Triage

[hmwaggs]

I work in a small hospital that staffs one nurse 24 hours a day, and an extra one from 1300 to 0100. There are 6 beds. If the OB nurse does not have a patient, she is expected to help out both the ED and M/S, but this of course is hit and miss. There is no triage, simply a waiting area. When the patients present, they ring the doorbell and we look at them. They are not checked in, vitals are not taken, and if we are busy they are asked to wait without anyone watching them. The only other staff is a unit clerk, whose only responsibility is to check the patient in after we room them. Our "great" new computer system has the nurses and docs doing all else. Although respiratory is there in the day and for paged out emergencies, at night we are expected to act as the "triage" nurse, charge nurse, respiratory therapy, pharmacy, ed tech, and housekeeping. We also do outpatient therapy. In the day, they do outpatient therapy, work meds and DOT physicals none of which are accounted for when staffing is considered. Recently, we had a pulseless patient present POV on the weekend, kitchen staff and housekeeping assisted with recording and compressions.....We were recently reprimanded for paging out for assistance and were told that ED standards require a 4 to 1 ratio. I explained that those standards are designed for ER's that have all the other resources and don't do ambulatory care treatments and asked for a protocol be in place. Needless to say, I was reprimanded and notified of lengthy wait times in urban hospitals. What are your experiences and comments? I am concerned with patient safety.

[hmwaggs]

This one has 12 med/surg beds, 2 L&D, 2 post partum, 2 OR's, and 6 ER beds. We have respiratory on call after 6pm and before 7am. There is a paging system used for Traumas and code medicals, but only respiratory, the surgeon for Tx1, a doctor, and anesthesia are legitimately on call. RN's aren't and so them showing up is sporadic, and so far only on dayshift or early evening. I had a septic patient one night and 3 other patients. Luckily the others were low acuity and were discharged. I had her for 4 hours titrating levo until the dayshift nurse showed up and provided transport, then I stayed over my shift 3 hours to wait until he returned. There aren't paramedics here, so we must transport any patients that need blood or drips.

I found staffing recommendation information through ENA that states that even the smallest facilities should have 2 ED RN's 24/7, but it was from 2005.

[freki, ADN, RN]

I would follow suit with what others have said and leave that place. I'm currently in a 9-bed rural emergency department with an annual volume of ~13,000. We staff a minimum of 2 ED RNs at all times, with increased coverage from about 11:00-03:00 (up to 5 RNs at the highest staffed times). There are nights when I feel that 2 RNs is unsafe - what you are describing is just playing dice with a lawsuit.

I believe that ENA standards of practice recommend a minimum of 2 RNs at all times staffed in the emergency department, although you should verify that. ACEP also has a policy on ED staffing that includes minimum competencies of RNs who provide care in the ED. You also might find this helpful, it's a document that has a tool for determining needed FTE's based on your volume: http://umms.org/shoremagnet/Attachments/pdf_folder/EP11l.pdf.

I'm assuming you are not unionized, but if you are you should definitely partner up with them and talk to your rep. Fill out "assignment despite objection" forms at every chance, describe and document the unsafe conditions. Keep copies of every time you tell management that the conditions are unsafe. Because like I said, it's only a matter of time before a lawsuit happens under those conditions, and if you've got a good documented history of telling management that the work conditions are unsafe you will be in a much better position when that happens.