWICE! seriously?

lol

pH7.40, LPN · Dec 18, 2008

I wonder if the ER forum on allnurses has a thread titled "things you'd like the ICU to know"

nrsang97, BSN, RN · Dec 19, 2008

Please do a CXR to check ETT placement. Last time they sent us a vented pt they were intubated into the right mainstem. Radiology told us it had been like that quite awhile. Didn't the fact that the tube was in as far as it would go and no left breath sounds clue you in???

RN1982 · Dec 20, 2008

Please actually look at the patient before giving me report. All too often have I received report from ER nurses who say "I just came on at 6:30pm, I'm not familiar with the patient". Ok, how does that help me. If I ask certain questions like "Does the patient have a foley" and you say "Um, let me go check", I just find it irritating. Most of the time, I just tell them to bring the patient up because I look up most of my patient's info in the online charting system we use because I know I will get a half-ass report from some of the ER nurses. Like one told me, "yeah we need a doc up there for this patient, he's got a c-collar because he has a C2 fracture and he could die"...Um ok. I've never needed a doc to move a patient before but ok.

I'm not trying to be mean but these are just some of my frustrations I've experienced.