9 ways to improve care of ED hold’ patients

When an intensive-care unit (ICU) nurse received a report on an emergency department (ED) patient who had lost consciousness and fallen, she learned that the man had used the bathroom and walked around in the ED and that the CT scan of his head was negative. However, the ICU nurse then asked the ED nurse if the patient had X-rays to clear his spine and discovered that he had not. The X-rays wound up revealing a fracture, which resulted in the man being transferred to the neurology unit.

This scenario shows the importance of ED and critical-care nurses working together to improve care, says Katherine Blee, RN, MSN, CNA, CCRN, nurse manager of the coronary care unit, medical intensive care unit and surgical intensive care unit at Jerry L. Pettis Memorial VA Medical Center in Loma Linda, CA. (For more information on caring for critical-care patients, see "Are you uncomfortable caring for ICU patients in the ED? Here are strategies," ED Nursing, June 2002, p. 101.)

Caring for critical-care patients in the ED often results in conflicts between ED and ICU nurses, Blee acknowledges. "But there is a lot you can do to make things easier for yourself, the patient, and the critical-care nurse who will receive the patient," she says.

Here is a nine-item "wish list" from critical-care nurses for you to consider:

1. Provide a time estimate for when the patient will be brought upstairs. This time estimate assists the ICU nurse in planning the care of other patients and ensures that the assigned nurse is present when the ED patient arrives, says Blee.

2. Draw labs in the ED. If an IV is started in the ED, Blee says to check with the physician for needed labs and draw them if possible. "This saves the patient from unnecessary pain," she explains.

3. Place a gown on the patient. With a gown, the patient can be placed in bed directly from the gurney without having to undress, Blee explains.

4. Check that property inventory sheets are complete and accurate. Blee recalls an incident in which a patient stated that he had brought in $1,000 with him, but no money was listed on the property sheet. She adds that the patient was disheveled and homeless, and staff doubted his credibility. However, when the patient repeatedly insisted this was the case, Blee went to the ED to search the cabinets. "I found a paper bag with $1,000 and other belongings stuffed under the sink cabinet," she says. She explains that during the time of the patient’s admission, the ED staff were busy, placed his belongings in a cabinet, and forgot to transport them with the patient.

5. If possible, place IV catheters in a nonantecubital area. A catheter in this site is very uncomfortable for patients, says Blee. "We often have to change the site within a few hours of the patient arriving to the unit," she adds. The antecubital often is used for an IV site because lab draws can be done in conjunction with the placement of the catheter, she explains. "However, if a large-gauge catheter is not needed, please start the IV in the lower-arm forearm areas if possible," says Blee.

6. Bring a defibrillator when transporting patients. For patient safety, Blee advises that a defibrillator always should travel with a critically ill patient, along with a mask/Ambu bag. "I sometimes ask nurses, If your patient goes into respiratory distress and needs to be ventilated during transport, will you be giving mouth-to-mouth resuscitation?" says Blee. "Yes, you will need to, unless you carry a mask/Ambu bag during transports."

7. If possible, leave IV pumps with the patient in ICU. Blee has received patients with medications infusing, only to have the ED nurse take the pumps upon leaving the unit. The problem is that critical-care medications are infusing without the control of a pump, until one is brought up from sterile processing, she explains. "This can be a long delay," she says. Blee also has received patients from the ED who have infusions such as dopamine, dobutamine, or tissue plasminogen activator running into the patient without an infusion pump."This is unsafe practice," she warns.

8. Don’t hesitate to ask for help. If you feel that you are unprepared in a particular situation, you should say so, urges Janice Piazza, RN, MSN, MBA, director of consulting services for VHA, a nationwide network of community-owned health care systems, and a former critical-care nurse and manager at Ochsner Clinic Foundation, Memorial Hospital, and Tulane Medical Center, all based in New Orleans.

Piazza recommends saying, "I need some help in managing this patient" or "I have no experience in caring for a patient with this diagnosis." Talk to critical-care nurses to formulate a plan for how support will be provided, she says. For example, Piazza suggests having an ICU nurse come to the ED to help manage the patient.

9. Place allergy bands while the patient still is in the ED. When an agitated patient at Blee’s facility was admitted from the ED, ICU nurses had no idea the patient was allergic to lorazepam (Ativan). "Admitting orders were not yet written for this patient. The only place the allergy was noted was in the physician progress notes," she says. "Consequently, the patient was given Ativan and had an adverse reaction."


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

Katherine Blee, RN, MSN, CNA, CCRN, Nurse Manager, Coronary Care Unit, Medical Intensive Care Unit and Surgical Intensive Care Unit, Jerry L. Pettis Memorial VA Medical Center/118, 11201 Benton St., Loma Linda, CA 92357. Telephone: (909) 825-7084 ext. 2377. Fax: (909) 777-3210. E-mail: Katherine.Blee@med.va.gov.

Janice Piazza, RN, MSN, MBA, Director, Consulting Services, VHA. Telephone: (504) 483-2330. Fax: (504) 482-9612. E-mail: jpiazza@vha.com.