What is your ER like?

IT'S EVERYWHERE! I work in the second busiest ED in the state, and holding admissions is a nightmare...usually much worse in the winter, but this year it's bad already. Every day I've worked this week, I've walked into holding 20+ pts waiting for beds. (85 bed ED, counting hall beds)

The ER I currently work in get 40-45% of its patients admitted (according to hospital statistics). I see about 50-60% admitted, depending on the day of the week. Even though a holding district was made for admitted patients, it only handles 6-8 beds. With 30+ beds and over 50,000 visits per year....well... you do the math. Beds are lined up end-to-end in hallways. ICU nurse to patient ratio is 1:2, so in any given day, 1-5 ICU patients are held for at least 4 hours, some up to 24. I have even seen the vented patients put in the hallways while on cardio, vasoactive and propofol drips. I think that they got the idea for the movie Coma from our place. I do think that the backlog into the ER is a widespread problem.

I don't know about your place; but, I see a lot of unnecessary admissions. Eg: 24 yo pitching for a weekend softball game with chest pain only upon movement & to palpation, normal EKG and 2 sets of neg CE, no hx, no SOB & a slightly swollen pec muscle---admitted for r/o ACS; where, another 54 year old with SOB, crackles that can be heard a block away, CHF hx is given a dose of Lasix and sent to f/u c PMD. The difference-------24 yo has a great insurance plan, 54 year old was unemployed due to medical problems. My favorite was a few weeks ago: Hypocondriac 30 yo frequent flyer felt she needed to be admitted, now, for angiogram/cardiac cath because her mother may have a heart condition. CE neg, no SOB, normal EKG X 2, no complaints whatsoever----she gets admitted and scheduled for an AM cath. I was also ordered by the admitting doctor to give her some delivery menus so she can order in. Do you see the same type of things at your hospital?

Seems like we admit everyone...

its everywhere .we hold alot also.

24 yo has a great insurance plan, 54 year old was unemployed due to medical problems. My favorite was a few weeks ago: Hypocondriac 30 yo frequent flyer felt she needed to be admitted, now, for angiogram/cardiac cath because her mother may have a heart condition. CE neg, no SOB, normal EKG X 2, no complaints whatsoever----she gets admitted and scheduled for an AM cath. I was also ordered by the admitting doctor to give her some delivery menus so she can order in. Do you see the same type of things at your hospital?

Yes, to some extent. One of our admitting dr's always tries to push his pts into ICU for silly stuff, and those holds are even longer (most of the time). Often, the ICU patients stay in the ER so long that they end up getting downgraded to tele before they get a room. And then, we frequently get admitting dr's coming in to order "stat" tests when the pt. has already been stabilized and we've got critical pt's laying around all over the place. Somebody needs to tell them that wanting to get to their golf game, doesn't justify stat orders. Hey, it's the ER--we have priorities! This is really discouraging to hear, though (that it's like this everywhere). I've only been an RN for 6 months, and I'm already disgusted and fed up with the system. It's pretty sad that I'm already looking for something else. This just isn't how I want to live!

To answer your question -- I once had a pt. admitted to neuro ICU. Dx was multiple TIAs -- her nuero status changed almost hourly. She never made it to NCCU -- I discharged her from the ER a day & a half later after caring for her for 2 12-hour shifts on consecutive days. Let me tell you how much fun q 30 min. neuro checks are when you have 3 other patients, 1 on a vent ...

well, i'm a new grad, and this is the only er i've ever worked in, but there are some issues here, and i was wondering if this is a facility/regional problem, or if it's like this everywhere. the main problem i'm interested in right now is that we seem to be admitting a huge number of patients, and when we get admission orders, there are not enough staff/rooms on the floors or icu, so we end up holding patients in the er, sometimes for hours (the longest i've seen is 32 hours). we regularly are holding 7-10 admitted patients (in a 12-bed er) and it makes it very difficult to continue moving new patients through the er. how widespread is this problem? thanks for the input!

rachel

i too am a new grad. normally during season we have 24 rooms that includes the 1 trauma room, and 6 fast track rooms.

since we are off season, we shut down the 6 rooms in the back , and operate with just the 18 rooms(fast track rooms 1-4).

there have been times that we would have hallway beds, and a back-up in the waiting room, but we seem to clear them out quickly, and we never devert, amazing!!!

the only real problem now; are the baker acts, they can stay in our ed for up to 2-2.5 days and it all depends if they have insurance or not. you can guess which kind of baker act ends up staying longer...

nurses have 1-4 patients and will take on more when hallway becomes crowded, but all in all we move them quickly.

most of our admissions are elderly copd,cardiac type patients. our peds patients will get tested and stablized and if admission is warranted; then they get shipped out to a specialized pediatric facility.

yes, it does sometimes take us forever to get a bed on the floor,sometimes as long as 6 hours, but it is unusual for it to be worse than that.

if you ever work the fast track, it becomes amazing on how many patients, really do not need to come to the ed.

after 1900 the fast-track closes then blends in with the reg er.

sometimes night shift has a hard time, dealing with fast-track type patients, and more codes taking place from 7p-7a shift with less staff working.

i work for a hma facility, and administration watches closely to the numbers and how and if we are moving them.

they will come in and help if needed (on week-days), and monitor all activities that are taking place.

in the past it was not like this. the ed has evolved into a workable envirionment.

of course the er is not for every type of nurse.

Yes, unfortunately, boarding patients in the ED has become an ugly fact of life for any ED nurse. It is almost as inevitable as having to work shifts in triage. It is a major pain. Because I am traveling, I have had the joy of experiencing it in multiple states. It is quite frustrating as most of us wanted to work in an ER and not on a tele unit or ICU unit or a med surg unit. (please do not think that I am dogging those who do not work in the ED. It takes a special talent, patience, and skill, that I do not possess, in order to work out of the ED. My hats off to those who work in tele, ICU, or med surg!) So, when trying to handle the various things you have to deal with when it comes to your normal ED patient flow, having to remember to maintain the admission orders for your hold patients becomes quite an arduous task. Because of the super-strict interpretation of EMTALA now, we absolutely cannot turn anyone away who enters our doors, no matter what the reason. While other units are able to say that they are full or that they don't have the staffing to keep the ratios, we in the ED do not have that luxury. This leads to resentment on our part and feeling that we are "stuck" with patients who should be somewhere other than being held in the ED.

So, the long answer to your question is that boarding admitted patients in the ED is an unfortunate fact of emergency medicine in this day and age. An even more unfortunate is that with all of the issues facing our healthcare system today we are going to be doing a lot more of it.

I especially like being told that ICU cannot take an ICU admit, because the nurses already have their max 2pts. apiece. I, however, in the ER have total pt. care of TWO ICU admits, & TWO tele admits. I must be very special & talented to be able to take care of FOUR admits, while ICU cannot take care of more than two.:angryfire

I especially like being told that ICU cannot take an ICU admit, because the nurses already have their max 2pts. apiece. I, however, in the ER have total pt. care of TWO ICU admits, & TWO tele admits. I must be very special & talented to be able to take care of FOUR admits, while ICU cannot take care of more than two.:angryfire

LOL, or the ICU nurse who says I am currently discharging my other patient, give me about 15 min to discharge them.:angryfire

You know how it is in the ER, I am usually discharging a patient constantly while juggleing my other 3 patients (or more)

I must have it pretty good. Though we are a fairly small ER (about 30-ish beds), I haven't had anyone there for more than 4 hours max (from walking in to being either (a) discharged or (b) admitted). We've got 2 docs, at least 1 PA, and I think that helps. And they're easy-going, and really good about seeing people promptly to get their care rolling.

I'm guessing your place isn't a teaching hospital with residents to muck things up?