These clinical changes could save patients being held in your ED

Minimize the 'potential for disaster'

Have you ever found yourself running back and forth between a myocardial infarction patient in one room and a patient with uncontrolled diabetes on an insulin drip in another room?

When ED nurses care for critically ill admitted patients being held while waiting for an available bed, in addition to their ED patients, this "is fraught with the potential for disaster," says Gary Howard, RN, MHA, director of emergency services at Vanderbilt Medical Center in Nashville, TN.

There are a "whole host of things that can go wrong," he says. "Make no mistake about it; there is a lot of opportunity for misadventure. We have recognized this potential at Vanderbilt and are taking steps on the front end to diminish or prevent opportunities for bad outcomes."

ED nurses are "front end-heavy people," says Michele Bascom, RN, an ED nurse at The Hospital of Central Connecticut in New Britain. "Once the legwork is done, admitted patients tend to slide down the list — not intentionally, but because they are set," she says. "The busier the ED, the lower down the line they go."

To add to those risks, admitted patients may fail to alert ED nurses if their condition changes. "In my experience, people are hesitant to 'bother' us when they can see and hear the place is crazy," says Bascom.

To improve care of those vulnerable patients, "you have to get creative," says Howard. "It's not an ideal situation in any ED — regardless of how small or large you are. But unfortunately, that is the reality we are living in."

Here are some clinical practice changes ED nurses have made:

Extra training is given for medication administration records.

"If you are asking an ED nurse to manage a medication administration record that they ordinarily do not have to manage, they need to be cross-trained on that," says Howard.

At University of Colorado Hospital in Denver, ED nurses were given an inservice on the way to administer scheduled medicines for inpatients being held. "In ED care, we give medications when they are ordered," explains Molly A. Evans, RN, ED manager. "We needed to make sure if medications are ordered every six hours for admitted patients, that we give them 8-2-8-2; not 6-12-6-12. Inpatients have a defined plan of care that will go over several days, not hours."

In addition, the ED has added a separate automated medication dispenser for inpatient medications, says Evans. "The pharmacy prints MARS [medication administration record sheets] for medication documentation," she says.

Nurses don't hesitate to ask for help.

If you're performing a procedure you have rarely done, or administering medications you have little experience with, then you need to say, "I'm just not comfortable taking care of this patient. I need somebody to help me," says Howard. "Most ED nurses are not comfortable saying that because we think we can save anybody anytime. That is our mentality," he says.

Repeat assessments are done.

Give boarded patients a complete secondary assessment, especially elderly and pediatric patients, because their conditions can change very quickly, says Stephanie Santana, RN, BSN, an ED nurse at The Hospital of Central Connecticut. "Don't assume that just because a patient has been in the ED for some time and has been completely worked up that they are 'all set,'" she warns. "We tend to get comfortable with these 'extended-stay' patients, and that's when the unexpected happens."

Nurses are reminded about medications and monitoring for inpatients.

Inpatients held in the ED must be adequately monitored, just as they would be on the floor, with daily medications given. Casey Kasenetz, BSN, RN, an ED nurse at The Hospital of Central Connecticut, says, "This is very different from the care of ED patients."

Sources

For more information on improving care of admitted patients held in the ED, contact:

  • Teri Arruda, MSN, FNP-BC, CEN, Emergency Department, Mission Hospital, Mission Viejo, CA. Phone: (949) 364-1400. E-mail: teri.arruda@stjoe.org.
  • Michele Bascom, RN, Clinical Manager, Emergency Department, The Hospital of Central Connecticut, New Britain. E-mail: mbascom@thocc.org.
  • Molly A. Evans, RN, Manager, Emergency Department, University of Colorado Hospital, Denver. Telephone: (720) 848-5181. E-mail: Molly.Evans@uch.edu.
  • Gary Howard, RN, MHA, Director of Emergency Services, Vanderbilt University Medical Center, Nashville, TN. Phone: (615) 343-8866. Fax: (615) 936-1633. E-mail: g.howard@Vanderbilt.edu.

Use one location for all 'boarded' patients

Admitted patients are in danger of getting lost in the shuffle when ED nurses are busy caring for immediate and lifesaving tasks, says Casey Kasenetz, BSN, RN, an ED nurse at The Hospital of Central Connecticut in New Britain. "A localized area for admitted patients can help continuity of care and save lives," she says.

Molly A. Evans, RN, ED manager at University of Colorado Hospital in Denver, reports that inpatients are moved to one area of the ED "in the hopes of keeping the area free of as much traffic and noise as possible."

Vanderbilt Medical Center's ED has two pods with long halls connecting each. The "A" pod is for patients with conditions such as myocardial infarctions, strokes, and traumas, and the "B" pod is for fast-track, observation, and admitted patients.

"We budget and staff it based on an inpatient model. Our nurse-to-patient ratios are never more than 1-to-4, and sometimes they are 1-to-3," reports Gary Howard, RN, MHA, director of emergency services at Vanderbilt Medical Center in Nashville, TN. "We have monitors and crash carts in strategic places."

Clinical Tip

Use a 'staff assist' light to get immediate help

If an ED nurse at Vanderbilt Medical Center in Nashville, TN, is drawing labs on a patient who suddenly complains of chest pain, has a syncopal episode, or is unresponsive, a light can be hit in any room that pages a distinct sound overhead.

"If a patient starts to deteriorate, it brings everybody to the room. It mobilizes the team, similar to when we have a trauma alert paged out," says Gary Howard, RN, MHA, director of emergency services.

Can you afford to add nurse to care for inpatients?

If emergency nurses are caring for admitted patients along with ED patients, this is dangerous as the "'new' ED patient will take precedent," says Michele Bascom, RN, an ED clinical manager at The Hospital of Central Connecticut in New Britain.

Gary Howard, RN, MHA, director of emergency services at Vanderbilt Medical Center in Nashville, TN, says, "Any time you can keep the ED nurse focused on ED patients and somebody else watching over your admitted patients, it's a better strategy."

Here are three approaches to offload some of the "inpatient" tasks from ED nurses:

A designated nurse handles charting and paperwork.

Vanderbilt's ED has switched to all electronic charting, but with inpatients, a completely different charting system has to be used. "That has been very frustrating for our ED nurses," says Howard. To offload this time-consuming task, the ED now has acute care nurses handle inpatient charting.

Vanderbilt also has hired "admission" nurses: medical/surgical nurses who do nothing but admit patients from the ED, including all the necessary paperwork, social screening, the history and physical required for admission, a complete medication reconciliation, and patient education. "They get their [intravenous lines] going and their meds started. Then the ED nurses just manage the patient as things come up," Howard explains. "Patients are getting a high level of care, equal to or better than what they get on the floor. They don't notice any big differences other than the lack of shower facilities."

Medical/surgical nurses occasionally care for ED inpatients.

When inpatient beds are not available at University of Colorado Hospital in Denver, the ED charge nurse requests two to four nurses to come down to the ED, depending on the number of inpatients being held. ED manager Molly A. Evans, RN, says, "We also bring in nurse assistants and clerical support to meet the inpatient standards."

Critical care nurses "round" on patients being held in the ED.

Teri Arruda, MSN, FNP-BC, CEN, an ED nurse at Mission Hospital in Mission Viejo, CA, reports, "When rounding, the critical care charge nurse collaborates with the ED nurse regarding the patient's care. We find that such an interaction is invaluable."

The two nurses review orders, labs, and medications to "bridge the gap between the ED and the critical care unit," says Arruda.