Why do I keep doing this?

[Dave11, BSN, RN]

I work in a small community hospital and recently took a charge position about 5 months ago. It has been stressful since the beginning but it seems to have gotten a lot worse lately. I work noon-midnight. I typically lose staff during the course of the shift whose patients I have to pick up so not only I am I doing charge duties, but I frequently am responsible for the psych patients and, on the bad days, have to cover triage also. One night a few weeks ago I was doing charge, covering 3 psych patients, 2medical patients and covering triage. Our medical director has been pushing the docs to get everyone in to be seen within a half hour. Most the docs will let me bring the patients in as rooms open but there are a couple that will bring them in on their own without consulting me to get a nurse assigned to them. I often hear "I just need to see them, they won't need anything" just before they order full sets of labs, ekg, cxr and ct scans.

I also have to put together all the transfer and admission paperwork, answer the phones (that depends on which ward clerk i get, the good one or the useless one), sign in and assign the ambulance patients, get the floors to take the admissions when they are "too busy", make sure patients get off to ct and ultrasound, assist any of my nurses if/when they get deep in the weeds and deal with IT on those occasions when the system is having a case of the hiccups.

Add to this that the house officers flat out insist on seeing patients in the ER instead of on the floor even though we have protocols in place for med/surg and tele patients. I wouldn't mind so much if we weren't busy, but it jambs up my beds waiting for orders on 4-6 patients in a 17 bed ER when we are busy. I'm not even going to go into the missing EKG, charts, orders etc that the admitting docs just leave lying around where ever and the wide variety of personalities/neurosis' of the nursing staff.

I'm sure I'm forgetting a few things too. I just got home awhile ago and am just winding down enough to consider going to bed.

Now, this is the first time I've done charge in the ER. Am I just being a whiny SOB or does his sound like a rediculous situation?

I plan on speaking with one of the bosses tomorrow about this, but I'll take any suggestions/tips/ideas anyone wants to offer.

[maryloufu]

That sounds super crazy. I am sorry that I have no help for you.

Someone here probably does.

[kakamegamama]

Is there a house supervisor you can turn to for assistance? I think speaking to management would be a good thing. Sounds like patient care could suffer (and sounds like you do a remarkable job keeping your head above water & the patients safe), not to mention you aging rapidly, having all your hair turn grey, or losing the hair you have! Best wishes & hang in there!

[Sarey Gamp 1987]

you are unfortunately in the same boat as I am in right now where do you practise ? im in las vegas, nv i work for a private hospital as er charge if it wasn't for my great hardworking staff the patients would not get care. do your docs work for the hosp or are they contracted

employees like mine. does your hosp use protocols in the er? are lpns allowed to work in your er? you are a hard worker make sure you are being $$ compensated for your work you deserve it good luck reply soon

[Dave11, BSN, RN]

I work in Massachusetts and the docs are employed by the hospital. My staff at night takes a lot of abuse and does a fantastic job each night. I'm lucky to be working with them. Our compensation is an insult right now. The hospital is just starting to have similar positions on the floors and with the last contract it was agreed to hold off on raising the rate till they see how well it works out. We do use protocols. We have no LPN's at all.

The supervisors do what they can but they generally have their hands full dealing with the floors.They have the thankless task of shuffling staff to meet demands, take sick calls and try to guess what the days census is going to be to call off extra staff when we have it. Then there have been a couple of supervisors that treat us like red headed step children in the ER.

Today was a better day. I guess my meltdown temporarily blew away the black clouds.

[KatieBell]

sounds like a bad situation, in which you are stretched too thin. Charge should be available to resource other nurses or lend a hand when a situation gets out of hand and you would simply not have time to do that.

Wondering if you could delegate some of the more mundane things.

One nurse on the shift could do the ambulance assignments and check them in.

And the situation with the house Officers wanting to see patients in the ER is intolerable. No one wants to be in the ER any longer than needed. I would simply document the incidents of making the patient stay in the ER longer than needed by the House Officers and then take it to the Management. They know that lengthy stays in the ER increase the Left without being seens and decrease some sort of revenue (If ER ever really generates any of that!) and decrease patient satisfaction both on those waiting for beds and those waiting in the Waiting room. Thus, it seems management could put a fire under the behinds of the House officers.

Those are my only suggestions... that and to wish you best of luck...in your er... difficult situation! hang in there.

[LilgirlRN, ADN, RN]

It sounds like a bad situation but it's like "they" say. They can only give you as much sh*t as you're willing to take. I have been in your position before, in most cases whatever needed to be done I ended up doing because I didn't want to inconvenience anyone else. The thing is that you will make yourself nuts with that kind of mentality. DELEGATE!!!! Have each member of your staff take an extra patient so that you can be in charge, see if that helps some so that yiou can actually think of a better way of doing things while you're there. We recently had GE come in and help us with some of our issues, they invited nurses, techs, secretaries, whatever position in a hospital you can think of and we all sat down and tried to think of better ways to do things. Our mission was to be able to cut the time a patient has to be hospitalized. We made up a patient, a diagnosis and took them from the ER door to admission to the hospital and d/c to a nursing home. It may seem silly but you can do that with your own staff, ask them if they have any suggestions to help with your situation, you may surprised with the results that you get from them. To me the main issue in your circumstance would be the doc going to the waiting area and taking patients back without them being triaged. You have to take control of the reins. One thing that could save you time and trouble is having ER standing orders... you know like if a chest pain comes in... ekg, O2, saline llock and appropriate labs can be drawn before the doctor even sees the pt. You can always turn to ENA and ask for suggestions too.

[Hagabel]

I feel for you. Document when it is unsafe on a UOR or whatever else you have that is separate from the chart and go up your chain of command. Can your union help you if you are unionised?

I am glad you have great staff, makes a huge difference.

[Dave11, BSN, RN]

I have absolutely no problem delegating or cajoling one of my nurses into taking another patient, believe me. I usually have to pick up the patients as the staff leaves because everyone else is loaded with 4-6 patients each already. The docs only take the triaged patients in. I would quit if they were taking patients that weren't triaged into the treatment area.

We have standing orders and the triage nurse typically starts drawing labs,doing EKGs and having patients drinking contrast (which I have issues with)while waiting to be brought in.

I have filed unsafe staffing forms but as far as I know, all they do is line bird cages with them. I have asked about the union stepping in but haven't gotten any solid answers on that as yet. No suprise there.

[KatieBell]

Dave I think you may have misread my post. clearly your nurses have enough patients etc. What I was suggesting is not that you continue to cajole them to take another patient, but that you simply put one of them in charge of dealing with the ambulance patients. this is really something any nurse with experience should be able to handle and would free you up to do the millions of other things you are doing.

[ozinurse]

Sounds Hideous. I certainly don't envy you. If you are supposed to be the shift coordinator, you can't do it when you are in the thick of it. You need to be objective and available to all the staff.

It sounds like you have pursued most options already.

If your going to stick with it, I'd suggest keep up the safe staffing reports. Make sure you keep a copy of any correspondence that goes up the chain as you may wish to it refer to later. Attatch literaure about 'ED overcrowding and increased mortality rates.' (one published in the last 6 months, but I can't remember off the top of my head which journal)

It is good to know how your department works out its safe staffing numbers, who keeps the stats, and who they get sent to. If it is anything like where I work, actually sorting the staff numbers is a tmely pain staking process. But knowing what evidence you need and who's tree you need to bark up might be useful.

Don't think you will solve it on your own. It will have to be a departmental approach to fixing the problem. Take it to the local authorites and make your case. It is also good to take strategies. If you can give them a reasonable resolution or something that they can negotiate over, you will get further. If they (the department seniors) are not interested then you might be better saving yourself the stress and the risk of an adverse event happening on your shift. (Give them the finger)It's nice just to be able to do your job properly, and there are pleanty more opportunities out there.