My whole day went like this:
Patient arrives and is triaged. Sits in room for over an hour before being seen. Half an hour after being seen orders are finally entered for IV, labs, EKG, cath UA, orthostatic vital signs (a basically useless way to check for dehydration by taking pulse and blood pressure lying, sitting and standing. Since it is rarely done correctly the information is basically useless) and multiple IV med's. An hour and a half later all the labs are back and the chart is flagged for recheck. An hour later is still not rechecked and patient is getting mad. Doctor is nagged and finally picks up chart, orders either A)an oral prep CT which takes several hours to prep the patient, get the test done and get the radiologist to wake up and read it or B)an ultrasound which takes several hours to wake the tech up to answer the page, get them to arrive and do the test and then get the radiologist to wake up and read it. 7.5% of the patients that signed in today left before being seen by the doctor after waiting an average of 3 hours in the lobby. All 9 of the patients I had in my twelve hour shift ended up being admitted after an average stay of 7 hours. I knew they would all be admitted when they arrived.
With most of our docs everything flows well and is quick and efficient.
With others it does not. Guess who was working today?
Monday, December 15, 2008
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11 comments:
Just wondering if nurses can do EKGs, start IVs, get labs done etc before the doc asesses the patient? In the ER that I'm working in, if we get a patient presenting with stuff like chest pain, sob, syncope we get it all while doing our initial assessment so it saves times later on. Also, sorry about your crappy day! I hate having to hold onto obvious admissions myself!
hi,
I am not in the USA, but we have had an American computer system introduced to our ED and it has terminology that we are not familiar with.
Can anyone please explain what a "falling" blood pressure entry means - it is an entry under othostatic BP entries.
thanks
sounds kind similar to some of my days..except that the nurses order appropriate tests when they get to a room, and we don't wait for them to be seen first. The same goes for iv fluids. Except for fever protocol, we ask before giving meds, but often are able to get orders for meds also. However, this doesn't prevent them from waiting for re-evaluation and admission. Plus all the add ons that the nurses don't order, and that the patient usually doesn't need anyway!
We do the EKG, IV draw labs etc but several of the doc's (read the slow ones) would have a tizzy if the nurse ordered labs - never mind that the patient might be the 48 millionth chest pain workup I've done in my career.
We have certain common sets of "protocol" orders that we can (and do) implement before the docs see the patients. The more common ones are for chest pain, abd. pain, sepsis, and stroke/TIA--all include IV's and labs, chest x-rays for the chest pain and sepsis protocols, and a head CT for the stroke/TIA. So even if Dr. Slowski and Dr. No-Dispo are working, we can usually have most of the stuff in the lab (and sometimes on the chart) by the time they get seen. Of course we still have to get med orders, but at least a lot of the time-consuming tests will be already underway. And naturally, if the patient is emergent, we drag them in to see the patient right away anyhow.
I would love to chat with you to really understand the challenges and pressures you face on a daily basis. It would really help with a project I am working on. Would you be open to this?
Thanks so much.
cmhs.pn@gmail.com
http://www.merck.com/mmhe/sec03/ch023/ch023c.html
Anonymous...here is a site that explains orthostatic hypotension.
I personally have never heard the term "falling" BP before. We always just said there was a "change" in the BP. If the patient stood up and the BP was lower then when lying...there was a change.
Steve
ERnursery....???? And this behaviour continues???? No intervention by the nursing superviser? None of the MD partners have chastised the slacker??? No "come to Jesus moment" for the boy!??!?!?
Steve
we have the same problem in our ED - one Dr in particular - who is lazy and will let his pts sit around for hours before either admitting or sending them home.
and we (RN) do ALL the work for the patient - he does nothing and will not do anything unless he absolutely has to.
and is often to be found out the back chatting on the phone / having a smoke.
and then the nursing staff cop the abuse from the pts and relatives.
he could not care less.
Chest pain should be the only scenario where labs are routinely ordered, and by labs I mean cardiac enzymes, not CMP, CBC or the other stuff. All chest pain is evaluated with an EKG and cardiac enzymes, even if the story is highly suggestive of non-cardiac chest pain. For syncope or stroke or any other complaint, I would not use automatic labs because you really have to understand the patient's story first and that requires a detailed medical interview.
Everybody on here thinks that drawing labs is no big deal, but what happens when you draw a CMP for chest pain (which is totally unnecessary) and it comes back with a liver enzyme bump? Now you just bought yourself a huge ass workup including possible liver biopsy because you had an incidental finding that didnt need to be worked up because it had nothing to do with the chief complaint.
Why do we think we have to investigate and solve every last medical problem that the patient has in the ED? If you find a liver enzyme bump then the patient either needs to be a)admitted for further workup or b)referred for follow-up. When did the whole idea become to keep the patient out of the hospital? Medicare pays what? $200 for an ER visit as opposed to $1200 a day for a hospitalization. Then why are we doing these huge workups in the ER when they can be done in the hospital? Or, God forbid, as an outpatient.
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