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 ER, Trauma, ICU/CCU/NICU, EMS, Transport.
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.
mwboswell....your post displays the problem, not the answer...your expectations can not ALWAYS be met, our world just does not allow it.
In my hospital the attendings have to see the patient within 1 hr after being admitted to the ICU...you can get your central line then thank you...
And we should not be hanging any ABX without having Cx drawn first, this is standard of care. Unlike you, who may have one other critical patient, just remember we may have another critical patient plus a drunk and a CP...try that balancing act and still be able to give you full CT results--like I even know those unless they have a big bleed...LOL
Don't worry you can call me the charge nurse I will listen to whine about how we didn't do this, we didn't do that, and I'll hang up with you, shake my head, and move about my busy day...
Like I said in the first post, our place is a level 1, no one has to wait for any procedure, our ER is full of attendings, residents, interns, and students, and when we take someone up to the ICU, again attendings, residents, interns, and students are all waiting to do whatever they can-they love procedures. We have ICU docs in the ICU a big chunk of the night just sitting around. So a lack of things getting done in a teaching hospital is not a problem. And our ICU has 48 beds and always always always has at least 25 nurses on-no matter what, and they will bring in more if someone has a 1-1 (like prismo) r something. Having said that, our ER is always, always, always, understaffed (its hard to judge how many pts. we will get in a shift. Where I know you may have 2 criticals (and crazy families) they have at least been through part of the stabilization process. Last night at one point I had 4 criticals, and a CP, a fresh OD, by myself for awhile (all had family there), while the rest of the team was with a MVC amputation trauma. Our ER has 90 beds, they are always full, with people in the hall, and a full waiting room. I know how the admitting process goes, I have been on both sides. I was looking for advice how to make it all a little better, I wasn't looking for people to tell me how silly I am for thinking I have it worse than the ICU nurses. See what I mean, there is no hope! They just want to continue to try and show superiority, and have something to rant about, not try and resolve the conflicts. But thanks to those of you who offered some advice...
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
mwboswell....your post displays the problem, not the answer...your expectations can not ALWAYS be met, our world just does not allow it.
In my hospital the attendings have to see the patient within 1 hr after being admitted to the ICU...you can get your central line then thank you...
And we should not be hanging any ABX without having Cx drawn first, this is standard of care. Unlike you, who may have one other critical patient, just remember we may have another critical patient plus a drunk and a CP...try that balancing act and still be able to give you full CT results--like I even know those unless they have a big bleed...LOL
Don't worry you can call me the charge nurse I will listen to whine about how we didn't do this, we didn't do that, and I'll hang up with you, shake my head, and move about my busy day...
Whoa, there hoss'...
I don't have a problem at all, I'm out of the loop on this one.
I work ED not ICU....
PS: On the Blood Culture thing - You say "Standard of Care" and it is probably your hospital policy, but do you realize that in an age of Evidence Based medicine, there is little if any scientific evidence showing a change in outcomes if Blood Cultures are drawn AFTER the antibiotics are started? What you're talking about is not based on evidence, it's a sacred cow.
My bad MB....I meant to reference to "dorimar" not you...I just looked at the wrong name...i sincerely apologize....
I'm surprised to hear that about the blood cx's the way the IM guys FREAK out about it...and yes I was taught it's the standard...and yes it's our hospital's policy...also at every hospital I've worked at as agency as well...
I disagree. Backboards have a role in specific situations. While, I agree they are grossly overused and iatrogenic injury from being on a back board is a serious and often forgotten problem, backboards can still fill a role. Especially in rapid extrication situations, limited and confined space situations and moving patients.
However, I think better modalities such as vac mattress devices exist for longer term transport considerations.
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.
If your ED is consistently sending you pts in this manner you may 1) want to request that they hire full RNs instead of what I can only imagine is nursing students and 2) want to consider the kind of day they must be having if this is the care they are providing and 3) want to remember that nurse had 4 other pts with YOUR ICU hold and 3) take report before shift change when it is less convenient for you instead of forcing the new ED nurse coming on to take care of the pt to give you report and then complain that the nurse giving report doesn't know the pt well enough...duh!
I do have a question for all you ER nurses here. Do you change shift at the same time as the floors or at a different time? Our floors change shifts at 7a,and 7p. Our ER and PACU change shifts at 6p and 6a. Do you feel this is a problem or is better? I was just wondering your feelings. I don't have a real feeling either way.
Our PACU and ER try to call report before night shift comes in. (This seems to be the time that all the admits tend to come because of everyone coming out of surgery and the beds start to open up).
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
I disagree. Backboards have a role in specific situations. While, I agree they are grossly overused and iatrogenic injury from being on a back board is a serious and often forgotten problem, backboards can still fill a role. Especially in rapid extrication situations, limited and confined space situations and moving patients.
However, I think better modalities such as vac mattress devices exist for longer term transport considerations.
Hey GilaRN - I'm not saying backboards are useless, the point of the graph if you looked at is, is that we are using them for the wrong reasons! As well the point of the graph/chart was that the evidence supporting their usefulness is lacking.
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
I do have a question for all you ER nurses here. Do you change shift at the same time as the floors or at a different time? Our floors change shifts at 7a,and 7p. Our ER and PACU change shifts at 6p and 6a. Do you feel this is a problem or is better? I was just wondering your feelings. I don't have a real feeling either way.
Our PACU and ER try to call report before night shift comes in. (This seems to be the time that all the admits tend to come because of everyone coming out of surgery and the beds start to open up).
That's a very novel idea!
AT one hospital I worked at I even discussed with the Nurse Mgr having the nsg staff change at one time (either before or after) the ER MD's....that way that "flurry" of "all of a sudden discharges" at 10 min before shift change is better managed!
He is an ICU nurse. I am a former ER nurse (but my heart is still in it).
He calls on the way home, venting about "the ER didn't do this, and didn't do this". Most of the time, I know which nurse he is talking about, and there are a few who don't do a good job.
I have to remind him that most of the time, we have a lobby full of people, EMS knocking on the door, patients in the hallway, and the charge nurse fussing to "get them upstairs now". While you're trying to get settled in for transport, they're starting an assessment on your patient that will be filling the room as soon as you leave with the admit. In the ideal world, I'd send them up fluffed, puffed, medicated and everything in place. Realistically, the attending has had my chart for two hours and just wrote two pages of new orders that I've barely looked at (just to make sure they didn't change the assignment or are sending them to the OR now), and the way I find out I have admission orders is when the charge nurse tells me I have a bed ready and to get the patient upstairs.
I've urged him to spend a little time in the ER- just a shift or two, to find out what it's really like. I don't think he wants to, b/c of my crazy stories. LOL
mwboswell
561 Posts
...quite a rant here.
-Mark