Unsafe ED

[HeartRN13]

Lately I've noticed more and more that I happen to get my admissions right at 1040, 1045, change of shift you get the drift. Today I was told at 5 I was getting an admission. The SBAR got faxed at 7, in my hand at 710. 930pm I'm wondering where my patient is. I called down and asked the nurse when they planned to send him and his response was "ehhh I'll send him up in a bit." I told him that if he sends the patient at change of shift I'm sending him back to the ED and writing it up. To me it's unjustifiable to send a patient 3-4 hours after sending the SBAR. They hold these patients until change of shift so they don't get new patients. Now I know why my patients are coding on me when they get to my floor, or coming to me in rapid afib. The patient told me that he never met a male nurse, in fact he didn't see a nurse for 3 hours before he came up. This infuriates me. If I'm sure of one thing, it's that I'm a good nurse and always will act for my patient. I would never ever do things like that. Does this go on in all ERs? I understand they deal with a lot of BS, but these people are ones that require attention, I work on a tele floor. These patients typically need the attention and they aren't getting it.

[BrnEyedGirl, BSN, MSN, RN, APRN]

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

Yes seriously we do!!!!!!!

[calivianya, BSN, RN]

I have to complain... I got a dead patient from the ED this week. Yep, a dead patient, not a dying one.

When I got report on him they had just coded him once (second time he'd coded that night) and I got in report that his BP was 50s/40s and his pulse was so faint they couldn't get a pulse ox reading anywhere, but he did have a carotid pulse. He was already maxed out on Levophed. They said they'd wait a bit and stabilize him some more before bringing him up to me. Stupidly, I assumed that meant they'd bolus him, start another pressor, etc. and not bring him up until he was a tad bit more stable.

They brought him up about 15 minutes later just running Levophed, an antibiotic, and normal saline. He was on the stretcher and the nurse and RT were just moving around casually like nothing was wrong. I picked up the transport monitor and looked at it - his A-line read 20s/10s, and there was no pulse ox attached to him. I looked the ED nurse straight in the eye and said, "Does this patient have a pulse?" and he said, "He had one in the ED," and I repeated, "Does he have a pulse NOW?" Of course, there was no pulse. I sent my coworker who was helping me admit out to grab help and hit the code button. We never even got him to the bed, we coded him on the ED stretcher. He rolled up at 0500 on the dot, the first entry on the code sheet was at 0501, and the patient was pronounced at 0530 after a total hot mess of a code that made me look like a total unorganized idiot because the patient wasn't even hooked up to our monitors yet when I called the code. Sorry, people who rolled their eyes at me like I was dumb, I was a little too busy jumping on chest compressions to hook up cables without help.

I'm still trying to figure out if that ED nurse just really didn't want all the fuss involved with getting the family in to view a body, explaining the patient had expired, calling the coroner, the AC, and the morgue, filling out the death sheet, calling the organ procurement agency... I just don't believe it's possible for the way this happened to be an accident. Seriously, if you have an A-line in your patient and the monitor is alarming 20s/10s, shouldn't someone think to check a pulse instead of just wandering around like nothing's wrong? How about at least let the nurses at the nurses' station know that the patient is pulseless as you roll by to get to the room so people can be rolling the crash cart alongside you? Or how about you have someone on the stretcher doing compressions as you roll?

Oh... and how about you not lose the BP cuff I walked down when I brought the ICU transport monitor down at the ED's request so that when the patient arrives to the unit, I don't look like an idiot because there's not a BP cuff in the room and the patient doesn't have one on to just double-check the A-line pressure? Or how about, you know, actually hooking them up to the ICU monitor instead of using the ICU monitor just for the A-line and having everything else hooked up to a second transport monitor, to facilitate monitoring of the patient so I can just plug our monitor in instead of unhooking yours, since you HAVE OUR MONITOR? Or, I don't know, how about actually having a pulse ox on a patient who experienced a respiratory event leading to cardiac arrest and is on the ventilator?

And this was an experienced nurse! I feel like this is really common sense stuff and not rocket science. I was so glad this was my second to last shift at that facility because it was a truly scary place.

And, for the record, I am still peeved that I looked like a moron.

[ChristineN, BSN, RN]

I have to complain... I got a dead patient from the ED this week. Yep, a dead patient, not a dying one.

When I got report on him they had just coded him once (second time he'd coded that night) and I got in report that his BP was 50s/40s and his pulse was so faint they couldn't get a pulse ox reading anywhere, but he did have a carotid pulse. He was already maxed out on Levophed. They said they'd wait a bit and stabilize him some more before bringing him up to me. Stupidly, I assumed that meant they'd bolus him, start another pressor, etc. and not bring him up until he was a tad bit more stable.

They brought him up about 15 minutes later just running Levophed, an antibiotic, and normal saline. He was on the stretcher and the nurse and RT were just moving around casually like nothing was wrong. I picked up the transport monitor and looked at it - his A-line read 20s/10s, and there was no pulse ox attached to him. I looked the ED nurse straight in the eye and said, "Does this patient have a pulse?" and he said, "He had one in the ED," and I repeated, "Does he have a pulse NOW?" Of course, there was no pulse. I sent my coworker who was helping me admit out to grab help and hit the code button. We never even got him to the bed, we coded him on the ED stretcher. He rolled up at 0500 on the dot, the first entry on the code sheet was at 0501, and the patient was pronounced at 0530 after a total hot mess of a code that made me look like a total unorganized idiot because the patient wasn't even hooked up to our monitors yet when I called the code. Sorry, people who rolled their eyes at me like I was dumb, I was a little too busy jumping on chest compressions to hook up cables without help.

I'm still trying to figure out if that ED nurse just really didn't want all the fuss involved with getting the family in to view a body, explaining the patient had expired, calling the coroner, the AC, and the morgue, filling out the death sheet, calling the organ procurement agency... I just don't believe it's possible for the way this happened to be an accident. Seriously, if you have an A-line in your patient and the monitor is alarming 20s/10s, shouldn't someone think to check a pulse instead of just wandering around like nothing's wrong? How about at least let the nurses at the nurses' station know that the patient is pulseless as you roll by to get to the room so people can be rolling the crash cart alongside you? Or how about you have someone on the stretcher doing compressions as you roll?

Oh... and how about you not lose the BP cuff I walked down when I brought the ICU transport monitor down at the ED's request so that when the patient arrives to the unit, I don't look like an idiot because there's not a BP cuff in the room and the patient doesn't have one on to just double-check the A-line pressure? Or how about, you know, actually hooking them up to the ICU monitor instead of using the ICU monitor just for the A-line and having everything else hooked up to a second transport monitor, to facilitate monitoring of the patient so I can just plug our monitor in instead of unhooking yours, since you HAVE OUR MONITOR? Or, I don't know, how about actually having a pulse ox on a patient who experienced a respiratory event leading to cardiac arrest and is on the ventilator?

And this was an experienced nurse! I feel like this is really common sense stuff and not rocket science. I was so glad this was my second to last shift at that facility because it was a truly scary place.

And, for the record, I am still peeved that I looked like a moron.

You did not look like a moron. You did the best you could under the circumstances. As an ER nurse, I would not have transported that pt up with out either additional interventions being done or getting his code status changed.

[Esme12, ASN, BSN, RN]

I have to complain... I got a dead patient from the ED this week. Yep, a dead patient, not a dying one.

When I got report on him they had just coded him once (second time he'd coded that night) and I got in report that his BP was 50s/40s and his pulse was so faint they couldn't get a pulse ox reading anywhere, but he did have a carotid pulse. He was already maxed out on Levophed. They said they'd wait a bit and stabilize him some more before bringing him up to me. Stupidly, I assumed that meant they'd bolus him, start another pressor, etc. and not bring him up until he was a tad bit more stable.

I would NEVER transport a patient like that as a full code!

As an ED nurse and an ICU nurse...this was a dump and unless they had overwhelming trauma or bio-hazard coming to the ED then this is NOT Okay. I"d be really P.O'd

I'd be writing this up to risk management.

[icuRNmaggie, BSN, RN]

to Calivianya:

you did very well. Coding him on the stretcher confirms that he was too unstable for transport. Save your notes. This is a sentinel event and I would ask for a root cause analysis.

[calivianya, BSN, RN]

I would NEVER transport a patient like that as a full code!

As an ED nurse and an ICU nurse...this was a dump and unless they had overwhelming trauma or bio-hazard coming to the ED then this is NOT Okay. I"d be really P.O'd

I'd be writing this up to risk management.

I was extremely angry. I like the super critical patients, but I prefer for them to be alive when they get to me. I had been super excited about getting this guy because he was supposed to be a therapeutic hypothermia and I've only had one of those before, and then only in the maintenance/rewarming stage, so I hadn't got to have someone during the cooling stage before. Obviously, I didn't get the opportunity this time either.

I was sleeping pretty hard yesterday - I missed my manager and the critical care secretary calling me. Apparently, this is a risk management deal now. I didn't report it because I am leaving (Tuesday night was my last night) and I just was over everything about that hospital, but apparently someone else did. I was supposed to go to a mandatory meeting yesterday at 1600, but when you call me at 1300 and the meeting's at 1600, and I didn't even wake up until 1800 because I got off work at 0730 and didn't fall asleep until 1000... that's not going to work. Yay for disrespecting night shift's sleeping patterns! We'll see how that goes down.

[icuRNmaggie, BSN, RN]

to Calivianya:

you did very well. Coding him on the stretcher confirms that he was too unstable for transport. Save your notes. Notify your malpractice carrier.

These negligent ER people have already shown you who they are and if there is a root cause analysis they will at first try to pin it all on you. "That all happened upstairs haha" Actually the people who are at really fault, the medical staff, never show up at the RCA, just the people who have to clean up their messes.

They all should be exposed. I had a travel nurse position in a low level hospital and this happened to me three times, one the drug addicted anesthesiologist brought me a post op THR in PEA, one the ER brought me a head bleed that occurred following an LP and they refused to rescan him when he seized and blew his pupils and the other a NH pt in urosepsis who was purple and mottled due to a pneumo and who needed a chest tube. It is appalling what passes for emergency room treatment in some facilities, they dont even try to stabilize the pt., just dump the person off in ICU and run.

Congrats on getting out of that job.

[calivianya, BSN, RN]

Oh yeah, this hospital's ER was terrible. They are doing critical staffing pay right now, too, because they can't get anyone to stay (time and a half + $15/hr if you pick up a shift). . They don't typically start drips down there unless it is a total emergency. I hear a lot of "It's harder for us to get things from pharmacy and it won't scan for you if I do, so you might as well just start that insulin drip when the patient gets to the unit."

They turf a lot of the work onto us.

There were a few good people down there, but not many. To their credit, I did get report from a nurse once on a patient who was Coumadin toxic, and the nurse went ahead and ran all six units of FFP and two units of PRBCs in the ED before bringing the patient up. She did all of my work for me. He was totally stabilized by the time I got him and it was the easiest admit ever. Some of them are gems, but the vast majority scared me to death.

[FlyingScot, RN]

Please consider having the mods edit your last post. The internet and this forum are not nearly as anonymous as some might believe. I'm afraid your accusation against this hospital, while it may be very true, may come back to haunt you legally!!!!!!!

[calivianya, BSN, RN]

Thanks for looking out for me, guys. I don't always think about that kind of stuff. :)

[NotMyProblem MSN, ASN, BSN, MSN, LPN, RN]

I wonder if we work at the same hospital! They called report to me on a basic foot injury; had been in the ER for 5 hours when I got him. But I never got a chance to assess his foot because RT was on the case upon arrival due to fluid overload and failure to maintain O2 Sats, cardiology had been consulted for A-fib, Rapid Response Team was activated, and we transported him to the unit for intubation! I got this on a med/surg floor!! CXR in the ER showed a collapsed lung upon arrival and even with rhonchi being heard without a stethoscope, not one milligram of Lasix was given. The patient's first dose of any kind of medication that day was given by me shortly before midnight (Lasix 40mg IVP) as RT struggled to get ABGs and place a ventimask that the patient would not leave on.

So, from ER to med/surg to ICU for intubation. I'm assuming he still has his foot injury because none of us gave a flip about it; that was ER's priority, not ours.

[calivianya, BSN, RN]

I wonder if we work at the same hospital! They called report to me on a basic foot injury; had been in the ER for 5 hours when I got him. But I never got a chance to assess his foot because RT was on the case upon arrival due to fluid overload and failure to maintain O2 Sats, cardiology had been consulted for A-fib, Rapid Response Team was activated, and we transported him to the unit for intubation! I got this on a med/surg floor!! CXR in the ER showed a collapsed lung upon arrival and even with rhonchi being heard without a stethoscope, not one milligram of Lasix was given. The patient's first dose of any kind of medication that day was given by me shortly before midnight (Lasix 40mg IVP) as RT struggled to get ABGs and place a ventimask that the patient would not leave on.

So, from ER to med/surg to ICU for intubation. I'm assuming he still has his foot injury because none of us gave a flip about it; that was ER's priority, not ours.

I doubt we worked in the same place - the way you said you activated the rapid response TEAM implied you have an actual rapid response team. When we called a rapid at my hospital, it's the ICU charge nurses that went, and whatever ICU nurses were free tended to go as well. I think it sucked for the patients because the experience and number of people who showed up vary considerably just based on who was free to go at the time. All I have to say is that I went to everything that was called on any shift that I worked, so it was great experience for me and I liked that setup quite a bit.

Your story is ridiculous, though - you'd think the ER could get a bit of Lasix in!