Time management

jojotoo, RN · Sep 24, 2007

Very quickly, walk through and make sure everybody is breathing and in no acute distress. You should be able to do this before the previous shift leaves.

You're in the ER. It's not like in school. You should be doing focal assessments. What is your patient's complaint/ problem? Follow your ABCs to prioritize who you're going to take care of first. You can be polite and supportive to your patients, but you are not there to bond with either them or their family members. Obvious exception: critical or dying patient. Tailor your assessment to the patient. Someone with flank pain (kidney stone) doesn't need their lungs listened to the moment they arrive. For that patient, you can get most of the H&P while you're putting in the line and drawing labs.

A young, well nourished, ambulatory patient doesn't need to be stripped to the skin and examined for decubs.

Think ahead. You've got a wheezer coming your way, page RT now (to get them in route while you're hooking them up to the monitor, starting IV, etc.)

Old guy from nursing home. Obviously septic. Don't wait for the MD to tell you to draw Bld Cx, draw them with your IV start and regular lab draw.

Old woman from nursing home. Has an indwelling Foley. Obviously uroseptic. Don't wait for the MD to tell you to change the Foley and send a specimen. When we have this type of septic patient come to our ER, there are many times that I have all the labs, EKG, CXR back by the time the ER MD is ready to see the patient. He just needs to order ABX and get the patient admitted.

Get familiar with what is and what isn't acceptable to be done under your own autonomy in your ER. Not sure? Ask your charge RN or your resource person.

And don't be too hard on yourself. It'll probably be about a year before you start to carry your own weight.

Good luck.

InmyblooD · Sep 24, 2007

Thanks jojotoo,

It really helps a lot when I can get feedback like that.

**canoehead, BSN, RN** · Sep 24, 2007

A new grad takes about three times as long as an old fogie, and that's normal. Focus on what brought them in, less on details re social history, other systems. If you relax about going slow your confidence in being able to do the task willbuild- and you'll get faster.

stayseerrn · Sep 24, 2007

I agree with JoJo. The ER is about addressing the chief complaint. Your assessments are ABCs and chief complaint specific. Not every pt on every assessment needs a complete head to toe assessment. Lung sounds assessment with each and every assessment is not important unless they are a CHF or difficulty breathing pt. The important thing is to notice their lip & nail bed color, their ability to speak, and the effort with which they are trying to breathe or speak. If all of those are fine, then you don't have to listen to lung sounds each time. Same principle for CV assessment (of course, this does not apply if you are dealing with heart issues or possible perfusion issues). Point is, most of your ER interventions and assessments are going to be specifically focused on the pt's complaint.

After you do your first "make sure everyone is breathing" round, again very limited and brief assessment, then work with your most critical pt first. They are always the top priority. The old addage of "if you are breathing and have a pluse, then you're waiting" is true for most ERs. Now if while you are doing your "everyone breathing round?" and you see someone critical (i.e. respiratory distress, weird rhythm on the monitor, abnormal VS readings on the monitor), stay with that patient until they are stabilized. After they are stabilized, then move on.

If you are unsure of what is the top priority in your patients, buddy up with a good preceptor or senior nurse who can help you pick out which patient should be your top priority. Again, this is where knowing your facility's standards and protocols will become a great help. Some facilities have strict protocols regarding the time frame in which antibiotics are to be administered (i.e. one hour from order written, or four hours withing presentation), and of course, there are the national core measures for things like pneumonia, STEMI, DVTs, etc. Therefore, the timeline for execution of orders is crucial. So, if you don't have an "obviously sick" person, then look for those who are protocols which have distinct timeframes for orders to be completed.

Also, standing protocols are your new best friend. It feels weird at first using them, as you almost feel like you are flying without a net. However, a large majority of ER use treatment protocols for things such as chest pain, abd pain, vag bleeding, ODs, resp distress. Try to find out your facility's policies and use them - RELIGIOUSLY. They really help expedite pt flow, which is a huge pt satisfaction issue. It makes the pt feel like we are really working towards getting things accomplished for them. Plus, it makes your life easier and keeps you from having all of your patients get seen at one time by the docs, them write all of your orders at once, and then spend the next four hours in hell trying to get them all executed. Protocols really help you stay ahead of the game. And if the facility has standardized protocols, using them does not constitute going beyond your scope of practice. The protocols are, typically, written by both the physicians and nurses of the ER who have agreed upon which orders to be executed and under what situations.

Okay, long rant to agree with JoJo. Keep your assessments to ABC, Chief Complaint. Focus on your most critical pt first. Use standardized protocols like there's no tomorrow! And lastly, relax, take a deep breath and try not to focus on the minutia of everthing. While there is great importance in the details, sometimes Emergency Medicine is looking at the minutia, but focusing more on the overall big picture of the pt.

Good luck!

gonzo1, ASN, RN · Sep 24, 2007

After I take report I go in and take a quick set of vital signs of my own on each of my four patients. At that time I tell them I am just coming on shift, need to check their vitals, introduce myself to them and tell them that I will be in within the hour to spend more time on their case. I don't always trust the reports I get so this is my way of making sure each pt is alive and breathing before we get down to the business of the shift. If I go in and something is obviously badly out of whack then I do have to deal with it and might not get to the others in a timely manner. This is the life of an ER nurse.

If a laceration comes in I right away put a lac kit, sterile gloves and lidocaine in the room, maybe a stapler.

If an eye pain comes in the eye tray goes in the room immediately, same for a nose bleed, the nose tray goes in.

After I do my first set of 4 hellos, I go to the charts and check each one and see if all the orders are done, do not always believe the nurse you follow that they are. Stuff gets missed or added in the heat of the moment.

Decide which of your 4 patients are the most likely to die on you and do them first.

Or if all are fairly stable, take care of the easiest first.

Of course, all good plans get screwed up so you must go with the flow.

One thing new nurses do is spend way to much time giving attention to the patients and trying too hard to please them. Unfortunately in todays world of nursing, esp in an ER environment there is not a lot of time for tender loving care.

We wish there was, but there isn't.

In time you will accomplish the skill of making your patients feel well cared for without a lot of fluff.

I am fortunate to work with a great set of knowledgeable nurses and doctors who do a great job and work well together.

It takes at least one year to feel like you have half a brain and two and half before you feel like you're a pretty good nurse.

Good luck in your endeavors

cmo421 · Sep 24, 2007

FYI drawing labs without lab tags is setting yourself up for errors. I know, it makes sence and we all have done in it the ER. But an increase in labs errors is making this a no no. Hospital liability and cost of labs is rising. At my facility getting caught doing this can and will get you written up and even suspended. What I have done is start two IV's and cap one off for lab draws and use the other for access. Even in the trauma rooms we have to wait for slips .( well we r suppose to).

jjjoy, LPN · Sep 24, 2007

A new grad takes about three times as long as an old fogie, and that's normal.

(OFF-TOPIC)

Given this, why are new grads given full assignments so soon? I'd guess because to schedule otherwise would be a nightmare. But the outcome is that the new nurse can't "carry their weight" for sometime, meaning that they are always behind, their patients aren't getting their care as quickly, and other nurses have to pick up their slack until the newbie can pull it all together... six months to a year?! I can see that one can't really learn how to handle a full load without having a full load, but why not a 3/4 load for the first 6 months to a year?

cmo421 · Sep 24, 2007

Ok ,I am gonna get killed for this but maybe the idea that new grads should not specialize for at least a year should be brought back. A year on a med/surg floor provides a wealth of knowledge and time management skills. I agree that new grads should be given lighter assignments for the first 6 mths no matter where they work. But we all know that will never happen.

gonzo1, ASN, RN · Sep 24, 2007

One hospital that I work ER at has you draw labs with the IV start and leave vials in the room until stickers come out.

The other we draw right away and it is usually not a problem because we label the tubes with the pt stickers which are printed almost the second the pt walks in the door.

This is just something that requires close and careful attention to, but I think it is good to avoid sticking pts twice whenever possible.

ybmad · Sep 24, 2007

Thanks for your post I am also a new grad, off orientation with 2 days on my own so far. I am on an acute care unit but the patients are total care and have many issues that all seem to need dealing with at the same time. If I could only clone myself! There is also family to speak with and my line is constantly ringing with doctors and their orders and the lab for critical results. Short staffing is a big problem as well. Often I get stuck in one room and then find myself behind, frustrated, and doubting my career choice. I did very well in school and am having a hard time coming to grips with not being able to be ahead time wise and on top of everything for each patient. I do not take breaks or a full lunch and I am still behind. I hate having to interrupt the other nurses with my questions and I hate leaving an undone task for the next shift even though it happens to me. But there are only 8 hrs to the shift. Oh, my I am so frustrated and afraid of failure! So the replies to you are helping me not feel so bad. I hope that it does not take me a whole year I hate feeling like this. Good luck to you. To write down my feelings is also therapeutic hip hip hooray for allnurses.com!

I'm a new grad that started out in the ED and we're about 10 weeks into the orientation.
I'm finding that my time management sucks. It takes me so long to assess, start a line, labs, and document.
I know that in time I'll start picking it up but what can I do to keep a faster pace.
Also, when I come on and already have 4 patients in my rooms, what is the best way for you to see all of your patients in the first hour? Do you see the sickest patient first and then do you start catching up on what you need to do with that patient? Or do you do an assessment on all the patients first then go back and start on what needs to be done on the sickest patient? And I know that this is all situation dependent but let's say all patients are stable.
I'm asking this because I tried to do set of v/s on all my patients when I first came on then my preceptor told me to concentrate on my first patient and go to my other patients when I was done. It literally took me about 1 hour to get my first patient set who was in DKA. Then I moved onto my next patient...........but it looked bad on my charting also because it looks like I didn't even touch my other patients until 1 hour after I came onto the shift.
Thanks in advance to all your replies,
Chris

cmo421 · Sep 24, 2007

One hospital that I work ER at has you draw labs with the IV start and leave vials in the room until stickers come out.
The other we draw right away and it is usually not a problem because we label the tubes with the pt stickers which are printed almost the second the pt walks in the door.
This is just something that requires close and careful attention to, but I think it is good to avoid sticking pts twice whenever possible.

Absolutely,But the rules are for error prevention. Just saying. We use to put the vials in draws in the pt's ER room,or place a name ID sticker on it which come in with the pt from triage. (or put them in ur pocket!)Nationally there has been a major increase in wrong labs being issued for pt, not just in the ER,but on floors,hence this rule that is backed by JACHO. A second IV for lab draws is always useful in repeat labs,serial tests and if main IV blows . A pt would rather be stuck twice in the beginning then be treated for something a lab value showed that was not theirs. When the doc is busy,we ask what he/she wants and put the labs in ourselves so we canhelp facilitate care.