Unsafe ED

HeartRN13 · May 6, 2014

Don't take that the wrong way either. I feel absolutely great being able to solve a critical problem. Nothing makes me happier than being the one that is able to pick up on an acute and critical problem and see the patient get better. But is it really fair to the patients? That's my point with it all. I love the rush of knowing what to do, use my critical thinking quick on my feet. But it's not fair to the patient that it's at their expense. That honestly was all I was getting at and where my frustration comes from. I had a woman in for CHF a couple days ago and 2 days later come in to find that we diuresed her, fixed her CHF, and she reacted too sensitively to the Lasix so someone had LR running at 125 an hour for 28 hours. Guess what happened? Yeah you guessed it, shortness of breath and crackles through the lungs with zero tolerance to ambulating. These things happen, but if we all put in a LITTLE mode effort to paying attention to the patients needs instead of squawking about what we are left with, I think our patients would be better off.

Anna Flaxis, BSN, RN · May 6, 2014

To me, sending up a patient who is in rapid a.fib and nothing was done about it at all is not acceptable. Sending up a pneumonia patient who has a pulse ox in the 80s and now needs bipap is not acceptable.

No, you are absolutely correct that those things should have been addressed in the ED. If things like this are happening on a regular basis, then I agree with you that it certainly appears that there is a problem. It's easy to get angry and jump to conclusions about the ED staff, but I think it begs the question "What else is going on here?" and maybe some digging a little deeper to try and understand it.

As an ED RN, I would say that based upon all you have told us, it certainly does sound like the ED staff is stretched too thin. I'm not sure what the solution might be, probably more RNs or even just adding some support staff like a few more techs would help a lot. But it can be hard to get administration to see it that way. Sometimes the only thing that will get their attention is a sentinel event. Unfortunately, even a sentinel event might not be enough until a family sues for wrongful death.

HeartRN13 · May 6, 2014

No, you are absolutely correct that those things should have been addressed in the ED. If things like this are happening on a regular basis, then I agree with you that it certainly appears that there is a problem. It's easy to get angry and jump to conclusions about the ED staff, but I think it begs the question "What else is going on here?" and maybe some digging a little deeper to try and understand it.
As an ED RN, I would say that based upon all you have told us, it certainly does sound like the ED staff is stretched too thin. I'm not sure what the solution might be, probably more RNs or even just adding some support staff like a few more techs would help a lot. But it can be hard to get administration to see it that way. Sometimes the only thing that will get their attention is a sentinel event. Unfortunately, even a sentinel event might not be enough until a family sues for wrongful death.

Absolutely. This has been a learning experience for me, especially in the sense that now I will be more sensitive to the things that the ED nurses have to deal with. If we are facing things like that on our floor then I can't imagine what they are up against there.

Anna Flaxis, BSN, RN · May 6, 2014

You just made me cry a little. Thank you.

Gabby-RN · May 8, 2014

Well here I am days later after posting this and definitely cooled down a lot since. It is unfortunate that there is a huge and obvious disconnect between the floors and the ED nurses. Unfortunately it seems as though a big factor in it all is attitude. To be quite honest, i can put any personal grievance aside if it means my patient is taken care of. To me, sending up a patient who is in rapid a.fib and nothing was done about it at all is not acceptable. Sending up a pneumonia patient who has a pulse ox in the 80s and now needs bipap is not acceptable. Both of which have happened in the last couple weeks, including a patient who was also a pneumonia, coded, and died. 3 patient scenarios all within a couple of weeks coming from the ED, something here is a little fishy. This may not be the case in all EDs but unfortunately I do suspect it is the case in mine. I'd do anything to help my patients and lately it feels like the ED doesn't. Could it be they are stretched too thin? Absolutely. But people are left in critical condition and nothing is being done until they get to our floors. I just wish there were a different answer than what has been happening.

If these things are happening it is certainly wrong but all the fault can not lie on the ED staff nurses. The doctors should be held responsible for not adequately stabilizing the patient. The management team should also be held accountable for not ensuring their staff execute orders prior to transferring patients, assuming orders were written. If meds were ordered to try and treat the rapid afib and the nurse did not administer that is one thing but if no meds were ordered prior to the transfer the ED nurse really can't do anything besides chart that the MD was notified and no new orders obtained.

BrnEyedGirl, BSN, MSN, RN, APRN · May 8, 2014

This argument is as old as nursing,....I spent 8 years "upstairs" before spending the last 9 years "downstairs" in the Ed. I've played this game from both teams and it stinks sometimes. We are all understaffed and overworked. It is never fair to assume that someone else isn't working as hard as you are or that someone is slacking because everything wasn't done to your liking. We all have too much to do in the time allotted,..we need to work together to fix the system rather than fight with each other! Happy nurses week everyone!

HeartRN13 · May 8, 2014

This argument is as old as nursing,....I spent 8 years "upstairs" before spending the last 9 years "downstairs" in the Ed. I've played this game from both teams and it stinks sometimes. We are all understaffed and overworked. It is never fair to assume that someone else isn't working as hard as you are or that someone is slacking because everything wasn't done to your liking. We all have too much to do in the time allotted,..we need to work together to fix the system rather than fight with each other! Happy nurses week everyone!

You are very right and happy nurses week to you as well.

sweetdreame, BSN, RN · May 21, 2014

I completely understand your concerns. I have worked MedSurg, ER and ICU and have seen it from all sides.

I would STRONGLY encourage you to pick up a couple shifts shadowing an ER nurse to see what is really like down there. Its pretty impossible to transfer your patient upstairs when you are doing CPR on someone else, starting an IV on the new patient, and medicating the crying kid with a broken arm ALL at the exact same time.

And honestly there have been times in the ER when my most stable floor patients do sit there for four hours without me doing much. Maybe hang an antibiotic? The lower priority patients go to the bottom of the list. It isn't ideal...its messy...but that's the beauty of ER. You should definitely check it out sometime.

sweetdreame, BSN, RN · May 21, 2014

The main thing that bothers me about this is the lack of communication on both ends. Why didn't the floor nurse at an hour call down and ask whats up? At 2 hours, 3 hours, 4 hours? Why isn't the floor nurse worried about where their pt is? The ER nurse should have also called up and updated on the delay too.
When I worked the floor, anything over 30 minutes warranted a call down to the ER asking whats up. But I had a very good working relationship with my ER nurses *shock and awe*. We were on the same team and we would offer to go get our pts all the time or send a tech to get them. We knew when they were getting killed. They would come and help us out when we needed it too.
Personally, I like getting rid of my pts as fast as I can. Gives me a new one with lots of stuff to do as opposed to an old pt that everything is done on.

I completely agree. I have been known to just go down and get my own patient. The ER nurses love me. :nurse: ...seriously they do.

suanna · May 21, 2014

With apologies to stargazer et al, I've been floated to an ER where exactly what heartRN13 described and for exactly for those reasons happens all the time. End of shift- the docs clear the floor so they aren't accused of leaving thier problems for the next shift. If patients are admitted the nursing staff tend to just drop them off the things to do list and since ER service isn't writing on them anymore- easy patient, they become the lowest priority despite being ill enough to warrent admission. Yes, if the nurse sends the patient up, you can bet he/she is going to get hit with the next patient through the door. If your other patient(s) are busy, you hold on to the "admit to floor" patient so you don't get hammered with another before you get your current problems solved. I've seeen it happen ALL THE TIME.

Anna Flaxis, BSN, RN · May 22, 2014

End of shift- the docs clear the floor so they aren't accused of leaving thier problems for the next shift.

In both the EDs I've worked in, the physicians do have to dispo their patients before they leave, but not for the reason you state. Unlike hospitalist service, where patient loads are transferred from one physician to the next, in the ED, the physician is responsible for the patient from the time they pick up the chart until the disposition is made. Of course, there are exceptions, as in a really long workup or a mental health patient on a hold, for instance. It would be impractical for the same physician to be responsible for the entire length of stay. This is why you will see physicians only picking up low acuity patients, like 4s and 5s (if using the ESI system) for the last hour or so of their shift. This is because they have to dictate on their patients, and they can't dictate until final disposition has been made. Again, there are exceptions, but this is the way it generally works.

As far as admitted patients getting dropped off the things to do list, if the patient is stable and all the ED orders have been done, then yes, that patient falls to the bottom of the priority list. Also, in general, patients get more frequent VS in the ED than they do on the floor- usually Q2 hours for stable patients as opposed to Q4 hours on the floor. Just because a person is ill enough to warrant admission does not mean they are unstable, and when you have a known stable patient compared to an unknown potentially unstable patient, guess who is at the top of the priority list?

Yes, if the nurse sends the patient up, you can bet he/she is going to get hit with the next patient through the door.

Maybe in EDs where they practice zone nursing, this is the case, but we don't practice zone nursing in my ED. And, if someone needs to come back, then they need to come back whether I have an admitted patient waiting for a room or not. I just take the new patient in addition to whatever I already have. I don't get to say "No, my rooms are already full". If someone needs to come back, I'd better figure out how to get them back.

Gabby-RN · May 22, 2014

The other day I called to give report to the intercare nurse, the patient had been pretty stable for a couple of hours, downgraded to nasal cannula, talking, etc. After giving report, I put the patient on the transport board. The orderlies were a little backed up, I let the nurse know it would be about a half hour. Meanwhile, the patient ended up having difficulty breathing, respirations increased to mid thirties, tachy 120-130, audible crackles, patient tanking, paged inpatient MD twice and ended up putting patient back on bipap and notified ED docs they may need to intervene if inpatient MD didn't get down here soon. Inpatient MD shows up orders lasix, dig, dilt, continue with bipap, prepare for possible intubation. Transfer to unit on hold until patient stabilizes. I do not want to hold this inpatient or any inpatient. Things can go south at any time. My assignment is supposed to be 4 patients. Patients don't stop coming in, I may not get level 2 patients but I still get more patients. This day 2 of my 4 patients were inpatients we were holding waiting for rooms, the above patient and an NSTEMI on a heparin drip. Understandably both families had a lot of questions and took up a lot of my time. Im fielding questions from family, the inpatient MD's that are coming down to assess their patients, the ED docs asking about their patients, families, coworkers, etc.

I do not know how other ED's run but I never hold on to inpatients any longer than I have to. If. I had been able to transport the above patient immediately It would have saved me a lot of time and been better for the patient because their nurse on the floor would have had them and one other patient and had way more time to focus on their needs.