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!
Actually, blood cx prior to ABX is a core measure for pneumonia. It is not required, but it goes into audits for our friends at the Joint Commission and reported on the hospital compare website. So it's neither a standard of care or a regulatory thing, it is an arbitrary measure of performance foisted upon us by a faceless commission. And we all know that evidenced based medicine and practice is something TJC is not too keen on (sometimes).
I am honestly shocked to read that some of you are responsible for 8- 10 critical care patients at one time as was posted by Ilovetrauma. If this is true, then I question the safety of that. I know it does not happen in my current hospital, because we get all the "criticals" and I assure we don't get 8-10 for one single nurse. I also want to clarify that I mentioned several situations that were not related to one single nurse, but many. I think people pick out pieces of information from posts and sometimes miss the major information or point.
It seems everyone here, including myself has missed the point-- maybe even the original poster after this ballooned into a defensive attack on each other. We all got defensive about specific comments that rubbed us the wrong way. Me- that it was implied the ICU was "quiet" when I rarely get lunch (truth). Others because i implied all the ED care was as bad as others. I do realize that some of you have some very valid points. Please realize that those of us who spoke up for the ICU have valid points as well. I have worked the bedside for 24 years as an RN and 21 of those have been in ICU. I have worked a number of different ICUs and have had issues with ED wanting to get the patient up to me NOW despite what I am dealing with.... And this post could help me understand a little of what you all are dealing with too.... but none of you gave an inch in trying to see the other side either.
The dude comment was addressed to MWBoswell, who signed his name Mark, in response to his evidence-based practice comment. I would like to apologize to MWboswell for the dude comment, even though it was not addressed to flyingscot who is the one who took offense and is who's is not the only thread here that people respond too- I do see that it sounded unprofessional and discourteous. Looking back, I think we could all be a little more professional and tolerant if we truly want to benefit from these threads and truly gain insight into the other side.
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.
WHOA!!! No I did not. You may want to reread the post. I just said to take. Please, anyone. I don't care who takes it, I just want to give it.
Also in defense of the PEA pt. I rarely check for a pulse when enroute to the ICU with a pt unless they suddenly look worse. I think we have all received pt in PEA from someone else, EMS, whatever. The pt probably had just lost his heartbeat as I have never seen PEA last all that long. Pts can be evil and tricky like that. Just my little opinion.
WHOA!!! No I did not. You may want to reread the post. I just said to take. Please, anyone. I don't care who takes it, I just want to give it.
Also in defense of the PEA pt. I rarely check for a pulse when enroute to the ICU with a pt unless they suddenly look worse. I think we have all received pt in PEA from someone else, EMS, whatever. The pt probably had just lost his heartbeat as I have never seen PEA last all that long. Pts can be evil and tricky like that. Just my little opinion.
I've had a patient code as we were moving from stretcher to bed. Talk about a cluster...When it was all done- "Who does the paperwork?" since we hadn't given report yet but were on the floor (we did it together).
So maybe I'll try to bring things back on topic.
Things I'd like the ICU to understand...
Sometimes patients DO poop in the elevator on the way up:rolleyes:
Especially after giving the OD patient charcoal with sorbitol. After the third time cleaning while getting ready to transport, I put several chux underneath her and we rolled. It wasn't going to stop for a while. I did stay to help clean it up, and she did it again before I left the floor.
It seems everyone here, including myself has missed the point-- maybe even the original poster after this ballooned into a defensive attack on each other. I have worked the bedside for 24 years as an RN and 21 of those have been in ICU. I have worked a number of different ICUs and have had issues with ED wanting to get the patient up to me NOW despite what I am dealing with....
I understand your point, and just understand that when the patient hits the front door of the ER with either 1. dead in the car 2.SOB w/ oxygen sats
I understand your point, and just understand that when the patient hits the front door of the ER with either 1. dead in the car 2.SOB w/ oxygen sats
You have to agree though that in your whole ER...you will have one stable patient that can move to the hall to open a bed up...which sucks, I know, I have done some shifts in the ER...not alot but enough to appreciate what you all do down there. Sometimes...when I say I do not have a bed...I really do not....I may not have someone I can send out. This past week out of 15 pt's in one unit I had 13 vents. We have worked with the staff in the unit to not sit on patients and to get report ASAP from ER, because if it is me I want them now rather than later. Some nurses just suck that that. Some will sit all day on a downgrade and that is absolutely unacceptable. However as charge I do not have time to go read every chart to make sure they are telling me that they recieved downgrade orders. I mean really they should do their job. There are also times that I have to have the ER hold, because I have very sick patients on the floor that i have to move. I mean seriously I cannot leave an aortic dissection on a floor with a nurse that has 6 other patients, and has no idea what esmolol is. At least I know that you guys know how to handle the patients in the ER. I am sure that they are taken care of...that cannot always be said about a bad pt on the floors. But as ER and ICU nurses we really need each other to keep the wheels turning.
And what is really bad at my hospital, is the misplaced patients. It causes backlog everywhere. Each of us cringes when we come on to see a tele patient in our assignment, because this means we will definitely have to transfer and accept--on a sudden rapid basis no less. My hospital routinely keeps teles in the ICU until ICU beds are needed. This is ridiculous in my eyes. It makes for hasty transfers and missed stuff on the poor tele patient. Most errors occur as a result of hand-offs and I think these rapid, sudden transfers set us up for error. At least whenever I have a tele they won't let me move, I try to get everything done (tele orders, med reconciliation, research everything on the patient and have all info written down) to facilitate a speedy safe transfer when the tele bed suddenly opens up so I or the next shift can accept the next ICU ASAP. Problem is, often the patient has been tele status for over a day, and no one has gotten this stuff in order, then I come on at shift change and have to get it all figured out and checked and frantically give report on a patient I don't know so I can accept the ICU patient that has been waiting for that bed. I will not transfer a patient without assessing, checking charts, labs, meds, etc. I just won't. It jeopardizes the patient and my license. Often I have big issues going on with my other patient as well (bronching, lining, road trips, hypotension, dysrrhythmias, desating, whatever--with tons of family dynamics to boot). Then when the ICU patient I admit from ED comes up a mess with very little info to work with as in some of the situations I mentionined, and I haven't even gotten to deal yet with my other very sick patient let alone document on the one I just sent out, it makes for extremely frustrating times. Then I read this post, and it rubs me, because I don't think many of you really do understand our side.
However, I do see the points raised by many of you all as well. I do understand that you can't refuse patients. You have issues too, just different. I wish we could all be a little more understanding of each other's predicament. I have not worked ED for many years. I don't think I could do it, because I would be ******* off the docs and the charges by trying to address the stuff I felt was important.I would be asking the doc for a line on a patient we could not get anything but one peripheral #22 on a hypotnesive patient on pressors. I would be asking the ED doc to swithc to levo on my tachycardic patient. I would ask for repeat ABGS on the patient we intubated 45 minutes prior that has not improved. I would asking for lactic acids and fluids, and blood cultures, etc. etc. etc. These are all the things I ask of my intensivists--it is expected of me. I guess it's not down there, because there stacking up. Your not just there to follow orders though? Or is that what it is in ED now? Is it so backed up that you are not allowed to critically think and question and ask for stuff? Maybe because the doc is there, it is on his/her shoulders and not yours so much. I know that in the teaching hosptial ICUs I have worked, the nurses were not expected to critically think near as much as in the hospitals without intensivists available on the units 24/7. My best friend who currently works in the big inner city level 1 teaching hospital where I used to work tells me they can't even get a gas without an order these days. So... maybe it's just different when docs are present now days. I guess it is not up to you... I can see that I guess.
I know I do critically think. I critically think all the time for pts who are waiting hours for an md exam. I diagnose, treat, and order interventions daily on pts who cannot wait on an md exam. I never stop critically thinking, it's just that I reserve a lot of time and energy for the ones who haven't been seen yet, they depend on me and only on me. That is a lot of responsibility. I can't afford to miss a symptom. Neither can they.
ThrowEdNurse: "I reserve a lot of time and energy for the ones who haven't been seen yet, they depend on me and only on me. That is a lot of responsibility".
I agree that is alot of responsibility. It seems that we are all trying not to let the non-critical patients suffer in the shuffle of critical care patients and bed availability. I can appreciate that.
Though this thread has drifted a bit, there are some great points.
Though not the most experienced nurse around, I have worked both ICU and ER. I feel like I have a pretty good understanding of both. I really enjoyed working both at the same hospital: while in the unit, I could complain "Those slacker ER nurses, sending me yet another mess to clean up." While down in the ER, it was "Uptight unit nurses. If I only had 2 patients for 12 hours, then I would have assessed his integumentary system. He's having a frigging MI..." Occasionally a coworker might realize it was toungue in cheek.
I think that the common ongoing problem contributing to the friction between the units is a lack of understanding. I think that during ER ir ICU orentaion, the orientee should be required to spend time in the other unit. So- an ER orientee follows the pt to the unit, does the intake assesment, etc. Finishes the shift with the pt- under ICU supervision, obviously. The ICU nurse works in the ER, and is directed toward any pt who is a likely ICU admit.
The other thing that would go a long way is report format. ICU nurses are used to a certain format. When I give ICU report, I try to speak their language. A couple of things I do:
I quickly read or scan an H and P or recent discharge summary. It doesn't take that long. Even though I may have felt perfectly safe caring for this critical PT without the detailed HX, the unit nurse needs a bit of a broader picture.
Then I do a quick systems based report. If there is a system I haven't fully assesed, I say that.
Taking a second to mention that I didn't do a skin assesment shows that I know it's part of the overall nursing process, but it wasn't one of my priorities.
Maybe I don't remember which area of the brain is bleeding. I was kind of busy keeping the airway clear of vomit, and now the admitting doc has the CT reading. I will simply say that the scan showed a bleed, I don't remeber where, and the doc has the chart.
There are many small details that an ICU nurse might want to hear that are well documented on the ER chart. Rather than verbalize all the details, I will mention that they are on the chart. I am not going to read somebody a medication list with 20 meds.
When I am done, I ask if there is anything else they need to know.
While it might seem that it would take longer to prepare an ICU style report, I would argue that in the long run it saves time. It also makes the transfer process go much more smoothly.
Especially after giving the OD patient charcoal with sorbitol. After the third time cleaning while getting ready to transport, I put several chux underneath her and we rolled. It wasn't going to stop for a while. I did stay to help clean it up, and she did it again before I left the floor.
Spatialized
1 Article; 301 Posts
Actually, blood cx prior to ABX is a core measure for pneumonia. It is not required, but it goes into audits for our friends at the Joint Commission and reported on the hospital compare website. So it's neither a standard of care or a regulatory thing, it is an arbitrary measure of performance foisted upon us by a faceless commission. And we all know that evidenced based medicine and practice is something TJC is not too keen on (sometimes).
Cheers,
Tom