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!
" 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?). "
Well, one reason is that because the ICU would not take report because they were in report and I am just coming on to my shift to an admitted ICU pt that I know nothing about but what the off going shift told me plus 3 or 4 other ER pts who need things done as well as a squad coming in to bring a pt.
The 2nd reason would be that I am busy with my MI pt that just came in by squad, I need to get people moving out of ER to the floors to open rooms for the next squad coming in and a waiting room full of pts so my charge nurse or another nurse who may have 2 min to call report does so by looking at my nurses notes and giving the ICU the basics.
I was an ICU nurse as well. I've gotten crappy reports for ER but as long as I knew what the pt came in for, I figured the rest out with my assessment and diagnostic tests. I was lucky if I got a med list or a history.
It is up to the hospital's Nurses.. They will ultimately decide. Thay'll decide if the reports are good, or Bad.. Which it can B
Give a good report is all... Tell them what you know about the before, and Tell them what you saw. Tell them meds - and the stuff done in the ED, or what we expect to come...
And, Most importantly, tell them what you do not know, plus what you thnk...the rest will come for them
The ICU/ER thing is both annoying and understandable. Nursing is not just one specialty but blends many.
It's simple, one nurse cannot care for 5-8 critical patients with minimal help in the same way an ICU nurse who has 1:1 or 1:2 can....it's impossible.
This isn't about being better or worse. My hectic pace and ability to multitask many sick patients will put me in an early grave, but in 99% of the cases patients are stabilized, packaged and sent. If I can they are clean, always medicated, and usually have a central line if the residents put it in! I am a pain and have no problem playing every card I have to get it placed so that lifesaving efforts are not in vain.
However, I am not the doctor! They have a huge role in doing or not doing the things required to make life easier on all of us. I will placed several small g catheters if necessary but I hate doing it! And truly do not have the time. When I see the fish eye over 5-15 minute vitals, titrate drips, or neuro/ accucks I then want to drag those with the face to the ER to see that I was lucky if they were done sequentially at all! Or that a list of vitals actually were charted! It isn't a luxury we have, plain and simple.
While I see the frustration on the faces of the ICU nurses when an ulceration or redness isn't documented in size, etc-or every facet hasn't been explored....I say, try my job then see if how you do. That I focus on the problem and manage a head to toe is amazing! That I initiate orders and medicate many times is a miracle.
With holding so high in many hospitals, including mine I have suggested rotating ICU nurses into our ER and letting them assume the ICU patients..Why not? Good for the patients, and I believe good for the ICU nurses to see (not do) what we are doing daily.
We shouldn't fight, and honestly I think we all do are damndest to save and assist our patients in their quest for wellness. Without solidarity in our profession we will continue to be splintered and fighting these stupd fights. Our fight should be for quality care, and how it is affected across the spectrum as patients travel through our varied specialties and departments. The walls we face as we do this are impacted by budgets, physicians, systems and US!
This is and has been a crap argument! We are all in it together, why can't we make it count?
I think more often than not, it depends on the nurses involved (and this isn't just limited to ICU Vs ER).
There are some nurses I LOVE handing patients off to: no-nonsense, no BS, get to the point, thank you. They don't whine. They don't moan. They're confident, capable and smart. They maybe curt at times but that's because they're busy and don't have time to waste.
They appreciate any "extra-stuff" I might have done for 'em [drawn extra sets of cultures, thrown in that extra line, requested additional sedation/pain meds etc.] but at the same time, take my apology at face value and generally not create a scene when I tell 'em about the stuff that I wasn't able to do [start the abx., draw the second set of labs etc.]
And THEN... there are some nurses. Well, I can just say that forget ICU - I don't like taking their patients when I follow 'em down in the ER!!! They're lazy, incompetent or both.
I'm not saying I'm "super nurse" but I'm sure y'all can figure out what I'm talking about.
I also think that the whole "squeaky wheel gets the grease" is quite true. We can all remember the "bad hand offs" but hardly think twice about the "good hand offs" [i suspect that if we compare numbers, the good will far outweigh the bad... and more often than not, it'll be the same set/group of nurses involved in the 'bad hand offs'].
Frankly, no amount of "let's see what the other side has to deal with" is going to help in such cases. More often than not, I suspect it might degenerate to "Oh, you're busy?! Well, so are we!" Understanding and accommodation has to come from within (on a tangential note: I do believe that we as a society in general are becoming a little more inconsiderate towards each other). Do unto others...
You can have a horrible shift and find it manageable because of the people working that shift - both in the ED and in other departments [floors, ICU - heck, even transport crew and EMS/medics!] And you can have a horrible night simply because you are fending for yourself and picking up after the slackers...
Personally:
* Bed assignments in the ER don't show up until a bed is ready and a nurse has been assigned to the bed [which means I should be able to call report and get it done without further delay].
But when I call report and the ER isn't slammed at the time and they ask for more time, I give the floors/unit a break and give 'em some time (to the supreme annoyance of my charge nurses - and they have a valid point. In the ER, there is no way to predict if we'll have 1 patient or 10 in the next 5 minutes... hence why once a spot opens up, it must be cleared immediately to prepare for any eventuality). I'm a nice guy - I've been in your shoes. Tell me why and more often than not, I'll be able to accommodate your request.
But please don't say "5 minutes" when you mean "15 minutes". Pick a time and stick to it.
* I'm a pretty laid back feller but when I say "I'm sorry. I can't hold off. I need to move the patient NOW"... I mean what I say. All hell is breaking lose down in The Pit and if I don't make room - someone is going to get seriously hurt or die. I don't like coding patients in the hallway anymore than you do...
* I don't tell you how to do your job. Please don't presume to tell me how to do mine.
Just a few thoughts from a current ED nurse/former floor nurse.
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.
my
You misunderstand me. I did not mean that the Swat ED/ICU miracle nurse could not be an ED nurse. I meant it was a position for either. An FTE with skills for both areas that is not in the count, so that when an ED patient becomes critical, this ED/ICU/SWAT nurse takes over that patient, thereby reliving the nurse responsible for 6 others to pay attention to those six other patients.
I think more often than not, it depends on the nurses involved (and this isn't just limited to ICU Vs ER).
I have been following this thread, but have yet to respond. I am an ICU nurse. I am responding to Roy's post, but I'm throwing in a few comments that don't pertain to what he's written.
There are some nurses I LOVE handing patients off to: no-nonsense, no BS, get to the point, thank you. They don't whine. They don't moan. They're confident, capable and smart. They maybe curt at times but that's because they're busy and don't have time to waste.
They appreciate any "extra-stuff" I might have done for 'em [drawn extra sets of cultures, thrown in that extra line, requested additional sedation/pain meds etc.] but at the same time, take my apology at face value and generally not create a scene when I tell 'em about the stuff that I wasn't able to do [start the abx., draw the second set of labs etc.]
ER, please understand that the culture in my ICU is to test the new ICU nurse. Transfer your existing patient and admit the ER patient all within an hour. It was stressful, and yes, I was known to whine. I just didn't have a clear picture of our ER patients. Now I know better and do my best in the beginning of my shift to prepare. But it was not part of my orientation. I've learned to be accepting of whatever the ER hands me, albeit the one or two ER nurses who are notorious for rolling up a patient without the basics. I'm not talking pulse ox and BP, I'm talking more of the "patient is being ruled out for swine flu" info or why a patient got intubated in the first place. (Yes, the patient may be a COPD'er but the real cause of his intubation was his alcohol level of 400 and his attitude.)
And THEN... there are some nurses. Well, I can just say that forget ICU - I don't like taking their patients when I follow 'em down in the ER!!! They're lazy, incompetent or both.
I'm not saying I'm "super nurse" but I'm sure y'all can figure out what I'm talking about.
I also think that the whole "squeaky wheel gets the grease" is quite true. We can all remember the "bad hand offs" but hardly think twice about the "good hand offs" [i suspect that if we compare numbers, the good will far outweigh the bad... and more often than not, it'll be the same set/group of nurses involved in the 'bad hand offs'].
This is so true. You know, if that resident doesn't get the line in two attempts, he or she is outta there. Same goes for bad handoffs from nurses. Clean up the mess and move on. They are weeded out eventually.
Frankly, no amount of "let's see what the other side has to deal with" is going to help in such cases. More often than not, I suspect it might degenerate to "Oh, you're busy?! Well, so are we!" Understanding and accommodation has to come from within (on a tangential note: I do believe that we as a society in general are becoming a little more inconsiderate towards each other). Do unto others...
As an ICU nurse, understand that I don't have one or two patients, instead a shared responsibility for all 12 patients on my side of the unit. That means I must help with the alcoholic in DTs, the coding patient, covering the nurse who must spend an hour in MRI with his patient, the intern/resident who has left his/her phone in the lunch room and can't be found in the unit, the respiratory therapist who is off the floor and isn't answering their pages (or worst yet the RT who refuses to help you transport a patient because they are just too busy). A day rarely goes by that I don't feel the squeeze of a labor shortage too. We are expected to do more with less. I'm sorry, but understanding is important. How can we possibly know what is reasonable without understanding the other's side?
You can have a horrible shift and find it manageable because of the people working that shift - both in the ED and in other departments [floors, ICU - heck, even transport crew and EMS/medics!] And you can have a horrible night simply because you are fending for yourself and picking up after the slackers...
Personally:
* Bed assignments in the ER don't show up until a bed is ready and a nurse has been assigned to the bed [which means I should be able to call report and get it done without further delay].
But when I call report and the ER isn't slammed at the time and they ask for more time, I give the floors/unit a break and give 'em some time (to the supreme annoyance of my charge nurses - and they have a valid point. In the ER, there is no way to predict if we'll have 1 patient or 10 in the next 5 minutes... hence why once a spot opens up, it must be cleared immediately to prepare for any eventuality). I'm a nice guy - I've been in your shoes. Tell me why and more often than not, I'll be able to accommodate your request.
But please don't say "5 minutes" when you mean "15 minutes". Pick a time and stick to it.
How can we do this when the stability of our unit is almost as unpredictable as yours? We have no control over the numerous rapid responses or a code on the floor, let alone on our unit. When I'm open to take an admission, rest assured that odds are I am the rapid responder. I try to hand off the rapid response, but sometimes (especially during certain hours) they is no one except myself to respond.
* I'm a pretty laid back feller but when I say "I'm sorry. I can't hold off. I need to move the patient NOW"... I mean what I say. All hell is breaking lose down in The Pit and if I don't make room - someone is going to get seriously hurt or die. I don't like coding patients in the hallway anymore than you do...
Do you think our shift is any different?
* I don't tell you how to do your job. Please don't presume to tell me how to do mine.
Just a few thoughts from a current ED nurse/former floor nurse.
cheers,
I'm sorry ER, but our ICU is often just an extension of your situation. Unstable patients with another one rolling through the doors. (And sometimes two at a time.)
I want to address all the issues that you have brought up (ie the 22 gauge, the change of pressor, the blood gases, the tests, etc) Here is what happens. I am in a room with 5 other patients, no tech, and one other nurse. I get a report that we have a resp failure coming code three..NO WAIT, they are here. Move one patient to the hall (presto...they are cured...LOL) I am taking report from the medics, while I am trying to get an EKG, another line, Labs....*** the patient coded...now I am running a code.....Well you get the picture. During this cluster...the hospitalist has came in, spoke with my other patient..taken the doctors chart...SOMEHOW, not managed to look at the monitor showing a SBP of 70's...and then leaves with the chart. In the meantime, we are told ww have ANOTHER patient coming that MUST be in the acute care area of the ER... I rarely have a chance to have a sit down with the hospitalist. I am luckyif I can have the entire chart when I need to call report. I DO appreciate that the ICU has no doc in house and they are working their butts off.
Here is what I try to do. I try to make sure that every patient I take gets a line and rainbow. If they have ANYTHING that looks suspcious, they get the first set of blood cultures drawn at the same time. They get a foley if they are unconscious, altered or sick. At least now I have urine. We have to get the antibiotic up w/i 4 hours of the patient signing their name triage (when the waits are 6 hours....we are screwed.) and w/i 30 minutes of the doc writing the order. So, what to do if the order was not given to me, or the code ate into the time. They get the antibiotic before the cultures. Now I am screwed whent they do a chart review.
As I said, I think we all have it hard right now (floor, ICU, ER) But please forgive me if I have not reviewed the labs, the patient has not been to CT to r/o PE....we are 6th on the list....meaning another 2 hour wait) I can not keep them here longer than 30 minutes waiting for a test. I certainly will keep them on a slow night.
What really upsets me is when I call report to the ICU and that nurse has already had time to review the computer chart, including a lot of background I do not have. PLEASE do not hold me responsible for not knowing things beyond the ABC's. I do appreciate that you need a central line, and I will now refuse to send the patient up without one when their pressure is low. This gets me introuble with the management. So you may get a central line, but not a clean patient.
"I'm sorry ER, but our ICU is often just an extension of your situation. Unstable patients with another one rolling through the doors. (And sometimes two at a time.)"
My ER doesn't send unstable patients. However, we do get many unstable patients at one time, via triage and by squad. 1 RN who also 4 or 5 other patients. We don't have the luxury of asking EMS to hold a patient because we are too busy or at lunch. I don't even get lunch in a 12 hr shift. WE find an open room and we take the patient. It's very sad that some of our ER pts wait 6-7 hrs in the ER and most being bed wait times to the floor.
I'm sorry ER, but our ICU is often just an extension of your situation. Unstable patients with another one rolling through the doors. (And sometimes two at a time.)
Classicaldreams
2 at a time? WOW!!!
The other day, my ER had 3 GSW, 1 STEMI, 1 Critical CPAP pt and 1 stab wound to the chest, pretty much all at one time. And, they were all stabilized by the time they left the ER.
Not saying the ICU nurses don't rock (at least in the ICU in my hospital, I love them!!), but come on.... On a slow night, all's good. On a busy, trauma or critical night, we give quick reports in order to make room for other sick people. And, many times ICU will get pts with crappy BPs, vitals, because that's what ICU nurse do. Monitor and treat critically ill patients. I don't want these sick, sick people down with me for long periods of time. Not that I can't take care of them clinically and professionally, but, with other sick people rolling in the door, it's impossible to monitor them one on one.
The other day, my ER had 3 GSW, 1 STEMI, 1 Critical CPAP pt and 1 stab wound to the chest, pretty much all at one time. And, they were all stabilized by the time they left the ER.
Not saying the ICU nurses don't rock (at least in the ICU in my hospital, I love them!!), but come on.... On a slow night, all's good. On a busy, trauma or critical night, we give quick reports in order to make room for other sick people. And, many times ICU will get pts with crappy BPs, vitals, because that's what ICU nurse do. Monitor and treat critically ill patients. I don't want these sick, sick people down with me for long periods of time. Not that I can't take care of them clinically and professionally, but, with other sick people rolling in the door, it's impossible to monitor them one on one.
Let me guess. You took care of all them and with one hand tied behind your back.
just face it er nurses are wimpy...dont take it to be a black mark on you, heck when i goto work in the er i find myself becomming a wimp too. as stated on another thread icu nurses are way more macho!!!
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robinzkj
29 Posts
" 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?). "
Well, one reason is that because the ICU would not take report because they were in report and I am just coming on to my shift to an admitted ICU pt that I know nothing about but what the off going shift told me plus 3 or 4 other ER pts who need things done as well as a squad coming in to bring a pt.
The 2nd reason would be that I am busy with my MI pt that just came in by squad, I need to get people moving out of ER to the floors to open rooms for the next squad coming in and a waiting room full of pts so my charge nurse or another nurse who may have 2 min to call report does so by looking at my nurses notes and giving the ICU the basics.
I was an ICU nurse as well. I've gotten crappy reports for ER but as long as I knew what the pt came in for, I figured the rest out with my assessment and diagnostic tests. I was lucky if I got a med list or a history.