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!
You didn't say if management has looked to see if this is a systemic problem or a problem with a few particular nurses. In my hospital, I fully understand and appreciate what the ER does, but there are one or two nurses who have reputations of sending up patients with poor reports and/or firing off inappropriate responses when asked questions.
Specializes in Critical Care, Emergency, Education, Informatics.
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.
Later, MB
But unfortunaty it IS standard of care right now. It's a regualatry thing, we get gigged when we don't do them. we ahve to report our stats to one agency or another. yes is is a sacrad cow, but we still have to make sacred hamburgers.
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...
I'm sorry your ER is such a mess but the vast majority of what you've requested is a physician issue...not nursing. Sure we can ask for a CVL but we can't MAKE the doc do it and yes I have been refused too many times to count. It is completely out of my SOP as a nurse to order STAT dialysis and I've never worked a place where they are willing to come to the ER to do it EVER even if I can get a doc to write the order. And do you really think if we can't get the doc to put in a CVL we're going to be able to get him to place a dialysis catheter?!!!! I, as the nurse, am not the one sending the patient up with crappy gases...it is the doctor who has decided not to intubate regardless of how much I've begged for it to be done. I can only suggest to the doc that Dopamine is making the patient tachy...I can't D/C it on my own nor can I change it to another agent. How is it my fault if the pharmacy didn't send up the antibiotics despite 50 phone calls asking for it STAT? And if they didn't send those could it be possible they also didn't send the Integrilin in a timely fashion either? CT results? If the doc has the only printed out report and it's not resulted on the computer and he doesn't tell me what was found regardless of my asking what would you like me to do? Psychically glean the results with a mind meld? As far as the nurse giving report not knowing the patient you can thank YOUR previous shift for that. If my shift is over I'm not going to wait for an indeterminate time for somebody from the ICU to finally take report. Sure I understand that you probably are busy but as long as the nurse taking over from me is competent then my job is done. Stating " I don't really know the patient" is a courtesy to help you understand why the information you require isn't coming as fast as you'd like. Your expectations are out of line with reality. We can only do so much with the powers we have.
I do consistently get patients like this from both of the hospitals I have worked in the last 10 years. Not from the teaching hopsital I worked in prior to that (where Ironically these situations could have been easier dealt with). Neither of those other hospitals have in-house intensivists to pick up the mess. It is always the ICU nurse and hopefully a good doc on the case who will come in, but sometimes the ED doc is often forced to come up to the unit immediately on ICU assessment to emergently intervene. IS this the fault of the ED nurse or the ED doc, or both? I think the poor ED medical care is translated to the ED nursing care. Speaking of evidence and sepsis, not only have I received patients with a diagnosiss of sepsis without cultures or antibx started, but they were hypotensive and tachy on dopamine and no fluids given whatsoever (for loooong time in ED)---There is evidence to dispute that care dude... I never hold report unless I am in the process of transferring my paitent so that I can fill the bed with yours, or I am on a road trip, or my patient is crumping. There are two perspectives to every situation....
I do consistently get patients like this from both of the hospitals I have worked in the last 10 years. Not from the teaching hopsital I worked in prior to that (where Ironically these situations could have been easier dealt with). Neither of those other hospitals have in-house intensivists to pick up the mess. It is always the ICU nurse and hopefully a good doc on the case who will come in, but sometimes the ED doc is often forced to come up to the unit immediately on ICU assessment to emergently intervene. IS this the fault of the ED nurse or the ED doc, or both? I think the poor ED medical care is translated to the ED nursing care. Speaking of evidence and sepsis, not only have I received patients with a diagnosiss of sepsis without cultures or antibx started, but they were hypotensive and tachy on dopamine and no fluids given whatsoever (for loooong time in ED)---There is evidence to dispute that care dude... I never hold report unless I am in the process of transferring my paitent so that I can fill the bed with yours, or I am on a road trip, or my patient is crumping. There are two perspectives to every situation....
I am not understanding you. How can an ER nurse be at fault if an ER doc has to come up to the ICU after an ICU nurse does an assessment and finds the patient needs intervention? I think you are not understanding that once an ER doc says the patient is admitted, a NEW doctor has to be responsible for the patient's management and for orders on that patient-the patient at that point is called an ICU HOLD and in many ERs, the ER nurse isn't allowed to even chart on that patient anymore unless there is a substantial and life threatening change in the patient's condition. The ER nurse CANNOT intervene without orders and that patient is no longer an ER patient after admission (in holding). It is the responsiblity of the admitting doc to promptly assess the patient and write orders (HA HA ). When the ER doc has to come to the ICU, it is usually because of the admitting doc dropping the ball. ER docs are not trained as intensivists and that is why the patient is transferred to the care of the intensivist (scope of practice thing).
Having worked both ICU and ER, I can tell you that it is the responsibility of the ER nurse to stabilze the patient based upon ER/hopsital protocols or get that patient to the ICU when the condition of the patient exceeds the capabilities and resources of the ER. Management, both nursing and medical, make the decisions on patient flow and unit responsibilities & nurses have very little imput.
If cultures were not taken prior to antibiotic administration, then it is the fault of whoever made the hospital policy. Some places mandate that cultures are drawn prior to abx administration and have documentation safeguards to assure this takes place, other places just don't care. If this is an issue that concerns you, it would be best to bring it up to those who make the policy and procedures for the hospital.
You really would benefit from doing some shifts in the ER so you can get an understanding of the different scopes of practice for both the medical and nursing staff. After you have had to manage 4-5 ICU holds [never had more than 3 in the ICU], along with a couple of new CVAs, GI bleeds or MIs, together with a drug seeker PIA and some belly aches/flu/asthma attacks (could be up to 10 patients in that mix) and nobody dies on your shift, then you may have an understanding of why the ER doc and ER nurse may have had an oversight of something you now consider essential.
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!
Great thoughts!
-MB
It just seems silly to me that we change shifts at different times. If we all changed shifts at the same time then none of those shift change calling report/admits.
I do consistently get patients like this from both of the hospitals I have worked in the last 10 years. Not from the teaching hopsital I worked in prior to that (where Ironically these situations could have been easier dealt with). Neither of those other hospitals have in-house intensivists to pick up the mess. It is always the ICU nurse and hopefully a good doc on the case who will come in, but sometimes the ED doc is often forced to come up to the unit immediately on ICU assessment to emergently intervene. IS this the fault of the ED nurse or the ED doc, or both? I think the poor ED medical care is translated to the ED nursing care. Speaking of evidence and sepsis, not only have I received patients with a diagnosiss of sepsis without cultures or antibx started, but they were hypotensive and tachy on dopamine and no fluids given whatsoever (for loooong time in ED)---There is evidence to dispute that care dude... I never hold report unless I am in the process of transferring my paitent so that I can fill the bed with yours, or I am on a road trip, or my patient is crumping. There are two perspectives to every situation....
Again you are attempting to place the blame of poor medical care on the nurses. We give nursing care! If the ER doc has to come up immediately to reassess a person he has been taking care of prior to the ICU admission then it is HE who dropped the ball. Again I must point out to you that it is beyond the ER nurses scope of practice to order ANYTHING or change any existing order or medical plan of care. We do not have that power!!!!!!!! You are assuming that things did not get done because the nurses are not doing their job. Unless your ER is full of a bunch of idiots I'm betting that they did everything they could WITHIN THEIR SOP. We cannot make a physician order anything, place lines, intubate, etc if they won't do it. Explain to me who you think ordered the Dopamine or did not order fluids on your hypotensive, tachy patients. How do you know the ER nurse did not beg for these things to be addressed. From what you are describing your hospital should be closed before someone gets killed. Incompetent ER doctors, nurse run ICU's with no medical coverage. Why do you even work there? Have you addressed this with the POB at your institution? Also, I never accused you of holding report I simply answered your complaint that getting report from someone who hasn't had the patient is a waste of time by pointing out that if that person is competent they will be able to give you report just maybe not as quickly as you'd like. Oh, and BTW I am not a dude and don't find that reference to be professional or courteous.
What I'm talking about are patients NOT stabilized before transfer to ICU. That story about the 6.9 pH on bibap was a true story and was from a gas obtained in ED. We recently also had a patient brought up to us in PEA--no lie. Last week I received a paiten from the ED with a report that "the patient came in with resp. distress, was immediately intubated, became hypotensive and tachycardic is on wide open dopamine and also some levophed and is trying to die" Swear to God that was the report and nurse could not tell me gases or if any repeats were done after intubation, could not tell me rhythm, or history, labs, or anything that was done for given to the patient prior to her coming on at 6PM and patient had been in ED for hours. Patient arrived to me in rapid afib with HR in 160's, bp in the 70's and truly had dopamine on gravity tubing running wide open. There was a bag of unlableled saline hanging which she said was levo but could not tell me how much was in the bag or how much levo she thought was running. Patients glucose wos 570 on arrival (nothing done about the 450 glucose in the ED. ABG's still sucked--bicarb of 12. Found out the next day from the internal med doc that patient was given an antibx in ED that she had a documented allergy to, and they think she had a reaction because THAT was when she got profoundly hypotensive. The nurse giving me report was the one who gave that antibx, but neglected to fill me in on that important detail.
Obviously both ICU nurses and ER nurses have valid issues, concerns, gripes-- but the comment about the ICU "being quiet" does not indicate some of the ED nurses understanding of our situation either. In addition, every hospital is different. I also realize that my current hospital's ED has some very big problemsthat involve the docs as well as the nurses, and my frustatration at our inability to rectify these problems has come through in my responses in this thread.
You did not accuse me of holding report, but throwEDnurse did. Again, this boils down to each of us not having an understanding of the other's situation, but making assumptions anyway. We all do it, I am guilty of it too.
I realize the ED in my facility has serious issues. I thought the last place was bad, but have repeatedly been shocked here. Every new ICU nurse or traveler who comes here is shocked. It has been addressed through our proper chain of command by myself and some others. However, I do not think our administration is willing to **** off the ED docs.
I do feel the ED nurse accountable for letting the docs know stuff. Or even knowing that there patient had an important change in status. Despite all this, I have never been rude (although sometimes just asking questions is taken as attitude). The one important difference between ED and ICU (at least in my current hospital) is that there are no docs in ICU. We have to fix the messes that arrive as messes. I have been here just over a year, and I am contracted until May due to my tuition reimbursement. I will not be staying after that.
The comments you made are surrounding one nurse and one ocassion. I am talking about the things that occur in general. We are looking for trends that happen frequently in hospitals. And compared to the ER, the ICU IS quiet. Like I said, I, and many other nurses I know work both ICU and ER frequently, so we can compare. Do you work in the ER some? If not then you really can't even begin to compare the differences between the two. I will tell you that all of my co-workers/friends (even from different level 1's) that normally work ER say that the ICU is very slow and controlled compared. And the ones who normally work ICU, but pick up in the ER say that the ER is crazy, and they can not hardle handle the reponsibility of having so many criticals. I understand that ICU want everything stabilized, controlled, and clean, etc... but that is because they can do that with 2 patients. I will dare anyone to do that with 8-10 criticals and more rolling through the door that you are responsible for. Technically, our job (ER nurses and docs) is to get them to you still pretty much alive and somewhat stabilized, your job is to keep them that way, watch them close, and gett them to more of a recovery phase. We just get them to you. If our job was to totally stabilze a pt., give them all of the meds, tests, and care that they needed. If we sent them to you totally stabilzed, and treated, then there would be no need for the ICU. It is called continuity of care. The point of this post was to talk about ways both ICU and ER nurses could make this easier on each other and the patient, not to bash other nurses. But I am starting to see why we have a problem...but I still haven't seen any ICU nurses who want to try and fix it. I am at school now and my ICU friend is reading this as well (we are in a class on break), and she wants all of you ER nurses to not hold this thread against her, she says that she understands our pain and doesn't agree with the posts here. She loves us and says she would never be able to do our job full time(I love her). She for one realizes that she has 12 hours to try and fix her 2 pts. problems, and she knows that is her job. She realizes that we may see 100 patients on our shift and only have a few minutes to decide what we should do for the next minute (if we have a minute) to save our patient and get them upstairs, befroe it starts all over again. See, I know that there are team players out there, ones who have worked on both sides of the fence. They may prefer one place over the other, but can relate and understand our different positions. Where are they all, they can offer ADVICE, and that's who I am wanting to here from. If you came here to bash the ER, then get out, you are not welcome here. This is a friendly thread, where the nurses are looking out for the pt. and wanting to do more to help them during their stay. This is not a place for people who are not ER nurses to vent, there are other places on this very site for that. If you can be professional and offer ways to help make nurses more productive then you may stay.
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.
some background first, i am a medic that has been an er rn my entire nursing career (although it only been 3 years). i am actually transferring to the sicu this week.
now as to your quote above, at my large level 1 trauma academic hospital i work at management encourages bedside report. this makes the patient feel like they are part of their medical care. i always give them the opportunity to add things or correct things as they see fit. this is called maintaining the continuum of care. if you speak of your patients in way that won't let you do it at the bedside maybe you should re-evaluate the way you treat them.
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
But unfortunaty it IS standard of care right now. It's a regualatry thing, we get gigged when we don't do them. we ahve to report our stats to one agency or another. yes is is a sacrad cow, but we still have to make sacred hamburgers.
Regulatory means something that is legislated and affects a license or a right to practice.
If you violated this you wouldn't just get "gigged" you'd be investigated and risk loosing licensure.
Standard of care and "regulatory thing" are two different monsters.
A "regulatory" violoation would be a criminal liability (IE: breaking the law)
Breaching the standard of care would become a civil liability (IE: get sued)
). When the ER doc has to come to the ICU, it is usually because of the admitting doc dropping the ball. ER docs are not trained as intensivists and that is why the patient is transferred to the care of the intensivist (scope of practice thing). 
classicaldreams
101 Posts
You didn't say if management has looked to see if this is a systemic problem or a problem with a few particular nurses. In my hospital, I fully understand and appreciate what the ER does, but there are one or two nurses who have reputations of sending up patients with poor reports and/or firing off inappropriate responses when asked questions.
Classicaldreams