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!
The thing is, honestly most of us ICU nurses did not know that when you have a patient that critical, no one picks up the other non-criticals. Swear to God, I would not do that. It is dangerous for both the critical and non-critical patients you are responsible for. (That is why the Californai Nurses Association pushed for and got minimum ratios established- in the ED if your patient is considered ICU, the ratio is 1:2 even in ED). Now I see the need for minimum ratio mandates all the more!
My friend had a great idea that she has been thinking about for quite some time. I don't think hospitals would go for it though, especailly in this economy of cutbacks. She thought of having a float/swat nurse between the ED and ICU that when a patient in the ED was determined to be critical or ICU status, this nurse would immediately be taken out of swat and that nurse would take over the patient in the ED until transitioned into ICU. That nurse would take over the ED critical patients from the ed nurses who have 4-6 other patients. Is this realistic and doable? Or do you get too many criticals or not enough criticals to warrant this in a hospital's budget? Just food for thought. Then we were thinking that if the budget was the issue, this ED/ICU hybrid miracle nurse could be part of the "stroke team" or "sepsis team", but then what do you do when you have other ED critical patients when strokes or sepsis patients arrive to the ED? Maybe there could be an ED/ICU transition team that took care of all of it: stroke, sepsis, trauma, and any critical care patient in the ED (this would take more than one nurse to sit in this role, but they would be working (swatting in between no patients--swatting in ED and ICU both).
Thoughts?
Thanks for coming back to post this. It is appreciated, and we've all learned something.
The swat nurse setup can work - I have seen it implemented. Predictably, it is the first staffing to get eliminated when staffing is short, though.
but the most important thing is that they are only swat on down time. The real and most important job is ER/ICU transition patients. Think of what this could do for throughput and safety!!
Specializes in Psych, ER, Resp/Med, LTC, Education.
When I worked on a medical/respiratory unit one thing that always just irritaed the hell out of me is when I would have a pateint who became unstable and needed to go to the ICU--prior to going the patient is very unstable and we are doing things like getting blood drawn, or an EKG whatever.......prior to this change in status the patient was continent, walked to the bathroom....or was incontinent and used briefs but no indication to have a foley placed.......no DOC ORDER to place one prior to the emergant change in status or in the middle of it........however as soon as I would get these patients to the unit-- I would help get the patient into their bed, nurses would be all around getting a BP cuff on, getting tele leads on, oxygen on, etc. and ALWAYS some nurse would say...does this patient have a foley? I would be like--um nope, she is normally up and can get to the bathroom....well why didn't you have one in??????they'd ask all annoyed. Um CAUSE THE DOCTOR NEVER ORDERED ONE and franky one was not indicated. We don't put foleys in every patient like in the ICU. And I don't put in a foley unless I have an order to do so. Maybe in ICU nurses can do this without an order but on a medical floor ya can't. I don't know why they were always so mad about that. I man come on that was not at the top of my priority list when the patient's VS are not stable--I got in a line and put on O2, etc, was not really thinking of a foley.......
But... Here I almost want to start a whole new thread: How many of your coworkers (ICU or ED) would take advantage of such a position (ED/ICU miracle nurse) and be hiding when most needed :-( I know many
Specializes in NICU, PICU, PCVICU and peds oncology.
Me, too! Our peds transport team fills that sort of role when they're not out.They're also supposed to help out with breaks, turns, and so on. But when certain ones are on... try finding them. The worst offender is also doing some research assistant work for one of our docs, and if she's not doing "transport" work then she's doing "research" work... or hiding.
The thing is, honestly most of us ICU nurses did not know that when you have a patient that critical, no one picks up the other non-criticals. Swear to God, I would not do that. It is dangerous for both the critical and non-critical patients you are responsible for. (That is why the Californai Nurses Association pushed for and got minimum ratios established- in the ED if your patient is considered ICU, the ratio is 1:2 even in ED). Now I see the need for minimum ratio mandates all the more!
My friend had a great idea that she has been thinking about for quite some time. I don't think hospitals would go for it though, especailly in this economy of cutbacks. She thought of having a float/swat nurse between the ED and ICU that when a patient in the ED was determined to be critical or ICU status, this nurse would immediately be taken out of swat and that nurse would take over the patient in the ED until transitioned into ICU. That nurse would take over the ED critical patients from the ed nurses who have 4-6 other patients. Is this realistic and doable? Or do you get too many criticals or not enough criticals to warrant this in a hospital's budget? Just food for thought. Then we were thinking that if the budget was the issue, this ED/ICU hybrid miracle nurse could be part of the "stroke team" or "sepsis team", but then what do you do when you have other ED critical patients when strokes or sepsis patients arrive to the ED? Maybe there could be an ED/ICU transition team that took care of all of it: stroke, sepsis, trauma, and any critical care patient in the ED (this would take more than one nurse to sit in this srole, but they would be working (swatting in between no patients--swatting in ED and ICU both).
Thoughts?
I am not an ED nurse, but I have friends who work in the ED at my hospital. Here an LPN is paired with 1-2 RN's, and a PCT/CNA is assigned per pod. I think there's 16 beds per pod. In theory that's how it's supposed to work, I'm told they don't always get the PCT. But if the RN has a critical, the LPN covers the others, within his/her scope of practice. Also, the LPN transfers the noncritical pt's that need to be monitored. I know the LPN's better than the RN's, seeing as I work tele.
I am asking this here just because I know there are many ICU nurses paying attention. Believe it or not, I really do my best. I know that my best isn't the best. I know I am not the best ED nurse nor the best ICU nurse. However, I have done my best and I feel that I have not done anything amazingly stupid. I have an extremely ill pt who became that way suddenly, without warning. She became ill without my knowing her complete hx or what happened or why. I have no diagnosis. Things happened suddenly and I remembered my ABC's. Now she is still alive. She's tubed, but alive. Her VS suck. I can't get an O2 sat to properly correlate, but we've done a lot of abgs. Unfortunately, it is new resident day. This resident doesn't want to hear me. It has taken him 1 hour to get the central line placed to her chest (a double lumen! Derrr...) I wasn't happy, but it was out of my hands. She was trendelenberged the whole time with all the fluid in her legs, rushing to her lungs. I asked more than once to let me sit her head up as he prepared to insert the line but no, "I am about to start cutting right now!" WAAAY out of my hands. She bled like crazy and now there are clots in the back of her hair. I gave a partial attempt to clean the blood out some but then here comes her family, DFO'ing and trying to wake her up and asking extremely stupid questions and blood bank is on the phone and bed 2 wants ice and she still isn't putting out, and the icu resident finally comes down and starts talking smack. Does he question the ED resident's orders with the ED resident, no! He questions and drills me! Now he is all in a big rush after 1 hour on the phone with a real md. "we either need to start some new interventions now or get her to icu now!" Augh! Then shut up and write your admit orders! Anyway, ICU had no pts all day. We finally roll the pt up and and no lie, there are about 10 employees kicking it around the nurse's station. One says jokingly, "finally! We've been waiting." Then why not come down and get YOUR PT and help stabilize YOUR pt for transport? Then the receiving rn does the usual passive aggressive junk and I advise him before moving the pt over, "Oh, you may want to throw a chuck pad on that pillow, her head is full of blood from the central line placement." He does the whole, long exaggerated sigh thing and ask me to get one from the cabinet behind me. I just don't get it. I am not that invested in his pillow. I don't really care if his pillow gets messy. I was trying to help him. What did I do wrong here? Does anyone read our stinking notes? Do they not see how much was done in a short period of time? Are they clueless to how hard it is to take a body off the street and turn it into the pts they receive? I always try anyway. Before I leave I smile and ask cheerfully, "Is there anything we can do before we leave?" They usually won't even answer. This time I got an 8 second pause before he muttered, "no." He never looked at me, never made eye contact. I can't imagine treating EMS the way ICU nurses treat me when I bring them a pt who is alive. Yeah! Go me! The pt has a pulse!!! Why the open hostililty? Ooooh, sorry about the blood in her hair! Hope it doesn't kill her! Gee, I guess one of the 4 extra staff members you have will have to wash her hair. Ooooh!
But... Here I almost want to start a whole new thread: How many of your coworkers (ICU or ED) would take advantage of such a position (ED/ICU miracle nurse) and be hiding when most needed :-( I know many
She thought of having a float/swat nurse between the ED and ICU that when a patient in the ED was determined to be critical or ICU status, this nurse would immediately be taken out of swat and that nurse would take over the patient in the ED until transitioned into ICU.
Thoughts?
I appreciate the idea, but I enjoy taking on critical patients, all because we work in the ER doesn't mean we can't handle a critical patient. Not that I think you are saying that. I have an idea how about when we get a critical patient a floor nurse or med/surg or critical care or float or swat or whom ever come on down and take care of my 4 other not so sick patients.
Moreover for the time it takes me to catch you up on my critical patient, I could have given you report on all 4 of my other patients. I think once I have initiated care on a patient that is critical I am better at noticing trends and effects and carry out the plan of care on that patient than a new critical care nurse who came down to take over in the midst of the crisis.
we have a critical care nurse assigned to be available to us at all times. it's both helpful and aggravating. some of the ed nurses, myself included, have our ccrn and act as the critical care nurse at times. in order to do that we float to the icu at least twice a month. the aggravating part is that by the time the icu nurse gets there, the patient has pretty much been stabilized. what they do is help the intensivist with the art line (etc) and getting them hooked up on the cvp monitors, etc. a lot of the icu nurses will come down and pretty much assume the care of those patients....but won't chart anything! if i'm not the icu nurse that day and they've come to help my one critical patient while i take care of my others...i'll check up and notice they've charted nothing. and their response is "well it's not my patient i'm just helping out so i'm not supposed to chart". makes me wanna scream...but it's a new thing we've been trying the past few months so there are still a few wrinkles. in my eyes, i don't care whose patient it is. if i've don't ANYTHING, i chart it. plain and simple. i really don't see much need for the icu nurse unless we are holding our critical patients due to lack of beds. then it becomes very helpful. they will manage the care of those patients, for the most part, until they get a bed. it has also helped bridge the gap between the two specialties a bit. they are able to understand the chaos we work under and therefore understand the reports and situation a bit better......and we're able to learn from them what things they would like to be done before receiving the patients. sometimes we're able, sometimes we're not....and now they know why. still a work in progress though!
Altra, BSN, RN
6,255 Posts
Thanks for coming back to post this. It is appreciated, and we've all learned something.
The swat nurse setup can work - I have seen it implemented. Predictably, it is the first staffing to get eliminated when staffing is short, though.