A few weeks back I was pulled to work in the emergency department to care for the patients that have been admitted to the hospital but have not been assigned to a unit or bed related to the fact that there were no beds available. This is not uncommon when the hospital fills up to maximum capacity and yet there are still more sick people who require hospital admission. I have mulled over this debacle many times, have been pulled to emergency for “tele holds” many a dreary occasion.
When I arrived to the department I found the place to be busy and chaotic, the nurse coordinator exclaimed with excitement, “Are you here for the critical care holding?” I replied with a quick no, no way, I am here for the telemetry holding, boarding patients. She seemed exasperated. Not only do I not have critical care experience, but even if I did, the emergency room setting is the last place I would want to be trying to maintain safety on sick patients.
I know there is research out there on the outcomes of patients holding in the emergency department waiting for admission beds, but it escapes me right now where I have read such research. It does not take a researcher in a white lab coat to figure out that: patients holding in the tank (while safety may be maintained) are not receiving the most optimal care. The emergency department is just not equipped, not set up, for routine nursing care as it is on the floor. Emergency rooms are set up for *gasps* emergencies. Here is a little article found in haste about this holding issue.
On this particular day, the coordinator for some strange reason pulled me to the middle of the department and all my holding patients were surrounded by patients in respiratory failure to my left and right. I must have seen at least 3 people roll in via EMS to be immediately intubated and 1 rolled in needing full ACLS. In the midst of all of this, I was giving report slowly and painfully to the floors on each patient that was lucky enough to receive bed assignments.
Jane in true narcissistic fashion wondered what it would have been like for my holding patients had I not been there to nurse these holdings, lost in the limbo patients. I mean certainly the emergency nurses were busy caring for the never-ending stream of emergent patients that were scurried in via medics.
The bottom line is this: A few hours of holding might not be a problem, but when the patient is holding for a shift or more, routine care is compromised. For example patients needing routine medications, or say: a bowel prep for surgery in the morning, the emergency dept is not the best place to provide this care. During my last 12 hour stint caring for the holding: I bowel prepped a patient for surgery and there was not toilet in the room to rinse the dirty bedpan after the patient downed the mg citrate! This means walking around the emergency dept to the nearest toilet that everyone uses to rinse a poopy bedpan! Can we hold off on surgery that the patient needs because there is no bed available? The surgeon wants to operate, the patient needs it, and yet where is the patients bed? Surely the patient will get a bed before the morning so there is no stopping this essential bowel prep just because the patient is sitting in the holding tank with no toilet nearby!
These patients are sick and they need to get to the floor, and in my opinion: the quicker the better for the patient. (Unless the patient can not breath, has no pulse, or has no blood pressure duh)
I used to rant and rave over the emergency dept sending patients to the floor without “doing” anything, but my opinion has been changing lately. Sure the ED should be screening the patient for sepsis when they present that way and yada yada yada, but my experience is the place is chaotic and the emergency department needs to tend to emergencies so if the ED calls me to give report on a stable patient that does not have a complete admission order set written, I take report and say: red rover red rover send my patient on over. I would rather assess the patient myself and then call the doctor for everything I need at one time anyway. This is not to say that I do not get miffed when my patient arrives from the 5 minute transport to the floor in respiratory distress and the patient presented that way, and ABGs have not been done and the patient needs BiPAP like right now and I end up rapidly responding the patient: that irritates me.
I am just sayin: there has to be a happy medium right? Getting these holding patients to a room was not easy, admissions appeared to like to give the bed assignment then page it away to someone else rather quickly and as soon as one patient left, another patient was added to my assignment. It was impossible to actually chart my assessments on all of these patients: probably 12 throughout the shift. I could only document the vital signs and the medications on the more stable range and type in only essential notes on the more critical side and only charting interventions performed because I spent the rest of my time trying to give report to the floor.
I hang on the receiving line and hear: the bed has not been assigned, the room is not ready, the curtain needs to be changed, can I call you right back?, this patient is to sick for telemetry call the doctor for ICU (nursing the numbers), the nurse is on lunch, etc, etc, etc.
Now I have been on the other end of this line and I have to say that I always take report immediately because I know that what my patient needs, they are probably not getting right now, not because of incompetence but because half the stuff they need is not even there! Hello Nurse world: The ED medication dispenser does not have coumadin loaded into it(as well as many other drugs)! You can wait and beg the pharmacy to send it to you via the awesome bullet system, but in a hospital built in utopia like the one that lives in my mind: admitted patients will not be holding that long in the emergency department!
I am not taking an “us versus them” attitude. I am taking a “let us be a functional family” attitude. We are all in this to care for the patient: that is the job at hand, the task, the mission, it is what we do this for. I can say that having seen how crazy the emergency room is: when filled with emergencies, there is no reason for the floor nurse to not take report and receive the patient as soon as possible. On the other hand: I understand the telemetry nurses complaints about patients that are sent to telemetry that are on the cusp of critical care and we tele nurses tend to blame it all on the ED nurses! Like: they sent this critically ill patient to me, and wasted time that could have been spent on resuscitating the patient! Of course the patients are sick! If we all wanted stable we would work in the doctor’s office!
Let us all just be friends and trust each other! Tele nurses: take report on the patient right away unless you feel that the admission to telemetry is totally inappropriate and the need to advocate for a critical care admit is completely obvious via report (do not nurse the computer). Emerg nurses: screen tele admits ie: if the patient has a respiratory rate greater than 30 and need 100% oxygen on a non rebreather please get the ABG and triage the patient for appropriate bed assignment especially when the admitting MD has not assessed the patient yet. It does not have to be a battle, we can all get along in my Utopian Hospital.
I know I have made this lengthy, trying to put words to my experiences from nursing the holds in the setting of the emergency department. I may not have summed it all up accurately, so here is how I felt: I just felt that sooner the patients could get to a more controlled environment with one primary nurse the quicker the patient could get appropriate treatments. Everyone should be where they belong and that goes for nurses and patients! The thing is I am not sure where I belong yet, but I still like my job! <3
Oh and Merry Christmas and Merry Holidays to everyone! I tend to cry lots around this time but heh, I am just a sack of emotions. ewww.