Things you would like the ICU to understand

caddismt · Feb 15, 2009

I'm an ICU RN and have cross trained and spent quite a bit of time in ER. I think that in itself is the key to understanding between these departments. ICU is relatively controlled and happy.

But giving a good report is still a basic nursing responsibily as far as I'm concerned. Giving report over the patient is lazy and makes the patient feel like an item on the shelf at target.

Larry77, RN · Feb 15, 2009

Couple years ago we had a committee (I forget what they called it) that had both ICU and ED nurses on it that met to try and improve relations between the departments....

We met for a few months and everybody voiced their issues most of which you have already stated in your post. ICU told us why they wanted what they wanted we told them why we couldn't always give it to them etc etc.

I think we are just inherently at odds with each other and the only thing you can do is do your job and don't react when the other party tries to complain or whine.

It could help to have a few meetings with the ICU so everyone can get their issues on the table...but that's just it, everyone WILL have their issues forever!

interleukin · Feb 15, 2009

essentially, it is a greater problem on the part of icu nurses, that those in the ed(here comes the hate mail)

why...too many icu nurses don't understand that once ed nurses stabilize an admit, they need to unload them to make room for another.

simple, eh? so what's the big deal.

ed nurses tell us when we have to jump, and we must say how high. it's in the nature of expeditious throughput and just the way it has to be.

having said that, if we are too busy, it is our obligation to let the manager or charge know that a serious situation will result if we exceed, what i call, "the speed of safety."

that means, i do not rush my patients out to any faster than what safety dictates(i'm not talking disaster situations here). that may not be so easy if you are new. but it is critical if you are to practice safely and not end up a blob of stomach acid in scrubs.

icu nurses feel like ed nurses give crummy reports.

sure, comprehensive is better, but again, they are stabilizing, detailed analysis is not necessary(no, doesn't mean sloppy). and the better icu you are, the faster you can compensate for, and predict what may ensue, from a sketchy report. we all miss stuff and we all feel lousy about it.

last time i looked we were all in this together, right? a little understanding goes a long way.

if you have little support from above, you're in trouble. if you a charge without patients he/she can greatly facilitate flow and transfers. if your charge has patients, you have a dysfunctional system that will foment discontent(but you already know that)

we're all under pressure. but let's have the courage to pass it on up the line when things are not working...not laterally. as long as we cloak it, management has no reason improve things.

nrsang97, BSN, RN · Feb 15, 2009

The only time I wont take report is if I am in the middle of cleaning up poop or starting an IV and then I will ask a co worker to take report for me if possible. If not I have someone give me a number where to call back. I know you all have to get those pt out of there when there is a bed. However I do have a co worker who refuses to let another RN take report for her. So that may be the case in some of those putting off report situations. Just a thought on that. If I ask to call back I do so in a timely manner like within 10 minutes or so.

Also the only thing I want a detailed report on is the reason they are there. So if I am getting one of my neuro patients then a detailed neuro exam is what I want. So when giving a neuro report I would want to know what is abnormal and all that. Pupils too (Our ER nurses seem to never check). I could care less about bowel sounds if the pt is here for a stroke I am going to assess anyway.

In the ICU we do report system by system. I know the ER dosen't do that. They focus on the problem the pt is having. So I think it is unnecessary for the ICU nurses to expect the ER nurses to do so.

I hope this helps some.

I_LOVE_TRAUMA, RN · Feb 15, 2009

Thank you guys for the fast, informative responses. I think that the managers helping to form a commitee would be very helpful in letting both sides understand the way each department works. Hey I wasn't trying to knock ICU nurses, I pick up shifts there often. This allows me to see that (even though our ICU charge often takes an assignment) for the most part the ICU runs like a well-oiled machine. It has to be safely staffed, everyone has max 2 patients (3 in a crisis), a lot of patient are tubed, sedated, etc, and except for the rhythmic sounds of the monitors, it is usually quite, and all the patients smell good. I understand that it is very hard to understand that the ER is non-stop noise, chaos, horrible and weird smells, and with no order/organization what-so-ever. Some nights I wonder how we managed to save everyone, and do so without forgetting a pt. Your right, we do 3-minute CC assessments and a lot of times our patients arrive not able to tell us the problem. My report to my on-coming nurses in the ER usually sounds something like this, "The guy in 2 just keeps trying to die, CP, ECG shows STEMI, labs still out, waiting on cath, drunk in three lavaged and charcoaled, MVA going to OR asap, doc is in there." I can give a thorough report on 8 pts. in just under 2 min, and the nurse knows everything going on (or we just fiqure it out because we have to do our own assessment anyways). Really just let them know what still needs done/what was found. When I give report in the ICU, it takes at LEAST 30 min to report off on 2 patients. Your right, I guess there will always be problems d/t our differences. Last week I called report on a comatose patient who was brought in septic with multiple system organ failure from an ECF,totally trying to die and family insisting that everything be done, the ICU nurse asked me if the ECF paperwork listed when the pt.'s last BM was??? I am going to talk to my manager tom. night about the possibility of forming a commitee, I think the patients would benefit greatly if we ran a smoother, more cohesive network!

Pediatric Critical Care Columnist · Feb 15, 2009

when i am told i'm getting an admission from er, if i have to transfer a patient out to be able to take the admission, that will have to happen. that can't be done in under half an hour. it just can't. and once that patient is on their way, i need a few minutes to set up the room. it will take me as long as it takes, and until the room is ready, i can't take the patient and run for equipment and supplies. i call when the room is ready. i don't go for coffee first, but i might pee, because who knows when the opportunity will come around again.

when i admit a patient from er, i don't expect them to come up all clean and shiny and ready for discharge, but i do expect that once they are in the icu they're not going to have to take any road trips to ct or x-ray... which are both just outside the er... unless there's a sudden decompensation. and i do expect them to be relatively stable, as in they have a blood pressure.

when i get report on a patient from er, i want to know what happened to bring them to the icu (reader's digest version), what has been done already and how they responded, what they have for lines and what's running and where the family is. i am quite capable of doing my own assessment of the rest.

i wish that er nurses realized that the icu nurse is continually squashed between the er needing to offload and the wards not wanting to take the icu patients when they should. our icu is always over-census and understaffed. we have no room at the inn, so when there's an emergent admission coming we have to offload too. our icu is not a quiet place: it's crowded, noisy, smelly, with overflowing laundry bags and garbage cans, filled with people trying their best to keep their patients safe. as interleukin said, we are all in this together and we all have to cut each other a little slack.

mwboswell · Feb 15, 2009

I'm gonna share something cool with you guys on this topic....

About 9-10 years ago I worked in the ED in a small community hospital (8 ED beds, 30 Med-surg beds, 7 "ICU" beds)....

After 11pm at nite it was 1 RN and 1 LPN in the ED. There were Always 2 RNs in the "ICU" sometimes 3. Any nite there were 3 and they were under-census, that 3rd RN would come to the ER if we got a Code or an intubation or someone critical. Anytime we had a pt that was an OBVIOUS ICU admit, that 3rd ICU RN came down and started workign with that pt at THAT TIME; it was awesome - they were team players, they loved the change from the ICU and they felt like they "got to know" their pt's beter prior to admission.

I thought it was cool the way it worked out.

mwboswell · Feb 15, 2009

A few of you have mentioned the difference between the ED report and an ICU report...well here's an example:

next time your ED Attending MD calls the medicine service for an admission consult; listen to him (or her); the ED MD does not go into great lengths as to the entire picture of the pt. they simply state the probable dx, the need for admission and some relevant diagnostic findings...that's it - it's simple and straightforward.

Then what happens next; at some point the admitting MD has to come see the pt (in the ED or on the Floor) and they will do an entire head to toe, full history, family hx, surgical hx, med hx, social hx, review of systems, meet with the family, go over all the admit labs/tests and then order a bunch more, then sit and write it all up; probably much more of an assessment in total than an ED attending.

not that the ED is "wrong", it's just an example that the ED in NO WAY goes as in depth as the inpatient units do as far as "getting to know" their pts' - it's just not the nature of the business.

Hope this helps.

dorimar, BSN, RN · Feb 15, 2009

I understand that ER is extremely busy, but these are not the patients you are discharging home or even sending to the floor. These are ICU patients because they are critical, and thus warrant a little more attention. I don't expect a full head to toe system assessment from the ER. I do expect an assessment of the system involving the chief complaint and ICU admission. I do expect a report from someone that actually looked at the patient within the last half hour (please not: I just took over for someone and I don't know this patient--why are you giving report then, what is the purpose?). I do expect you to know stuff about the problem for which the patient is being admitted. You see, I will be speaking to docs/consults and family that will ask me for information that only you have, and I may not have access to at 1 am. If your sending me a patient with ALOC I expect you to know if the head CT showed anything acute, because I very likely will not have access to that info tonight, and the neuro consult you guys did not call will be asking me for that info. If I ask if blood cultures were done on the patient being admitted with a diagnosis of sepsis (because you didn't mention that you did blood cultures in report), please don't act liking i'm giving you attitude. Blood cultures are a standard, before I have to administer the antibx that you apparently did not receive from pharmacy. If you have to hold a patient in ED for several hours due to no ICU beds available (we are backed up too-go figure), I do expect the Integrelin to be started that was ordered 2 hours prior, even if it is on the ICU orders. If the patient you're sending me is hypotensive after several fluid boluses and is on dopamine running into a #22 that the paramedics placed---please ask for a central. What am I going to do about a line at 2 am?- and this truly jeopordizes the patient--we have no docs in house except for the ER docs. For that matter, if the patient has a heart rate of 120, please do not send him to me on dopamine. Also, how does sending me a patient with a pH of 6.9 and a pCo2 of 102 on bipap save the ED time when I then have to pull the ED doc up to ICU to intubate my patient. Also maybe calling the dialysis nurse stat to dialyze in the ER for a K+ level of 7.2 might prevent serious problems for the patient and then eliminate the need for ICU to begin with...

My ICU unit is not quiet. It holds 32 patients and is usually full. We deal with hypotension, hypoxia, franK GI hemorhaging, full blown ETOH withdrawal, chest pain, dysrrhythmias, etc., let alone all the subtle stuff we are responsible for picking up, and all with no docs present, and are required to critically think through all of it-- while all of a sudden a tele bed has miraculously been found at 1 am that did not exist in the hospital for my tele patient until the ED had an ICU admission, and I am told I must move to tele right now to take the ICU admit from the ER and ER is on the phone already, and I have to go to VQ scan on my desatting patient who's family is standing at the desk with questions.

LilyBlue · Feb 15, 2009

From my experiences as a float nurse, I think both departments held equal resonsibility - something that drives me nuts is that the ER constantly expects me to drop my entire hall of 8 PCU patients to come down and pick up my admission from them - and when I get down there, they are all standing around. I once said something about it, and they said, "Oh, but we never know what's going to walk through the door" and I replied "I never know what's going to go wrong with the 8 patients upstairs I'm already responsible for, either, but here I am".

I have also worked ER a ton and when the receiving nurse tells me she's slammed on her hall, I believe her - ER isn't the only place that is hopping. Likewise, if I was in ER and told the receiving nurse that I was really busy, and couldn't bring the patient up, she believed me...because I had a history of helping out where I could.

nrsang97, BSN, RN · Feb 15, 2009

when i am told i'm getting an admission from er, if i have to transfer a patient out to be able to take the admission, that will have to happen. that can't be done in under half an hour. it just can't. and once that patient is on their way, i need a few minutes to set up the room. it will take me as long as it takes, and until the room is ready, i can't take the patient and run for equipment and supplies. i call when the room is ready. i don't go for coffee first, but i might pee, because who knows when the opportunity will come around again.
when i admit a patient from er, i don't expect them to come up all clean and shiny and ready for discharge, but i do expect that once they are in the icu they're not going to have to take any road trips to ct or x-ray... which are both just outside the er... unless there's a sudden decompensation. and i do expect them to be relatively stable, as in they have a blood pressure.
when i get report on a patient from er, i want to know what happened to bring them to the icu (reader's digest version), what has been done already and how they responded, what they have for lines and what's running and where the family is. i am quite capable of doing my own assessment of the rest.
i wish that er nurses realized that the icu nurse is continually squashed between the er needing to offload and the wards not wanting to take the icu patients when they should. our icu is always over-census and understaffed. we have no room at the inn, so when there's an emergent admission coming we have to offload too. our icu is not a quiet place: it's crowded, noisy, smelly, with overflowing laundry bags and garbage cans, filled with people trying their best to keep their patients safe. as interleukin said, we are all in this together and we all have to cut each other a little slack.

well said.