As usual, there is some animosity amongst the ER nurses and the ICU nurses at my hospital. We are a very large level 1 trauma center. The managers of both of these departments would like us to become more educated about the very different roles that we have, and are even thinking about making I float to the ICU (and vice versa) to try and make us understand the differences. Some of the problems that have occurred b/n myself and some of the ICU staff relates to them wanting a very detailed, full-bodied system (when I barely got to know the pt.cause the is a constant flow in the pit), putting off taking report even though they have the staff/bed( they are constantly arriving through our door and we can't make them wait), thinking that ER nurses don't understand how to do CCRN "stuff" (I kept them alive didn't I), expecting the pt. to be clean, totally medicated, and cured before I send them up (charcoal, ETOH, GI blood, and poop stain and sometimes they just keep coming). I would really like to hear how other places have overcome their barriers related to this. What has helped other hospitals ER/ICU nurses better understand each other and how their roles differ, but are equally important. Our managers are fed up and would surely welcome any advice! Thanks ahead of time for your thoughts!
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
there is no way this *hasn't* been said in this thread, but it bears repeating:
we don't get any kicks out of calling report before/during/after shift change. when a patient is assigned a bed is totally out of my control. it happens at all times of the day, just like how the er gets squads, traumas, and codes all times during the day or night. do we get angry at the medics when they bring in a level 1 trauma at 06:50 or 18:50? no, because that is ridiculous and out of their control. it is the same situation when transferring a patient from et to icu.
i wish the icu nurses would do what the er sometimes does. when the er gets a code or trauma alert within 10-15 minutes before shift change, the next shift will clock in early and take care of it. if i took care of an er patient for the past 5 hours and now they are going to the icu, wouldn't you rather get report from me and not a second hand report? and this is only concerning those patient who are assigned a bed right before shift change. i wish the icu nurse would clock in early, take report from me, and then get report for his/her other patient. this is assuming a lot of things (icu nurse is at work early, charge nurse knows who is going to get pt, etc) but i think it would be best for the patient.
*phew* :)
and we in the icu might grumble a bit about getting report right at change of shift, but we haven't deliberately been dragging our feet just to inconvenience the er. believe me, we wanted to take the patient three hours ago when you first called. unfortunately, we cannot take your patient without bumping one of ours out of the icu to the floor. and even though the electronic bed board says the floor has three empty beds, we cannot get them to take any of our patients so we can take yours and the two who are already in surgery. the floor insists that the room isn't clean yet. (and many times when we just happen to pass through the floor on the way to somewhere else, it appears that the room is clean.) more than once, the charge nurse and/or a cna from the icu has gone down to the floor and cleaned their room so that we could transfer our patient out. and then we've cleaned our room so that we can take your patient.
i don't get any pleasure out of refusing to take your patient. but ccu sent a patient for an emergent cabg, and they'll be coming out of the or in 20 minutes into the only empty bed we have. do you think you could talk the attending into admitting to the ccu instead of waiting for our stepdown unit to discharge a patient, clean the room and allow the nurse a lunch break before they take one of our patients so we can take yours?
or yes, i know electronic bed board says we have an empty room. we do and it's clean, too because the charge nurse just helped the housekeeper change it. but there's a patient on the stepdown unit coding, and all of our "spare nurses" are down there helping with the code and preparing to bring that patient up to us. i trust that the patient you're holding in er is getting adequate care while they wait, unlike the patient on the floor who doesn't have a rhythm right now.
i know you work hard, are prepared to take anything that comes through the door when it comes through the door and can take care of anything that comes through your door. we work hard, too. when the patient codes downstairs, we sometimes transfer a patient to the hall so that we can take that patient while they work on cleaning their bed so we can transfer someone down in exchange. we have to take what comes out of the or when it comes out of the or -- or send a nurse to take care of them in the pacu. when ccu puts ecmo in a patient, we have to immediately take that patient -- or send a nurse to ccu until we can. the er patient has to wait -- but we know you're taking care of them.
No, your right, we don't have 2:1 staffing; we usually have 4 or even 6:1 or more. I said that we have 45 beds, not a max of 45 like you mentioned. It would be a very, very slow night at work if we only saw 45 patients-try 245 and you would be a little closer! You also gotta count all of those in the waiting room, all of those in the hall way, and all of those on the way with EMS, and life flight.
Like you mentioned..."I'm not an ER nurse," you shouldn"t be making assumptioned about our "dreamland!"
You guys will NEVER get it...even though we keep explaining it, so just give it up already would ya. We admit it, we are incapable of working in an ICU (way to incompetent), (even though I work in one )!
Wow. Not sure how to respond to this. First of all, maybe I didn't communicate it well, but my thought that this was dreamland was moreso related to the 160 nurses for 80 ICU beds originally mentioned in the post I was wondering about. (Like you mentioned in a subsequent post, this was flipped. That would definitely be dreamland to have 2 nurses per patient!)
Next. Although I'll again clarify that I don't think you work in dreamland. I'm quite aware that 45 beds doesn't mean 45 patients for the shift. But it does mean 45 patients in beds at a time. I can't really count the ones in ambulances and helicopters on the way since you're not really responsible for them at that time. I have worked in an ER, so the snotty answers about how naive I am and how I will never get it don't really work here. I didn't make any assumptions about your staffing. I actually asked you if I was misunderstanding. Because the ER I worked in did not staff 20 nurses for their 46 beds. We didn't put patients in the hall, so there I can't relate. But 20 nurses to 46 patients being actively treated doesn't add up to 4-6 patients per nurse. I and also mentioned that if your ER beds are always full, this staffing would make sense. I just haven't experienced many ERs that are at capacity all the time.
The ER at the hospital I currently work at is staffed with wonderful nurses who I'm quite sure could work in an ICU if appropriately oriented (as could I work in the ER with the appropriate orientation). They're pretty smart cookies, and so am I and my co-workers. We have mutual respect for each other and the different types of work we do. I have been watching this thread to get more perspective on their jobs because we don't interact as much as I'd like, but I'm realizing the negativity on many of these posts is not helpful to me in gaining healthy perspective. So with that, I think I'll politely step out of this thread. Thanks to those who have shared helpful perspectives on what it is like to work in an ED.
Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.
ICU RN. ER RN.
It's neverending..the argument about who is better. That's the bottom line...one group trying to outdo the other.
I've done both. It's both hard, and both exciting in different ways. I love both specialties. Great learning, great camaraderie. Great experiences.
ER/ICU...in the end, as long as the patient gets the right kind of care...
Some ER nurses are better than others...some ICU nurses are better than others.
I find that the more experience one has, the less he/she grills or demands--in either area.
Inevitably, there is only so much one can do on one's end--that applies to ER and that applies to ICU. Assigning blame and gossiping..such a waste of time and energy.
Go forward and just work with what you have....you'll be a happier nurse...
Why or when ED and ICU started having conflicts I am not sure. I do get frustrated with the argument of "we take whatever whenever." Sorry to point out that is what an ED is for. I have taken report on numerous pt that come up 1.5 or 2hr later, not because I told them we couldn't take it so it goes both ways. I bust my butt to get the rooms available for ED b/c I know they need to move them out either b/c they need more room or the pt has moved past the initial resuscitation phase and needs to get up to us before something else goes wrong (not saying the ED was doing something wrong, but that's how those typs of pt work).
Were I work I don't really get the hx. I have been there for a year (actually worked in the ED as a tech during school), I rarely ask questions (some of the nurses down in ED have actually said what I tell you is all you need), and if they say we are swamped can I give you report at bedside I always tell them sure. Yet in my last evaluation w/my manager she told me that ER had complaints...I try to be a team player and still....
We are different worlds different specialties who need to work together
I can't really count the ones in ambulances and helicopters on the way since you're not really responsible for them at that time. I have worked in an er, so the snotty answers about how naive i am and how i will never get it don't really work here.
We are responsible for pts who are waiting, report received, in our unit. They are our responsibility, even with ems baby sitting. They count. All pts count. They are our responsibility, baby sitter in tow or not. And we must be properly prepared for them which we can be with your icu hold hogging the bed.
We have mutual respect for each other and the different types of work we do. .
If you don't like the fact that the ED has to "take whatever whenever" sorry, as we are, but it is still a fact. Ergo, rushing your pt up to you immediately after report may not be my priority, but if the arduous 20 min wait on your pt to arrive to your unit was just too long for you, then take your bored self down to the ED with your extra tech that we don't have because we always have so many psych pts holding and retrieve your pt. Because my other fresher, sicker pts need me NOW. And the transportation of the ICU hold will have to wait unless you can condescend to come to the ED to help out, seeing as how wonderful all ICU nurses are, that shouldn't be too hard.
Wow...not every place is the same. If it'd be helpful for me to come got my pt then tell me that but I'd prefer not to leave THE other nurse in the unit alone. If the psychs are causing you problems Im sorry...but guess what they are going to cause me a problem when you send them to me w/o the security & and special "psych" room. If for whatever reason it's going to be a while would it really be that big of a deal to have the HUC call and tell me that, or use that little communicator thing that is around your neck? Yeah...just play nice for crying out loud.
....not act so condescending when I don't know every detail about my patient....I don't have the full medical history....please understand the family is in the lobby crying because their loved one just coded repeatedly and maybe all I have is the hx surrounding the event and a list of meds....
....stop yelling at me because I didn't - pick from below -
measure all intake and output
fill out one of their nifty ICU flowsheets
call the attending physician about something they can when the patient comes to them
clean up my patient, have them in fresh gown and sheets
hold my patient because they want to go on their hour lunch break
......understand that we are holding 40 in our lobby, have 13 in gurneys in our hallyway, and many of our RNs have multiple ICUs,IMCs in addition to regular pts. We simply can't provide the quality of care you can on a busy night. That's why we want to get our peeps up to you. You have 2 patients. We have four each, usually at least 2 ICUS per RN. Which means it all comes down to ABCs. I also usually don't get a lunch break, and sometimes don't even get to pee once on a 12 hr shift. I might be grumpy and the brain a bit foggy because of this. I will get jealous and even grumpier if you ask me to wait to send up your pt because you want to take your HOUR lunch break.
I mean I try not to get frustrated but here are some of the situations I've run into:
An ICU RN was called in during the middle of a shift. She called the ED 2 HOURS! after she clocked in to complain no one had given her a patient yet. She stated she was bored and might as well go home since we "couldn't get it together." to give her report. We didn't know she had been called in and she made no attempt to contact us or come down to get report. This has happened more than once.
One of our ICUs loudly complaining when they got two patients from us at once. One I had to hold more than an hour because the "room was not ready yet." It just hadn't been cleaned. No special precautions and their was a bed. Our ICU and regular floors never clean their own rooms. Never.
One night one our docs got ticked because there were apparently no ICU beds. He called up our house supervisor and said "Tell those **** on **** to move out those dead bodies so I can get my patient up!" It turned out he had been up on the floor and spied a few beds with deceased patients. No family around. No reason they shouldn't have been moved. They had been their for hours. Found out later it is a common practice so the ICU RN can "catch up" on documentation, take a break etc.
For me at least, this is the kind of stuff that breeds animosity between the ICU and ER. When I have situations like the above it makes me less inclined to do the extras that you like. Granted, I've had situations where and ICU RN has been awesome ie "Just send them up, don't worry about - fill in the blank." But more often than not ER Rns are treated like stupid second class nurses by our ICU.
Whew! That felt better! Thanks for letting me vent!!!
It's just not ICU to be fair. It's hard to take more patients on any unit when you are already feeling well supplied with work. But paying patients are good for business. The more we can get and send to ICU and other units the better it is. I try to be kind when nurses from other units rant a little about getting ED patients. We are the gateway to the hospital.
Our hospital has a high ED census plan and all of the supervisors housewide are in on it. Whether it is ICU or any other unit that is creating problems for the ED the supervisory staff work on making a way for us to get patients where they need to go. The plan has developed over the years and we keep working as a team to make it go.
Our hospital's goal is to keep the ED open to ambulance traffic since our community has the option of diverting patients if any ED is too busy. The accountants have figured out how much revenue we lose each hour by diverting ambulances and it is big money. Patients that leave our waiting room without being seen also lose us money. So if there is any way to move a patient during high ED census time the supervisors will help us do it. They move staff to the unit that is taking the patient, they call in staff, they open units, they will even come and transport the patients themselves if necessary. If the ED is getting too long of a delay we call the house supervisor and let them help work it out for us. We also have to trust that things are being worked out as well as can be done.
In addition we try to give. If we can hold a patient for a little while during a stressful time for another unit we do. To be sure, it does come back to bite us but not that much if the wait times are short. It is no fun to realize that you can no longer transport a patient because you are swirling in a bunch of other unstable patients. Sometimes I simply cannot hold a patient for any reason such as shift change, etc. That's where the house supervisor comes in, to help prioritize the resources. They get to make the call whether it is more important to hold patients in the ED and close the door to more revenue rather than let any more ambulances come to us. It's important enough to our hospital that the top administrators take responsibility for making the call. The house supervisors consult with them. They have become quite creative about getting things moving along.
Perhaps money could be a data point if you are continuing to keep patients in your ED that you shouldn't. If you turn away ambulances or if patients leave your waiting room because they can't be seen in a timely manner your hospital is losing money. If you have someone who can crunch the numbers and lay it out in dollars and cents the administrators love it. The research already supports better outcomes if patients are transferred to the ICU when they need to go. And little wonder if the ED nurse is spread too thinly.
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Ruby Vee, BSN
17 Articles; 14,051 Posts
and we in the icu might grumble a bit about getting report right at change of shift, but we haven't deliberately been dragging our feet just to inconvenience the er. believe me, we wanted to take the patient three hours ago when you first called. unfortunately, we cannot take your patient without bumping one of ours out of the icu to the floor. and even though the electronic bed board says the floor has three empty beds, we cannot get them to take any of our patients so we can take yours and the two who are already in surgery. the floor insists that the room isn't clean yet. (and many times when we just happen to pass through the floor on the way to somewhere else, it appears that the room is clean.) more than once, the charge nurse and/or a cna from the icu has gone down to the floor and cleaned their room so that we could transfer our patient out. and then we've cleaned our room so that we can take your patient.
i don't get any pleasure out of refusing to take your patient. but ccu sent a patient for an emergent cabg, and they'll be coming out of the or in 20 minutes into the only empty bed we have. do you think you could talk the attending into admitting to the ccu instead of waiting for our stepdown unit to discharge a patient, clean the room and allow the nurse a lunch break before they take one of our patients so we can take yours?
or yes, i know electronic bed board says we have an empty room. we do and it's clean, too because the charge nurse just helped the housekeeper change it. but there's a patient on the stepdown unit coding, and all of our "spare nurses" are down there helping with the code and preparing to bring that patient up to us. i trust that the patient you're holding in er is getting adequate care while they wait, unlike the patient on the floor who doesn't have a rhythm right now.
i know you work hard, are prepared to take anything that comes through the door when it comes through the door and can take care of anything that comes through your door. we work hard, too. when the patient codes downstairs, we sometimes transfer a patient to the hall so that we can take that patient while they work on cleaning their bed so we can transfer someone down in exchange. we have to take what comes out of the or when it comes out of the or -- or send a nurse to take care of them in the pacu. when ccu puts ecmo in a patient, we have to immediately take that patient -- or send a nurse to ccu until we can. the er patient has to wait -- but we know you're taking care of them.