Hospital administration announced today that along with all our other duties in the ER we will now have to fill out a new form for the documentation of wounds as well as photograph any little ditzles that the patient may have.
Now I realize with the incredibly stupid new reg's that deny payment for wounds acquired while in the hospital it is necessary to do a thorough documentation of the patients skin BUT, since our ER sees approximately 200 patients a day and admits around 50 of them on average and since it takes about 1/2 hour to fill out the assessment form and photograph and print pictures it will take 25 hours of nursing time a day to do this on top of the job we are already doing that we are already understaffed to do.
Yesterday out of my assignment I admitted 8 patients, that would be close to 4 hours of wound assessment and documentation. That is 4 hours that I won't be starting IV's, doing EKG's, giving medications, drawing lab's or any of the other thousands of things I do every day. What is that going to do to the flow in our ER that is already functioning well over capacity. What will the effect be on the LWOBs as well as diversion times? Our average LOS for an admitted patient is already a ridiculous 5.34 hours - now we are going to add 30 more minutes on top of that? Ridiculous. On the other hand, the floor nurse may only get one or two admits during their shift. So who on earth would think it would make sense for the ER nurses to do this stuff?
Oh yeah, right. someone who has never worked in the ER. Duh.
What are your facilities doing?
Wednesday, February 18, 2009
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29 comments:
Now you've given me one more thing to dread. Thanks a bunch. ;-)
I work on a psychiatric adolescent unit and skin integrity checks are done on admission, not in the ER. That's ridiculous - ER waiting times are long enough of as it is for patients and the staff already has enough to do!
The ER should do the assessment if the pt is admitted because of the wound or it's so obvious that it's noticed on the primary survey.
Otherwise the floor can do it.
Sure, the wound should be noted in the first assessment, but we do that when the patient arrives on the floor. We have a little more time (at times) to thoroughly document said wounds. Granted, if it is a huge wound, or the reason they are being admitted, then the ER should do some documentation, but not much more beyond a simple one.
We have to photograph and document all pressure ulcers (admitted or not). It's a pain
Done only on admission, by the floor nurses.
No photos, just document. Don't take but 5 minutes, unless patient is a living bedsore.
If I see 'em, I document 'em. I don't strip the patient and do a full head-to-toe wound check though unless there is some really obvious reason why, like the patient is septic with no known cause or something. That's called "floor nursing stuff". On our routine floor nursing documentation when I worked up there, there was a "wound" section where you wrote down the location and status of each wound (pressure ulcer, surgical, etc).
You guys should fight that. That's crayzee.
somebody kill me now
Why not have a sole person to do wound assessments? Ahhhh, that would cost money. We do assessments on admission and then document every shift.
I am not in the US, but our management has also launched into saving money - by getting rid of the nurses, especially ED (where I work).
5 ED evening staff have been reduced to 4.
in the last week, most evenings have been 3 - one in charge and triage , and 2 on the floor
recently when there were 2 am staff (the third RN had not yet started), one of those two staff was sent to the ward to help with the showers
so that left one RN by himself in ED for over an hour - covering patient care and triage etc etc
we cannot cope with the workload and it is dangerous.
management do not care
I don't know what to do - I want to leave and do something else, but need the money for my family and mortgage
I would submit these number estimates in writing to whomever decides your staffing ratios. You should have minimum one 4 hour equivalent nurse per day soley dedicated to wound documentation!!!!
HMac
Yes, we are required to document all pressure ulcers in the ED. With photographs. It's ridiculous.
Step 1: see a pressure ulcer on a butt. Don't clean or dress it, just look at it.
Step 2: Go find the magic digital camera and the special stickers. Pray that it's charged up, and that it's able to be found. Write the pt's medical record number on a bunch of little stickers.
Step 3: Go BACK to the patient, prepared to clean, photograph, and dress all the pt's wounds. Place a little MR sticker near each wound and take a picture of it. Clean the wound. Dress the wound. Move along.
Step 4: Place an MR sticker in the "Skin Care log book" at the nurses station. Note that you took the pictures.
Step 5: log onto the computer and document the sizes, shapes, depth, tunnelling, drainage, and everything else on each wound separately.
This takes FOREVER. We have a wound care nurse in our hospital. Why can't she do it on the floor? I'm perfectly willing to note, clean, and dress decubiti when I see them as I'm assessing a patient, but the extra step with the damn camera takes FOREVER. I have an average of 8 patients in the ER at a time. Do you REALLY think I have time to do all this crap? What I do now as a form of passive-agressive protest is to dress and chart on all the wounds I see, but leave a note in the skin care book that photos were not taken due to high caseload and patient acuity. Then someone else goes and does it--usually the wound care nurse.
Oh--and when we DON'T do it, we get complaints from the floor. Once one of our RNs got called upstairs to take a picture of A RUG BURN. not a decubitus ulcer. A RUG BURN. I was in charge, so I went up, looked at the wound, and told them they could write me up, but as far as I knew, the protocol was for decubiti only, and this was not one.
Sounds like California is again leading the way in health care. On the other coast, I have not seen this requirement, yet. That doesn't mean that it isn't happening, just that I have not seen it - yet.
Don't they realize that this may get in the way of doing the rest of the JCAHO non-emergency assessments prior to emergency care? They will probably add an assessment documentation synthesis assessment document - sort of a feng shui of documentation of assessment documents. Then the rest of the world will truly be jealous.
I work in a CA hospital and I've had to do this for years!!
All patient wounds are photographed and the wound sheet is filled out BY THE ADMITTING NURSE on the floor.
I agree; it should not be done in the ER. ER is for stabilization.
Your facility is whack.
Nice informative blog post....Good work keep it up!
It's time for me to start that cashmere goat farm I've been dreaming of.
Why on earth document it to death unless they're admitted?
Isn't it called the emergency room for emergencies? Last time I checked, no pressure ulcers caused any heart attacks or strokes.
Yes, they are serious, but if they're that bad, I'm all for calling the wound nurse to bring the camera to help me document on the floor, where it's out of the way. Or you tell that MD to get his/her derriere here to admit so you can consult the surgeon on the mess.
What kind of efficiency is that having ER nurses do this stuff? Insane!
Wait wait wait. Please back up a minute.
Please define "wound".
An actively bleeding wound? A scabbed up wound? An older wound with stitches? An abrasion? A mole? A mole I picked at the other day and is now scabbed up? A pimple (which is an infection)? A popped pimple? An ingrown hair (shows as red bump)?
we arent doing this in my ed. it has been casually mentioned that we should be documenting a thorough skin assessment on our admitted patients, but so far, I haven't seen that done. No special form. I assume the floor nurses are doing it.
we arent doing this in my ed. it has been casually mentioned that we should be documenting a thorough skin assessment on our admitted patients, but so far, I haven't seen that done. No special form. I assume the floor nurses are doing it.
What a waste of ER nurses time! I feel for you plus most hospitals have skin nurses up on the floors that salivate to document and take pictures of wounds. I work on the floor and ED so I see both sides and think having ED nurses do this is ridiculous! Some really important person sitting behind a desk thought this up and it's gotto be motivated by $. I smell no reimbersement for hospital aquired wound. $$$$ motivates most policy changes in the hospital it's a bummer. If good patient care motivated policies I think there would be alot less paperwork. Toni
chuckr44 - in my hospital it is every last ditzle - I got written up the other day by a floor nurse because I didn't photograph the superficial scratches my suicidal patient had made on his wrists.
HA! Unbelievable. Let's see our facility has us the ER nurses calling patients to follow-up. Are you kidding me?! So instead of patient care we are to sit down and call patients that were seen the previous day to see how their visit was....I for one am boycotting and have not performed one 'discharge' phone call.
That is the biggest waste of time (and thus money)I have ever heard of.
i work on a med/surg floor at la county and we do it on the floor - we really only have to take pics of a stage 2 decub or worse (for reimbursement purposes of course :) ) - anything else - like lacs or something - just verbal documentation .. yeah it's not really an emergency to take a pic - and it's easy enough to do on the floor .. you should ask them to revamp the policy and change it to a ward rn duty
I work in a 450 bed hospital and we have ONE wound care nurse for the entire hospital. She is great but can not possibly see all the patients that need wound care. Then we have a "skin team" that does nothing when you ask for help (because they are staff nurses with 2 hours of "training" and their own assignment everyday, leaving no time for skin assessments for anyone other than their own patients) and they do "rounds" once a month. Not sure why they do the rounds, most of our patients stay 4 days or less so I don't know how they decided on once a month rounds.
Also, if patients are sitting in your ER for hours/days waiting for a bed, perhaps a few wounds are coming from sitting on those carts and not being turned q2 hours, due to nurses having way too many patients to be responsible for. If the wound is not photographed until the patient hits the floor, how can it be determined when the wound occurred? Who can be blamed for it, or not paid for it? I know ER staff have more serious things to take care of and you have to prioritize but maybe it's just to cover your asses and say, yeah the patient DID in fact arrive with these wounds. I agree that you need more help though, if they expect you to doc all wounds, even scratches.
As a floor nurse, I agree that we should do the documentation/photographing. We have to look at all the wounds upon admission anyway, so even if it was documented earlier, I still have to look at it and do my own assessment and documentation. Plus, I will be seeing the patient everyday and if I saw the wound upon admission, I will also know if it's changing.
FYI--I am not in CA but our union has forms we can fill out when we have an unsafe assignment. By submitting that form the nurse is absolved of any responsibility for what may or may not happen on her shift. The floor managers are then held accountable if something happens. Although, they will never tell you the form is available, good thing our nurses talk to each other. Hopefully you have something similar...
In our hospital we have admit nurses. They transport the pt. from the ER to the appropriate floor and conducts the admit assessment including wound photos at that time.
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