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Old 07-06-2008, 07:41 PM
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Default ER and Floor Nursing

Eons ago, I worked in the Critical Care areas; before that I worked on a general medical floor. Now, for the past 15 years or so I have worked in the ER. ER grabs you with it's claws and either makes you stay forever or forces you out never to return. I'm not saying that ER is better than any other area of nursing, I'm just saying that the ED is comprised of nurses who love emergency medicine and in emergency medicine you either love it or you hate it and there is no middle ground.

Some nurses, who have never worked ER, do not understand ER's goal which is to stabilize and either transfer or street. It is not our goal to keep patients for extended periods of time to make them "all better." Our goal is to take care of the most emergent need at the time and then allow the patient to be taken care of long term either at home by the primary care physician or in the hosptial.

For the past 6 months, the ER in which I work (a 29 bed Chest Pain Center and Level 3 Trauma Center) has been, on a daily basis, holding patients in the ER for greater than 24 hours. They sleep with us, eat with us, bathe with us, go to tests with us (some monitored), and generally are treated like any other inpatient because, they are in fact, inpatients. Why are we doing this? It's because there are no rooms in the inn.

In our 29 bed ED, we have held up to 21 patients because we've had no rooms. Keep in mind, that's in addition to our "real" emergency room patients that we get. Now, get out your pencils and note pads and do some calculations. I have 6 nurses at 6am. One nurse is in triage, one nurse is in charge, and 4 nurses give direct patient care. Twenty one divided by 4 is 5 patients a piece. Not too bad right? Wait!!! How about the other emergency patients? The patients that need things STAT? Where are they in the mix? You guessed it, they are added to the nurse patient ratio which elevates the nurses to patients to, at times, 8 to 1. On many occassions, the charge nurse has taken an assignment so as not to overburden the other nurses; this is in addition to keeping the ED flow moving, listening to irrate doctors scream because their patient is not yet in a bed, and listening to family members and patients complain because the bed is uncomfortable and they haven't eaten.

ER nurses are NOT floor nurses. Yes, we can do the same things that other floor nurses do, but our priorities are different. We don't think that an AM med is as important as a person who is having chest pain. We don't think that getting a person food, although necessary takes precidence over someone in a full cardiac arrest. Call me skewed, but that's just how it is.

I can't imagine that the ER I work in is any different than any number of ERs across the country. Recently, the news was alive with a patient who died in a psychiatric ER. Most of us murmured to ourselves that "that could never happen in our ER." The fact is, I'm terrified that it will. How can an ER do floor nursing and ER nursing at the same time; all the while knowing that there are patients waiting in the waiting area that need to go to an ER room, but there are none available, and the hallway has been used to it's capacity?

Any ER nurses out there have any suggestions? I have written a four page speech that I will be presenting to the powers that be on Tuesday. The speech is biting, and intended to be that way. God only knows if I will have a job after my little speech, but I can no longer remain silent.
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Old 07-07-2008, 01:07 AM
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Unfortunately we see it every day in the hospitals in the Fraser Valley (BC) I'm not a ER nurse, but have been on the recieving end of those admitted ER patients...we try our best to accomodate them but there are days when it isn't possible. I really think that the public themselves need to get encouraged to be a part of the solution, it seems many patients end up being repeat customers so to speak because of the attention that they give them. Is it maybe a suggestion to poll the seriousness of the patients that are coming into emergency, but really could do without a bed for days on end?? We have a NurseLine here that I give the number for, along with the doctors phone number, to anyone that I discharge home so if they have any concerns, they can call that before immediately goig to the emergency. we also have walkin clinics available but those get swamped very quickly due to the lack of family doctors and the huge number of patients that don't have them.
I'm not sure if I'm hitting the nail on the head in regards to your post, but you are definitely right in that emergency care needs to be reformed (really the entirety of health care)...they are prediciting that by 2010-2015 we in BC will have lost 45% of our nurses due to retirement...a scary thought-what's going to happen to those patients when we no longer have the supply (of nurses) meeting demand (oh wait it is already happening)
Hope this helps and good luck with the meeting with the higher ups-who knows they may surprise you and have some common sense to agree with you!
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Old 07-07-2008, 04:50 PM
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I hear you girl, and I don't have an answer for you. The same crap is happening at our hospital. I'm wondering how many other patients have died in ERs that didn't make it into the news. The health care system is toxic, and it's killing our patients and the nursing profession.

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Old 07-08-2008, 01:09 AM
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Long term care beds. That's part of it, thus people won't be waiting for 1 year on an acute care floor for a bed at a long term care facility. No waiters, more beds for emerg. Now if only we could get the surgeons to stop filling the beds with surgery patients.....
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Old 07-14-2008, 10:00 PM
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Two lyrics come to mind on this topic:

"...the answer my friend is blowing in the wind.."

".. Like a circle in a spiral Like a wheel within a wheel Never ending or beginning ..."

Like many things in our society the roles of many people and departments are having to adapt, but the community are not keeping up, or can't keep up. Where once if it was after hours and you were sick you went to the ED, now we can't handle the load. People are thinking that they will be admitted and they end up being sent home. Some people are coming into hospital thinking they will get a rest, but end up being marched up and down corridors twice a day and sent home after a week.

Is it worth putting a doctor (GP) next to the ED, and not bulk billing. If the hospital thinks it is not and emergency, you have to see the doctor and pay for it. If it does require a hospital stay they can always admit.

Hospitals are fined for having patients sitting in EDs for too long, but where is this money going. Should it be used to increase the size of the ED? I'm sure that some hospitals are shelling out enough in fines to improve conditions in the hospitals, but it is just a vicious circle.

It also dosen't help when Hospitals are being built will less beds, but bigger private rooms. The classic case is one in Melbourne Australia. The New woman's hospital (replacing an older one) has less neonatal beds than the old hospital, but there is an increasing rate of neonatal need.
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