What is your pt load? & Locking pts in room.

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Over the past 2 years the our ED census has increased significantly. We now have 3 RNS and USUALLY a tech on our night shift. In addition our pt load has increased. I've gone from managing a max of 3 pts at a time to having as many as 6 to 8 pts. And that includes have several patients with an ESI of 2. So maybe 3 Level 2's and 3 level 3's and the rest 4's. We have gone from having to put stretchers in the hallways to catch overflows to the hallway stretchers being given "Room Numbers." ie, it is now an everyday thing. I know that things have gotten busier over the past few years - I think people just come to the ER now because it is easier and requires no appointments. However, I am not familiar as to what the standard of care is for the number of pt's an ED RN takes. Or if not a standard, then how many pts do you, as an ER nurse, take at a time? And what ESI levels? I mean I can take 12 pts with an ESI of 5 but you make them an ESI of 2 and that drops how many I can really provide safe care for. You can assign more but that doesn't mean they are getting safe care. And putting them on a monitor doesn't help all that much because all the other nurses are just as busy. I'm just curious as to what others are doing - both to protect the pt and to protect myself.

My other question is in regards to "involuntary committals." They are called different things in different places. I know them as 5150's or 1013's. I was wondering if anyone uses a locked room to place these pts? We take all their personal items and place item in gowns and they have someone that watches them 1 on 1. But some are so aggressive I was wondering if placing them in a locked room for this purpose is something that is done in places?

Also the place I now work is different from others I've worked at. In violent or aggressive patients the MD will order a sedative and expect it to be give immediately. I know, nothing new there. I even love it when they tell the pt "We will give you some meds to help you." Especially because we always means "the nurse." So they order meds and the pt is violent. I try to talk to the pt, reason with the pt and to de-escalate the situation. If you are a nurse that actually does pt care and not just HR or management, you understand that there are some pts you cannot reason with. At this point we call the hospital's police force who is suppose to restrain the pt so I may give them medications. They storm in all "big and bad" and grab the pt, I'm ready with the meds, then the pt will say something like, "Ok, Ok. Just let me stand up and you I'll let you give it to me." At this point you can see everyone just relax, they let the person go and then the pt spends the next hour refusing to take the meds. I have seen the scenario so many times. The only time it varies is when the person is really crazy (oh? Am I allowed to say that anymore?) or just stupid enough to try and strike the police officer. Then they get taken down hard and with a vengeance. Then they get the medication.

But despite many doctors yelling at me, I have made a personal decision, up to and including being dismissed, I have decided I will not fight with a pt. I will defend myself and my coworkers, I will help put the pt in 4 pt restraints. But I am not going into a room by myself and through physical force administer medication. This may not be everyone's choice but I'm not a large person and I have a family. And I have no doubt the hospital will not support me in any way should someone get injured.

If someone is out of their head on drugs/other, I will attempt to keep them safe. The last time I helped defend a coworker the pt kicked me in the head before placing his hands around my throat. It is not a matter of being afraid though I do fear permanent injury as I have seen nurses permanently disabled by pts. I just don't think it is safe for me or the other staff to be brawling in the ED. Nor should I be fighting a pt one moment and then giving care the next because a case could be made should anything untoward happen to the pt that I was "ANGRY" with the pt so I did something for payback.

So, I would love to hear if not exactly suggestions, then what do you do? How do you handle these situations? Do you "fight" with the pts?

Thanks

Irving

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What state are you in? Where I am, unless a patient has a inked petition for psychiatric evaluation, either by our psychiatrists or a third party (e.g. family), we can't actually hold people against their will even if they're verbalizing SI. And I'm not fighting anyone, restraining people because their BAC is 1.0, B52ing them just because a doc put a legally meaningless order in the chart that say "pt is a psych hold", etc.

With regard to ratios, it sounds like someone decided to reduce lobby wait times by simply making the lobby-safe ESIs wait on a stretcher under your care instead? If you have a way to audit your through-put times, I'd be interested to see if they're getting dispositioned any faster. At most, we have a 6:1 area for patients who can sit in chairs sans cardiac monitor and get some fluids and zofran while their labs are running. Anything beyond that is 3, 4 or 5:1.

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Wow. There's a lot here, Irving. Your situation sounds frustrating. How many beds in this place and how many hall stretchers?

Do you have social work available?

"We will give you some meds to help you." Especially because we always means "the nurse." So they order meds and the pt is violent. I try to talk to the pt, reason with the pt and to de-escalate the situation. If you are a nurse that actually does pt care and not just HR or management, you understand that there are some pts you cannot reason with. At this point we call the hospital's police force who is suppose to restrain the pt so I may give them medications. They storm in all "big and bad" and grab the pt, I'm ready with the meds, then the pt will say something like, "Ok, Ok. Just let me stand up and you I'll let you give it to me." At this point you can see everyone just relax, they let the person go and then the pt spends the next hour refusing to take the meds. I have seen the scenario so many times.

.....

Thanks

Irving

Don't get upset by stuff like the bolded part. Not sure if its the stress of the situation or poor working relationships on the unit, but you're presenting this in a 'me vs. the doc' way. That is unnecessary. It is your job to administer medications. The doctor will order them.

I suspect you have some resentment because...you don't have support for YOUR part of the process. That's certainly understandable, but it's not the doctor's fault.

So, I would love to hear if not exactly suggestions, then what do you do? How do you handle these situations? Do you "fight" with the patients?

Thanks

Irving

No I absolutely do NOT "fight" with patients under any circumstance! Not verbally, and certainly not physically. I will apply appropriate physical restraint as MY part of a well-orchestrated TEAM maneuver if necessary, and that is it. Under no circumstances will I be part of an action with team members who are behaving in a rogue fashion.

Number two, no patient should be "taken down hard and with a vengeance". The vengeance part is where you know for certain that things went wrong. I know exactly what you're referring to, I have seen it many times. Those individuals should not be dealing with patients.

You are having problems because these situations are being handled (not necessarily by you) in "cowboy" fashion, rather than professionally, and piece-meal rather than as a team effort.

-Doctor and RN assess situation

-Meds ordered (and they'd better be adequate for the situation at hand. I'm not coordinating a take down in order to force someone to swallow 0.5mg Ativan!!!)

-Security team assembled and plan verbalized

-Go into room. Give the patient ONE opportunity to comply. Minimize your words. "Mr Patient, I have the medication the doctor mentioned. It is a shot. You want it in your hip or your leg?"

-Team secures patient

-Injection administered.

-Done.

If the situation is such that the patient is currently acting very violently, the team must secure the patient before you approach. Don't neglect to communicate what you're about to do though.

I understand how hard it can be if there isn't a professional TEAM spirit on your unit. You can try to talk to mgmnt about it, but in real time the only thing YOU can do is behave like a professional and take the lead. YOU assemble the team, and YOU tell them what you need from them, and YOU model appropriate handling of it.

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Everything JKL33 said is exactly how it goes down in my ED. To OP, yes it IS time to speak with management or maybe start small by partnering up informally with security or the "hospital police". Perhaps you CAN be part of the solution. It sounds like you're in a relatively "small pond" so maybe this is an opportunity to be a "big fish". "Be the change you want to see" and all that... :) I'm a serial optimist so don't mind me... I wish you luck, and I salute you for caring, which you obviously do.

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Wow. There's a lot here, Irving. Your situation sounds frustrating. How many beds in this place and how many hall stretchers?

Do you have social work available?

Don't get upset by stuff like the bolded part. Not sure if its the stress of the situation or poor working relationships on the unit, but you're presenting this in a 'me vs. the doc' way. That is unnecessary. It is your job to administer medications. The doctor will order them.

I suspect you have some resentment because...you don't have support for YOUR part of the process. That's certainly understandable, but it's not the doctor's fault.

No I absolutely do NOT "fight" with patients under any circumstance! Not verbally, and certainly not physically. I will apply appropriate physical restraint as MY part of a well-orchestrated TEAM maneuver if necessary, and that is it. Under no circumstances will I be part of an action with team members who are behaving in a rogue fashion.

Number two, no patient should be "taken down hard and with a vengeance". The vengeance part is where you know for certain that things went wrong. I know exactly what you're referring to, I have seen it many times. Those individuals should not be dealing with patients.

You are having problems because these situations are being handled (not necessarily by you) in "cowboy" fashion, rather than professionally, and piece-meal rather than as a team effort.

-Doctor and RN assess situation

-Meds ordered (and they'd better be adequate for the situation at hand. I'm not coordinating a take down in order to force someone to swallow 0.5mg Ativan!!!)

-Security team assembled and plan verbalized

-Go into room. Give the patient ONE opportunity to comply. Minimize your words. "Mr Patient, I have the medication the doctor mentioned. It is a shot. You want it in your hip or your leg?"

-Team secures patient

-Injection administered.

-Done.

If the situation is such that the patient is currently acting very violently, the team must secure the patient before you approach. Don't neglect to communicate what you're about to do though.

I understand how hard it can be if there isn't a professional TEAM spirit on your unit. You can try to talk to mgmnt about it, but in real time the only thing YOU can do is behave like a professional and take the lead. YOU assemble the team, and YOU tell them what you need from them, and YOU model appropriate handling of it.

They need to hold him after the shot, too, long enough for you to secure the needle and get away before they let him up.

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