Emergency Department Care Reconsidered

  By Jeffrey E. Phillips BS, RN

What is patient care in the emergency department (ED) supposed to be about? Patients arrive either presenting with an already concluded diagnosis (e.g., “I cut my finger”, “I fell”) and require treatment, or a patient arrives with a set of symptoms that must have a diagnosis assigned to them (e.g., headache, chest pain, abdominal pain). In either possibility, the staff must determine the severity of the complaint, decide on a mode a treatment, and then transition the patient to treatment outside of the ED. That transition may be in the form of admission to the hospital, transfer to another facility, or discharge with or without primary care follow-up. Or in the words of emergency medicine physician, Dr. Ken Milne, “meet ‘em, greet ‘em, treat ‘em, and street ‘em” (Milne, 2014).

Our responsibility to our patients in the ED is about early intervention, stabilization, treatment, and transition, although according to Dr. Scott Weingart of Stony Brook University Hospital, it is much more than that. “Bring upstairs care, downstairs,” is the mantra Weingart tries to impart on those who will listen (Weingart, 2009). In a more verbose translation, he is advocating that the depth of care provided in the Intensive Care Unit (ICU) be provided in the ED as well. Of course Weingart is referring to the sickest of patients, those requiring the most intensive resuscitation efforts. But what about those patients outside of the resuscitation rooms; the rule out septicemia, the decompensated nursing home transfer, the undifferentiated abdominal pain? The concept of providing ICU or “floor” level care can be expanded to any patient in the ED. In the same way, the concept of providing excellent care goes beyond medicine and into nursing as well, or at least in theory it should.

As a gross generalization, emergency care boils down to treating emergent complaints and supporting airway, breathing and circulation (ABC) until the patient can be transferred to a facility or unit that is capable of more appropriately handling the patient’s condition. But in the modern, urban emergency department, overcrowding, long admission wait lists, and unsanitary conditions dampen what should be a seamless extension of excellent hospital care. The increase in patient visits coupled with the extended stays in the ED, both demand improved nursing care and also reduce the ability to provide it. As the patient census rises, and nurse-to-patient ratios creep into the teens, the ability to provide comprehensive care steadily diminishes. A patient load of twelve or fifteen patients devolves nursing care to the bare necessities of ensuring safety, monitoring ABCs, and providing “essential” treatment at the expense of quality patient-centered care.

emergency room     The implications of Dr. Weingart’s philosophy on medical practice is a conversation for another day. Discussions about whether to perform needle or knife cricothyrotomy, or when to implement extracorporeal membrane oxygenation on post-cardiac arrests patients is best left for medical experts to debate. The question posed here is whether Dr. Weingart’s philosophy of bringing floor level medical care in the ED can be extended to nursing care. Can nursing care bo optimize so that nurses go beyond efficiently keeping patient’s vitals stable and inserting IVs and Foley’s in the ED.

Something must change in this era when it is not unusual for 40% of patients in ED to be admitted, when the average wait time for an in-patient bed might take over 24 hours. It is interesting to consider how ED nurses perceive the level of care provided to “admitted” patients in the ED, those who are in transition limbo, praying for a bed (note to nursing students: this is an excellent researchable PICO project!). It is ironic that patients could be horizontal in the ED, but waiting for a bed. They are “resting” but yet there is something restless about and around them. How is the care different to the same type of patient, but one is “waiting” in the ED and the other is “waited on” in the medical-surgical unit? How do nurses make the distinction?

To illustrate this, let’s consider a scenario. Say an ED nurse is walking along a crowded corridor and saw an adult patient, tucked away in a corner stretcher, crying. The nurse recognized the patient as “not one of my patients”. Will the nurse go in and find out what’s happening with this patient. Or will the nurse simply walk on by and brush off the scene as “not an emergency” and move on perform another task? The incomplete explanation on what influences a nurse’s response to potential nursing moment in any setting is personal values. Every nurse agrees that nursing is the skilled (crafty in the positive sense) application of healing sciences, but ultimately it is also an attitude and a reflection of what the nurse holds true in his or her heart.

To fully integrate the ongoing ED initiatives to improve patient experience such as hourly rounding, reducing falls, decreasing incidence of left-without-being-seen, and providing timely antibiotic or discharge instructions requires a reflective recalibration of the collective and individual attitude of ED nurses or all nurses for that matter. It is troubling to note that medical records contain a disclaimer when a nursing procedure was performed in the ED (e.g., Foley insertion) as if it is probable that sterility may have been compromised. Floor level or ICU level nursing in the ED cannot be achieved by drive-by in-service but through careful consideration of personal values, mentorship and coaching, the use of checklists, and purposeful huddle to truly put patients first.

Increasing number of sicker patients will continue to descend upon the doors of EDs. In 2010, the number of visits to the ED increased by 32% nationwide, from 102.8 in 1999 to 129.8 million (Centers for Disease Control and Prevention, 2010). ED nurses, being the first nursing care contact of patients, will continue to rise to the challenge of implementing the same nursing care benchmarks for inpatients and leave a lasting positive impression in the patient beyond triage. Nurses save lives not just by cardiac compressions, but also holding our patients’ hands. In this regard, we are all floor nurses, no matter where we work.

 

References

Centers for Disease Prevention and Control. (2010). National Hospital Ambulatory Medical Care Survey: 2010 Emergency Department Summary Tables. Retrieved from http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf

Milne, Ken MD (2014, Nov 16). The Skeptics Guide to Emergency Medicine (Audio Podcast). Retrieved from http://thesgem.com

Weingart, Scott MD. (2009, Mar 1). Emcrit Podcast (Audio Podcast). Retrieved from http://emcrit.org

 

Jeffrey PhillipsJeffrey E. Phillips BS, RN works in the Emergency Department at New York-Presbyterian Weil-Cornell Medical Center. Disclaimer: The views expressed in this essay are my own opinion and personal observations of patient care.