Are you uncomfortable caring for ICU patients in the ED? Here are strategies

Many ED nurses feel they’re in over their heads’

An elderly man is a brittle diabetic and hypothermic, and he is on numerous intravenous medications, including insulin, fluids, and dopamine. This patient requires one-on-one nursing care with frequent vital signs, glucoscans, lab draws, an arterial line, and a Bair hugger. Does this sound like a typical emergency department (ED) patient? Maybe not, but caring for critical care patients for extended periods is occurring in EDs across the country — a practice that is putting patients at risk, according to many emergency nurses interviewed by ED Nursing.

The patient above was managed in the ED for nine hours while waiting for an intensive care unit (ICU) bed at Eastern Maine Medical Center in Bangor, according to Karen Clements, RN, BSN, department head nurse for the ED.

"It’s becoming the norm to hold ICU and telemetry patients in the ED," reports Colleen Bock-Laudenslager, MS, RN, an ED nurse at Redlands (CA) Community Hospital and a Redlands-based consultant who specializes in staffing. "This morning, we were already holding nine inpatients at 9 a.m."

The ED at Community General Osteopathic Hospital in Harrisburg, PA, cares for approximately five inpatients a month with a prolonged stay due to lack of available ICU beds, says Gene O’Donnell, RN, nurse manager of the ED. "The premise for patients in the ED is that they are individuals who need emergent episodic care, not sustained intensive care," O’Donnell says. "That is the crux of the problem."

ED nurses don’t feel qualified

In the past, when ICU patients were held in the ED, you often were afforded a critical-care nurse who would come down to manage them, says Bock-Laudenslager. "But since the root cause of the problem is a shortage of nurses and availability of beds, that rarely happens" now, she explains.

Instead, these critical-care patients are often managed by ED nurses who feel they’re "in over their heads," says Bock-Laudenslager. "Many of my colleagues tell me they do not feel qualified to take care of these patients for long periods of time," she adds. She explains that nurses feel unable to provide the same standard of care as the patients would receive in a self-contained, controlled ICU environment. 

In fact, it’s likely that critical-care patients will not receive the same level of care in the ED as they would in the ICU, warns O’Donnell. "The same patient in an ICU setting may have one nurse, but in the ED has to vie for that nurse’s attention with not just one, but maybe two or three other individuals," he says. As a result, there may be delays in initiation of treatments, medications, and documentation, says O’Donnell.

To make things worse, patients are being held for increasingly long periods of time, reports Bock-Laudenslager. "The bed and staffing shortage is so grim, we have actually discharged ICU patients out of the ED," she adds. ED nurses are experts at resuscitating and stabilizing patients and transporting to a definitive care area, says Bock-Laudenslager. "Now we are in the position of having to manage patients clinically for longer periods of time than we are used to," she adds.

The patients actually are staying long enough for their condition to significantly change, says Bock-Laudenslager. "Recently, a patient was being admitted to a direct observation bed, and when their condition deteriorated, they were upgraded to an ICU bed, while still in the ED," she says.

Here are strategies to use when managing critical care patients in the ED:

• Float ED nurses with critical care nurses.

Clements has ED nurses "shadow" an ICU or critical-care unit (CCU) nurse to gain hands-on experience with arterial lines, intracranial pressure lines, and chest tubes. "We usually do this for four hours at a time, and they love it," she reports. "We can go months without an arterial line, and this keeps their confidence levels up." These nurses then share pertinent information with other ED nurses, she explains.

• Provide nurses with a designated support person.

O’Donnell recommends assigning a designated support technician exclusively to the nurse caring for ICU patients to perform tasks such as vital signs, intake and output, and recurring labs. "This individual can help maintain an orderly, clean area for the ICU patient and the other patients the nurse may have under his or her care," he adds. The support person can also help with "basic human needs," says O’Donnell, such as giving the patient a back rub, running for an extra blanket, handing out diet trays, or getting a phone to the bedside. The nurse, who may be engrossed in keeping a critical patient hemodynamically stable, often overlooks such tasks, he explains.

• Ask for resources to provide quality inpatient care.

Be sure your ED stocks organizational office tools to support patient care directives, such as copies of inpatient charts with dividers, Bock-Laudenslager says. "These paper tools will allow you to organize your day," she explains. Also ask administrators to provide the same services to the ED as they would the inpatient wards, such as recurring labs drawn by lab services at appropriate intervals and food trays sent from dietary so you don’t have to remember to call to request them, advises Bock-Laudenslager.

• Use medication administration records (MAR).

Make use of the MAR generated by pharmacy after it’s entered in the computer, Clements recommends. At Eastern Maine’s ED, nurses use this to keep track and document the medications a patient is supposed to receive, she adds. "When a patient is held so long in the ED, we sometimes miss the regular scheduled meds."

• Use reminder boards.

Clements says boards are posted outside the critical care rooms in her ED, which are easily visible from the nurses station, so nurses can write down the times for medications, repeat labs, and glucoscans. "By doing that, it is visible and not buried in the paperwork," she says.

• Have ICU nurses act as resources.

Clements uses "resource nurses" from the ICU who come to the ED periodically to assist with critical care patients. "They are a huge resource when it comes to questions about the setup of difficult lines, and mixing and titration of some of the more intense drugs," she says. If a patient is on a monitor, hospital policy requires a nurse to transport the patient from the ED to the ICU, CCU, or telemetry inpatient bed, so the resource nurses often do this, says Clements.

• Group all inpatients.

When you mix ED patients with inpatients, it creates a hardship for the nurse, says Bock-Laudenslager. "The ED nurse is then operating off two different tracks," she explains. "The ED mindset for one cluster of patients is different from the ICU mindset for the other cluster of patients." At Redlands’ ED, a decision was made to cluster all the inpatients under a single ED nurse, she says. "So one nurse is defined as the inpatient nurse," she says. "That nurse is able to organize the shift in a more methodical way." Complying with the inpatient standards of vital signs monitoring, completion of the plan of care within a certain amount of time, and charting the assessment every eight hours becomes more automatic, says Bock-Laudenslager. "If possible, place the inpatients next to each other so they are closer together," she suggests.

Sources

For more information about caring for critical care patients in the ED, contact:

Colleen Bock-Laudenslager, MS, RN, Director, Inpatient Care, Jerry L. Pettis Memorial VA Medical Center, 11201 Benton St., Loma Linda, CA 92357. Telephone: (800) 741-8387, ext. 2589. Fax: (909) 777-3210. E-mail: Colleen. Bock-Laudenslager@med.va.gov.

Karen Clements, RN, BSN, Eastern Maine Medical Center, 489 State St., Bangor, ME 04401. Telephone: (207) 973-8010. Fax: (207) 973-7985. E-mail: kfclements@emh.org.

Gene O’Donnell, RN, Nurse Manager, Emergency Department, Community General Osteopathic Hospital, 4300 Londonderry Road, Harrisburg, PA 17103. Telephone: (717) 657-7495. E-mail: eodonnell@pinnaclehealth.org.